Perceptions and Barriers to SNAP Utilization Among Asian and Pacific Islanders in Greater Los Angeles

Abstract

Purpose:

To examine the perceptions of and barriers to Supplemental Nutrition Assistance Program (SNAP) participation among Asian and Pacific Islander (API) immigrants.

Design:

Qualitative focus groups were conducted in 4 API communities.

Setting and Participants:

Participants were recruited from 4 API communities (n = 68; 22 Tongan, 18 Vietnamese, 16 Filipino, and 12 Chinese) through local community-based organizations in Los Angeles and Orange Counties.

Method:

Trained bilingual and bicultural researchers conducted 8 focus groups in English, Chinese, and Vietnamese. Prior to the start of each focus group, participants completed a demographic questionnaire which included a United States Department of Agriculture (USDA) Food Security Module.

Analysis:

Audio recordings were transcribed verbatim and those in the native languages were transcribed verbatim. Transcripts in native languages were reviewed and translated into English. All transcripts were organized in ATLAS ti version 8.0 and analyzed using thematic analysis. The USDA Food Security Module results were scored and assessed for food insecurity.

Results:

Median age of participants was 58 years and 59.4% (n = 38) were food insecure. Barriers to SNAP participation were identified and organized within the Social Ecological Model by the following themes: (1) unclear program information, (2) application process, (3) shame, and (4) pride. Despite commonalities found across API subgroups, unique challenges with public charge and immigration existed within the subgroups.

Conclusion:

Culturally relevant in-language SNAP materials and multilevel interventions are needed to mitigate barriers and increase SNAP participation rates among low-income API groups.

Keywords

SNAP Asian Pacific Islanders immigrant low-income public charge Chinese Filipino Tongan Vietnamese CalFresh

Purpose/Introduction

Hunger and food insecurity are associated with increased risk of poor nutrition and chronic diseases, and long-term food insecurity is associated with obesity and its comorbidities.¹ The Supplemental Nutrition Assistance Program (SNAP) is a federally funded program that mitigates food insecurity by increasing low-income individuals’ purchasing power for nutritious foods. During the economic downturn in 2007, SNAP was one of the most responsive federal programs to alleviate food insecurity for under-resourced families.²

Due to its population size, California has the largest number of participants receiving benefits through SNAP—named “CalFresh” in California.³ However, in 2015, only about 70% of eligible California residents received CalFresh benefits, one of the lowest participation rates in the nation.⁴ In May 2017, the Los Angeles County Board of Supervisors sought to increase CalFresh utilization by 20% within 2 years; however, recent data revealed an increase of less than 1% (5755 individuals) after 1 year.^5,6 Given the tremendous potential for CalFresh to ease the burden of food insecurity among low-income households, it is concerning that not more eligible participants are capitalizing on available SNAP benefits.

Underutilization of CalFresh benefits is especially prominent among Asian and Pacific Islanders (APIs). Although APIs represent only 5% of the total US population, they were the fastest growing group in the United States between 2000 and 2010 and are estimated to comprise 10% of the population by 2050.⁷ As of 2010, approximately 59% of Asian Americans and 40% of Tongans living in California are US born.⁸ Immigration patterns affect the economic and educational status of communities once they arrive in the United States, resulting in immigrants facing culturally and environmentally unique barriers and experiencing greater rates of food insecurity than their US-born counterparts.⁹ Hunger among legal immigrants is twice the rate of the general public (41%); simultaneously, eligible immigrants report low participation in public assistance programs.¹⁰ Barriers to SNAP participation include inadequate knowledge concerning program eligibility, lack of transportation, language barriers, and misconceptions about the program.^11
-13

Los Angeles County is home to the nation’s largest Asian American (∼1.5 million) and Native Hawaiian and Pacific Islander (NHPI) populations (54 169).¹⁴ While aggregated Los Angeles County data suggest that Asian Americans and NHPIs have low poverty rates (11% and 13%, respectively), disaggregation exposes a much different story.¹⁴ Poverty rates in Tongan (51%), Vietnamese (16%), and Chinese (13%) communities exceed aggregate rates, while the poverty rate among Filipinos is lower than the aggregate at 5%.¹⁴ Additionally, 78% of Tongans are considered low income compared to the 31% average for NHPIs.¹⁴ Poverty is intertwined with food insecurity and limited access to fresh produce in these API communities. According to 2015 data from Los Angeles County, while 23% of APIs reside in food insecure households and 11% of API children live in communities with poor or fair access to fresh food, APIs represent only 6% of CalFresh households in Los Angeles and Orange Counties.^15
-17

Despite the increasing number of API immigrants in the United States, there remains a paucity of research on APIs as a whole and even less research among API subgroups. This study fills a gap in the literature by providing a nuanced understanding of perceptions and barriers impacting the utilization of SNAP benefits among diverse and underrepresented API communities in southern California. Understanding the reasons for SNAP underutilization is valuable for informing future program development of culturally and linguistically appropriate outreach efforts for API immigrant communities.

Approach

A cross-sectional qualitative study was conducted with 68 participants across 4 API communities (Tongan, Vietnamese, Chinese, and Filipino) in greater Los Angeles. Data were collected through 8 total focus groups, 2 per subgroup, between June 2016 and December 2017.

Design and Samples

The 4 participating API communities represent some of the lowest CalFresh participation rates in Los Angeles and Orange Counties and thus were specifically selected for this study. Asian Pacific Islander Forward Movement (APIFM) is a community-based organization (CBO) advocating for API health in southern California. Community-based organizations, as trusted organizations in the community, acted as bridges between the research team and community members. APIFM staff and other CBO partners invited their clients to participate in the study using face-to-face recruitment and flyers posted in their offices and clinics. Community partners utilized a screener to identify potential participants. Eligibility criteria for participation included adults aged 18 years and older who (1) identified with the selected ethnic group and (2) low-income based on the 2016 federal poverty level or (3) had prior knowledge of or had participated in CalFresh within the past 5 years. Tongan focus group participants were stratified by age with a younger (ages 18-40) and older group (ages 40+). Due to recruitment limitations, other focus groups were not stratified by age.

Measures

Previous literature on SNAP participation in underrepresented communities were used to inform the development of focus group questions.^12,18,19 Discussion topics explored 4 key areas of interest: (1) general perceptions of the CalFresh program, (2) participants’ personal experiences with applying for and using CalFresh benefits, (3) barriers to participation, and (4) suggestions for improving the program and increasing participation. (Henceforth, CalFresh is used instead of SNAP to be California specific.) The principal investigator (PI) and research assistant developed the initial draft of the focus group guide, then collaborated with APIFM staff to revise and finalize the focus group guide. The guide was then translated into Vietnamese and Chinese by the research team and moderators, who were bilingual, bicultural, trained university researchers, and from the same API subgroup as the study participants. All moderators were individually trained by the PI, who has extensive experience in qualitative methods. During each focus group, moderators and the PI kept extensive field notes; following each focus group, the PI and moderators discussed their notes and any discrepancies were reconciled until consensus was reached.

Focus groups were clustered by API subgroup and conducted at local community centers near or within the participating community neighborhoods. Filipino and Tongan focus groups were conducted in English, while Vietnamese and Chinese focus groups were conducted in their native languages. Focus groups were approximately 1 hour long and each participant received a $20 gift card as a token of gratitude for their time and participation. Prior to the start of each focus group, all participants signed written consent forms in English or their preferred native language. Participants also filled out a demographic questionnaire, which included sociodemographic questions and the previously validated United States Department of Agriculture (USDA) Adult Food Security Module.^20,21 All focus group materials and consent forms were translated into Mandarin and Vietnamese for in-language focus groups by their respective focus group moderators. Back translations of Mandarin and Chinese focus groups were provided by an independent reviewer. Interviews were audio and video recorded for transcription purposes. Focus groups conducted in English were transcribed verbatim, while those conducted in Vietnamese and Mandarin were transcribed in-language and then translated to English by their respective focus group moderators. All research members completed training in research ethics and confidentiality and all aspects of this study were reviewed and approved by the institutional review board (IRB) of Seaver College of Pepperdine University (IRB #16-05-283).

Analysis

Transcripts were uploaded and organized in ATLAS.ti version 8.0 (ATLAS.ti Scientific Software Development GmbH). The PI, research assistant, and APIFM staff analyzed the focus groups using thematic analysis.²² During the first pass, each member independently read through the transcripts and identified key themes within the focus groups. Subsequently, the team met to discuss and reconcile any discrepancies prior to arriving at a consensus on key themes. The codebook was then developed and quotes were organized under each theme and subtheme. Saturation was reached when the research team reached consensus about no new or original ideas. After analysis of the data, themes and subthemes were organized under each level of the Social Ecological Model (SEM), a framework identified by Food and Nutrition Services for SNAP education and also used in other studies to address barriers to health.^23,24 The SEM addressed barriers that arose across themes and between the 4 communities collectively.

Demographic data and the food security module responses were entered into the SPSS Statistics Program version 24 and summarized in Table 1. Composite scores were computed for the food security responses, then categorized according to the USDA’s measurement guide.²⁵

Table 1.

Demographic and Food Insecurity Data of Focus Group Participants, by Asian Pacific Islander Subgroup (n = 68).

	Tongan	Vietnamese	Filipino	Chinese	Overall
	Median (range) or n (%)^a	Median (range) or n (%)^a	Median (range) or n (%)^a	Median (range) or n (%)^a	Median (range) or n (%)^a
Age	40.5 (19-70)	58.5 (22-70)	77.0 (38-94)^b	64.0 (35-82)	58.0 (19-94)
Number of participants	22 (32)	18 (27)	16 (24)	12 (18)	68 (100)
Gender
Male	3 (14)	5 (28)	8 (50)	5 (42)	21 (31)
Female	19 (86)	13 (72)	8 (50)	7 (58)	47 (69)
US citizenship^b
Yes	7 (32)	2 (12)	0 (0)	0 (0)	9 (13)
No	15 (68)	15 (88)	16 (100)	12 (100)	58 (87)
Number of years in the United States^b,c	26.0 (10-40)	20.0 (3-27)	30.0 (1-41)	23.5 (4-37)	25.0 (1-41)
Number of household members^b
1-4	7 (32)	17 (94)	11 (73)	10 (83)	45 (67)
5 or more	15 (68)	1 (6)	4 (27)	2 (17)	22 (33)
Living in shared housing^b
Yes	12 (56)	2 (12)	1 (6)	5 (50)	20 (31)
No	10 (46)	15 (88)	15 (94)	5 (50)	45 (69)
Level of schooling
9-11	2 (9)	4 (22)	1 (6)	2 (17)	9 (13)
High school graduate/GED	10 (46)	7 (39)	2 (13)	6 (50)	25 (37)
Some college/associate’s	4 (18)	6 (33)	2 (13)	3 (25)	15 (22)
Bachelor’s degree or higher	6 (27)	1 (6)	11 (69)	1 (8)	19 (28)
Estimated household income^b
$9999 or less	6 (32)	8 (47)	8 (53)	2 (22)	24 (40)
$10 000-$29 999	7 (37)	8 (47)	7 (47)	7 (78)	29 (48)
$30 000 or more	6 (32)	1 (6)	0 (0)	0 (0)	7 (12)
Previously applied for CalFresh^b
Yes	3 (14.3)	12 (66.7)	0 (0.0)	5 (41.7)	20 (31.3)
No	18 (85.7)	6 (33.3)	13 (100.0)	7 (58.3)	44 (68.8)
Food insecurity category^b
Food secure	4 (20)	13 (72)	0 (0)	9 (75)	26 (41)
Food insecure	16 (80)	5 (28)	14 (100)	3 (25)	38 (59)

^a The n is divided by the total number of participants who responded to the question to result in the percentage. Percentages for rows in a single category (row titles in bold) are rounded up to the nearest whole percentage and sum to approximately 100% within each column.

^b Sample sizes may vary due to missing data.

^c Data only collected among those who are foreign born.

Results

The median age of focus group participants was 58 years (range: 19-94 years) and most participants in each subgroup were older than 50 years, with the exception of Tongan participants who were generally younger and lived in larger households. Majority of participants older than 50 years had an annual income less than $15 000, and 59% reported living in shared housing. Eighty-seven percent of participants were not US citizens and the median length of stay in the United States was 25 years (range: 1-41 years). More than half of all participants were food insecure, with the highest rates of food insecurity among Tongans (42%) and Filipinos (37%; see Table 1). Additionally, almost one-third of participants (31.3%) - had previously applied for CalFresh benefits, the majority of whom were Vietnamese and Chinese participants. No Filipino participants reported previously applying for benefits but had knowledge of the program through family members and friends in the community.

Focus Group Themes

Figure 1 summarizes the key themes and subthemes, which included (1) unclear program information, (2) complex and difficult application process, (3) shame, and (4) pride. Each API subgroup experienced the aforementioned barriers with differing levels of severity. Participants’ suggestions for improving CalFresh utilization are summarized in Table 2.

Figure 1.

Themes, subthemes, and supporting quotes from Tongan, Vietnamese, Filipino, and Chinese community members.

Table 2.

Suggested Strategies by Level of the Social Ecological Model and Asian Pacific Islander Subgroup in Greater Los Angeles.

	Tongan	Vietnamese	Filipino	Chinese
Public policy	• Reduce amount of required verification documents• Reduce amount of paperwork	• Reduce restrictions on purchasing precooked foods for recipients without kitchen access• Reduce amount of paperwork• Simplify language on English and Vietnamese-translated materials to be more colloquial	• Expand eligibility for sponsored and petitioned individuals, especially in cases where sponsor is no longer present.	• Reduce frequency of recertification process to annually
Community	• Involve Tongan churches, especially pastors and elders• Create local events for Tongans to learn about CalFresh and apply• Train NHPI CBO staff and local stakeholders to increase their capacity to promote CalFresh and help Tongans apply.	• Train Vietnamese CBO staff and local stakeholders to increase their capacity to promote CalFresh and help Vietnamese apply	• Train social workers at adult day cares to help adults apply• Train Filipino CBO staff and local stakeholders to increase their capacity to promote CalFresh and help Filipinos apply• Involve senior homes and community centers	• Involve local CBOs/NPOs, like the food banks, to provide information and promote CalFresh• Create local promotional events/activities• Create an event where a social worker or CalFresh expert can give a “lecture” to introduce the program• Train local stakeholders to promote CalFresh
Organizational	• Hire more Tongan social workers to reduce wait time• Increase weekly hours that a Tongan-speaking social worker is available	• Create a separate station for answering CalFresh questions, especially on eligibility• Hire more Vietnamese social workers to reduce wait time• Increase staff to answer phones• Train staff to treat recipients with compassion and to have a clear understanding of guidelines• Create an anonymous feedback system for current CalFresh participants	• Train staff to treat recipients with compassion and to be consistent with follow-up phone calls• Train front desk staff about eligibility criteria and to answer questions• Hire more Filipino social workers to reduce wait time• Increase staff to answer phones	• Train staff to have better working attitude and to be more friendly• Train front desk staff to understand eligibility criteria and answer questions• Hire more Chinese social workers to reduce wait time
Interpersonal	• Social media campaign on Facebook• Create a bilingual video about CalFresh featuring respected pastors/elder in Tongan churches	• Multimedia campaign via Vietnamese radio (KVNR 1480 AM, Radio Bolsa 106.3 FM), television, and Nguoi Viet daily news• Feature a social worker on Vietnamese television to answer questions about CalFresh	• Multimedia campaign via Filipino television (TFC, GMA, ABSCBN, TV Patrol News, Channel 18), newspapers (the Asian Journal), and Facebook	• Multimedia campaign via Chinese television, newspaper (Da Ji Yuan for non-Mainland Chinese), radio (KAZN 1300 AM), and online (ChineseInLA.com)
Individual	• Create bilingual materials that provide information about CalFresh and where EBT can be used• Messaging should use “humble phrasing” and can include the use of the word “free”	• Create clear, simple, short, and in-language materials that outline eligibility criteria and the necessary paperwork for applying• Poster campaign at Vietnamese markets and crossing intersections frequented by the community	• Flier campaign in Tagalog and English or Taglish• Messaging emphasize not feeling ashamed using CalFresh because it is part of their benefits (especially among seniors)• Create materials about eligibility criteria	• Messaging should be short and simple• Create in-language advertising materials that provide information on eligibility criteria and how to apply for CalFresh• Poster campaign at Chinese grocery stores and mail an information packet (not flyers)• Create a user-friendly, in-language online resource for CalFresh information

Abbreviations: CBO, community-based organization; EBT, electronic benefit transfer; NHPI, Native Hawaiian and Pacific Islander; NPO, nonprofit organization.

Theme 1: Unclear Program Information

The theme of “unclear program information” included the following subthemes: lack of information or misinformation about the program and unclear eligibility criteria; these resulted in fear about the negative consequences of participation. Sample quotes are embedded in each section below.

Lack of information about the program

Primarily noted by Tongan participants and some Filipino and Chinese participants, knowledge and awareness of CalFresh program information was limited. Additionally, communities with limited CalFresh participation shared common misconceptions about CalFresh benefits, such as the nutritional benefit of CalFresh participation. A recent Chinese immigrant participant shared, “I have never seen any food stamps information or advertising in the newspaper or on television. Many new immigrants are not familiar with the new environment and know nothing about food stamps.” Tongans knew of the program but explained that few details were available to new immigrants: “Coming to America is a whole different ballgame because there’s help outside of our family, but we don’t know how to use it or take advantage of what’s available to us.” Participants offered API-specific suggestions for increasing awareness of the program, such as using Facebook, radio stations, and television channels, and these are summarized in Table 2.

Unclear eligibility criteria

Those who had more knowledge of CalFresh in the Vietnamese, Filipino, and Chinese communities noted the lack of clarity concerning eligibility. A Filipino participant shared how the unclear eligibility guideline was a significant deterrent, “I don’t even know if I’m qualified. I don’t know the conditions for how to apply.” One Vietnamese participant suggested, “I think the eligibility criteria should be clearer for people to understand because right now it’s not so clear. If they can make that east to understand, then you can know and not just go there and waste time.” To make eligibility criteria clearer for participants, Vietnamese participants suggested having a designated station at the Department of Public Social Services (DPSS) office to only answer questions related to eligibility. Other groups suggested developing a mobile application or a simple in-language handout that can screen participants for eligibility.

Unclear eligibility criteria also confused older adults with other social benefits, such as Supplemental Security Income (SSI). A Filipino participant shared, “It should be made clear that whatever food stamps that they receive will not be deducted from whatever they are receiving from SSI.” According to the Los Angeles County DPSS website, any individual receiving SSI benefits does not qualify for CalFresh benefits; however, it was unclear to our participants that California’s cash-out policy actually allows SSI recipients to receive some supplemental CalFresh benefit in addition to their SSI benefit.^26,27

Unclear eligibility criteria were associated with issues of residency status and assets determination. One Chinese participant expressed frustration with the limited assets eligibility criteria,

Chinese people are frugal and they always try their best to save money. No matter how poor the family is, they may still have a saving of $1000-2000 in their bank account. Because of this, they feel they are not qualified to apply for food stamps.

Filipino participants shared that their complex residency status, particularly sponsorship or petitioned residency, led them to believe they were ineligible to receive CalFresh benefits. A Filipino participant recalled,

They are told they are not qualified because they were petitioned here, but they have been separated from those who petitioned them for years and they can’t even find their sponsor; they should receive the financial help so that they can eat properly.

Filipino participants recommended expanding eligibility for these unique residency statuses, especially those in which the sponsor is no longer providing financial support.

Fear of consequences

Misinformation and unclear criteria about CalFresh resulted in participants feeling afraid of receiving CalFresh benefits because they believed it would negatively impact their own application for US citizenship or sponsorship of family members. A Vietnamese participant commented,

Some Vietnamese immigrants think that if they use services like food stamps, it will hurt their citizenship application because they are afraid that they will be judged as being a burden on society, so the US government won’t grant them citizenship.

For those in the Filipino community who sponsor family members, being a CalFresh recipient may negatively affect their chances to sponsor family members. One participant shared, “it might affect their petition application for the children because the government may think that when their children come they will also use the food stamps.”

Theme 2: Application Process

The second theme encompasses issues with the application process, which included a confusing and complex application, time-consuming to apply, limited in-language support and access to DPSS office, and unhelpful staff.

Complex application

Participants shared that there are a number of documents required to apply for benefits, and participants in all groups felt confused about the different aspects of the application process. Thinking about a neighbor who went through the application process, a Tongan participant recalled,

She was looking for work at the time, so they needed proof and stuff like that, and then I remember her saying that they always sent her letters for just a lot of different documents, like every week or something. It was just a hassle…at the time it seemed really stressful.

Time-consuming

One Vietnamese participant lamented about how much time it took to apply,

After we filled out the paperwork, they told us to go have lunch and come back in two hours. I wanted to just go home because it took so long. I eventually did qualify to get food stamps, but it was a lot of time and a lot of hassle. Honestly, if it’s just up to me to go and apply, I would not have gone.

A participant shared personal frustrations with missing a day’s wage, “I am self-employed and if I take time out to go apply then I have to use almost a whole day to do this, so I lose work and I may not get food stamps.” Although the application process can be completed entirely over the phone rather than in-person, this option was not apparent to participants; the long wait time (for those who reported waiting over 30 minutes) discouraged them and led many to give up.²⁸

Lack of in-language support

Limited and hard-to-understand in-language materials were found to be a significant barrier, particularly for Vietnamese and Chinese participants, as shared by a Vietnamese participant, “The Vietnamese forms are hard to understand. I used food stamps for several years and then I just gave up because it was not worth the hassle.” Additionally, one Chinese participant who helped friends apply remarked,

Language is the biggest barrier for them. They get information from others but are not so sure about it. Then they go to the social services office and get answers, but they don’t quite understand these answers either because of the language problem.

Access to the DPSS office

The access issue encompassed transportation to DPSS offices and the limited hours of service. One Chinese participant stated, “Some people are too busy to finish the application process. One can only apply for the food stamps from Mondays to Fridays, but many people cannot afford to take one day off from work on weekdays.” Others also shared their frustrations about not being able to find parking when coming during lunch breaks or navigating public transportation to the DPSS office. Participants suggested expanding DPSS offices on Saturdays or longer hours during the weekdays to increase access.

Unhelpful staff

Each group mentioned their struggles with social workers from their API subgroup being disparaging rather than supportive of potential participants. A Chinese participant discussed social workers’ unhelpful attitudes, “When I first went to the social service center, the staff there were not friendly. When I asked them questions, they just pointed to the materials, saying that I should read it myself.” A Vietnamese participant shared a similar experience,

there are some social workers who are really mean and they look down on people who are in need, and they make you ‘beg’ for food stamps…if people make me feel bad then I don’t feel like I want to apply. I would just rather bear it and just eat less and make do with less.

Many participants suggested hiring more staff at DPSS offices and improving customer interface among frontline staff who interact with potential participants.

Theme 3: Shame

Thirdly, “shame” was an important barrier to applying for CalFresh. Participants shared about the social stigma of poverty. In the following section, shame is differentiated from pride because shame is associated with the negative valuation of self or others, while pride is associated with the positive valuation of self.²⁹

Social stigma

Participants revealed a common notion of shame associated with acknowledging their poverty. Because CalFresh benefits are readily associated with poverty, one Vietnamese participant admitted, “I feel sensitive and embarrassed to use CalFresh. When I use it and go out to buy food and use my card, it tells people I’m poor. It does make me feel uncomfortable.”

Stress associated with poverty and its negative social stigma influences perceptions of CalFresh and results in barriers to participation. Some participants shared stories of community members shaming those who use CalFresh benefits, which have augmented feelings of social ridicule. One Vietnamese participant explained, “I think a big barrier is how Vietnamese think that society will look down on those who use government services.”

Theme 4: Pride

Related to an overarching characteristic of API culture, pride was a significant barrier to CalFresh participation. This theme of pride manifested in a strong sense of family and self-reliance, not wanting to admit need, and not wanting to depend on the government.

Family-/self-reliance

Across each focus group, a majority of participants expressed the cultural expectation to take care of oneself and one’s family. One Tongan participant shared, “I want people to know that I can take care of my family. I don’t need help. I got it.” Additionally, a Chinese participant shared, “They (Chinese people) tend to rely on themselves. As long as they can still make a living, they will not reach out for social welfare.” Particularly in the Tongan community, faith is a critical aspect to life and church leaders were recommended as a resource for changing social perceptions about CalFresh in order to encourage participants to accept support and utilize government benefits.

Not wanting to admit need

A Vietnamese participant shared that the concept of “saving face” and maintaining a strong sense of dignity and pride was important for Vietnamese, regardless of their socioeconomic status. This cultural value was not only evident among Vietnamese but was shared across all 4 API groups interviewed. A participant explained,

Vietnamese people are proud and want to maintain their dignity and ‘save face.’ They would rather cut back and eat less than ask for help or be in need. Even though they eat less, they still feel that they are healthy enough to work and take care of themselves and their families.

As a result of their strong motivation to save face, many API participants who are in need may be reluctant to apply for CalFresh. Participants suggested that one way to change this was to reframe and rebrand the CalFresh program, not as a program for the low income but for those who need additional support. As one participant explained,

If you explain it as something you can use temporarily, then they don’t feel as bad about it because once they make enough money, they can stop using CalFresh and their tax dollars will be put back into the program to help others after them.

Not wanting to depend on the government

Embedded in the concept of self-reliance was a parallel perspective that the government is not perceived to be a source of help for these communities. One Tongan participant shared, “Because I know our people, they just want to be independent themselves, they don’t wanna get help from the government even though they need it.” Regarding fellow community members, a Vietnamese participant mentioned, “They don’t want to be a burden to the government.”

Distinct API Subgroup Barriers

Although these main themes were common across all 4 API subgroups, certain barriers were more pronounced in some subgroups over others. For example, Vietnamese participants expressed more negative encounters with social workers during the application process than other groups; this often led to an unwillingness for Vietnamese participants to reapply for CalFresh. Unfavorable experiences that spread by word of mouth in the Chinese community resulted in some participants sharing negative views of CalFresh. More notably, differences in immigration status impacted eligibility for CalFresh benefits. For example, sponsored legal permanent residents experience an increasing number of requirements until citizenship or credit for 40 quarters of work.³⁰ Filipino participants reported that this additional barrier deterred them from wanting to apply. These examples speak to unique cultural variations in perceptions of and barriers to CalFresh utilization within each API subgroup in this study.

Discussion

This study sought to elucidate perceptions of and barriers to CalFresh participation among low-income API communities in Los Angeles. The SEM frames the data about perceptions and barriers to CalFresh, emphasizing the need to address concerns at multiple levels to affect change in CalFresh participation rates among APIs (see Figure 2). On the individual level, focus group participants expressed a lack of knowledge about the program and fear of the effects of participation. Correlated with the largely collectivist culture in API communities, interpersonal-level issues were expressed in not wanting to admit the need and desire to be family-/self-sufficient. At the organizational level, DPSS can modify barriers to CalFresh by addressing aspects of the application which are the most time-consuming, as well as access issues to the office, and improving staff–client interactions. Within these API communities, social stigma is a prominent issue, along with a strong sense of pride and not wanting to depend on the government. Lastly, at the state and federal policy level, there are several aspects of the application that need to be addressed, including clarifying the eligibility criteria, simplifying the application process, and expanding in-language support for multiple API groups.

Figure 2.

Identified focus group subthemes organized within the Social Ecological Model.

Our findings reflect previous research in this area; for example, the complex application process with its multiple forms and required documents has previously discouraged CalFresh participation.³¹ Additionally, the literature emphasizes that individuals’ self-awareness of society-, community-, and relationally imposed stereotypes and stigmas accentuates the shame associated with how others view “you.”³² Participants were acutely aware of the stigma surrounding poverty. In 2000, Lynch et al³³ proposed that the perception of social rank is primarily understood by income relativity, potentially contributing to negative emotions and community shaming. During one Vietnamese focus group, a particularly poignant experience was shared of an observed reaction between 2 women at a local market:

The woman in line who was using her EBT card had jewelry on and she was buying expensive food like crab and shrimp. So another lady behind her made a negative comment, saying ‘you are on food stamps, but look at you dressing so nicely, lots of jewelry and buying really expensive food’. It was an embarrassing situation to witness that.

The internalized pressure to appear in a positive light to others can lead to coping mechanisms, including altering personal appearance. As a result, the individual is judged as “fake” and perpetuates the common stereotype that SNAP recipients are not truly needy, but defrauding the welfare system.³²

Each community experienced differing degrees of severity among the barriers and perceptions, some that overlapped across multiple groups while others did not. For example, the Filipino community did not report any issues with language barrier, while the Vietnamese community had been largely affected by it. Immigration status appears to be a key contributor to these differences. Tongan community members, being more recent immigrants, showed little experience with CalFresh and fewer fears of program repercussions, while Filipino community members experienced difficulties in applications when having a petitioned or sponsored immigration status. These distinct immigration patterns may impact socioeconomic disparities between and within each API group. More common to API communities is the high cost of visiting their countries of origin—previous literature has highlighted the “Resource Limit” as particularly restrictive for immigrants and elderly individual because saving to travel to one’s home country or for funeral expenses may exceed the prescribed limit.³¹ According to the California Department of Social Services, the Resource Limit evaluation is not commonly required for CalFresh applicants but may be required in certain partially disqualified households.³⁴

Consequently, a one-size-fits-all model for future intervention efforts does not work for these API communities because strategies that address barriers in one API community may not easily translate to other API communities. Developing culturally specific interventions for each API community can improve participation and increase redemption rates. Participants provided suggestions for outreach efforts tailored to their communities, an approach used in other studies.^35,36 The subthemes and community-specific recommendations were organized according to each level of the SEM framework to address barriers most pertinent to each respective community. Table 2 summarizes these community-specific recommendations for future efforts, reinforcing the main point of our findings: Barriers to CalFresh participation occur at multiple levels.

At the individual level, developing educational resources and materials that are clear and easy to understand can increase awareness and participation. Easily accessible, culturally appropriate messaging with-in language materials can promote CalFresh participation. Providing clear eligibility guidelines with simple and linguistically appropriate directions for the application process can facilitate a better understanding of the application process. On the whole, focus group participants suggested interpersonal-level changes through in-language media campaigns to dispel misinformation about CalFresh and to address cultural values of family/self-reliance. Culturally specific considerations such as using Facebook for Tongan outreach and local radio for Vietnamese outreach are important for the effective design of future interventions.

Improved training for social service personnel at the organizational level is a vital avenue for intervention since they are often the first point of contact for eligible participants. Previous literature also emphasizes addressing the applicants’ exacerbated feelings of stigma from unhelpful social service staff.^37,38

At the community level, partnering with local CBOs has been previously found to increase participation rates in California; also, CBOs have flexible hours during the weekdays and weekends that can substantially improve applicants’ experiences.³⁸ Tongan and Chinese participants reported more positive CalFresh application experiences when assisted by CBOs, suggesting that increasing the capacity and reach of CBOs in API communities can support greater CalFresh participation. Targeted and culturally adapted interventions have been shown to be effectively implemented at the community level through CBOs.³⁵ In addition to CBOs, partnerships with the Department of Public Health, faith-based organizations, and community liaisons can greatly reduce stigma and promote participation.

At the policy level of the SEM, suggestions include simplifying and streamlining the application process to reduce the amount of required paperwork and increase the integration of various services. Supported by other literature, our findings suggest API immigrants face significant complexities in accessing CalFresh benefits; therefore, simplifying and clarifying immigrant eligibility requirements can increase participation.³⁶ Local government agencies can stress the need for API support efforts to include linguistically and culturally relevant resources and services. Additionally, a policy, systems, and environmental approach to address nutrition and physical activity issues among APIs has been shown to be potentially effective among APIs.³⁵

Although our study advances the literature on SNAP underutilization among APIs, limitations exist. The age and gender imbalance of our sample is a limitation; a majority older female sample could have limited the perspectives of other groups, such as older males, or younger female and male participants. Second, the recruitment of 4 API communities does not reflect perspectives of more than several dozen other API subgroups. This exploratory study should be expanded to other API subgroups, both in other regions of California and across different states with sizeable API populations. The nonprobability purposive sampling strategy also limits the generalizability of these data, as the recruitment through CBOs limits the range of participants and may not represent the ethnic communities as a whole. Despite these limitations, the strengths of this qualitative study include a large qualitative sample from underrepresented API communities. This study is the first of its kind to examine barriers to CalFresh participation and utilization among specific API groups who are underrepresented in the literature. Additionally, practical resources, suggestions, and guidelines for future outreach in the Greater Los Angeles region were identified directly from community members.

Perceptions and barriers to CalFresh participation in one or several API communities cannot be generalized across all API groups; this research is necessary to clarify specific barriers to CalFresh participation in each of the 4 specified API communities. The unique perceptions and barriers of each community need to be understood before meaningful interventions can be developed. Additionally, engaging and collaborating with specific API communities to tailor interventions is a critical strategy to achieve a greater likelihood of increasing CalFresh utilization in respective API communities.

This research also revealed participants’ fears about the perceived public charge associated with participating in social programs like CalFresh in these immigrant communities. Although this study took place in 2016-17, prior to the current public charge determination, the participants voiced relevant concerns related to this change in legislation. Though previous fears were unfounded, the new public charge ruling can significantly impact immigrants who need CalFresh.

Conclusion

The complex factors influencing CalFresh utilization among API communities involve a wide range of perceptions and barriers at each level of the SEM. Given significant underutilization of CalFresh benefits and prevalence of food insecurity in API communities, these findings provide practical guidelines for future outreach efforts in low-income API communities. Culturally specific and appropriate interventions that address multiple levels of the SEM in API communities are important for targeting the specific barriers identified. Addressing and reducing these barriers can improve food insecurity rates and ultimately contribute to reducing health inequities that API communities experience.

So What? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

API groups have one of the lowest rates of SNAP utilization. Barriers to SNAP participation include inadequate knowledge concerning program eligibility, lack of transportation, language barriers, and misconceptions about the program.

What does this article add?

This study provides a nuanced understanding of perceptions and barriers to SNAP utilization that are unique to Chinese, Filipino, Tongan, and Vietnamese immigrants. Issues of immigration, fear of public charge, difficult application process, shame, and pride often deter these groups of applying for SNAP.

What are the implications for health promotion practice or research?

Complex factors influencing SNAP utilization among API communities involve a wide range of perceptions and barriers at each level of the SEM. Consequently, interventions should address multiple levels of the SEM and be tailored to be culturally specific. Practical suggestions are provided by community members for how these outreach interventions should be designed.

Footnotes

Authors’ Note

All researchers were involved in data analysis and interpretation and drafting of the manuscript. Specifically, LPK was responsible for the conceptualization of the study and all aspects of data analysis and drafting of this manuscript. NTL was assisted with data collection, analysis, and drafting of the manuscript. SC was responsible for overseeing the recruitment of study participants, data analysis, and drafting of this manuscript.

Acknowledgments

The authors thank all community agencies who participated in this study and assisted with participant outreach: Orange County Asian Pacific Islander Community Alliance (OCAPICA), Korean Youth Community Center, Asian Pacific Health Care Venture, Inc, and the Los Angeles Council of Filipino American Seniors. The authors also thank the following individuals who have assisted in the recruitment of participants and administration of the focus groups: Lauren Campbell, Larry Calonzo, Sina Fifita, Lucy Huynh, Linghui Jiang, and Sina Uipi. The authors are grateful to Dipa Shah and Naho Fukushima from Los Angeles County Department of Public Health, and Jared Call and Kevin Lee from the California Food Policy Advocates for reviewing and providing feedback on the manuscript.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LPK was the principal investigator on this project. NTL was the student researcher. SEC was the community research partner at the time of this study.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the Seaver Research Council Grant from Pepperdine University, 2016-2017.

ORCID iD

Loan Pham Kim

References

Cheung

Shen

Tilahun

Cohen

Berkowitz

. Food insecurity and body mass index: a longitudinal mixed methods study, Chelsea, Massachusetts, 2009–2013. Prev Chronic Dis. 2015;12:E125. doi:10.5888/pcd12.150001

Rosenbaum

. SNAP Is Effective and Efficient. 2010. Accessed September 7, 2017. https://www.cbpp.org/research/snap-is-effective-and-efficient

United States Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program. State Activity Report Fiscal Year 2016; 2017.

Cunnyngham

. Reaching Those in Need: Estimates of State Supplemental Nutrition Assistance Program Participation Rates in 2015. Mathematica Policy Research; 2018. Accessed December 13, 2018. https://fns-prod.azureedge.net/sites/default/files/ops/Reaching2015.pdf

Board Votes to Increase CalFresh Participation. Los Angel Cty Superv Sheila Kuehl. May 2017. Accessed March 26, 2018. http://supervisorkuehl.com/board-votes-increase-calfresh-participation/

California Department of Social Services. CalFresh Data Dashboard – Persons, Monthly Counts. California Department of Social Services. Updated May 5, 2020. http://www.cdss.ca.gov/inforesources/Data-Portal/Research-and-Data/CalFresh-Data-Dashboard

Hoeffel

Rastogi

Kim

Shahid

. The Asian Population: 2010. U.S. Department of Commerce, Economics and Statistics Administration; 2012. Accessed January 15, 2020. https://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf

Asian American Center for Advancing Justice. A Community of Contrasts: Asian Americans, Native Hawaiians, and Pacific Islanders in California; 2015. Accessed August 1, 2018. https://www.advancingjustice-la.org/system/files/Communities_of_Contrast_California_2013.pdf

Walsemann

Gee

. Trends in food insecurity among California residents from 2001 to 2011: inequities at the intersection of immigration status and ethnicity. Prev Med. 2017;105(suppl C):142–148. doi:10.1016/j.ypmed.2017.09.007

10.

Kasper

Gupta

Tran

Cook

Meyers

. Hunger in legal immigrants in California, Texas, and Illinois. Am J Public Health. 2000;90(10):1629–1633.

11.

Kaiser

. Why do low-income women not use food stamps? Findings from the California Women’s Health Survey. Public Health Nutr. 2008;11(12):1288–1295. doi:10.1017/S1368980008002528

12.

Gabor

Williams

Bellamy

Hardison

Dagata

. Seniors’ Views of the Food Stamp Program and Ways To Improve Participation—Focus Group Findings in Washington State: Final Report. Health Systems Research; 2002:236. Accessed December 13, 2018. https://www.ers.usda.gov/webdocs/publications/43151/51497_efan02012.pdf?v=42081

13.

Algert

Reibel

Renvall

. Barriers to participation in the food stamp program among food pantry clients in Los Angeles. Am J Public Health. 2006;96(5):807–809. doi:10.2105/AJPH.2005.066977

14.

Asian American Center for Advancing Justice. A Community of Contrasts: Asian Americans, Native Hawaiians, and Pacific Islanders in Los Angeles County. 2015. Accessed August 1, 2018. https://advancingjustice-la.org/system/files/CommunityofContrasts_LACounty2013.pdf

15.

Los Angeles County Department of Public Health, Office of Planning, Evaluation, and Development. Community Health Assessment 2015. 2015. Accessed January 15, 2020. http://www.bhclongbeach.org/wp-content/uploads/2012/06/LACDPHCommunityHealthAssessment2015Final.pdf

16.

California Department of Social Services. DFA358F – CalFresh Participants by Race/Ethnicity – Federal-Only and Combined Households. California Department of Social Services; 2018. Accessed November 5, 2018. http://www.cdss.ca.gov/inforesources/Research-and-Data/CalFresh-Data-Tables/DFA358F

17.

California Department of Social Services. DFA358S – CalFresh Participants by Race/Ethnicity – State-Only Households. California Department of Social Services; 2018. Accessed November 5, 2018. http://www.cdss.ca.gov/inforesources/Research-and-Data/CalFresh-Data-Tables/DFA358S

18.

Mills

Vericker

Koball

Lippold

Wheaton

Elkin

. Understanding the Rates, Causes, and Costs of Churning in the Supplemental Nutrition Assistance Program (SNAP) – Final Report. Urban Institute for the US Department of Agriculture, Food and Nutrition Service; 2014.

19.

Partners for a Hunger-Free Oregon. Washington County Senior Focus Groups Report; 2012.

20.

Economic Research Service, United States Department of Agriculture. U.S, Adult Food Security Survey Module. Three-Stage Design, With Screeners; 2012.

21.

Derrickson

Fisher

Anderson

JEL

. The core food security module scale measure is valid and reliable when used with Asians and Pacific Islanders. J Nutr. 2000;130(11):2666–2674. doi:10.1093/jn/130.11.2666

22.

Braun

Clarke

Thematic analysis. In: APA Handbook of Research Methods in Psychology. Vol 2. American Psychological Association; 2012.

23.

King

Merten

Wong

Pomeranz

. Applying a social–ecological framework to factors related to nicotine replacement therapy for adolescent smoking cessation. Am J Health Promot. 2018;32(5):1291–1303.

24.

Gressard

DeGroff

Richards

, et al. A qualitative analysis of smokers’ perceptions about lung cancer screening. BMC Public Health. 2017;17(1):589. doi:10.1186/s12889-017-4496-0

25.

Bickel

Nord

Price

Hamilton

Cook

. Guide to Measuring Household Food Security. Office of Analysis, Nutrition, and Evaluation Food and Nutrition Service, USDA; 2000.

26.

Los Angeles County Department of Public Social Services. CalFresh Eligibility. 2015. Accessed December 13, 2018. http://dpss.lacounty.gov/wps/portal/dpss/main/programs-and-services/calfresh/eligibility/!ut/p/b1/04_Sj9Q1tDQxM7SwNDUz1Y_Qj8pLLMtMTyzJzM9LzAHxo8zi3QwMDNz9nYKNDFzNHA0c_YO9DEMtvA2DTQ2ACiJRFPiGuRl4Bhka-zq5mxtZhBkS0u-lH5Wek58EtCpcPwpVsbsPkOnoH-Dk7RUWaGDiY0BAgZkJugIsrgErMMABHDGswHSwn0d-bqp-blSORXamZ5aJo6IiAHeLK_Y!/dl4/d5/L2dJQSEvUUt3QS80SmtFL1o2X0YwMDBHT0JTMjBFNkEwQU9TSjFVOEsxMkQ0/

27.

California Food Policy Advocates. California’s Cashout Policy. 2016. Updated April 14, 2016. Accessed January 15, 2020. https://cfpa.net/CalFresh/CFPAPublications/CalFresh-Cashout101-2015.pdf

28.

California Food Policy Advocates. The 411 on Phone Interviews in California. California Food Policy Advocates; Accessed May 28, 2018. https://cfpa.net/phone-interviews/

29.

Stoeber

Harris

Moon

. Perfectionism and the experience of pride, shame, and guilt: comparing healthy perfectionists, unhealthy perfectionists, and non-perfectionists. Personal Individ Differ. 2007;43(1):131–141. doi:10.1016/j.paid.2006.11.012

30.

Los Angeles County Department of Public Social Services. General Relief Policy. 2013. http://file.lacounty.gov/SDSInter/dpss/237572_GeneralReliefPolicyHandbook.pdf

31.

Porter

Summers

Toton

Aisenstein

. Service-learning with a food stamp enrollment campaign: community and student benefits. Mich J Community Serv Learn. 2008;14(2):66–75.

32.

MacDonald

. The Other Side of Racism: Welfare Recipients and Racial Privilege in Greater Boston. 2015. Accessed January 15, 2020. https://search.proquest.com/psycinfo/docview/1726841488/abstract/85A7776408BC49E2PQ/2

33.

Lynch

Smith

Kaplan

House

. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ. 2000;320(7243):1200–1204.

34.

California Department of Social Services. Eligibility and Issuance Requirements. Updated December 13, 2018. Accessed January 15, 2020. http://www.cdss.ca.gov/inforesources/CDSS-Programs/CalFresh/Eligibility-and-Issuance-Requirements

35.

Patel

Kwon

Arista

, et al. Using evidence-based policy, systems, and environmental strategies to increase access to healthy food and opportunities for physical activity among Asian Americans, Native Hawaiians, and Pacific Islanders. Am J Public Health. 2015;105(suppl 3):S455–S458. doi:10.2105/AJPH.2015.302637

36.

Kaye

Lee

Chen

. Barriers to food stamps in New York State: a perspective from the field. J Poverty. 2013;17(1):13–28. doi:10.1080/10875549.2012.747995

37.

Gundersen

Oliveira

. The food stamp program and food insufficiency. Am J Agric Econ. 2001;83(4):875–887. doi:10.1111/0002-9092.00216

38.

Campbell

SE.

Working the Poor: Barriers to CalFresh Participation and Enrollment Exploring Client Experiences and the Role of Community-Based Organizations in Outreach. 2014. Accessed January 15, 2020. https://search.proquest.com/docview/1665309174/abstract/9CBC5FDEAC23483FPQ/1