Subsidised Café Meals Program: more than “just a

Subsidised Café Meals Program: more than “just a
Subsidised Café Meals Program: more than “just a cheap meal”
Katrina Doljanin and Kristine Olaris
North Yarra Community Health
This paper describes the Café Meals Program that is operating in the City of Yarra. The Program
has resulted from a collaboration of North Yarra Community Health (NYCH) and City of Yarra,
and aims to improve access to nutritious, affordable and socially acceptable meals for homeless
people. The Program forms a part of City of Yarra’s Meals Program; it is managed by NYCH.
The Café Meals Program is currently feeding 50-60 homeless people in Yarra. It targets those
who are homeless (or at risk of becoming homeless), find it difficult to prepare their own meals,
and have no other prepared meal options that are appropriate for them in the community. It
provides a choice of four local cafés and restaurants for its participants. Each person is provided
with a membership card that can be used once per day to purchase a meal (to the value of
$8.80) for the price of $2.00. The program empowers clients by giving them control over when,
where and what they will eat. It also enables the homeless person to participate in the life of the
community by dining in venues where the general community eats and socialises. This improved
sense of social connectedness and inclusion can have significant effects on the self-esteem of
the program participants, and, subsequently, on their ability to make choices that improve
their health and wellbeing. This paper presents this innovative program in detail and provides
some insight into its outcomes, the components of the program that make it work, as well as the
challenges that the program has had to address.
Key words: Cafe Meals Program, Homelessness, Food insecurity, Food security, Food access, Social inclusion
The Café Meals Program is a collaborative program
of North Yarra Community Health (NYCH) and the
City of Yarra. It provides homeless people with
access to a low cost prepared meal, at a time that
suits them, at one of the four participating cafes,
once per day. The Café Meals Program enables
participants to dine in a cafe with the rest of the
community by making the café meals more
affordable. The price of meals is kept low through
subsidy.
People are referred to the Café Meals Program
when they are unable to prepare meals for
themselves and the prepared meal options in the
community are not suitable or acceptable to them.
The program therefore targets people who are
homeless or living in insecure accommodation;
who often lack the facilities, support and income
to prepare meals for themselves, and who find
that options such as council delivered meals or
cheap communal dining establishments are not
suitable for them.
The program has been trialled in various urban
regions - where the expansion of cafés and
restaurants designed for the “weekend tourist” and
more affluent local population has limited the food
options for the less affluent population. The City
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
of Yarra was one municipality that had previously
established a small trial program.
Project funding from VicHealth and the Victorian
Department of Human Services in 2001-2002 allowed
the Café Meals Program to be expanded and
remodelled to suit the local community in the City
of Yarra, as a part of the Yarra Food Insecurity
Community Demonstration Project. This funding has
also enabled an external evaluation and
documentation of the model. The Program
subsequently received recurrent funding through
the Home and Community Care Program (HACC),
and has been incorporated into the broader City of
Yarra Meals Program; as such its sustainability is
assured. This paper will present the rationale of the
Program, a description of the model, the outcomes
and the components that make it work, as well as
the challenges that have confronted the Program.
Background
Homelessness and its health consequences
The Council to Homeless Persons (1998) define a
homeless person as someone who is “....without a
conventional home and lacks the economic and
social supports that a home normally affords. He
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Katrina Doljanin and Kristine Olaris
or she is often cut off from the support of relatives
and friends, has few independent resources and
often has no immediate means and, some cases,
little prospect of self support.” Chamberlain (1999)
definitions, as used in the national census, describe
homelessness as including people living “on the
streets” (primary homelessness), people in
temporary or crisis accommodation (secondary
homelessness) and people living in insecure
housing or in housing that lacks the facilities to
promote good health (tertiary homelessness).
The results of the 2001 census showed there to
be a rate of 149 homeless people to every 10,000
population in Inner Melbourne (Council to
Homeless Persons, 2004). Based on Yarra’s
population of 68,018 (City of Yarra, 2003) we can
assume there were at least 1013 homeless people
in Yarra in 2001. This gives us an indication of the
potential size of the target group for the Café Meals
Program, although it is almost impossible for us to
know how many of these people would also meet
the other eligibility criteria for the Program, as were
described in the introduction to this paper.
People who are homeless experience poor
health and also have poorer access to health and
welfare services (Swanborough, 1999; Victorian
Homelessness Strategy Unit, 2002). This is not
surprising when the health capital ( “economic and
social support”, “support of relatives and friends”,
“independent resources” and “immediate means
and ....prospect of self support” as cited earlier)
that is vital to optimising good health is absent or
minimal for this population. Consequently, the risk
of poor nutritional health is high in the homeless
population (Swanborough).
Homelessness and food insecurity
Food security exists when there is “access by all
people at all times to enough food for an active,
healthy life” (Anderson, 1990). The core concept
in the definition of food security is that safe,
nutritious and culturally acceptable food is accessed
regularly and reliably in “socially acceptable ways”
and “through local non-emergency sources”
(Community Food Security Coalition, 1995).
An individual’s food security can be challenged
by the interaction of external (food supply) and
internal (food access) factors (NSW Centre for
Public Health Nutrition, 2003). External influences
include location of food outlets, availability, variety,
price, and quality of food in local outlets, as well
2
as the way food is promoted. Internal factors
include financial resources, personal ability to walk
or access transport to food outlets, storage and
food preparation facilities, personal life skills, and
social support structures.
Healthy Eating, Healthy Victoria (Victorian
Department of Human Services, 1996) identifies
the following groups as most vulnerable to food
insecurity: low income families; people who have
socioeconomic problems; people with mental
illness; people who are non-English speaking;
chronically ill people; frail elderly people; people
affected by alcohol and/or substance abuse;
homeless people; people of Aboriginal and Torres
Strait Islander background.
The homeless population is particularly
vulnerable to the food access aspect of food
insecurity. Often there is a limited income for food
and there may be limited (or no) food storage and
food preparation facilities. Poor mobility and lack
of social support may also impede access to food
(Doljanin, 2002; Croxford, 1996). This becomes
increasingly problematic in a community setting
where the food supply is more expensive and is
targeted to the more affluent sections of the
population, as is the case in Yarra. Because food
insecurity for this inner-urban population is
compounded by the interaction of an incomplete
or inappropriate food supply, and people’s
individual food access issues, interventions aimed
at improving food security need to address both
these variables.
The Yarra Food Insecurity Community
Demonstration Project collected data on the food
insecurity issues for the local homeless population,
highlighting the scale and intensity of the problem.
Community consultation revealed that less than
25% of 49 people interviewed ate three meals per
day, with 50% of respondents eating one meal per
day or less (Doljanin, 2002). This project also
revealed that 94% of respondents regularly relied
on emergency relief for food (this includes food
parcels, food vouchers, and free meals). Other
studies also confirm that a significant proportion
of people who are homeless rarely enjoy three
meals per day and that many have limited funds
for food, forcing them to rely on emergency relief
(Croxford, 1996; Booth, 2004; Danton-Hill et al.,
1990).
The consequences of irregular eating and limited
food choices have both physical and psycho-social
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
Subsidised Café Meals Program: more than “just a cheap meal”
manifestations. Irregular eating patterns along with
a poor dietary variety have been shown to impact
on individuals’ cognitive and psychological
functioning, immunity, iron status, obesity and
hunger (Booth & Smith, 2001). It is now recognised
that the consequences of food deprivation go
beyond the physical manifestations and have
psycho-social impacts associated with anticipated
periods of deprivation and anxiety, related to the
uncertainty of when they will obtain their next
meal (Carlson, Andrews, & Bichel, 1999).
The Café Meals Program aims to provide an
alternative dining option to address the fact that
some individuals:
• are unable to prepare meals for themselves due
to disability, lack of facilities or inadequate or
unsafe food storage and food preparation facilities
• are too transient or not house-bound, making
delivered meals inappropriate
• lack kitchen facilities or the ability to reheat
delivered meals
• cannot afford the prepared meal options in the
community (e.g., take-away or restaurant meals)
• do not find free or cheap meals offered by welfare
establishments culturally appropriate or socially
acceptable (Astbury, Elsworth, & Rogers, 2004).
The Café Meals Program: A description of
the model
How it works
The Café Meals Program allows clients to access
one meal per day at one of the four participating
cafés. The clients present their membership card
and pay $2 for a meal valued up to $8.80, with the
remaining subsidy being covered by HACC Flexible
Service Response funding. Clients can be referred
to the program by any of a range of community
workers across agencies in the City of Yarra
(outreach support workers, dietitians, community
nurses and Royal District Nursing Service Homeless
Persons Program staff) and are re-assessed every
six months. The program is managed by the
program manager at NYCH. The model is
summarised in Figure 1.
Program outcomes
The Café Meals Program began its implementation
phase in June 2002. Internal evaluation of the
Figure 1: The Café Meals Program Model
(I) PROGRAM PROMOTION
(II) ASSESSMENT
(III) WAITING LIST
(IV) MEMBERSHIP
Client linked with a referring
worker informed of program via
their worker.
Client completes referral form
with their worker.
Assessment form faxed to
program manager and placed
on waiting list.
Membership availability
determined by program manager
via analysis of spending and client
utilisation.
Client not linked with a referring
worker informed of program via
pamphlet or word of mouth.
Client accesses one of referring
workers advertised on
pamphlet to complete referral
form.
Waiting list priority based on
nutrition and food insecurity risk
scores.
Available membership offered to
clients with highest wait list score
& longest waiting time,
respectively.
Client re-assessed every 6
months & new card re-issued
with expiry date that is reassessment date.
Referring worker informed of
membership availability, who then
contacts client.
Client given a membership card
labelled with their name,
membership no. & expiry date. If
declined, membership offered to
person next on the waiting list.
VII) DATA ENTRY
VI) RECORDING UTILISATION
V) CAFÉ UTILISATION
Program manager enters data from utilisation forms,
referral forms & membership status. Data used to
monitor utilisation, wait list status & program
vacancies. Report compiled & sent to referring
workers, quarterly.
Café staff record date, client’s membership no, value
of meal & $ paid on utilisation form.
Utilisation form and invoice for subsidy faxed to
program manager monthly.
Client visits one of the cafes
during open hours and orders up
to $8.80 worth of food, pays $2
and shows membership card.
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
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Katrina Doljanin and Kristine Olaris
Program was conducted by NYCH in October 2002,
as a part of the Yarra Food Insecurity Community
Demonstration Project. Additionally, the
Collaborative Institute for Research, Consulting and
Learning in Evaluation (CIRCLE) at RMIT University
were commissioned by VicHealth and NYCH in
May 2003 to conduct a 12-month follow-up
evaluation of the Café Meals Program. Internal
evaluation used records of utilisation, client referral
forms, client evaluation and satisfaction forms (of
the 33 participants at the time, 19 forms were
completed,) and interviews with café proprietors
and referring workers. The external evaluation by
CIRCLE involved interviews with the program
manager, referring workers, café proprietors and
six participants of the program. The results from
internal and external evaluation have been
documented in two final reports (Doljanin, 2003;
Astbury et al., 2004) and are summarised below.
Outcomes for the program participants
Improvements in nutritional status
The impact of the Café Meals Program on nutritional
status was difficult to quantify, as many referring
workers are unable to measure weight and height
of their clients. However, in the internal and external
evaluation of the program, some participants
reported improvements in weight, glycaemic control,
appetite and a sense of general wellbeing. Referring
workers also reported improvements in the
appearance of some of their clients.
Improved frequency of meals
Impacts on frequency of eating are more clearly
demonstrated. From the data collected from 19
participants who completed internal client
evaluation and satisfaction forms it was reported
that at referral 14 of these participants ate only
once per day or less, and four ate 2-3 meals per
day (with one non-respondent to this question).
At evaluation eight of the 19 people reported eating
once per day or less, and 10 were eating 2-3 meals
per day. The program is accessed by each
participant an average of 2-3 times per week; with
utilisation varying from daily to once per month.
Increased focus on food and eating
In both internal and external evaluations referring
workers and participants reported that the Café
Meals Program empowered clients to address their
food security issues by:
4
1) Restoring a trust in the “system” and workers,
allowing improved dialogue and client
understanding regarding their food security
determinants.
2) Increasing the assurance of a regular meal which
decreased the hunger-food seeking cycle, and
was demonstrated in participants eating more
regularly.
3) An improvement in nutrition, which increased
participants’ ability to address their individual
food insecurity determinants.
4) The regular social interaction with café staff
assisted in improving participants’ confidence and
social skills, which also impacted on participants’
ability to address their food insecurity issues.
The consequence of the abovementioned was
demonstrated by the increase in number of
participants cooking for themselves (from two to
seven people of the 19 surveyed) and a decrease
in the number of participants relying on emergency
relief (from eight to six people).
Social benefits
Program participants, café proprietors and referring
workers overwhelmingly report that the strength
of the Café Meals Program lies in the social
outcomes for participants. The program provides
opportunity for social interaction - with café staff,
other patrons, and/or family or friends that some
participants bring in to dine with them. The benefits
of this include:
• the opportunity for improved interpersonal skills,
that can sometimes be lost due to social isolation
• a perception of social inclusion or feeling a part
of the community by eating in a “mainstream”
café where everyone else eats
• improved self-esteem/confidence in providing the
choice of a “dignified eating environment” and
through positive interaction with café staff.
Economic benefits
Provision of cheap meals made it affordable for
participants to eat regularly in a gentrified
environment where the price of food is becoming
increasingly unaffordable for this target group. This
was strengthened with café proprietors allowing
participants to pay for meals 1-2 weeks in advance,
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
Subsidised Café Meals Program: more than “just a cheap meal”
reducing the pressure to come up with money at
the end of a pension payment period.
The secondary economic benefit lies in the
potential to gain employment. The program alone
does not assure this; however, ongoing positive
social engagement with café staff and patrons can
increase participant confidence, pride in one’s
appearance, social skills and other competencies
that can improve chances of employment.
Outcomes for organisations and the community
• Referring workers report that the program helps
them engage with clients - helps restore trust by
offering something that is “tangible and
immediate” for participants who have a sense of
distrust toward health and welfare agencies.
• Participating organisations have an improved
relationship and consequently improved referrals
between organisations.
• Increased community awareness of food
insecurity and worker’s capacity to address food
insecurity.
• Reduced discrimination against clients by tackling
community stereotypes and myths about welfare
recipients and breaking down barriers between
marginalised groups, traders, and the broader
community.
• Café proprietors felt the program raised their
profile (through the media), as well as their
income.
• The Café Meals Program is a cost effective method
of offering prepared meals, when compared with
traditional delivered meal programs. A meal in
the Café Meals Program costs the Program $6.60
and the client $2.00 per meal accessed, compared
with $7.50 program costs and $4.50 client costs
for Yarra’s delivered meals program.
Program components essential to success
Many factors contribute to delivering the
abovementioned benefits of the Café Meals
Program.
Funding
A program such as this is obviously dependant on
funds to cover the subsidy of meals. The program
receives recurrent HACC Flexible Service Response
funds, which cover the meal subsidy of $6.80.
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
These funds also cover the 0.1 EFT allocated to
the program manager. The amount of HACC
funding has increased since the program began in
2002, when it allowed 40 program participants; it
now enables 50-60 people to utilise the program.
The incorporation of the program into the City of
Yarra Meals Program has also assisted its growth
by providing access to some council funds. Despite
this growth, there remains a waiting list of 50
people at any given time, and as many as another
900 homeless people who could potentially be
eligible for the program in Yarra (as outlined earlier
in this paper). The program is, however, included
as a priority in the regional HACC plan for the
next two years and the authors are hopeful of
increased funding in future funding rounds.
Choice of Café
Café proprietors with a commitment to the program
and a positive attitude towards clients have
encouraged the ongoing patronage of clients by
providing the positive social interaction that
contributes to the social outcomes demonstrated.
Project management
A paid program manager has been vital to the coordination of the program. The program manager
undertakes the important role of ensuring timely
and effective communication with key
stakeholders, as well as providing ongoing
monitoring and evaluation of the program. This is
vital to maintaining stakeholder commitment to the
program as well as ensuring that the program
remains viable and responsive. Additionally, the
program manager takes responsibility for the
administrative tasks that are vital to the program
functioning.
Partnerships and consolidation of these
relationships
Referring workers from a range of health and
welfare agencies, local government and café
proprietors have strongly participated in this
program. This has been through their respective
roles of referring clients and providing food and
social opportunity for participants, and also through
their involvement in the Café Meals Committee
Meetings. These meetings have presented a forum
for stakeholders to have input into the program,
receive updates via quarterly reports and to
communicate with one another. As a result, the
program has enjoyed a broad ownership and
5
Katrina Doljanin and Kristine Olaris
various champions that have been instrumental to
securing recurrent funding.
Challenges
There have been numerous challenges in the
development of this program. One of the early
challenges was the engagement of relevant
stakeholders. This proved easier than expected as
the concern about the food security of homeless
people was widespread in Yarra. NYCH undertakes
a significant amount of work with the homeless
population and had established ties with other
agencies dealing with this target group, with local
council, and with the target group themselves.
The recruitment of interested café proprietors
occurred through mailouts and specific targeting
of some cafés that were known to be “friendly”
to homeless people. The relationship with these
small business operators has required constant
and ongoing attention. From the outset NYCH
has had regular contact with the café owners to
ensure their understanding of the program aims
and philosophy, and to increase their knowledge
of the issues faced by participants. This
communication has occurred via individual visits,
phone calls and also through meetings and
workshops. Additionally, café proprietors have
been involved with the promotion of the
program; they have spoken at the launch of the
program and have been quoted in media articles.
This support has paid off; the external evaluation
by CIRCLE identified the “attitude (of proprietors)
toward the target group” and the impact of this
“on the social objectives of the project” as a
critical success factor of the Program (Astbury,
2004, p. 56).
Another significant challenge was to develop
the program in a way that would be both flexible
(in order to maximise access) and accountable.
The small pilot program that had been running
in Yarra previously had provided only one point
of assessment (HACC assessment workers at
council) and had complex assessment
requirements. The City of Yarra had identified that
this was inhibiting access to that program. Other
previously trialled programs had also anecdotally
reported issues around ensuring the accountability
of participating cafés.
In order to address the access issue the authors
developed relevant and simplified assessment tools.
6
Training was provided for staff in agencies in Yarra
that provide services for the target group to become
assessment and referral points. This increases the
likelihood that a client will be assessed by a worker
they already know and have rapport with and
therefore significantly increases the reach and
accessibility of the program. Additionally, workers
will facilitate the first visit to a café for those
participants who lack the confidence to do this on
their own.
The utilisation of a numbered membership card
provides both a respectful way for the participants
to indicate their involvement in the program, and
also an accountable method for café owners to
record café data. Perhaps more important to the
accountability of the Program, however, is the
strong relationship that has been developed with
the café proprietors, and the strong commitment
to the program displayed by these proprietors.
The promotion of the Café Meals Program to
funding bodies was an additional early challenge.
Our response to this challenge was facilitated by
the substantial amount of evaluation that has been
undertaken, which allowed us to clearly
demonstrate the success of the program and its
ability to deliver on its objectives.
An outstanding challenge, or course, is the need
to grow the program and thus make it accessible
to a greater number of people in the homeless
population. Potentially, the program could also be
made available to other vulnerable target groups.
Conclusion
Eating well involves a complex interaction of
factors; a person’s individual ability to acquire,
prepare and consume food and the presence or
absence of an environment that offers acceptable
and affordable options. People who are homeless
may find that both aspects of this food security
equation are lacking, limiting their food choices.
The Café Meals Program has attempted to address
this by providing more affordable meals (through
subsidy) in a range of venues; allowing participants
to choose what they want to eat, where and when.
The restoration of choice as well as positive social
interaction with café staff has been important to
the participants. The Café Meals Program strongly
promotes the social and cultural importance of food
and eating, and demonstrates that food programs
have the capacity to enhance social inclusion and
community cohesion.
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
Subsidised Café Meals Program: more than “just a cheap meal”
Acknowledgments
Funding from VicHealth and the Department of Human Services has allowed the expansion and evaluation
of this program by Deakin University. Additional funding from VicHealth has also allowed the 12-month
follow-up evaluation of the program by CIRCLE (RMIT), and funding from HACC and City of Yarra has
contributed to program sustainability. These funding opportunities as well as the immense input from the
community stakeholders, including program participants, have been vital to the program’s success to date.
North Yarra Community Health has been a supportive setting for this program to expand and strengthen
itself. Thanks to all these key stakeholders for allowing this program to take off from its formative years,
as a pilot program based at local government initially intended as an alternative to meals on wheels.
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Katrina Doljanin
North Yarra Community Health
75 Brunswick Street
Fitzroy Victoria 3065
AUSTRALIA
E-mail: katrina.doljanin@nych.org.au
Kristine Olaris
North Yarra Community Health
365 Hoddle Street
Collingwood Victoria 3066
AUSTRALIA
E-mail : kristine.olaris@nych.org.au
Correspondence to Katrina Doljanin
Australian Journal of Primary Health — Vol. 10, No. 3, 2004
7
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