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Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC 27514-4145 and * Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853
3To whom correspondence should be addressed. E-mail: jung-sun.lee{at}mail.cscc.unc.edu.
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ABSTRACT |
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 TOP ABSTRACT LITERATURE CITED |
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KEY WORDS: • targeting • program workers • nutrition program • food assistance program
Targeting is required and is used by a variety of nutrition programs to deliver the program to the intended population group (1). Targeting involves 1) defining the target population, 2) establishing the targeting goal, 3) assessing whether individuals are members of target population, and 4) developing approaches to cover those identified as members of the target population in the service delivery system. These procedures entail value judgments by program providers across different levels of program design and operation. For appropriate targeting in any nutrition program, it is important how clearly and practically these established procedures reflect the reality that programs are intended to address and how reliably the procedures will be implemented at the frontline of service delivery.
Thus, the role of program workers is critical for targeting. Program workers have important understandings of and experiences with service delivery, knowledge of practical strategies and challenges to improve targeting, and the capacity to implement appropriate targeting. Until now, however, little has been studied about the concepts and the operation of targeting in nutrition programs from the perspectives of frontline program workers. Better understanding of targeting from the perspectives of program workers is essential for learning how the target audience and targeting processes are perceived and operated within the service delivery system, and for formulating better ways of targeting in nutrition programs.
The aim of this paper is to introduce and to compare meanings of targeting from the perspective of frontline program workers in food assistance programs in the U.S. Food assistance programs provide supplemental income, food, or nutrition education for those who have limited resources and who are at risk of poor nutrition. Means tests using standardized eligibility criteria, such as household income/assets, and a set of nutritional risk criteria have been used to specify target groups in these programs (2). These programs, however, have been criticized for their lack of success in targeting. For example, only 46% of working Food Stamp Program (FSP)4-eligible households participated in the FSP in 1994 (3). The Women, Infant, and Children’s Program was challenged to provide its limited resources to those at higher nutritional risk (4). Around 25% of the children who were certified for a free or a reduced-price school lunch in the National School Lunch Program (NSLP) in 2002 may be ineligible (5). Over 60% of food-insecure elderly in a national sample had not received services from the Elderly Nutrition Program (ENP) and FSP available in their community (6). These programs have been called on to become more efficient and effective in targeting in a time of shrinking resources and increasing needs. Understanding the issues of targeting in food assistance programs from the perspective of frontline program workers may contribute to the development of better targeting of U.S. food assistance programs.
Conceptual meaning of targeting from local program workers in ENP
We first introduce our qualitative work in pursuit of understanding conceptual meanings of targeting from the perspective of local program workers in the context of ENP (7). The ENP is the USDA’s cash and commodity program administered by the U.S. Department of Health and Human Services under the Older American Act (OAA). It provides congregate meals, home-delivered meals, and related nutrition services to older adults in the community. This program provides a unique opportunity to understand the issues of targeting, because of its unique target group, targeting mechanisms, and the latitude given to local program workers compared with other food assistance programs. Unlike other major food assistance programs, universal eligibility was a central feature of the ENP from its inception in the OAA, and is thought to contribute to its success. From the beginning, however, there were concerns that the limited resources available under the OAA would be insufficient to reach the needy elderly persons without restricting participation by some individuals 60 y or older. Thus, the issue of targeting services in the ENP has grown over time. Because of the highly decentralized nature of the program, the operation of targeting in ENP has been difficult for program workers (8,9).
Conceptual meanings of targeting
Qualitative interviews with a heterogeneous sample of 36 local ENP program workers in upstate New York suggested that local program workers implemented targeting throughout the continuum of their service delivery system in 4 different ways: maximum outreach, reaching out to those most in need, serving only the most needy, and evaluating coverage (Table 1). The meanings of targeting and corresponding roles of program workers are summarized below.
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2. Reaching out to the most needy: reaching out to cover those who are most in need. The objective of this targeting was to assure service delivery to elders who had the greatest need. Both universal and selective eligibility were embedded as the choice of service allocation, so the decision to participate depended on elders, program providers and other relevant service professionals in the community. All the targeting activities consisted of an enhanced community-wide collaboration to find elders who "fell between the cracks." The provider’s role was to alert the community as a whole to recognize elders in greatest need and then to link them to available services. They hoped to prevent any elders in greatest need from being missed due to indifference to their needs in the community.
3. Serving only the most needy: providing service to cover only those who are in need. The objective of this targeting was selective service delivery for elders. Selective eligibility criteria were embedded as the choice of service allocation, so the decision of participation totally depended on program providers. All targeting activities enabled providers to decide whose need to meet with which program. The provider’s role was to evaluate and to prioritize the needs and demands for the service among the elderly. Their goals were to direct services to those who were most in need of service, while excluding elders who wanted the service for whatever reason and to match elders with other appropriate services.
4. Evaluating coverage: whether covering those who programs are intended to serve. Unlike the other 3 meanings, this meaning of targeting was not closely related to the actual program delivery process. Providers did not relate this to the decisions about program participation or eligibility. Targeting was portrayed as an administrative tool for evaluating program performance that enabled the providers to check whether a specific proportion of service resources was provided to the target audience.
Challenges in targeting
Providers reported universal challenges in implementing targeting strategies. These challenges lead providers to determine the kind and the degree to which different meanings of targeting were implemented in their programs. The challenges ranged widely from program difficulties to the social and psychological dynamics of help-seeking behaviors among elders. Lack of resources, either in funds or volunteers, was the predominant barrier to targeting. Also, providers were challenged in their localized targeting to implement program regulations or policies from the federal and state levels that were not easily applied in their localities or reflective of their customary local program operation. Another critical challenge for providers was to identify needs and unmet needs among elders. Providers did not have a consensus on identifying who was needy.
Framework for targeting in program design and administration of U.S. food assistance programs
A recent report from the USDA presented 5 types of targeting used in food assistance programs (10). At the stage of program design, guidelines targeting and benefit targeting are prominent, because they should ensure that the program, once in operation, will be directed at the right target population, with an appropriate level of benefit. Guidelines targeting determines eligibility criteria that are used to decide who can receive program benefits. It is critical that guidelines targeting balances program resources at hand and serving those groups of people specified in the program goals. Thus, eligibility criteria should support balancing the trade-offs between the size of the eligible target population (which determines the program cost) and the coverage of the target population. Benefit targeting concerns whether eligible participants all receive the same level of benefits. Several food assistance programs, such as FSP and NSLP, use a tiered system of benefits, so those with a greater need receive a greater benefit.
At the stage of program administration, operational targeting, certification targeting, and program-access targeting are prominent. Operational targeting seeks to minimize program costs by reducing administrative expenses and expenses for program benefits. Certification targeting focuses on providing service only to those who are the intended recipients of program benefits. Program-access targeting for the program concerns minimizing potential barriers to, and promoting participation among, those who are eligible. There are trade-offs among these types of targeting during the program administration process. Serving only those who are eligible for the program helps to maintain the integrity of programs supported with public funds. However, thorough and strict program procedures in certification targeting increase the burden on both eligible and ineligible participants, as well as increase administrative expenses. A high level of burden may deter some participants from applying for benefits for which they are eligible, and decrease program access. Achieving appropriate balance among these types of targeting is critical for successful targeting.
Comparison of the meanings of targeting
Comparison of the meanings of targeting reveals some consensus. Meanings of targeting from local program workers share aspects with those from USDA program planners (mostly at the stage of program administration): serving only the most needy through certification targeting, reaching out to most needy through program-access targeting.
However, perspectives of program workers on targeting were not exactly the same in terms of kind, meaning, and degree. Unlike USDA program planners, local program workers considered a "maximum outreach" approach to targeting. This difference may be, in part, due to different features of targeting in the various food assistance programs. However, it suggests that there may be variations in perceptions of the goals of targeting and of the actual operational procedures adopted by program workers at different levels of program operation.
Local program workers perceived targeting as an evaluation of program performance. That is, how well the program provides service to eligible or needy persons has been used to measure the performance in administering programs. Better targeting is thought to pertain to improving the process of program operation, performance, and outcome in major food assistance programs. In FSP, measures of serving only those eligible (such as participant access rate, negative error rate, or payment error rate) are now used to determine financial incentives or liabilities that can further affect the program operation. Similarly, NSLP recently required a stricter certification procedure to reduce overcertification (11), but it has raised concerns that the stricter certification would deter participation among eligible students and would increase the administrative burden for program providers (5). Notwithstanding that successful targeting becomes an important indicator of program performance and quality control in local operations of food assistance programs, USDA program planners’ view did not include targeting as evaluating coverage.
Local providers chose the kind and the degree of different targeting approaches that allowed them to understand the needs of the potential participants and to allocate their services to the needy. Different meanings of targeting of local program workers reflected the varied size of the target population and the targeting approaches used. For example, in serving only the most needy and in evaluating the coverage, targeting activities were focused only on those who sought the program. On the other hand, in maximum outreach and reaching out to the most needy, targeting activities were focused on those who both did or did not seek the program. These different views of local program workers on potential target population and targeting approaches could result in different size, makeup, and coverage of program recipients. However, these were not well captured in the framework of targeting from program planners.
Implication to improve targeting in nutrition programs
Regardless of some differences in the conceptual meanings or focused aspects of targeting between local and federal levels, the perspective of program workers suggests a new framework of targeting, which consists of key components and issues in need of careful attention in targeting nutrition programs (Table 2). This framework is more complete, being inclusive of the perspective of targeting from program providers at different levels of program operation. In this new framework, targeting is viewed broadly in terms of program access, service, and evaluation. Targeting is the process of translating these key components and related issues into program policy, rules, and procedures that are appropriately adapted into varied sets of context and players of program operation. The success of targeting depends on how well the translation is accomplished throughout all levels of program operation. The new framework of targeting based on program workers’ perspectives may contribute to developing a conceptual definition, as well as practical guidance of targeting, which can be used to formulate better ways of targeting in nutrition programs.
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FOOTNOTES |
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2 Supported in part by the Cornell University Agricultural Experiment Station federal formula funds, Project No. NYC-399425, received from Cooperative State Research, Education, and Extension Service, USDA. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the USDA.
4 Abbreviations used: ENP, Elderly Nutrition Program; FSP, Food Stamp Program; NSLP. National School Lunch Program; OAA, Older American Act.
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LITERATURE CITED |
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TOPABSTRACTLITERATURE CITED |
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1. Food and Agriculture Organization (2001) Targeting for Nutrition Improvement: Resources for Advancing Nutritional Well-Being 2001 United Nations Rome, Italy.
2. U.S. Department of Agriculture Food Assistance and Nutrition Research Program (2002) The Food Assistance Landscape 2002:6 Department of Agriculture Economic Research Service Washington, DC.
3. McConnell, S. & Ponza, M. (1999) The Reaching the Working Poor and Poor Elderly Study: What We Learned and Recommendations for Future Research 1999 Mathematica Policy Research Washington, DC.
4. Besharov, D. J. & Germanis, P. (2001) Rethinking WIC: An Evaluation of the Women, Infants, and Children Program 2001 The AEI Press Washington, DC.
5. Gundersen, C., Morrison, R. M. & Shelfi, L. M. (2003) Certifying and Verifying Eligibility in the National School Lunch Program 2003 USDA, Economic Research Service Washington, DC.
6. Burt, M. R. (1993) Hunger Among the Elderly: Local and National Comparison 1993 The Urban Institute Washington, DC.
7. Lee, J. S. (2002) Understanding targeting in the elderly nutrition program: a focus of food insecurity. Doctoral thesis 2002 Cornell University Ithaca, NY.
8. Balsam, A. (1987) Developing a continuum of community nutrition services: Massachusetts Elderly Nutrition Programs. J. Nutr. Elder 6:51-67.[Medline]
9. Arcury, T. A., Quandt, S. A., Bell, R. A., McDonald, J. & Vitolins, M. Z. (1998) Barriers to nutritional well-being for rural elders: community experts’ perceptions. Gerontologist 38:490-498.[Abstract]
10. Prell, M. A. (2003) Aiming for targets, saving on arrows: insight from two USDA food assistance programs. Amber Waves 1:30-37.
11. U.S. Federal Register (2003) Determining Eligibility for Free and Reduced Price Meals in Schools—Verification Reporting and Recordkeeping Requirements 68:53483-53490 U.S. Government Printing Office Washington, DC. no. 176.
12. The Nutrition Safety Net: Help for the Elderly and Disabled. U.S. Department of Agriculture Food and Nutrition Service 2002 http://www.fns.usda.gov/fsp/public_advocacy/pdfs/elderly_guide.pdf [accessed February 5, 2004].
13. The Nutrition Safety Net: At work for families. U.S. Department of Agriculture Food and Nutrition Service 2002 http://www.fns.usda.gov/fsp/public_advocacy/pdfs/access_guide.pdf [accessed February 5, 2004].
14. The 2002 farm bill: provisions and economic implications. U.S. Department of Agriculture Food and Nutrition Service 2003 http://www.ers.usda.gov/Features/FarmBill/ [accessed February 5, 2004].
15. Food Stamp Program Access Study—Local Office Policies and Practices. U.S. Department of Agriculture Economic Research Service 2003 http://www.ers.usda.gov/publications/efan03013/efan03013-1/efan03013-1.pdf [accessed February 5, 2004].
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  J.-P. Habicht and E. A. Frongillo Discussion: Targeting is Making Trade-offs J. Nutr., April 1, 2005; 135(4): 894 - 897. [Abstract] [Full Text] [PDF]
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