Nutrition & Health in Homeless Pregnancy

The Mission Neighborhood Resource Center

By Alora Phillips, Erin Sevilla, Ninette

Westendorff, and Zainab Khalid
2. Table of Contents

1. Introduction to Part 1 1

2. Conclusion Statement & Literature Review 2

a. EAL Overview Table 4

​ 3. Community Nutrition Assessment Findings 8

a. Assessment Parameters 8

b. Data Collection Plan 10

c. Summary of Data Collected - including Tables 1, 2, & 3 10

d. Interpretation of Data 13

e. Main Finding/Need 15

4. Proposed Community Project 16

a. Program goal & Objectives 16

b. Program Plan Details 17

c. Program Management System 17

5. Summary 18

6. Introduction (Part 2) 18

7. Results of Program 19

a. Demographic Table 20

8. Discussion/Conclusion 21

9. Appendix 25

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3. Original Part 1 (with marks)
DFM 451
SCLP PART 1
Zainab Khalid
Alora Philips31
Erin Sevilla
Ninette Westendorff

Nutrition Education and Resources for Homeless Pregnant Women

Introduction: ​Our group chose to focus on low income pregnant women. This community

includes women who are low income, homeless, have-suffered or are still suffering from

substance abuse. Women who are dealing with homelessness are more likely to give birth

prematurely or have an infant with a lower birth weight. (Richards, Merrill, et al. 2007) These

women can range from adolescents to women in their older adult years. However, after analyzing

various articles and studies, these women are more commonly younger in age varying from early

teens to early 30’s. Among being homeless, other issues for this community includes a lack of

knowledge towards different resources available for these women including prenatal care as well

as postpartum. The purpose of this program is to help guide homeless/low-income women to

various resources to help aid with prenatal care. This program would include describing the

prenatal nutrients that are vital for the infant as well as where to obtain them at a low/free cost.

With the correct guidance the overall goal is to reduce the risk of preterm birth as well as low

birth weight. Does antenatal education and care in homeless pregnant women improve neonatal

health and wellness?

Conclusion Statement and Literature review: ​Based on the literature, it was found that

antenatal care and education does, indeed, improve neonatal health and wellness. A majority of

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the studies found that homeless women experience higher rates of stillbirth, low birth weight and

overall poorer infant outcome (Azarmehr et al., 2018, Bloom, C.K. et al., 2004, Hollowell, J. et

al., 201, Little, M. et al., 2009, Braveman P, et al., 2010, Richard. R, et al., 2011). Other infant

outcomes include longer hospital stay for the mother and increased likelihood of being in the

NICU. There are numerous factors that may contribute to the prevalence of poor infant outcome,

including the hardships that pregnant homeless women face.

During this time, the normal hardships endured by pregnant women are intensified to a

significant degree to women who are pregnant and also homeless/ low income (Azarmehr et al.,

2018). These hardships range from lack of education, malnutrition, lack of resources,

transportation, or lack of childcare (Braveman P, et al., 2010). These hardships were found to be

more significant in homeless women, having a greater effect on their fetuses. Along with the

hardships of being pregnant. Homeless women also experience a greater amount of mental health

and depression symptoms, physical abuse, substance abuse, STIs and trade-sex behavior,

compared to their housed counterparts (Bloom, C.K. et al., 2004). Bloom, notes that it is

extremely hard for a homeless person to maintain their health. There risk to environmental

exposures and diseases is greatly increased. The accumulation of these factors contribute to the

adverse health of an expectant mother and her developing baby.

It was also commonly found that pregnant homeless women do not receive prenatal care.

Prenatal care includes, an adequate diet to support fetal development, prenatal multivitamins,

well- baby checkups and screenings, breastfeeding education. There was a strong decline in the

number of homeless women and length of time they breastfeed, although breast milk is found to

be the most adequate food for a newborn (Richard. R, et al., 2011). This emphasizes the need for

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 breastfeeding education as part of a comprehensive antenatal care program for this particular

community. Prenatal care is thought to be one of the most effective preventative measures for

reducing premature birth and stillbirths (Hollowell, J. et al., 2011). However, it was shown that

homeless pregnant women face many obstacles to prenatal care these include, logistical,

psychosocial, education and attitudinal barriers (Azarmehr et al., 2018). Homeless women report

inadequate financial support and resources as the main reason for not seeking prenatal care

(Azarmehr et al., 2018). In conclusion, pregnant homeless women experience a lifestyle that has

negative effects on fetal development, however this may be prevented with prenatal education

and care. The literature review examined analytical and descriptive studies of strong design,

meriting a I- good/strong as the strength of evidence grade.

EAL Overview Table​:

Author, year, Study Study Intervention Outcomes Limitations

Study Design, Type/ Populations
Class Rating Purpose

Richards, R., To Ages <19->30 A PRAMS 4% of PRAMS Despite lack of prenatal

Merrill, R.M. & describe (all ages). survey was respondents were vitamin use, neural tube
Baksh, L. (2011) selected Ethnicities distributed, homeless and defect information was
demograph ranging from only pregnant. Homeless not collected. Other
Cross-Sectional ics; non-hispanic, states/cities compared w/ limitations include not
maternal hispanic, black, with a 70% non-homeless women asking for how long the
Class D health white, other, response rate were significantly mothers were homeless
behaviors unidentified,etc were included more likely to be for or whether they were
before, . Demographic in the survey. younger, black, currently. This could
during and and medical Asked hispanic, reside in affect recall bias. Survey
after info collected questions midwest or west, have only administered to
pregnancy from 31 about race, not graduated high women with a known
and infant participating age, school, be single, mailing address (at a
health states from substance receive gov. Aid, be shelter or a family
outcomes 2000-2007. use, prenatal underweight smoke member’s house). This
among Homeless vitamin use, cigarettes, and not survey provides good
homeless within last 12 health take preconception information but likely
women in mos before insurance, vitamins. They also underrepresents

4
 the U.S. birth of infant. etc. These produced a higher % homeless women
results were of LBW babies and population.
then were more likely not
described to BF.
and analyzed.

Bloom, K.C., Purpose of N=47, all A The average woman Limitations include the
Bednarzyk, this study pregnant convenience who responded was researchers not being
M.S., Devitt, was to homeless sample of 25 and African present when the
D.L., Renault, explore females, ages homeless American. A questionnaire was filled
R.A., Teaman, and 12-38. pregnant significant relationship out, which may have
V. & Loock, D.M. describe Black/african women was found between # elicited bias in
(2004) the barriers american, recruited of children living with participants’ hopes of not
to prenatal white/caucasia through the woman and her being judged by their
(an exceptional care for n, hispanic, agencies perception of service providers.
resource despite homeless native serving them, site-related factors as Additionally, this was a
year) pregnant american, completed barriers. Lack of self-selected population,
women multiracial, no questionnaire convenience and and women must have
Other children or s were taken competing factors in been connected to an
Descriptive having had 1 or as material for relation to agency of some sort to
Study more children the study. homelessness participate in the study.
already. Melnyk’s outweighed Barriers for women not in
Class D scoring table importance of an agency may be even
was used to prenatal care. Most of greater...
describe these women had
perceived available community
barriers to service nearby but
prenatal care, access with the issue.
including
site-related
factors, fear,
transportation,
etc.

Hollowell, J. To identify There were 24 Overall the All included studies The study could have
Oakley, L. the best studies done quality of the reported PTB/preterm taken a more focused
Kurinczuk, J. et available separately evidence was labor and/or a approach with smaller
al. evidence targeting poor and, the measure of range of specific
on the various interventions neonatal/infant as an interventions that
2011. effectivene populations. proved there outcome. Eight of the potentially would have
ss of 8 was nine included been more consistent
Cluster interventio disadvantaged insufficient randomised controlled with standard systematic
Randomized ns focused women with evidence to trials (RCT’s) were reviewing methods. But
Trial. on the risk for PTB or evaluate assessed as having also this approach would
delivery LBW. 9 consistency of ‘adequate’ internal have lacked the flexibility
Class A. and pregnant findings validity. of having such a broad
organizatio teenagers. 4 across evidence base to review.

5
 n of pregnant multiple
antenatal substance studies.
care to users. 2
reduce pregnant
infant indigenous
mortality Australians. 1
on one of pregnant HIV+.
its 3 major
causes in
vulnerable
groups.

Azarmehr, H. Proving Homeless or Homeless Infants of homeless The research could have
Lowry, K. that unstable living females using mothers live with chosen a more specific
Sherman, A. et women females ages and accepting greater rates of group of participants
al. who are vary from the clinical depression and because the data
homeless younger than and hospital mental health collected was so broad
2018. or in an 18 through care provided. symptoms. Infants that there is no close
unstable greater than born to women who pool of participant data to
Cross sectional. living 24. are homeless mothers be able to further close
situation are born in prenatal out information about this
Class D. and period. Homeless article.
pregnant women are less likely
are more to receive
likely to preconception care or
have prenatal care in first
neonatal trimester.
complicatio
ns due to
lack of
resources.

Little, M., Shah, The objective Data was Neonatal wellbeing Data set were dependent
R., Vermeulen, was to study collected from may be affected by on accurate recordings
M. J., Gorman, women who the database homelessness and done by nurses and
A., Dzendoletas, are homeless at St. maternal based on mothers
D., & Ray, J. G. or marginally Michaels substance use due to personal accounts.
housed during Hospital in prematurity and low Ethnicity was not
2009 pregnancy and Toronto birth weight. Maternal recorded and a clear
estimate the Canada. malnutrition is higher limitation was that
risk of adverse Including in homeless women. duration of
Retrospective
natal outcomes pregnant More homeless homelessness was not
Cohort among these women who women who were recorded.
women. delivered also smokers tended
Class B between to be younger.
October 2006
and

6
 December
2008 and
were
homeless,
substance
users or
neither

Braveman, P., A cross 161, 784 Data was Half the women in The PRAMS survey
Marchi, K., sectional multi-ethnic collected from each sample were conducted research 12
Egerter, S. et al. study was pregnant 2 postpartum low income, 30% month prior to delivery,
done to women across surveys living in poverty and so possible hardships
2010 describe the united (PRAMS and 20% near-poor. could come from the 3
income states. Age 15 MIHA), Moreover, serious month prior to
Cross Sectional levels and and older, with including hardships are more pregnancy.
major a variety of information on common among
Class D hardships education and income, low-income women
in women income levels, sociodemogra during pregnancy.
during or as well as, phic Childbearing women
just before martial and characteristics were found to have
pregnancy. insurance , possible considerably lower
statues. hardships. income than women
of childbearing age in
general.

Exploratory Two 13 adult Pre designed 13 needs identified Small sample size and
Author: Tegan study to women groups questionnaire using the study after single site
Ake Sabina identify the currently followed by pooling the data of (Might not be
Diehr Leslie needs of residing at the content the 2 focus groups representative of the
Ruffalo Emily homeless Milwaukee analysis population)
pregnant Women’s
Farias Ashton
women for Center
Fitzgerald
creating a
Samuel D. Good patient-cen
Lindsay B. tered
Howard Stefan community
P. Kostelyna engaged
Linda N. Meurer health
2018. program
for them

Exploratory
Study
Neutral

7
 To Young Adult Low Birth Prenatal Data dependent on the
2014,Cross-secti compare women who weights or homelessness was memory of the mothers
onal study the birth belong to a pretimed associated with a which can be erratic
Class D weight and low-income delivery higher odds of low
the group among birth weight and
Housing quality of the
pregnancy homeless preterm delivery
mothers beyond the
time of women compared to group of
young housed mothers. scope of this study.
low-income
children
whose
mothers
are
homeless
during
pregnancy,
are housed
during
pregnancy
but
became
homeless
after the
child’s birth
or are
housed
during and
after
pregnancy

Needs Assessment for Homeless Pregnant Women in San Francisco

Step 1: Parameters

Definition of the Community​: Pregnant homeless women in San Francisco.

Purpose of Needs Assessment​: Homeless pregnant women are at higher risk for encountering

infant mortality, unmet nutritional needs for both mother and infant, inadequate weight gain for

the mother, low infant birth weight, miscarriage or other pregnancy complications, lower rates of

breastfeeding (Health Behaviors). All are at risk for having lack of care or none at all within the

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first trimester of pregnancy-- a crucial time for infant health outcomes (Barriers). Additionally,

many of these women are on long waiting lists to gain access to shelters and will spend most of

their pregnancy without prenatal care and on the streets before they are prioritized for a family

shelter (SF chronicle).

Focus of Assessment​: This needs assessment is directed towards the understanding of which

nutritional and nutritional educational needs are needed to most effectively benefit a deficit in

prenatal care in the homeless pregnant population.

Overall Goal of Assessment:​ To identify unmet needs of the homeless pregnant population

related to perinatal health, thereby allowing us to create a focus group or nutrition education

program to assist them in deficit areas of prenatal care by presenting topics such as prenatal

vitamins and accessibility, the importance of longer-term breastfeeding, etc.

Objectives​:

→ Assessing the demographics of the area along with perceived barriers to prenatal care and

assistance.

→ Further objectives include assessing to what degree women are using various programs,

versus what the programs do not offer and how they can be expanded to provide additional

services.

→ Finally, the assessment is geared towards assessing women’s knowledge and awareness of

vital infant development periods during each trimester and perceived importance of prenatal

vitamin/nutrient intake during pregnancy.

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→ Most studies show that homeless pregnant women are not likely to breastfeed for longer than

8 weeks, if at all. Breastfeeding is one of the main ways to provide optimal health for infants;

encouraging the activity would contribute to adequate weight gain and health.

2. Developing a Data Collection Plan

In order to collect necessary data, our team is researching multiple variables involved

with homelessness and pregnancy, including demographics such as age, race, education level,

reason for leaving home, etc. In addition, research has described common trends in substance

abuse related to homelessness during pregnancy, infant health outcomes (such as low birth

weight or other health implications), breastfeeding rates, as well as factors associated with

likelihood of being homeless and pregnant. To encompass this data, we will be calling multiple

homeless shelters, women’s shelters, as well as the Homeless Pregnant Prenatal program in San

Francisco to gather more data about needs of women in the area. Upon collecting this data, we

can further assess the needs of the homeless pregnant population and subsequently create a

community learning project.

3. Types of Data Needed: Community Data

● Demographics of homeless pregnant women of all ages (age, race, education level, health

insurance, medicaid. etc.)

● Assess differences between demographics and outcome of infant and maternal health

Table 1 ​- Demographics of Homeless Versus Non-homeless women in the United States ONLY.
Data gathered from women who completed a PRAMS survey. For this survey, to be identified as
homeless, mothers must have been homeless at some point within 12 months before the birth of
the baby, or changed residencies at least 3 times.

Demographic Category Non-homeless % Homeless %

Maternal Age

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 <19 6% 9%
19-25 34% 47%
26-29 22% 20%
>30 38% 24%

Race
White 75% 73%
Black 17% 18%
Other 8% 9%

Ethnicity
Non-hispanic 84% 46%
Hispanic 13% 52%
Missing 3% 2%

Region
East 21% 48%
Midwest 31% 34%
South 31% 15%
West 17% 3%

Marital Status
Yes 66% 39%
No 34% 61%
Missing <1% <1%

Health Insurance
Yes 64% 21%
No 36% 79%
Missing <1% <1%

Types of Data Needed: Community Environment and Background Factors

● Convenience of surrounding transportation

● Availability of food, grocery stores nearby

● Perceived barriers to prenatal care

Table 2 - Perceived Barriers to Prenatal Care

This data is organized via the Melnyk’s Barriers Scale, which consists of 27 items scored on a

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4-point Likertype scale. These items are score from 3 to 0, with 3 indicating that the item at hand
greatly affects these homeless women from accessing prenatal care, and 0 indicating that the
item has no effect at all. Below, the percentages represent a n=47 sample size of women replying
to a questionnaire (out of 250 administered to various agencies).

Barrier Average None Slight Moderate Strong

Score (0-0.74) (0.75-1.49) (1.50-2.24) (2.25-3.00)

Site-Related 1.71 21.95% 7.32% 4.88% 65.85%

Provider-client 1.10 26.83% 36.59% 26.83% 9.76%

relationship

Inconvenience 1.02 24.39% 29.27% 24.39% 21.95%

Fear 0.68 56.10% 24.39% 17.08% 2.44%

Cost 0.61 53.66% 14.63% 26.83% 4.88%

Total 1.03 24.39% 39.02% 34.16% 2.44%

Types of Data Needed: Individuals Who Represent the Target Population

● Existing programs and services (Homeless Prenatal Program, Women’s Shelters)

● Health status of homeless pregnant women as well as their infants

● Drug/alcohol/tobacco use, preconception vitamin use, etc.

● Infant mortality rate

● Breastfeeding rates

Table 3​ - Data Specific for Individuals Who Represent the Target Population. Data collected
from a sample of 47 states in the U.S. with at least a 70% response rate to PRAMS (Pregnancy
Risk Assessment Monitoring System) survey.

Target Category Non-homeless Homeless

Pre-pregnancy BMI
Underweight <18.5 5% 6%
Normal weight 18.5-24.9 51% 40%
Overweight 25-29.9 22% 18%
Class I and II obesity 30-39.9 4% 13%

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 Class III obesity >40 3% 3%
Missing 5% 20%

Preconception Multivitamin Use

0 times per week 56% 74%
1-3 times per week 9% 6%
4-6 times per week 6% 3%
Daily 29% 16%
Missing <1% 1%

Drank alcohol in last 2 years

Yes 62% 48%
No 37% 50%
Missing 1% 2%

Smoked >100 cigarettes in last 2 y

Yes 25% 33%
No 74% 65%
Missing 1% 2%

Prenatal-visits in 1st trimester

Yes 78% 57%
No 20% 40%
Missing 2% 3%

Breastfeeding initiation post-delivery

Yes 32% 26%
No 10% 9%
Missing/Skipped 58% 65%

Breastfeeding duration
<1 week 1% 2%
1-3 week 4% 3%
4-7 week 4% 3%
>8 week 23% 17%
Did not breastfeed 10% 9%
Missing/Skipped 58% 66%

4. ​Analyze and Interpret Data

According to the sociodemographic characteristics presented by PRAMS data, homeless

compared with non-homeless pregnant women are more likely to not have graduated high

13
school, to be younger, black, Hispanic, single, receive government aid, not have health

insurance, not take prenatal vitamins, and were also more likely to abuse substances such as

tobacco, alcohol, or illicit drugs (Richards 2011). Homeless women experience higher rates of

domestic violence, traumatic events, and recurrent instability related to financial and housing

issues (Ake 2018). To add to these stresses, African American women make up a significantly

higher percentage of the homeless population, which is linked to chronic stress related to racism

and being on the streets (Ake 2018).

Homeless pregnant women are also far less likely to have a prenatal visit during the first

trimester, which can be correlated to the perceived barriers listed in Table 2, such as

inconvenience, fear, or as stated by the Wellness Director of the Homeless Prenatal Program in

San Francisco, “Consistency in attending appointments is difficult due to a number of competing

priorities and transportation difficulties in our client’s lives” (Homeless Prenatal Program).

These barriers may involve the fear of facing judgment from prenatal care providers who can’t

comprehend their situations, even if the women do make it to the appointment (Ake 2018). To

expand on this psychosocial barriers such as fear, women have expressed in other studies that

they fear if they attend prenatal care, Child Protective Services will remove the child. A

proportion of these women also fear gynecological examinations, which is likely do to

past-endured abuse and mistreatment (Azarmehr 2018).

According to one research study, the most predominant factor in preventing homeless

women from accessing care were site-related factors (Bloom 2004). A strong correlation was

drawn between the number of children living with the woman and her consequently enlarged

view of site-related factors as a roadblock to receiving adequate care (Azarmehr 2018). These

14
include wait time, distance, and transportation difficulties, as well as competing factors for their

time such as having one or more other children to find care for during appointments (Bloom

2004). In sum, economic hardship is one of the main discouraging factors in receiving prenatal

care; many of these women don’t have the funds to cover the costs or do not understand how to

use the programs that are available to them, leading to frustration and despair (Azarmehr 2018).

In a study of 9,995 women, 9% of women were found to be homeless during their

pregnancy (Cutts 2015). This is a stark contrast to the 4% that was recorded in the previously

mentioned PRAMS survey. In the later study, over two-thirds of the women participating in the

research were homeless prenatally, and low birth weight rates were 21% in homeless prenatal

group as opposed to 14% in the non-homeless prenatal group (Cutts 2015). Not only are low

birth weights more likely, but preterm babies and longer hospital stays are more common in

homeless pregnancies (Cutts 2015). Overall, homelessness during pregnancy is heavily

associated with unfavorable maternal and infant outcomes (Azarmehr 2018). These unfavorable

rates of health outcomes for mothers and babies are mimicked in a variety of studies, leading to

the discovery of predominantly important findings regarding the needs of the homeless pregnant

population.

5. Main Finding/Need

The main findings, which appeared to reoccur in a variety resources, involved lack of

knowledge, access or funds regarding prenatal care (nutrition, vitamins, supplements), as well as

low breastfeeding rates. Infants born to homeless mothers are more likely to be susceptible to

low birth weights, malnutrition, limited growth, and prematurity (Needs Assessment). This can

be referred to as an “information gap”, which can be attributed partially to attitudinal and

15
intellectual barriers (Azarmehr 2018). Some of these attitudes or lack of awareness stem from the

unplanned nature of the pregnancy, and consequently many of these women lack awareness of

being pregnant until they see visible physical changes in their bodies (Azarmehr 2018). At this

point, receiving care would likely occur in the second trimester rather than the first, which is a

crucial time for the development of a fetus. For our program, the preparation required to birthing

a healthy infant is of importance, and therefore integrating the importance of prenatal vitamins

and consuming adequate sources of folate, iron, etc. We would also like to incorporate postnatal

care as well, which involves addressing low rates of breastfeeding and highlighting the

importance of breastfeeding initiation and increased duration.

Proposed Community Project:

The goal of our project is to educate homeless pregnant women about nutrition during

pregnancy as well as introduce them to programs, which can assist them with staying nourished

during pregnancy at a low cost.

We will be tabling at the Mission Neighborhood Resource center, and will include

examples of foods appropriate in iron and folate , handouts summarizing the points in the

presentation including nutrition and breastfeeding, and remaining open to any questions during

or after our tabling session. One of the goals of this tabling session is to raise awareness for

homeless pregnant women as well as other homeless members of the community who may know

someone who is pregnant and in need of resources.

Program plan details:​ Our group will table from 8-12 p.m. during the hours of the

health fair, while talking to any community member who approaches our table about the

importance of prenatal and postnatal health.. We will first share the significance of prenatal

16
vitamins and other significant nutrients for the growth of a healthy baby, in addition to the

benefits of breastfeeding in terms of cost-efficiency and positive effects for the infant.

If interest is presented and they are so inclined, we will also inform them about the

Homeless prenatal program, which provides prenatal education and parenting classes and other

resources for support (homelessprenatal.org). We then move on to talk about Women, infants

and Children (WIC) which is a special supplemental nutrition program for Women, Infants and

children that provides grants to states for supplemental foods and nutrition education for

low-income pregnant, breast-feeding, infant and children up to age 5 who may be found to be at

a nutritional risk (fns.usda.gov).

If given the opportunity, we will then transition to giving out handouts

Food examples: Nuts, fruit, fortified cereals, etc.

Printing cost for handouts, snacks, and blow-up posters: Around $20-30 each. May change

depending on the number of people we present to.

Prenatal supplement bottle to show as a model: Zainab already has one.

Total cost: $15-$20.

Management system:

3 days prior to presentation​: Erin and Ninette: Finish final touches on each of our posters, get

food examples together

Zainab and Alora: Finish final touches on handouts and posters; print posters and handouts

All group members​--2 days prior: schedule for all group members to meet up to discuss the

nature of our tabling session, appropriate conduct, and confirm with the director that we will be

arriving at the instructed time for set-up.

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30 minutes prior​: all group members meet at the site to set up.

Summary: ​The primary barriers that our team has facing our program is the participants’

willingness to discuss or possibly show interest for any of our selected topics. Any further

concerns shown are the presence of other tables competing for the attention of the community.

Another concern would be the potential to create any possible way to follow-up or have

communication with the participants after using any further guidance or services. However, if the

participants are attentive and willing all should remain well in regards to creating a smart and

resourceful program to help neonatal health as well as guidance for the mothers.

4. Revision of Part 1
→ description of specific changes to pages after meeting with instructor

We made a few changes to our proposed community project after meeting with the

instructor on 3/14. Initially, our team had planned to get the approval of the director of a

women’s homeless shelter to create a 15 minute workshop to discuss breastfeeding, the

importance of folate, iron, food safety, and other vitamins and minerals during critical periods of

pregnancy, as well as informing them of their resources such as the Homeless Prenatal Program

in San Francisco, WIC, and other shelters/programs. We had also originally planned to discuss

the harmful nature of tobacco and alcohol use during pregnancy.

After walking in to multiple shelters and contacting/following up with the directors, we

had little luck in finding someone willing to add us to their busy schedules. Instead, a program

director offered us a table at their community health fair for the homeless. Instead of creating a

presentation, we created three posters about the importance of iron, folate and breast feeding for

18
homeless mothers. The project was rearranged to suit the new environment provided by the

resource center and also on behalf of the instruction of our professor to keep our topics more

simple and focused on areas of our scope.

Our difficulties remained the same as far as the possibility of communicating with our

chosen population and obtaining their interest. In order to gain some popularity for our table and

support our concepts we brought small oranges (citrus fruits contain folate), fortified cereal (iron

and other important vitamins), as well as trail mix. We did not end up giving out a survey,

because we were told by our instructor that many of the people there might not be interested

enough to participate, and to instead count how many people walked up to our table.

Additional changes to the preparation of our program include the price, which certainly

increased a little bit with the printing of posters; we wanted them to look more

professional/clean-cut. It was $35 to print each poster, and then additional costs to purchase

snacks for the table.

5. Intro to Part 2

The day of the Health Fair at the Mission Neighborhood Resource Center, we carpooled

to the center 30 minutes ahead of time to get our table. We set up our table with posters as well

as snacks and waited for the fair to begin at 8:00 a.m. We created a poster for food safety, iron,

breastfeeding, and folate, all of which were printed at Office Depot. Our goal was to interact

with the members of the community and to have potential discussions about the importance of

these nutrients for pregnancy, the importance of breastfeeding post-pregnancy, if they knew

anyone who was homeless and pregnant, and to talk about their overall knowledge of heightened

nutrition/food safety needs during pregnancy.

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 During the session, we had a total of 15 people approach our table, the majority of which

happened to be male. At the beginning of the health fair, we were placed outside in the smoking

section, which we felt might limit our chances of encountering pregnant women. About two

hours into the program we shifted downstairs where we got a new flow of people approaching

our booth. The homeless community showed a little interest but the choice to interact seemed to

be an achievement in itself. People mainly asked what our booth was about, and then maybe a

few questions afterwards. They did, however, come back for snacks repeatedly, and those who

did seemed to think of a question or two to ask us in order to buffer coming back from seconds,

which actually led to more conversation. Once lunch was being served at 11:00 a.m., we got a lot

less interest at our booth. We said thank you to the directors and packed up our table.

6. Results of Program

a. Demographic tables (results of people: age, gender, one other factor (pregnant?))

Table 4: Demographic Results of Health Fair Community

Age Number of Men Number of Women Pregnant?

18-24 1 0 No

26-35 2 1 No

36-45 4 0 No

46-55 3 0 No

56 + 3 1 No

The amount of men who approached our table far outnumbered the women, which was

also echoed in the facility; there were more men than women present in general. However, a few

of the men we interacted with did express interest by saying they knew women who would

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benefit from this information. Most of those who expressed any interest read our posters from a

distance for a while and eventually came over to talk to us. One of the very few women who

express interest was in her late fifties and although she read the posters, she told us she was “way

too old to worry about this”. Unfortunately, we had no pregnant women approach the table, nor

were there any who came to the health fair (that we could see).

7. Discussion/Conclusion of Results​ - in comparison to expectations AND ​literature review

findings

a. Overall Outcome​: While our team had hoped to encounter at least one pregnant woman,

we encountered only a few women and a higher volume of men. People minimal to some

interest in our table, and our group was appreciative of any interaction from people who

didn’t necessarily come for the health fair, but to use the Mission Neighborhood

Resource center for its resources. Some people continually walked by, and we were told

to let people approach us rather than approach them. For the most part, our target

population was more interested in our snacks, but it gave us the opportunity to interact

and get a little closer to our goal of pregnancy education, male or female.

b. Comparison to Group Expectations​: Initially, our group had hoped to interact with

more pregnant women at a women-centered shelter. We envisioned an intimate group

setting where we would get a chance to answer specific question and give more in depth

information to women who truly needed it. However, that was found to be extremely

difficult to arrange for numerous reasons. The opportunity arose to booth at a health fair

geared towards homeless people. It was decided that we would attempt reaching a

broader audience, in hopes that the information would be used by participants in the

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 future or passed on to other people it may apply to. We were informed that the facility

was used by homeless people for laundry and showers and they may not be interested in

what we had to say. As a result, we had to find a simplistic way to attract and educate

passer-bys. The table featured some snacks and samples to give away, like cuties, trail

mix and granola. We also created bright, simple posters to clearly demonstrate some

major topics regarding pregnancy nutrition. We found people came to our booth for

snacks, and stayed to read the fun and inviting posters. At that point, it was easy to slip a

few comments about how the snack being eaten contained the nutrient pregnant women

needed. We had more interaction than we expected, because most of the participants were

male and we were in the smoker section, however, bright colors and snacks never fail to

get people’s attention.

c. Comparison to Literature and Other Studies

In comparison to the literature and other studies, the need for nutrition

information was indeed present among the homeless community. Focusing on the

homeless population’s nutrition in general shows that they have less access to kitchen

facilities or opportunities for food preparation, refrigeration, and storage, contributing to

a poor dietary intake (Martins 2015). To add to these issues, the homeless population

experiences food insecurity, meaning they have less access to healthful foods (Martins

2015). Food insecurity is associated with a diet low in essential vitamins and minerals,

but high in unhealthy fats and cholesterol (Martins 2015). Luckily our posters educated

on healthy food groups that contain adequate vitamins. As for the needs of pregnant

women, we did not get to explore this as much as there were none present at the health

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 fair (that we know of). However, we can likely assume that with the lack of resources and

access to proper nutrition that the general homeless community experiences, it would be

even more so for pregnant homeless women. Some of the members who approached our

table did show that they did not know much about the vitamins on our posters or the

benefits of breastfeeding. The general need presented by the community was food

insecurity and lack of access to nutrition, which is magnified by the homeless pregnant

community.

d. What went well? What did not go well?

With our initial table, we were placed outside in the smoking section, which wasn’t ideal

for interacting with pregnant women. As previously stated, we also did not get the amount of

pregnant women we had hoped. We predominantly educated men at the facility who had a

few questions about what our posters were about. Lastly, we were correct in suspecting that

there would be some, but perhaps limited, interest in our topics. These were the main things

that did not go well; however, we did get a chance to interact with the homeless community

and gain experience in communicating with them and discovering better ways to connect

with them. About a quarter of them were Spanish speakers, which could have made

communication limited had Ninette, who is fluent in Spanish, not been there. We had a good

amount of people approach our table, about 15 to be exact, which was a fair number

considering lack of interest. We did still get questions from community members and got the

opportunity to speak with them about our topics, ask them if they knew any women who

were pregnant or could become pregnant, and overall explore what they knew about

nutrition. We were able to answer almost just about every question given to us, and felt that

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we were able to connect with community members. Overall it was a truly incredible

experience for our team; we enjoyed interacting with the community and being a part of a

group of people with the same goal of helping close a resource gap for the underserved.

Almost every interaction was genuine, positive, or one we could learn from. At the end of

our time slot, we all felt good about the effort we put in to try to conversate with people and

contribute to the health fair.

e. Ideas for the Future

For the future, we would like to find a better platform or location to communicate

our information. For this, we would need more time to allocate a women’s shelter that

would help us recruit their community of women for our project and allow us to come

talk about pregnancy nutrition and breastfeeding. We came close to securing shelters, but

in the end, nothing came to fruition other than the health fair. A couple of the other

tables, including the HealthRight 360 organization, offered to collaborate with us and the

San Francisco State Dietetics Program students to create an educational presentation at

their facility. Combining forces may be a better way to reach the community of homeless

pregnant women or homeless women in general. Exploring more about what kind of

support women are not receiving from shelters and the information gaps about pregnancy

nutrition would also assist our group in creating a better presentation. Mostly we realized

that food insecurity and lack of access to healthful food is still a huge issue for the

homeless community and would like to propose policy reform that aims at redirecting

leftover produce from grocery stores and farmers markets and implementing a free

donated-produce street market for the homeless population. To increase the efficacy of

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this idea, we would also like to recruit volunteers from food delivery companies such as

Postmates, Caviar, or Uber to pick up extra produce and deliver it to street markets in

order to aid farmers in transportation.

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8. Appendix

a. Educational Handout + Posters

b. Powerpoint Slides

c. Public Policy Letter

d. Reference List

e. Part 2 Rubric

Educational Posters

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i. Iron During Pregnancy

ii. Folate During Pregnancy

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iii. Breastfeeding

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iv. Food Safety During Pregnancy

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