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To use cognitive interviewing and pilot testing to develop a survey instrument feasible for administering in the food pantry setting to assess daily intake frequency from several major food groups and dietary correlates (e.g. fruit and vegetable barriers) – the FRESH Foods Survey.
New and existing survey items were adapted and refined following cognitive interviews. After piloting the survey with food pantry users in the USA, preliminary psychometric and construct validity analyses were performed.
Three US food banks and accompanying food pantries in Atlanta, GA, San Diego, CA, and Buffalo, NY.
Food pantry clients (n 246), mostly female (68 %), mean age 54·5 (sd 14·7) years.
Measures of dietary correlates performed well psychometrically: Cronbach’s α range 0·71–0·90, slope (α) parameter range 1·26–6·36, and threshold parameters (β) indicated variability in the ‘difficulty’ of the items. Additionally, all scales had only one eigenvalue above 1·0 (range 2·07–4·71), indicating unidimensionality. Average (median, Q1–Q3) daily intakes (times/d) across six dietary groups were: fruits and vegetables (2·87, 1·87–4·58); junk foods (1·16, 0·58–2·16); fast foods and similar entrées (1·45, 0·58–2·03); whole-grain foods (0·87, 0·58–1·71); sugar-sweetened beverages (0·58, 0·29–1·29); milk and milk alternatives (0·71, 0·29–1·29). Significant correlations between dietary groups and dietary correlates were largely in the directions expected based on the literature, giving initial indication of convergent and discriminant validity.
The FRESH Foods Survey is efficient, tailored to food pantry populations, can be used to monitor dietary behaviours and may be useful to measure intervention impact.
Increased out-of-pocket health-care expenditures may exert budget pressure on low-income households that leads to food insecurity. The objective of the present study was to examine whether older adults with higher chronic disease burden are at increased risk of food insecurity.
Secondary analysis of the 2013 Health and Retirement Study (HRS) Health Care and Nutrition Study (HCNS) linked to the 2012 nationally representative HRS.
Respondents of the 2013 HRS HCNS with household incomes <300 % of the federal poverty line (n 3552). Chronic disease burden was categorized by number of concurrent chronic conditions (0–1, 2–4, ≥5 conditions), with multiple chronic conditions (MCC) defined as ≥2 conditions.
The prevalence of food insecurity was 27·8 %. Compared with those having 0–1 conditions, respondents with MCC were significantly more likely to report food insecurity, with the adjusted odds ratio for those with 2–4 conditions being 2·12 (95 % CI 1·45, 3·09) and for those with ≥5 conditions being 3·64 (95 % CI 2·47, 5·37).
A heavy chronic disease burden likely exerts substantial pressure on the household budgets of older adults, creating an increased risk for food insecurity. Given the high prevalence of food insecurity among older adults, screening those with MCC for food insecurity in the clinical setting may be warranted in order to refer to community food resources.
To facilitate the introduction of food insecurity screening into clinical settings, we examined the test performance of two-item screening questions for food insecurity against the US Department of Agriculture’s Core Food Security Module.
We examined sensitivity, specificity and accuracy of various two-item combinations of questions assessing food insecurity in the general population and high-risk population subgroups.
2013 Current Population Survey December Supplement, a population-based US survey.
All survey participants from the general population and high-risk subgroups.
The test characteristics of multiple two-item combinations of questions assessing food insecurity had adequate sensitivity (>97 %) and specificity (>70 %) for widespread adoption as clinical screening measures.
We recommend two specific items for clinical screening programmes based on their widespread current use and high sensitivity for detecting food insecurity. These items query how often the household ‘worried whether food would run out before we got money to buy more’ and how often ‘the food that we bought just didn’t last and we didn’t have money to get more’. The recommended items have sensitivity across high-risk population subgroups of ≥97 % and a specificity of ≥74 % for food insecurity.
To examine the association between level of food security and diabetes self-management among food pantry clients, which is largely not possible using clinic-based sampling methods.
Cross-sectional descriptive study.
Community-based food pantries in California, Ohio and Texas, USA, from March 2012 through March 2014.
Convenience sample of adults with diabetes queuing at pantries (n 1237; 83 % response). Sampled adults were stratified as food secure, low food secure or very low food secure. We used point-of-care glycated Hb (HbA1c) testing to determine glycaemic control and captured diabetes self-management using validated survey items.
The sample was 70 % female, 55 % Latino/Hispanic, 25 % white and 10 % black/African American, with a mean age of 56 years. Eighty-four per cent were food insecure, one-half of whom had very low food security. Mean HbA1c was 8·1 % and did not vary significantly by food security status. In adjusted models, very-low-food-secure participants, compared with both low-food-secure and food-secure participants, had poorer diabetes self-efficacy, greater diabetes distress, greater medication non-adherence, higher prevalence of severe hypoglycaemic episodes, higher prevalence of depressive symptoms, more medication affordability challenges, and more food and medicine or health supply trade-offs.
Few studies of the health impact of food security have been able to examine very low food security. In a food pantry sample with high rates of food insecurity, we found that diabetes self-management becomes increasingly difficult as food security worsens. The efficacy of interventions to improve diabetes self-management may increase if food security is simultaneously addressed.
To examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes.
Using a cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies.
An urban medical centre, between June and December 2013.
Four hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes.
Of respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80).
While food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.
To develop a conceptually equivalent Chinese-language translation of the eighteen-item US Household Food Security Survey Module.
In the current qualitative study, we (i) highlight methodological challenges which arise in developing survey instruments that will be used to make comparisons across language groups and (ii) describe the development of a Chinese-language translation of the US Household Food Security Survey Module, called the San Francisco Chinese Food Security Module.
Community sites in San Francisco, CA, USA.
We conducted cognitive interviews with twenty-two community members recruited from community sites hosting food pantries and with five professionals recruited from clinical settings.
Development of conceptually equivalent surveys can be difficult. We highlight challenges related to dialect, education, literacy (e.g. preferences for more or less formal phrasing), English words and phrases for which there is no Chinese language equivalent (e.g. ‘balanced meals’ and ‘eat less than you felt you should’) and response formats. We selected final translations to maximize: (i) consistency of the Chinese translation with the intent of the English version; (ii) clarity; and (iii) similarities in understanding across dialects and literacy levels.
Survey translation is essential for conducting research in many communities. The challenges encountered illustrate how literal translations can affect the conceptual equivalence of survey items across languages. Cognitive interview methods should be routinely used for survey translation when such non-equivalence is suspected, such as in surveys addressing highly culturally bound behaviours such as diet and eating behaviours. Literally translated surveys lacking conceptual equivalence may magnify or obscure important health inequalities.
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