YORK INSTITUE FOR HEALTH RESEARCH

Minding our Bodies: Eating Well for Mental Health

Algoma Public Health and the Bee-Hive: Good Food, New Friends Program

Case Study Report

January 2011

Submitted to: Scott Mitchell Canadian Mental Health Association, Ontario Division

Marie Giroux, Algoma Public Health Brenda McConnell, The Bee-Hive Submitted by: Michaela Hynie York Institute for Health Research, Program Evaluation Unit York University

Carolyn Steele Gray University of Toronto

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Table of Contents Introduction .................................................................................................................................................. 3

Methods ........................................................................................................................................................ 3

Data Sources ............................................................................................................................................. 3

Background ................................................................................................................................................... 4

Algoma Public Health ................................................................................................................................ 4

Community mental health services ...................................................................................................... 4

The Bee-Hive ............................................................................................................................................. 5

The Good Food, New Friends Program ..................................................................................................... 5

Findings ......................................................................................................................................................... 7

Context Evaluation Questions ................................................................................................................... 7

Do the goals or needs of the sites conflict with program goals? .......................................................... 8

Do pilot sites have other goals they hope to achieve through these programs? ................................. 9

Are the project goals viewed as important? Are the project goals perceived to be attainable? ......... 9

What resources do sites have to contribute? ....................................................................................... 9

Input Evaluation Questions ..................................................................................................................... 10

How does the program meet the needs of stakeholders (staff, site and clients)? ............................. 10

Are there sufficient resources for the program to be carried out? .................................................... 10

Process Evaluation Questions ................................................................................................................. 11

Are partnerships unfolding as planned? How are partners working together? ................................. 11

Are pilot sites implementing programs as planned? .......................................................................... 12

Who is participating? Who is not? ...................................................................................................... 13

Products Evaluation Questions ............................................................................................................... 13

Has awareness of the relationship between healthy eating and mental health increased; among staff, organization, community, clients? ............................................................................................. 13

MOB project activities ......................................................................................................................... 15

Are partnerships being built?.............................................................................................................. 17

Client outcomes .................................................................................................................................. 17

Staff outcomes .................................................................................................................................... 22

Organizational outcomes .................................................................................................................... 23

Were there unexpected outcomes (clients, staff, organization)? ...................................................... 23

Important Learnings and Future Considerations .................................................................................... 24

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Program challenges ............................................................................................................................. 24

Evaluation ........................................................................................................................................... 24

Future Needs and Program Changes .................................................................................................. 24

Summary ..................................................................................................................................................... 25

Appendix A: Photos ..................................................................................................................................... 26

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Introduction This case study report overviews and evaluates the joint pilot project called “Good Food, New Friends,” a community kitchen program that was implemented by Algoma Public Health and the Bee-Hive (a consumer supportive initiative). The Good Food New Friends (GFNF) program is one of six pilot programs funded by CMHA Ontario’s Minding Our Bodies (MOB) Eating Well for Mental Health program. This report is intended to provide evaluative feedback to the MOB Program Leaders, Advisory Committee, Algoma Public Health and Bee-Hive staff regarding the community kitchen. The evaluative analysis includes context, input, process and product evaluation questions set out in the original Minding Our Bodies evaluation proposal that can be answered by examining the individual pilot programs. This case study report provides feedback on the goals, development, implementation, outputs and short-term outcomes of the pilot program in relation to the MOB program goals and objectives. The final MOB Eating Well for Mental Health program evaluation report will draw upon this and other case study reports in order to determine whether the MOB program met its short-term goals, unfolded as planned, and how it could be improved.

Methods To gather required data, a representative of the evaluation team conducted a visit to Algoma Public Health and the community kitchen site. The visit included interviews, surveys and focus groups with program leaders, staff and program participants (clients). Consent forms were signed prior to participation. Interviews and focus groups were audio recorded and transcribed. Documents pertaining to any aspect of the community kitchen program (including promotional materials, communications, information provided to clients, and internal evaluation materials) as well as evaluator observations during the site visit are included. Participation in pilot teleconferences or other communications with the MOB program leaders or advisory committee are also included in the analysis. Documents and interviews were coded by the evaluation team using NVivo 7 under a basic thematic coding scheme. Themes were then linked to evaluation questions as a means to provide answers to the original evaluation questions, but novel themes were also allowed to emerge and will be identified below.

Data Sources The analysis and findings of this case study report are based on the following documents and data sources. Table 1. Data Sources

Source Date Materials Expression of Interest July 9th 2010 Proposal remitted to MOB project for funding Site Visit Dec 15th 2010 Program leader interview (transcription and

notes) Interview with Elizabeth Larocque (supervisor from Algoma Pubic Health) –notes only Staff focus group (transcription and notes) Staff survey (on-line) – 3 responses as of Jan 17th 2011 Client focus group (transcription and notes) Photos of the site Evaluator observations (in site visit notes) Information conversations with staff and program leaders

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Site visit follow-up Dec 2010 Jan 2010

Mailed internal evaluation forms Follow-up questions for program leaders via email.

Background

Algoma Public Health1

Algoma Public Health (APH) is a public health unit that serves the Algoma district. Like all public health units within Ontario, APH offers services targeted at disease prevention, health promotion, and health protection.

2 APH offers programs for individuals with mental illness and addiction. They offer community mental health services designed to assist adults with severe and persistent mental illness to live successfully in the community. Services are supported by the North East Local Health Integration Network and offered in partnership with other community mental health agencies, with funding provided by the Ministry of Health and Long Term Care.3 Services are available at all APH offices located in Sault Ste. Marie, Wawa and area, Blind River/North Shore, and Elliot Lake. APH also offers a community alcohol/drug assessment program, which provides services to individuals who are experiencing alcohol and/or other drug related problems.4

Community mental health services

Case Management: Psychiatric Case Managers work collaboratively with individuals who experience severe and persistent mental illness to help them improve their level of wellness and quality of life. Services are client centred and provide assistance in: interpersonal support; improving living skills; consultation and assessment; coordination and advocacy with other supports and services; assistance to obtain secure appropriate affordable housing; financial assistance and budgeting; family support; crisis support; supportive counselling; and medication monitoring. Supportive Housing: Services are provided by Psychiatric Case Managers and Community Rehabilitation Workers to support clients to live where they choose. Services offered under the supportive housing program include flexible and individualized support that varies in intensity, and assistance in locating and maintaining housing. A selection committee screens individuals to determine need; priority is given to people who are homeless or at risk of being homeless. Community Treatment Orders: These are treatment and service plans that are issued by a physician in consultation and coordination with the consumer and services providers. APH also offers a Community Rehabilitation Program, which includes fitness, nutrition and gardening programs. The GFNF program falls under the community rehabilitation programs offered by APH. The GFNF program is delivered through the Elliot Lake site. The Elliot Lake office is located in the mall in Elliot Lake in which there is a grocery store and a number of food stands (in addition to other retailers).

1 From submitted expression of interest and website http://www.algomapublichealth.com/index.aspx?l=,1,2,3 [Retrieved January 17th 2011] 2 From Public Health Ontario website, https://www.publichealthontario.ca/portal/server.pt?open=512&objID=213&PageID=0&cached=true&mode=2&userID=11863 [Retrieved January 24th 2011] 3 http://www.algomapublichealth.com/Default.aspx?l=,1,10,67 4 http://www.algomapublichealth.com/Default.aspx?l=,1,31,108

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Organizational mandate and mission: Algoma Public Health (APH) seeks to support healthy communities by providing a variety of quality health services. The organization’s broad vision is to achieve optimal health for each person and community in the district of Algoma. Community mental health services mandate and mission: To assist individuals, 16 and over, who experience severe and persistent mental illness, to achieve their highest level of functioning in the community.

The Bee-Hive5

The Bee-Hive is a consumer initiative in Elliot Lake that uses the Wellness Recovery Action Plan (WRAP) to assist members. This is a tool intended to help individuals recover from their mental illness and reduce their number of hospital stays by teaching members awareness about their illness to help them manage it more effectively. Programs delivered by the Bee-Hive provide a fun experience for members as well as a sense of belonging. Programs include: games; exercising; crafts; community kitchen; outreach; self-help groups; peer support; sandwich lunches; and access to computers and the internet. As of October 2010, the Bee-Hive had 45 members. The Bee-Hive also operates a program in Blind River called the BRP Lounge, which has 10 members. The Bee-Hive partners with local mental health organizations including Algoma Mental Health, East Algoma Mental Health and Club ’90; the nature of these partnerships is not clear.

The Good Food, New Friends Program The GFNF program was originally intended to build on the existing Meals for Good Health Program for diabetics, delivered by APH. This program sought to incorporate the “harm reduction method” in relation to food/nutrition. Program leaders from APH and Bee-Hive, who had shared interest in developing a community kitchen, developed and submitted a letter of interest to MOB. The program was developed to teach participants a number of skills: menu planning; budgeting; meal planning; reading labels; shopping skills and becoming an informed shopper; adult daily living skills; food preparation and food handling safety; social and community skills, and inclusiveness; and a sense of belonging. Program leaders sought to help individuals succeed with their lifestyle changes and to inspire a sense of hope and optimism for recovery. 6

Consumer leadership was encouraged by providing interested members with skills to take on future leadership roles in program development, implementation and evaluation. Two consumer volunteers were recruited to help with the program. One volunteer completed peer support leadership training shortly before the start of the program and helped to run the program generally; the other volunteer was a consumer with skills in accounting who took on the budgeting and finances for the program.

The program was delivered collaboratively by a community rehabilitation worker from APH and a peer support facilitator for Bee-Hive. MOB pilot funding flowed through APH and was provided to the community rehabilitation worker (APH program leader) as needed. Ontario Works (OW) partnered with the project; case workers referred clients to participate in the program and OW provided funding for ODSP and OW clients to take part in the program if they could not afford the $25/month fee. Ontario Works also offered to fund any other client from the other sites if they could not afford fees. Beyond having clients referred by Ontario Works, clients were also recruited by case workers from APH and peer

5 From program overview available at http://www.nelhin.on.ca/WorkArea/showcontent.aspx?id=8106 6 From the submitted expression of interest

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support workers from Bee-Hive. As well, participants were recruited from Club 90 (another existing partner). An information session was held on September 29, 2010, for individuals who were invited to participate. Twelve participants attended the first introductory session and all 12 joined the program. They were assigned to two groups (seven in group 1 and five in group 2). Two groups were used in order to make the cooking classes more manageable; staff noted that it would be too crowded with more than eight participants. There were no discernable differences between the groups. Sessions were held in the same location for both groups. Most of these clients were from APH and Bee-Hive, while two participants were from Ontario Works and no participants came from Club 90. Over the course of the program, four individuals dropped out of the program due to illness (three left group 1 and one left group 2), leaving eight participants who completed the program.

In addition to the two program leaders from APH and Bee-Hive, the program had six other individuals engaged in program delivery: one case worker from APH helping to run the sessions; two consumer volunteers; two participant volunteers who were Kitchen Support Workers (mainly clean-up duties); and a supervisor from APH. The volunteers were specifically recruited for this project. The program ran from October 4th to December 15th 2010 and included two sessions each week for both groups: one planning session and one cooking session. The program also had four education days which included guest speakers. The first speaker addressed each group separately, and the remaining speakers addressed both groups together. This reduced the time required of the presenters, and also provided an opportunity for participants from the two groups to come together and get to know one another. Each participant was asked to contribute $25/month to cover the cost of food. At the end of each cooking session participants would bring home the food they had cooked, which would often provide a meal each day for a month. Table 2. The Community Kitchen program activities

Session Activities(s) Handouts GROUP 1 • Canada’s Food Guide

• Health Canada handout about turkey food safety tips (printed from online source)

• Proper hand washing • Proper food storage • “About salt” • “About sugar” • “About fats: Good fats vs

bad fats” • Water • Cooking temperature charts • Recipes • Reading labels template • Hand out on chronic

disease: diabetes, blood pressure etc.

October 4th 2010 Planning Session and Education day: Elliot Lake Fire Department and APH Health Inspector presentation of food safety

October 13th 2010 Cooking day October 20th 2010 Second cooking day November 1st 2010 Planning day November 3rd 2010 Cooking day November 29th 2010 Planning day December 1st 2010 Cooking day GROUP 2 October 25th 2010 Planning day October 27th 2010 Cooking day November 15th 2010 Education day: Elliot Lake Fire Department

and APH Health Inspector presentation of food safety

November 22nd 2010 Planning day November 25th 2010 Cooking day December 6th 2010 Planning day December 8th 2010 Cooking day

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JOINT SESSIONS November 8th 2010 Education day: Dietitian from APH December 13th 2010 Education day: Local pharmacist & Fitness

Instructor (Zumba) December 15th 2010 Celebration Christmas meal (see Figure 5 and

6 in Appendix A) **Healthy snacks were given out at education sessions. These were either made by participants or they were shown how to make the snack after the session. Participants were given small gift bags at the last session (Celebration Day), which were assembled at a low cost ($5/bag) and contained mostly donated items from local business, including a food handling safety calendar (in-kind); water bottle; measuring cup and spoons; colander; and CMHA stress cards (in-kind). Participants who completed the program were also given a certificate of completion on the last day. Participants were provided with information regarding site rules, protocols, common chores, food safety and hygiene. The importance of sharing chores and responsibilities was emphasized. Participants were also asked to sign a participation contract, which stipulated the following:

• Attendance is mandatory in order to receive cooked food • Expectations of clients: share in chores and be active participants • Participants must supply own transportation • Participants must keep other group members’ information confidential • Participants must maintain a positive attitude • Participants must contribute the necessary funds ($25/month)

The kitchen support volunteers were also given a contract to sign that provided an overview of the Kitchen Support Worker job description. All planning, cooking and education sessions were held at the kitchen site. The kitchen site was provided by a local retirement facility (see Figure 7 in Appendix A) that donated the space and covered the cost of utilities. The retirement facility is a local agency that is providing modern housing and improved quality of life for senior residents. At the kitchen site there were various healthy eating messages (see Figure 8 in Appendix A), food safety messages and other information about healthy eating (see Figure 9 in Appendix A). In exchange for providing the site and covering some costs, APH is offering services to some of the clients of the retirement home who have been identified by the retirement home manager as requiring assistance. The site was accessible by public transit and was only a 5-10 minute drive from Elliot Lake town centre. Communication regarding the program and recruitment was mostly through word of mouth. Individuals in the community who knew about the program would often ask for updates on how it was running. No other communications about the program to the organization, staff, or community was reported.

Findings

Context Evaluation Questions Table 3. Overarching goals of the organization, program, and MOB project

Algoma Public Health Overarching:

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organizational goals 1) Support healthy communities 2) Achieve optimal health for all individuals living in the district of Algoma Sub-goals: 3) Chronic health management and disease prevention and preventing

stress related to chronic disease 4) Taking an active role on the determinants of health 5) Community health and addictions

a. To assist individuals, 16 and over, who experience severe and persistent mental illness, to achieve their highest level of functioning in the community.

b. Improve wellness and reduce social stigma Bee-Hive organizational goals

Central goal: 1) Promoting independence: self-awareness, self-responsibility, self-support

and self-care Sub-goals: 2) Building social inclusion 3) Developing skills

Good Food, New Friends program goals

1) Teach skills related to: food security, healthy eating skills, food preparation and safe food handling, adult daily living skills, social inclusion and community skills

2) Create a sense of inclusiveness and belonging in participants 3) Help participants succeed with their lifestyle changes 4) Inspire a sense of hope and optimism for recovery 5) Provide evidence to support programs that help build client

independence. MOB goals 1) Improve physical health

2) Improve mental health 3) Support social inclusion

Do the goals or needs of the sites conflict with program goals? In terms of the goals associated specifically with the community mental health and addictions mandate of APH, the GFNF program supports these goals well. Teaching skills, helping individuals make important lifestyle changes, and inspiring a sense of hope for recovery can be seen as providing the tools individuals need to achieve a higher level of functioning. Creating a sense of inclusion supports the APH goal of reducing social stigma by helping clients to integrate into the community and potentially have positive impacts on community members’ feelings about individuals suffering from mental illness. The program supervisor from APH found the goal of reducing social stigma was well reflected in the program. Program leaders considered the focus on skills and social inclusion as meeting key organizational goals for both APH and the Bee-Hive.

The program also assists in attaining broader organizational goals of APH, such as taking an active role in the social determinants of health. The program supervisor felt that the program was addressing some key determinants of interest to APH. While not explicitly stated by the program supervisor, program activities supported healthy eating and improved food security, which are key social determinants of health. In terms of health management and chronic disease prevention, the program addressed a variety of chronic diseases including diabetes and heart disease and included discussions around smoking cessation. Program leaders indicated that handouts, resources and web-links on smoking

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cessation were distributed to participants. Guest speakers such as the pharmacist also covered smoking cessation in relation to mental health wellbeing and also provided handouts. The fire department discussed smoking as a health hazard. The program thus was able to meet broader organizational goals around addressing the determinants of health and helping individuals manage chronic disease.

In addition to building skills and increasing social inclusion, the Bee-Hive seeks to promote independence and empower members. The program leader from Bee-Hive felt that the GFNF program was able to meet all of the Bee-Hive’s central goals. Promoting independence, for example, is an important goal for the Bee-Hive and is shared by the program leader from APH. This shared belief shaped how the program was developed and implemented (e.g., using contracts to promote accountability among participants so that they take responsibility for themselves).

Do pilot sites have other goals they hope to achieve through these programs? A strong focus on building independence among participants was a central program goal for both program leaders. While this can be seen as fitting both APH and Bee-Hive broader organizational goals, there was a sense that this was not as prominent a goal in APH as the program leader from APH would have liked. The program leader hoped to show evidence of how important this goal was through this (and other) programs.

Are the project goals viewed as important? Are the project goals perceived to be attainable? The program supervisor, program leaders and staff collectively felt that the MOB goals were important and also supported by their program. The program supervisor felt that social inclusion and addressing food security (a sub-goal of the MOB project) were well supported by the GFNF program. Reducing stress associated with food insecurity was a particularly important goal for APH, as food insecurity and poverty are key social determinants of health and addressing these are central to the mandate of APH.

Staff felt as though all three MOB goals were important to them and to their program.

“I think it’s supporting physical health, with a causal connection affecting mental health and the social inclusion’s important because it’s a group dynamic.” (GFNF staff, staff focus group)

Staff also felt the goals of the MOB project were attainable with this program. While the program activities focused on physical health, staff felt the group atmosphere contributed to supporting mental health. Staff drew from the positive outcomes for clients to determine that the MOB project goals were attainable through their program:

Interviewer: You think that those goals have been attainable through this program? Staff: Oh absolutely, I think we’ve heard that from members, definitely

What resources do sites have to contribute? Both APH and Bee-Hive contributed staff and APH was able to take on consumer volunteers as well to help run the program. One of the consumer volunteers was given an honorarium for their work (paid for out of pilot funding). Both APH and Bee-Hive also have an existing network of formal and informal partners within the community which they drew on to deliver this program. There appeared to be a strong community relationship among residents of Elliot Lake that resulted not only in interest in program activities but also a desire to support program activities. Program leaders expressed that they could get assistance from local businesses and organizations based upon their existing relationships.

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APH provided additional funds for shared food items between groups, staff travel expenses, and additional furniture for the kitchen (cabinets). APH also provided in-kind donations for “freebies” for the participants including: tote bags, the Christmas bag goodies (identified in the background section), and cooking thermometers. The Bee-Hive provided additional funds to assist in the purchase of snacks for the program and also provided in-kind donations of cookbooks. A number of additional in-kind donations were provided including: additional cookbooks from the participants, hairnets from the local Tim Horton’s, donated food items from staff (this helped to reduce the costs of the program, and stress cards donated from the local CMHA). The Zumba instructor also donated her time to teach a free session and provided all participants was a free pass for one Zumba lesson. Other resources available within the community include: public transportation (which made it easier to get to the site); grocery stores in town to serve residents of Elliot Lake; and a vast amount of outdoor space that can be used for future community gardens and physical activity (hiking, skiing, etc.).

Input Evaluation Questions

How does the program meet the needs of stakeholders (staff, site and clients)? The program was able to meet consumer volunteer needs to build valuable skills such as self-confidence and independence to promote those volunteers’ recovery and social integration. The program was also able to satisfy the program leaders’ (other staff) needs by demonstrating the importance of building independence and providing additional evidence to support this goal.

Both APH and Bee-Hive were able to attain their organizational goals of supporting healthy communities by helping individuals of Algoma district to achieve optimal health, helping individuals manage their chronic illness, taking a role in addressing the determinants of health, assisting individuals to reach a higher level of functioning, promoting independence, fostering social inclusion, and building skills (see goals discussion above). Clients’ needs were also addressed as they were referred by case managers who believed they could benefit from this program. It was not explicitly stated how clients were selected — that is, if it was based on need or the potential for change (or both). Program leaders believe that all individuals suffering from severe mental illness should be encouraged to take these types of programs as they should not feel limited by their illness:

“I really have a problem when people say, ‘I can’t do that because I have a mental illness.’ ‘Excuse me? Yes, you can.’ I believe your illness is only 10% of you, you are 90%, you can do anything you want to do.” (GFNF program leader, staff focus group).

Are there sufficient resources for the program to be carried out? Staff and program leaders found there were enough funds to deliver the program. MOB project funding went towards: purchasing kitchen supplies including utensils, bake ware, storage containers, latex gloves, cookware, and spices; purchasing a mobile counter top (picture in Figure 7 in Appendix A); and providing the honorarium to one of the volunteers. Beyond these purchases, program leaders identified a need for additional kitchen supplies, such as a stove and fridge. The stove they were using was small and only had one functional burner and the fridge was often too small to fit all the food they purchased for the cooking sessions.

Time was the most significant need identified by program leaders. The program leaders felt they spent more hours on this project than expected and it was taking away from their other existing duties. They

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did not feel that additional staff would have helped as they could not delegate many of the activities needing to be completed. In retrospect, they felt that designating more work hours to the project was required.

A limitation noted by program leaders was access to food. This required increasing the time to two days a week for each group to run the program. They discovered through consultation that a Sault Ste Marie community kitchen (soup kitchen) was able to run its program more efficiently due to the food bank being part of its organization. Program leaders acknowledge this would reduce the time needed to plan and their program.

Process Evaluation Questions

Are partnerships unfolding as planned? How are partners working together? In the initial pilot application APH expected to build on existing partnerships with the Bee-Hive consumer initiative and Ontario Works. They also anticipated creating or developing the following partnerships as part of the GFNF program:

Table 4. Expected partnerships

Expected partnership7 Actual activities Comments Local retirement facility Provided the kitchen space for

the classes. An existing partnership that was strengthened by this program – there is considerable interest from both parties to continue the relationship over the long term.

Community garden Not explored as part of this program.

Have done community gardens in the past and are considering continuing this as part of a community kitchen program in the future (cooking the food you grow).

Food Bank Visited another mental health agency that runs a community kitchen that is attached to a food bank. Shared information only.

This was more of an informative visit rather than the development of a partnership. There was no mention of whether this would be a future partnership or not.

Health Inspector The health inspector from Algoma public health provided education sessions with the participants.

This does not seem to be a new partnership as the health inspector is from APH.

Fire Department The Fire Department provided education sessions for the participants.

This is a new partnership built as part of this program.

Pharmacist The new local pharmacist came in to deliver an education session.

While there is another pharmacist in Elliot Lake that APH already had a relationship with, they asked the new pharmacist in town to deliver the sessions which created a new

7 From submitted expression of interest

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partnership. Walking program Did not occur as part of the

program There was mention of the walking program, but this seemed to be an existing program run outside of the GFNF program.

Fitness program The local Zumba fitness instructor ran a session with participants.

This is a new partnership for APH however an existing one with Bee-Hive

Family Health Team Did client referrals to the FHT for smoking cessation and nicotine replacement therapies.

NISA *existing partnership not specified in the submitted expression of interest

Re-connected to Bee-Hive to provide over the phone computer support.

This existing relationship was strengthened by the MOB project at training day.

No existing partnerships were lost due to this program.

Are pilot sites implementing programs as planned? For a summary of program activities please see Table 2 in the background section.

Sessions were delivered largely as expected. One change that occurred was in how the education sessions were delivered. Initially education sessions were planned separately for two groups. It was decided to amalgamate the groups for education sessions to increase socialization among attendees.

“[The change was implemented] so everybody had a chance to meet and make new friends and get to know everyone. It opens new doors and it certainly has when we come together. It has opened new doors for the folks.” (GFNF program leader, staff focus group).

Bee-Hive had to rearrange their other activities to accommodate the community kitchen project. Rather than considering it a problem, the program leader from Bee-Hive saw this as a positive opportunity to demonstrate that change is part of life:

“… we’ve had to change activities to fit the kitchen, which people got used to, and I tell them, ‘Everything’s doesn’t stay the same. Change happens, it’s a part of life, it’s who we are, everything changes.’ They’re okay with it now, but at first they were kind of… [gestures to indicate that they were iffy about the change]” (GFNF program leader, staff focus group)

In regard to consumer leadership, the original proposal indicated that one consumer volunteer would brought onto the project. When the program started, they added a second consumer volunteer who was identified as having a valuable skill set (accounting) and who could benefit from the experience. They also expanded consumer leadership when the program began to include two consumer kitchen support staff to help with clean up and kitchen organization. Consumer leadership took on a more significant role in the program than was previously expected.

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Who is participating? Who is not?

Figure 1: How did the actual number of participants relate to the number you expected?

Twelve members were invited to participate in the program, seven in one group and five in the other. Four dropped out over the course of the program due to illness. Initially, program leaders felt they would not have difficulty recruiting as there had already been considerable interest from clients of APH, Bee-Hive and Public Works to be part of a community kitchen. Through the course of discussion, it emerged that they experienced several recruitment challenges. First, there were many who expressed interest who did not sign up for the program. This was attributed to concerns about the cost of the program, anxiety or other personal reasons:

“Oh yeah, there’s a lot that I thought would be here that expressed an interest but for their own reasons, for some it’s anxiety, they didn’t end up joining because of the anxiety.” (GFNF staff, staff focus group).

A second challenge was related to receiving referrals and participants from an existing community kitchen. This challenge presented early and made it difficult to recruit sufficient members from APH, Bee-Hive and Ontario Works alone. For this reason, they branched out to other partners for referrals. Program leaders were unable to mend this problem despite reaching out to potentially create a new partnership. These challenges demonstrate the importance of identifying potential program overlap in communities prior to initiating new programs. This will reduce the potential for competition between programs, low attendance and potentially open doors for partnership earlier in the program process.

Products Evaluation Questions

Has awareness of the relationship between healthy eating and mental health increased; among staff, organization, community, clients? Client awareness is discussed in the client outcomes section below

0

1

2

3

4

5

Many fewer than expected

Fewer than expected

About what expected

More than expected

Many more than expected

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Staff awareness

Figure 2: What proportion of staff have increased awareness about healthy eating and mental health?

The survey suggests staff had gained awareness about the relationships between healthy eating and mental health (see Figure 1). When asked, staff seemed to attribute this learning to observing changes in participants who were making healthy food choices, rather than to delivering the sessions:

“Also, some people said, ‘I’ve been able to concentrate more, it sinks in more because I’m eating properly now, so I’m not as tired, so I can learn easier now.’” (GFNF staff, staff focus group).

Staff also noticed the connection between addressing chronic diseases through healthy eating as a conduit to learn about how clients can start to address their mental health needs:

“They’re eating properly now, and part of your mental health is, you have diabetes, you have to nurture that, you have to look after yourself. When you are sick with diabetes, it’s the same as when you have a mental health problem…” (GFNF staff, staff focus group).

This interesting observation demonstrates that staff believe teaching clients the skills to address one of their needs (chronic health issues) may be transferable to teaching them to address their mental health needs. This could indicate that teaching a broad range of skills designed to encourage healthy practices (beyond healthy eating) may help to encourage clients to adopt other healthy practices with regard to their mental illness.

Organizational and community awareness The program supervisor stated that healthy eating has always been important to APH. The GFNF program served to reinforce the importance of teaching skills and developing programs that go beyond grocery store tours. The program supervisor also noted the program has increased awareness around food management and preparation. However, there was not much mention of any increased awareness

0

1

2

3

None A few Some Most All

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about the relationship between eating well and mental health; rather, at the organizational level, there was more learning around programming and implementation (discussed in a later section).

There did not seem to be any explicit community level learning about the connection between mental health and healthy eating. Staff felt as though they were able to connect to a number of different potential partners in the community in developing the program and, in doing so, may have increased community awareness about a connection between healthy eating and mental health. Community members who were not approached to participate had an increased awareness about the program, which may have impacted on their awareness about the connection between healthy eating and mental health.

MOB project activities

Figure 3: Ratings of usefulness of program elements

Staff found the toolkits and training day useful (see Figure 2). Program leaders used “bits and pieces” of the program toolkit, but could not specifically recall which ones. They did use the program toolkit to help develop the participant contract that clients were asked to sign when joining the program. The evaluation toolkit was used to develop evaluations. While the toolkits were useful (identified in both the survey and in the interview), staff found it difficult to sift through all the material and to link their program activities to the toolkits. Feedback from program leaders indicated that meeting with a MOB representative to review the toolkit would have been a practical method to learn more about the information and its application to the program:

“I think that if you had been able to come here to Elliot Lake on a day like today … and walk us through some of it [toolkits], I think it would’ve been more practical for us, I think that we would’ve used it more, we would’ve followed it more, because honestly, once the ball got rolling … there was no time to read that, there was no time for anything, and I would’ve really wanted you to come and sit and do that, we would’ve made the time, and … I think

0

1

2

3

Not useful Somewhat useful Useful Very useful

Program toolkit

Evaluation toolkit

Environmental scan

Training day

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that we would’ve followed through with more of the toolkits and we would’ve used them more.” (GFNF program leader, program leader interview)

It was also noted that having someone review the toolkit with them would have helped them to understand the toolkit and would have helped identify how the toolkit could fit into the different stages/parts of their program. Program leaders felt the toolkit would not necessarily have changed how they delivered the program, but would have assisted them in documenting the program more effectively and developing tools to run the program. They did not document their program as well as others did and so this could have been an important learning for them early in their program development. The types of tools required were not specified but it seemed that they were referring to any type of written tool to help with the running of the program (i.e., handouts or information packets).

Program leaders felt the training day provided some direction early in their program development and helped them to move forward with their program. This is supported by the survey finding in which all three respondents found the day to be very useful. Program leaders mentioned that the teleconferences provided some useful ideas which they incorporated into their program. Program leaders participated in both conferences (phoned into the first and presented at the second). One idea obtained from the teleconference was to incorporate snacks into the sessions.

Figure 4: Ratings of usefulness of CMHA mediated partnerships

Survey results suggest that partnerships and connections facilitated by the CMHA were perceived as useful (Figure 3). The MOB training day provided the opportunity for NISA and Bee-Hive to build a relationship. The Bee-Hive now calls NISA members who are in their computer repair program to get computer maintenance support over the phone. NISA also identified that the Bee-Hive has shared some recipe ideas for NISA’s cookbook.

The MOB project team also provided the GFNF program with information via email, although program leaders felt that they did not have the time to sift through the information to incorporate much of it into their program.

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Not useful Somewhat useful Useful Very useful

Partnerships

Connections

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Are partnerships being built?

The most significant relationship built from this program is that between APH and Bee-Hive, although they did have a previous relationship. They identified a mutual desire to do a community kitchen and proceeded to combine resources and submit the MOB expression of interest together. The program leader from Bee-Hive was particularly enthusiastic about this partnership because she and the other program leader shared many of the same values around supporting the mental health population and this was an opportunity for her to run a community kitchen, which she had had trouble with previously.

Program leaders also felt that the new partnership they developed with the retirement facility that donated the space for the program to be among the more valuable of their new relationships. Other important partnerships were also built as a result of this program. Many of these partnerships were with local experts and organizations who presented on education days.

It was noted that many partnerships in the community are built on identifying a mutually beneficial relationship. Program leaders indicated that they could build relationships by offering services in exchange for assistance. This was seen as a key way to help APH clients access needed resources from the community while also ensuring other community members could access APH resources.

Client outcomes Program leaders developed internal evaluation materials intended to capture client outcomes. Program leaders sent evaluation findings to the MOB project evaluation team in hard copy only (a more thorough discussion of this process is described in the following section entitled “Important Learnings and Future Considerations”). A key indicator of success was general positive client feedback which was captured in internal evaluations. Program leaders strongly focused on general positive feedback as an indicator of success of the program which may indicate that the most important goal for program leaders in to engage their clients.

Where applicable, findings from the internal evaluation are linked to client outcomes identified by the MOB project evaluation team and overviewed in the following sections.

Survey Summary Results: • On a 4 point scale ranging from no, somewhat, and yes, very much, 2 out of 3 respondents

believed the MOB pilot project VERY MUCH resulted in new partnerships.[ 1 “didn’t know”]. • Staff believed there were between 5-6 new partnerships created • Partnerships were mainly about information sharing and resource sharing. • Communications occurred primarily through email and phone/conference calls, but staff

believed that “face to face is best.” This may indicated that they relied on face to face communications as well.

• Staff ranged in how much contact they reported with their most useful new partner; one replied five or more times per month, the second answered 40-50 times per month, and the last replied once per month

• The MOB project helped build new partnerships by: o Bringing groups together to help share ideas and build friendships o Providing the opportunity to make new partners (fire department, health inspector and

dietitian) o Supporting common goals of mental health protection

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Awareness and knowledge gained

Clients who participated in the GFNF program started to make the connection between healthy eating and mental health. This was discussed in terms of having energy and feeling good about eating:

“[Eating poorly] doesn’t give you a lot of energy to do anything” (Client 1, client focus group)

“Well if you take the time to prepare your food and you feel better about it rather than just be lazy and eat junk food…” (Client 2, client focus group).

“I actually have food that I have to take out of my fridge that’s healthy and it’s really good for my brain.” (Client 3, client focus group).

As found in the survey, staff also felt clients were making the connection between healthy eating and mental health:

“I certainly heard that from people saying, “You know what, my mental health is better. Is it because I’m eating better or I’m eating better foods, I think that they’re all, connect the dots.” (GFNF staff, staff focus group).

The internal evaluation did not investigate whether clients learned about the connection between healthy eating and mental health. Although this connection was not an explicit goal of the program, clients did learn about the relationship and it will indirectly help support individuals to succeed with their lifestyle changes around healthy eating by knowing that it may also impact their mental health. Making lifestyle changes to promote healthy living is also an important goal of APH.

Improved awareness about the connection may also help the Bee-Hive reach its goal of promoting self-care by demonstrating to clients that they can care for their own mental health by eating well.

Learning and applying new skills

Clients reported learning a number of important skills from participating in the program and applying many of these skills at home (a number of these new skills were also mentioned in the internal evaluations):

• How to manage sodium levels • Cooking skills • Portion control • Budgeting skills

Survey Summary Results: • On a 5 point scale ranging from none, a few, some, most, and all, 3 of 3 respondents believed

that MOST (2) or ALL (1) clients have an increased awareness about the relationship between healthy eating and mental health since enrolling in the program.

Survey Summary Results: • On a 5 point scale ranging from none, a few, some, most, and all, the three staff responded that

MOST (2) or ALL (1) clients have learned different food preferences since enrolling in the program and MOST (2) or ALL (1) clients have learned to apply these preferences.

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• Social skills • Food safety (e.g. using a meat thermometer)

Staff also noted a number of skills clients learned as part of the program, including: reading labels; reading and following recipes; and using flyers when shopping. Staff reported that clients were applying skills in their day to day lives and being very conscious of the food they eat after having participated in the program:

“[Name of participant], she’s always reading the labels, ‘okay, too much salt, no, that’s not good.’” (GFNF staff, staff focus group).

In the internal evaluations, most clients reporting using new skills at home since joining the program. These included cooking skills, food budgeting skills, recipe reading skills and skills around making healthy food choices while at home.

Building skills was listed as a central goal for the GFNF program. Clients not only identified skills they learned in the focus group but were also excited to share all the new tools they had at their disposal due to this program. The program was successful in attaining the goal of teaching these skills and encouraging clients to use them in their daily lives.

Improving access to healthy foods and other community resources

Compared to other skills, clients were less enthusiastic about applying food budgeting skills because budgeting is difficult when money is limited:

“It doesn’t go that well, because it’s all mental [laughs]” (Client 1, client focus group).

“When we have enough money, it’s okay [laughs]” (Client 2, client focus group).

Clients identified that some of them already access healthy food baskets offered locally and have identified ways they can further cut food costs:

“Even the food basket, that would be ideal to split in half, ‘cause I find it too much for one person, like they’ll come out with a sack of potatoes, I hardly eat potatoes.” (Client, client focus group)

Staff were enthusiastic about clients’ use of food budgeting skills, particularly around the use of flyers and how to “smart shop”:

“And they’re using their flyers more often. We bargain-shopped, we smart-shopped… then they came back and then they found out there was still $70 left… you pool money together and you can make it stretch a really long way, and that was something like everybody [learned], ‘cause everyone had an opportunity to go to the grocery store with me…” (GFNF staff, staff focus group).

In addition to teaching food budgeting skills the program also discussed alternative food sources like participating in a community garden, accessing good food box programs, and accessing local farmers’

Survey Summary Results: • On a 5 point scale ranging from none, a few, some, most, and all, the three respondents

believed that MOST (2) or ALL (1) clients have learned how to improve their access to healthy f d

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markets. Unfortunately, Elliot Lake does not currently have a farmers’ market. The other alternatives are available and would be good inexpensive healthy food resources for clients. This program did an excellent job of improving clients’ access to healthy foods during the course of the program, as clients were able to give a relatively small amount of money and get back a significant number of healthy meals for the month. In the future, if a community garden is set up in relation to this program it could serve as an avenue to support food security.

In terms of goals, the program supported the building of food security skills and supported APH’s goal of building healthy communities by enhancing those skills and improving clients’ access to healthy food while they were in the program. Learning skills that improve food security can be viewed as promoting independence, which is a central goal for the Bee-Hive.

Engaging in leadership and peer counselling

Figure 5: Client participation in the program

As reported in the survey (see Figure 4), the program provided opportunities for peer leadership and counselling. Much of the peer leadership that arose from this program was on the part of the consumer volunteers and kitchen support staff. The volunteers felt as though they had an important role to play in the program and showed a great sense of confidence and pride in what they had accomplished. Taking on the new roles not only taught new skills but also helped one volunteer with her own recovery:

“…I’m coming back (Laughs)… I was a BSW, for a peer support group … I also worked … as a coordinator, so I have a lot of learned skills that I put on the backburner and I said, ‘I don’t want to deal with that stuff, I’ve had enough of that for a long time’, so now I’m getting out and I’m coming out of my shell.” (GFNF volunteer, staff focus group)

Staff also noted that other clients were beginning to take on leadership roles, such as being in charge of the group when staff members needed to step away from the kitchen:

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None A few Some Most All

Peer counselng

Leadership

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“…there’s a couple of times where maybe [Name of staff] wasn’t available or [Name of staff], or [Name of staff] and I, so we left other people in charge. We said, “You’re second-hand today…, I’ve seen the change in some folks that their confidence level … they would say, ‘what, you trust me to do that?’ and [I replied] ‘why wouldn’t I?’” (GFNF staff, staff focus group).

The program leader from Bee-Hive also noticed clients initiating peer counselling regarding healthy eating and budget skills with other members of the Bee-Hive:

“[clients from the program who go to other Bee-Hive members and say] ‘hey you know that’s really bad for you?’ [and then the client would] just sit there and I’ll explain it [to the Bee-Hive member]. Someone was doing their shopping list, and [a client of the program said], ‘no look, I brought flyers, let’s sit and do this together and how much money do you have?’ and they did their whole shopping list and the person was going to spend so much and now the person’s only spending very little.” (GFNF staff, staff focus group).

Encouraging clients to assume peer counselling and leadership roles can be seen as a way to promote independence, which is a key goal for the Bee-Hive. It also may help individuals to improve their functioning in the community, which is an important goal for APH. While the GFNF program did not have explicitly stated goals around building peer counselling and leadership through the program, this may contribute to building a sense of hope and optimism for recovery, which was one of the goals of the program.

Improvements in physical health, mental health, social inclusion and community integration Program clients identified some improvements in their physical and mental health that they attributed to being part of the program.

“… more energy” (Client 1, client focus group)

“Since I’ve been on it, I’ve lost a little bit of weight” (Client 2, client focus group).

Staff also noticed one client having improved mobility since starting the program, although it is unclear whether these gains were attributable to the program since it did not include a strong physical activity component.

All clients who participated in the survey felt that they had made improvements in their mental health since participating in the program. For some these gains were around improving their discipline:

“It’s given me some discipline and some routine” (Client, client focus group)

Others felt improvements in mental health were connected to their improved social inclusion and ability to interact with others:

Interviewer: Did any of you feel some changes in that, in your social interaction? Client: Well that’s part of my being better mentally.

Improvements in social inclusion were among the more significant gains identified by clients, staff and program leaders. Clients spoke at length about how interacting with others was an improvement for them since joining this program. Staff and program leaders were very enthusiastic about the gains in social interaction and feelings of inclusion fostered by this program. Staff also reported that the group fostered a sense of belonging:

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“A sense of belonging… “It’s okay to be here”… [clients felt ] “we all belong here, we all have a reason to be here”. (GFNF staff, staff focus group)

In attending the final celebration session, it did feel as though clients had created a strong sense of camaraderie, and demonstrated interest in continuing their new friendships. Program leaders attributed these gains to the significant amount of time the group spent together over a relative short period of time; frequent interaction seemed to support the building of strong bonds not only between clients but also between staff and clients.

Client improvements in physical and mental health, and increased social inclusion, demonstrated that the program was able to meet MOB goals even in the short term. It also met the program goal of creating a sense of inclusiveness and belonging among clients. It will be important to follow-up with these clients to see if they are experiencing continuous gains in these three areas to determine whether these short term changes lead to significant long term gains.

Staff also reported significant improvements in clients’ self-confidence, which is another important part of clients’ mental health.

“People got empowered here, so their self-esteem went up, and when your self-esteem goes up, your mental health does better.” (GFNF staff, staff focus group)

Improving self-confidence and empowerment is a central goal for the Bee-Hive and was also an important goal for the program leader from APH. The program leader from APH saw the building of confidence and independence as key factor in client recovery. Gains in confidence due to this program are important steps towards these goals.

Client outcomes regarding improving physical health and social inclusion were important outcomes for program leaders. Seeing behaviour changes with regards to improved social inclusion between clients and within the broader community, trying new activities, and starting to eat better were among key indicators of success for program leaders. They found that a number of members had begun to exhibit these behaviours and thus considered the program to be successful.

Achieving personal goals Some clients also reported having personal goals when entering the program:

• Improving cooking skills • Learning about what foods are nutritious and what foods are harmful

Having learned cooking skills and information about nutrition, these personal goals were likely met by the program (although this was not explicitly stated by participants). Most clients did not express many personal goals before coming to the program. They were very enthusiastic about the skills they learned, though, and being able to apply them in their day to day lives. In future, it may be helpful to identify personalized program goals for each participant and follow-up on them on an individual basis. Other programs found this was helpful to support case managers in their one on one work with clients as they were able to align program goals to client goals and demonstrate to clients their personal gains.

Staff outcomes The most significant staff outcomes were the leadership skills and confidence gained by the consumer volunteers. Other staff also noted some important learning about how their clients interact with each other. For instance staff were concerned there could be challenges in one group due to the diversity,

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such as younger, louder members mixed with older, quieter members. Instead, they found that being around the younger members gave both the older clients and staff the opportunity to remember what it was like being young and demonstrated to staff that a wide variety of individuals could get along despite what seem to be significant differences.

Organizational outcomes A valuable organizational outcome from the program leaders’ perspective was acknowledgement regarding the importance of building independence in clients as part of the community mental health and addictions mandate. Program leaders felt as though directors at the organizational level were beginning to see the value of building independence among clients as part of their programs. This was an important goal for the program leader at APH, which she felt was being supported by this program. What is not clear, however, is whether this program alone has raised awareness at the organizational level about the importance of building independence. It seemed as though this program was one of several other activities taken on by the program leader from APH that were providing evidence to support this goal.

The APH Board strongly supported this program. Program information and learning from the development and implementation of the GFNF program will have a direct impact on future community kitchen programs currently being planned by APH. The program supervisor was drawing upon the experiences from the GFNF program to help build a new community kitchen in Wawa and the program will likely have an impact on existing community kitchen programs in Blind River and Sault Ste. Marie. The program supervisor was particularly looking forward to the internal (and MOB) evaluations to help identify promising practices to pass on to the other programs.

For the Bee-Hive the most significant outcome was the opportunity to run a community kitchen and create a new and strong partnership with APH. The program leaders from APH and Bee-Hive seemed keen to continue to work together on this, and potentially other, future projects. This could have an impact on the Bee-Hive’s capacity to run more programs and could also increase their membership by making them more visible in the community. Both program leaders suggested that the program was getting significant recognition in the community, which would likely impact the visibility of both APH and Bee-Hive.

“…we actually take the time to explain to them what we’re doing and what it’s all about and they’ll say, ‘wow, this is fantastic’” (GFNF program leader, staff focus group).

Were there unexpected outcomes (clients, staff, organization)? At the client level, an unexpected outcome was a client losing weight when they needed to actually put on weight. Staff identified this as a potential concern given that the client was advised by a physician to put on weight. This demonstrates that healthy eating programs need to be aware of their clients’ dietary needs before the start of the program. There may be a need to include information on weight gain as well as weight loss as part of these programs — particularly if there are clientele who suffer from weight-related mental illness like anorexia nervosa or bulimia.

Staff were also surprised at some of the more striking gains by some of the clients in the group. One member in particular who they were concerned would be too “negative” to enjoy or stick with the program demonstrated a significant improvement in overall mood by the end of the program:

“…she’s blowing me away here, she’s doing great, and she hasn’t been negative, she’s actually been really encouraging and empowering and positive and wow, what a breath of fresh air it’s been!” (GFNF staff, staff focus group).

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Staff, and clients, were also genuinely surprised that all the clients got along so well:

“You never know what’s going to happen, and a couple of members said, and [Name of staff] even said too this morning, “There was no scrapping!” Not even disagreements” (GFNF staff, staff focus group)

Important Learnings and Future Considerations

Program challenges The program faced a number of challenges which were dealt with over the course of the program. A significant challenge for the APH program leader was being able to access the MOB pilot funds in order to purchase food and other supplies needed for the program. The funds were held by the APH Sault Ste. Marie site and the program leader in Elliot Lake was unable to access funds until after purchases were made and she could be reimbursed. The program leader’s role would have been facilitated by having direct access to funds for the program.

Another challenge was time. Program leaders felt they were putting in more hours to plan and deliver the program than previously expected. Program leaders identified two possible solutions to the time issue: having more of their time dedicated to running this program (taken from other duties); or having access to a stock of food as was the case in the community kitchen they visited (linked to the food bank).

Evaluation Program leaders struggled with the internal evaluations. They had not developed any evaluation tools as of the teleconference on November 29th. When they did develop evaluations in early December, program leaders consulted with the MOB evaluation team with regard to their internal evaluations, but they did not have time to get these started until halfway through the program. By the time the evaluation forms were finalized it was the end of the program. Staff asked clients who attended the final session to fill out all evaluation forms for each education session and an overall evaluation form for the cooking classes. This meant that a number of the participants who attended earlier sessions but who were not at the final session (mostly due to illness) were unable to respond to evaluations.

Clients found it difficult to remember how they felt about past sessions and many of them got tired of filling out so many forms all at once. A few of the clients also had some difficulty with having to read so much information at once and required assistance filling out the forms. As a result, not all evaluation forms were filled out and the program missed important client feedback.

This program would have benefited greatly from significantly more support in developing their internal evaluations before the start of the GFNF program. A consultation at an earlier point may have revealed the difficulty they were experiencing and support could have been offered then. It may be of value to assess an organization’s evaluation capacity as part of the pilot selection process in order to identify which organizations will need added support before the start of the program.

Future Needs and Program Changes When asked about future needs, program leaders and staff identified a few key issues and provided suggestions for future healthy eating programs:

Funding: Program leaders identified that they were looking to apply for future funding in order to keep the program going. Funding would pay for staff hours and potentially pursuing a new location. However, it is expected that the current kitchen could still be used for future programs.

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Time: Program leaders were concerned the program would be unsustainable given they cannot continue to allot as much time to the program in future.

Program changes: • Reduce paperwork and classroom time as a means to boost participation.

o The program supervisor found that the Sault St. Marie community kitchen, which was place before the GFNF program, had better attendance and did not have such a strong classroom focus.

o The program leader was concerned about the amount of evaluation paperwork given at the end of the program, and was particularly concerned with how this impacted clients who have literacy problems.

• Incorporate a community garden project as part of the community kitchen program (i.e., cook the food you grow). This could help the program to reduce the time required to pick up food at the grocery store by providing the community kitchen with a stock of healthy foods (similar to how the local food bank community kitchen was run).

Summary Overall, the GFNF program was able to meet many of the goals of the MOB program. Client outcomes demonstrate early improvements in physical and mental health, as well as improved social inclusion. The program was able to build on the community of practice in Elliot Lake by supporting new partnerships between APH, the Bee-Hive and other local organizations and experts. The amount of communication between partners, however, was unclear, and the type of communication seemed to be mostly informal. APH and the Bee-Hive also connected with other MOB pilot sites through the teleconferences and a new relationship between NISA and Bee-Hive was developed.

The GFNF program was able to meet a number of the organizational goals of APH and Bee-Hive through teaching clients skills to help improve client functioning, building social inclusion and a sense of belonging, and by promoting independence in clients. This last goal, while already important to the Bee-Hive is not a goal explicitly recognized by APH. The APH program leader was confident this program demonstrated to APH board members that promoting independence through programs was an important goal and should be included in the community health and addictions mandate.

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Appendix A: Photos

Figure 5. A holiday celebration and healthy holiday lunch cooked by staff: roasted turkey and stuffing, home-made rolls, green salad, mashed potatoes, peas and carrots, curried sweet potato and cauliflower

Figure 6. Wrapping up the program after lunch

Figure7. Kitchen

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Figure 8. Healthy eating messages were posted all around kitchen

Figure 9. Health and safety messages posted around kitchen

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Figure10. Good Food, New Friends program staff