HD: Food Security (2011)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To determine factors associated with food stamp program participation among potentially eligible women participating in the California Women's Health Survey from 2002 to 2004. The researchers specifically investigated what factors are associated with participation, how reasons for not applying may differ and if women stating that they do not need food stamps are truly less needy than women who give other reasons for not applying.

Inclusion Criteria:

Participants were part of the California Women's Health Survey, an ongoing annual telephone survey collecting information on health-related behaviors and attitudes from a randomly selected sample of women. A screened random-digit dial sample was used; all women age 18 and older living in the selected household are eligible to participate in the survey. If more than one woman per household was eligible, one woman was randomly selected for the survey interview.

Exclusion Criteria:

None were discussed.

Description of Study Protocol:

Recruitment

Participants were part of the ongoing annual telephone California Women's Health Study (CWHS), a randomly selected sample of women. Interviewers made two additional attempts to recruit participants who initially refused to participate. 15 attempts were made to reach households with busy signals, who did not answer or with answering machines.

Design

The CWHS collected data through telephone surveys. The questionnaire was approximately 200 questions and took about 30 minutes to administer in English. Trained interviewers called participants and conducted the surveys in English or Spanish. The survey asked about past and present involvement in health care systems, participation in public and food assistance programs, food insecurity, prenatal care, breastfeeding, vitamin use, physical activity, substance use, utilization of cancer-screening procedures, domestic violence and demographic information.  

Intervention

Participation in the Food Stamp Program.

Statistical Analysis

Bivariate analyses were done using chi-squared analysis. Multivariate analyses using logistic regression were done to identify factors related to food stamp participation. All multivariate analyses were done adjusting or controlling for income level. Best variables (P<0.10) were selected using stepwise procedures in three stages, including best demographic variables, best other private and public assistance and best health and psychosocial variables. The final step looked at the best candidate variables in a stepwise logistic regression analysis, using variables that were significant at P<0.05 from each stage. Additional chi-squared analyses were done to see if reasons for not applying for food stamps and the level of perceived need differed among sub-groups less likely to be Food Stamp Program participants. For the potential effects of US citizenship status, the sample was restricted in some of the analyses to either US born women or foreign-born women likely to have at least one US born child.  

Data Collection Summary:

Timing of Measurements

Data were collected from the surveys monthly, from January through December. The surveys were conducted from 2002 to 2004. Participants completed the survey once.

Dependent Variables

Food Stamp Program participation.

Independent Variables

  • Reasons for not applying to the Food Stamp Program:
    • No need: "I don't need them"
    • Lack of information: "Don't think I'm eligible" or "don't know how to get them"
    • Too hard: "Too hard to apply"
    • Stigma: "Don't want government help" or "too embarrassed"
    • US citizenship: "Worried about US citizenship status"
  • Level of need:
    • Food security level (based on a six-item subset of the federal Food Security Module)
    • Considers income adequate for basic needs (yes or no)
    • Use of emergency food banks (yes or no).
Description of Actual Data Sample:
  • Initial N: 527 food stamp participants and 1,405 potentially eligible non-participants
  • Attrition (final N): To identify reasons why women do not participate in the Food Stamp Program [FSP], responses were available on 1,390 potentially eligible non-participants
  • Age: All participants were age 18 or older. Of the FSP participants, 100 were age 18 to 24, 395 were age 25 to 54, and 32 were age 55 or older. Of the potentially eligible non-participants, 355 were 18 to 24, 700 were 25 to 54 and 350 were 55 or older.
  • Ethnicity: Participants identified themselves as white, black, Hispanic, or other. Of the FSP participants, 145 were white, 82 were black, 245 were Hispanic and 55 were other. Of the potentially eligible non-participants, 365 were white, 81 were black, 762 were Hispanic, and 197 were other.
  • Other relevant demographics: To be potentially eligible for the FSP, household income was less than 130% of the federal poverty level.
  • Location: California.
Summary of Results:

Key Findings

  • Self-reported Food Stamp Program participation was 27% among all potentially eligible households. This rate increased to 31.7% when only households with US-born women and children were considered.
  • Independent and positive factors for food stamp participation were:
    • Single mother with children
    • Unemployed
    • On welfare
    • On WIC
    • US-born
  • Women under 25 and older than 54 were less likely to participate than women age 25 to 54
  • US-born was positively associated with participation in the models, including all potentially eligible households, while Hispanic/Latino ethnicity was negatively associated with participation
  • The main reason for not applying among all types of households is "don't need them," but more than one-third either don't think they are eligible for food stamp participation or don't know how to apply
  • Younger women were more likely to say "don't need them" as a reason for not applying, while 31% of women age 55 and older think they are not eligible
  • Potentially eligible non-participants who said "don't need them" as a reason for not using food stamps  are less likely to be food insecure, to have inadequate income and to use alternative emergency aid
  • Those who say worry about US citizenship or stigma are reasons for not applying have the highest level of need.
Characteristics Food Stamp Program Participants Potentially Food Stamp Program-eligible Non-participants Statistical Significance of Group Difference
Race/ethnicity   P<0.0001 
White 

145 (27.6%)

365 (26.0%)

 
Black 

82 (15.6%) 

81 (5.8%) 

 
Hispanic 

245 (46.4%) 

762 (54.2%) 

 
Other 

55 (10.5%) 

197 (14.0%) 

 
Marital/child status    P<0.0001 
Single with children

337 (64.0%)

386 (27.5%)

 
Married with children 

132 (25.0%)

394 (28.1%)

 
Single, no children 

40 (7.6%)

493 (35.1%)

 
Married, no children 

18 (3.5%)

131 (9.3%)

 
Age    P<0.0001 
18 to 24 years 

100 (18.9%)

355 (25.3%)

 
25 to 54 years 

395 (74.9%)

700 (49.8%)

 
55 years and older 

32 (6.2%)

350 (24.9%) 

 
Unemployed  170 (32.2%)  308 (21.9%)  P<0.0001 
Immigrant/birthplace   
US-born 

335 (63.6%)

659 (46.9%)

P<0.0001

Born in Latin America 

158 (30.0%)

592 (42.1%) 

P<0.0001 

Interviewed in Spanish 

147 (27.9%)

544 (38.7%)

P<0.0001

Use of public or private or other food assistance or services    P<0.0001
Welfare/TANF 

323 (61.3%)

28 (2.0%)

 
WIC

228 (43.3%)

264 (18.8%) 

 
Emergency food banks   85 (16.1%)

81 (5.8%)

 
Formerly in foster care 

59 (11.2%)

31 (2.2%)

 
Has medical insurance 

123 (23.3%)

274 (40.3%)

 
Psychosocial and health status    
Domestic violence 

61 (11.6%)

69 (4.9%) 

P<0.0001 

Poor mental or physical health 

229 (43.5%)

492 (35.0%)

P<0.01

Feeling overwhelmed 

292 (55.5%)

575 (40.9%) 

P<0.0001

Sadness 

372 (70.6%)

910 (64.8%)

P<0.0001 

Self-reported health (excellent or good) 

174 (33.1%)

472 (33.6%) 

NS

Pregnant 

33 (6.2%)

49 (3.5%)

P<0.0001 

Has mental, physical or emotional problem that limits activities 

125 (23.8%)

293 (20.9%)

P<0.01 

 

Factors Associated with Food Stamp Program Participation  Adjusted OR          95% CI
Single with children 2.28 1.68, 3.09
Unemployed 2.06 1.77, 2.44
US-born 1.77 1.46, 2.14
Welfare/TANF 64.10 52.2, 78.9
WIC 2.55 2.16, 3.02

Other Findings

Of potentially eligible low-income women not applying for the Food Stamp Program:

  • 85.3% citing stigma were food insecure (P<0.0001)
  • 74.5% citing stigma had an income inadequate for basic needs (P<0.0001)
  • 94.1% citing worry about citizenship were food insecure (P<0.0001)
  • 85.4% citing worry about citizenship had an income inadequate for basic needs (P<0.0001). 

 

Author Conclusion:
  • The strongest positive predictors of Food Stamp Program participation are welfare, unemployment and single motherhood; these are consistent with the view that the Food Stamp Program in California is serving a very high-need population.
  • Barriers to applying and stigma are reported more often among potentially eligible foreign-born women compared to US-born women
  • Older women cite reasons related to lack of information more often than stigma. Since women experience more health problems with age, greater Food Stamp Program outreach through healthcare providers and senior services may be helpful.
  • Of concern are the very high rates of food insecurity among women who do not apply for reasons related to stigma and fear
  • Greater Food Stamp Program outreach through trusted community-based channels may be needed. The outreach message to the low-income population should highlight the benefits of using foods stamps to purchase a more healthful diet for the family.
  • Potentially eligible individuals need to understand that food stamps are not just for those in a crisis situation but are also meant to help the working poor, low-income seniors and struggling families
  • In addition to promoting the benefits of the Food Stamp Program to purchase a healthful diet, other steps are needed to simplify the application process, make people aware of their eligibility and improve customer service.
Funding Source:
Government: California Department of Social Services
Reviewer Comments:
  • Limitations discussed by the author include the fact that the analysis attempted to determine potential US citizenship based on whether the participant was US born or had a child after immigrating to the US. Participants may have returned to their home country to give birth, so this method is not a definitive way to determine citizenship.
  • The author recommends adding another follow-up question to the survey, asking foreign-born women if any household members are US-born or US citizens.
  • Another limitation is that the California Women's Health Study could not analyze rural and urban differences in Food Stamp Program participation.
Quality Criteria Checklist: Primary Research
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) N/A
  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) N/A
 
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.) N/A
  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? Yes
  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.) Yes
  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? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  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? No
  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? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  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? Yes
  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? Yes
  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