HD: Food Security (2011)
Citation:
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
Purpose: To determine the effect of Food Stamp Nutrition Education in Indiana on participants' food insecurity and food insufficiency.
Hypothesis: The series of five tailored educational lessons provided through Food Stamp Nutrition Education would improve a participant's self-reported food security level and food sufficiency compared with participants receiving no Food Stamp Nutrition Education.
Inclusion Criteria:
- Eligible to receive Food Stamp Nutrition Education services
- ≥18 years or older
- Qualified to receive food stamps or under 130% of the income-to-poverty ratio
- Head of household, or person responsible for food purchases and food dollar management
- Women.
Exclusion Criteria:
- Not eligible to receive Food Stamp Nutrition Education Services
- Men.
Description of Study Protocol:
Recruitment
- Food Stamp Nutrition Education assistants were asked to volunteer to recruit participants
- Assistants from 28 Indiana counties volunteered
- Assistants from 24 Indiana counties recruited participants
- Counties were composed of a representative mix of urban and rural areas.
Design
Single-blind randomized design
Blinding used
- Food Stamp Nutrition Education assistants randomly assigned participants into the experimental or control group
- Clients arriving together were assigned to the same group to prevent knowledge of a difference in treatment.
Intervention
- Food Stamp Nutrition Education lessons targeting food insecurity and nutrition
- Education provided based on theoretical framework of social cognitive theory
- Participants spend time with Food Stamp Nutrition Education assistant, a peer educator and a paraprofessional trained in nutrition education
- Food Stamp Nutrition Education assistant models food preparation, healthful food selection, and cooking skills
- Lessons include interactive presentation of the ideas discussed (e.g., preparing a meal, learning how to read food labels, visual examples of more and less healthful foods, practical tips on budgeting and thrifty food purchasing)
- Lessons include five topical domains: MyPyramid, food groups, food safety, shopping behaviors and resource management and wellness.
Statistical Analysis
- Chi-square analysis was used to compare participants' characteristics
- Each measured independent variable and proportion of individuals classified to the various levels of food security or food insufficiency were compared
- Pre-test, post-test and test difference scores were compared by two-sample T-test using the Satterthwaite test to account for sample size differences
- Analysis of covariance models were constructed to find the effect of treatment group on food insecurity and food insufficiency
- Missing data for the six-item US Food Security Scale were assigned values using the method outlined in the USDA Guide to Measuring Household Food Security
- All statistical analysis were performed with SAS (Version 9.1, SAS Institute Inc., Cary, North Carolina, 2003).
Data Collection Summary:
Timing of Measurements
- Participants were recruited, lessons were delivered,and food security questionnaires were collected from January 27, 2005 through October 14, 2005
- Experimental Group
- One Food Stamp Nutrition Education lesson
- Complete questionnaire including food security or insufficiency measures
- Receive four additional Food Stamp Nutrition Education lessons
- Complete questionnaire again
- Control (Delayed-Lesson) Group
- One Food Stamp Nutrition Education lesson
- Complete questionnaire including food security or insufficiency measures
- Wait five weeks
- Complete questionnaire again
- Receive four additional Food Stamp Nutrition Education lessons.
Dependent Variables
- Food insecurity quantified with six-item United States Household Food Security Scale
- Modified to direct the participants to consider food eaten in their households over the past 30-days instead of the past 12 months
- Food insufficiency quantified with United States Department of Agriculture Food Insufficiency Question.
Independent Variables
Food Stamp Nutrition Education lessons targeting food insecurity and nutrition
Control Variables
- Age
- High school diploma
- Marital status
- Household employment
- Number fed in household
- Food stamp use.
Description of Actual Data Sample:
- Initial N: N=236
- Attrition (final N): N=219
- N=137, experimental group
- N=82, control group
- Age: ≥18 years
- 18-39 years
- N=91, experimental group
- N=55, control group
- 40-59 years
- N=18, experimental group
- N=10, control group
- 60-100 years
- N=27, experimental group
- N=17, control group
- 18-39 years
- Ethnicity:
- 96.8% non-Hispanic white
- 2.3% Hispanic
- 0.5% black
- 0.5% other
- Other relevant demographics:
- Female
- Head of household
- High School diploma
- Yes
- N=94, experimental group
- N=57, control group
- No
- N=43, experimental group
- N=25, control group
- Yes
- Marital status
- Married/with partner
- N=77, experimental group
- N=38, control group
- Single adult
- N=60, experimental group
- N=44, control group
- Married/with partner
- Household employment
- Yes
- N=74, experimental group
- N=35, control group
- No
- N=63, experimental group
- N=47, control group
- Yes
- Number fed in household
- One
- N=21, experimental group
- N=18, control group
- Two
- N=16, experimental group
- N=15, control group
- Three or more
- N=100, experimental group
- N=49, control group
- One
- Food Stamp use
- Yes
- N=72, experimental group
- N=37, control group
- No
- N=65, experimental group
- N=45, control group
- Yes
- Anthropometrics: Information not provided
- Location: 24 Indiana counties
- Food Stamp Nutrition Education lessons and food security questionnaires completed in client homes or at community locations where the clients were recruited
- County offices of Special Supplemental Nutrition Program for Women, Infants and Children
- Head Start centers
- Food pantries.
- Food Stamp Nutrition Education lessons and food security questionnaires completed in client homes or at community locations where the clients were recruited
Summary of Results:
Key Findings
- Food security in the experimental group compared with the control group was significantly improved (R2=0.3073, β -0.37±0.17, P=0.03) after adjusting for pretest score and employment
- Food insufficiency in the experimental group compared with the control group was significantly improved (R2=0.4384, β -0.08±0.04, P=0.04) after adjusting for pre-test score.
Other Findings
- No significant differences between control and experimental groups
- In self-reported characteristics of control and experimental groups
- In initial food security or food insufficiency status
- In proportion of individuals classified as food secure, food insecure without hunger, or food insecure with hunger
- 40% of participants were food insecure.
Author Conclusion:
- Food Stamp Nutrition Education was successful in improving participants' food insecurity and food insufficiency, indicating nutrition education is an appropriate intervention for food insecurity
- Employed Food Stamp Nutrition Education participants and/or those with employed partners were able to improve household food security more than households without employment.
Funding Source:
University/Hospital: | Purdue University Extension Program |
Reviewer Comments:
- Results may not apply to a more racially or ethnically diverse population
- Asking about food security for the past 30 days immediately after lesson five may not have accurately captured the impact of the lessons.
Quality Criteria Checklist: Primary Research
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Relevance Questions | |||
1. | Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) | Yes | |
2. | Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? | Yes | |
3. | Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? | Yes | |
4. | Is the intervention or procedure feasible? (NA for some epidemiological studies) | Yes | |
Validity Questions | |||
1. | Was the research question clearly stated? | Yes | |
1.1. | Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? | Yes | |
1.2. | Was (were) the outcome(s) [dependent variable(s)] clearly indicated? | Yes | |
1.3. | Were the target population and setting specified? | Yes | |
2. | Was the selection of study subjects/patients free from bias? | Yes | |
2.1. | Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? | Yes | |
2.2. | Were criteria applied equally to all study groups? | Yes | |
2.3. | Were health, demographics, and other characteristics of subjects described? | Yes | |
2.4. | Were the subjects/patients a representative sample of the relevant population? | Yes | |
3. | Were study groups comparable? | Yes | |
3.1. | Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) | Yes | |
3.2. | Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? | Yes | |
3.3. | Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) | Yes | |
3.4. | If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? | N/A | |
3.5. | If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) | N/A | |
3.6. | If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? | N/A | |
4. | Was method of handling withdrawals described? | No | |
4.1. | Were follow-up methods described and the same for all groups? | Yes | |
4.2. | Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) | No | |
4.3. | Were all enrolled subjects/patients (in the original sample) accounted for? | Yes | |
4.4. | Were reasons for withdrawals similar across groups? | ??? | |
4.5. | If diagnostic test, was decision to perform reference test not dependent on results of test under study? | N/A | |
5. | Was blinding used to prevent introduction of bias? | Yes | |
5.1. | In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? | Yes | |
5.2. | Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) | No | |
5.3. | In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? | N/A | |
5.4. | In case control study, was case definition explicit and case ascertainment not influenced by exposure status? | N/A | |
5.5. | In diagnostic study, were test results blinded to patient history and other test results? | N/A | |
6. | Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? | Yes | |
6.1. | In RCT or other intervention trial, were protocols described for all regimens studied? | Yes | |
6.2. | In observational study, were interventions, study settings, and clinicians/provider described? | N/A | |
6.3. | Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? | Yes | |
6.4. | Was the amount of exposure and, if relevant, subject/patient compliance measured? | Yes | |
6.5. | Were co-interventions (e.g., ancillary treatments, other therapies) described? | N/A | |
6.6. | Were extra or unplanned treatments described? | N/A | |
6.7. | Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? | Yes | |
6.8. | In diagnostic study, were details of test administration and replication sufficient? | N/A | |
7. | Were outcomes clearly defined and the measurements valid and reliable? | Yes | |
7.1. | Were primary and secondary endpoints described and relevant to the question? | Yes | |
7.2. | Were nutrition measures appropriate to question and outcomes of concern? | Yes | |
7.3. | Was the period of follow-up long enough for important outcome(s) to occur? | Yes | |
7.4. | Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? | Yes | |
7.5. | Was the measurement of effect at an appropriate level of precision? | Yes | |
7.6. | Were other factors accounted for (measured) that could affect outcomes? | Yes | |
7.7. | Were the measurements conducted consistently across groups? | Yes | |
8. | Was the statistical analysis appropriate for the study design and type of outcome indicators? | Yes | |
8.1. | Were statistical analyses adequately described and the results reported appropriately? | Yes | |
8.2. | Were correct statistical tests used and assumptions of test not violated? | Yes | |
8.3. | Were statistics reported with levels of significance and/or confidence intervals? | Yes | |
8.4. | Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? | N/A | |
8.5. | Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? | Yes | |
8.6. | Was clinical significance as well as statistical significance reported? | N/A | |
8.7. | If negative findings, was a power calculation reported to address type 2 error? | N/A | |
9. | Are conclusions supported by results with biases and limitations taken into consideration? | Yes | |
9.1. | Is there a discussion of findings? | Yes | |
9.2. | Are biases and study limitations identified and discussed? | Yes | |
10. | Is bias due to study's funding or sponsorship unlikely? | Yes | |
10.1. | Were sources of funding and investigators' affiliations described? | Yes | |
10.2. | Was the study free from apparent conflict of interest? | Yes | |