Health Disparities

HD: Food Security (2011)

Assessment
What are effective intervention strategies that have been identified to assist food insecure individuals in meeting their nutritional needs?
- Conclusion
  10 studies (one randomized controlled trial, five cross-sectional studies, two trend studies, one nonrandomized controlled trial, and one narrative review) evaluated various intervention strategies to determine their effectiveness in assisting food insecure individuals in meeting their nutritional needs.
  
  Characteristics of effective interventions included the following:
  
  Methods
  - Participation in the Food Stamp Program
  - Including fruits and vegetables in the WIC package
  - Providing vouchers for the purchase of fresh fruits and vegetables
  - Fruit and vegetable vouchers to be used at a traveling “store”
  - Encouraging Farmers' Market nutrition programs
  - Tailoring efforts to the culture and language of the targeted population
  - Advocacy for efforts to address adult and child/adolescent stressors (i.e., drug and alcohol abuse, domestic violence, financial strain, health insurance issues, unemployment)
  - Advocacy for efforts to improve the social capital of persons at risk for food insecurity (i.e., education level, participation in social and civic groups, access to transportation, access to employment)
  - Advocacy for efforts to improve access to fresh fruits and vegetables in the home, particularly for adolescents
  - Policies and nutrition education interventions that take into account the needs of the working poor, including time pressures that increase the difficulty of preparing healthful meals at home (i.e., time-intensive meals such as those recommended in the Thrifty Food Plan)
  - Nutrition education interventions focused on increasing home meal preparation, including time-saving meal preparation, shopping and cooking techniques
  - Advocacy for efforts to improve access to healthful foods, including community initiatives to bring supermarkets to low-income areas
  - Advocacy for efforts to ease the application process for food stamps
  - Outreach efforts to persons eligible for the Food Stamp Program.
  Providers
  - Food Stamp Program staff
  - WIC program staff
  - Trained interviewers
  - Nutrition educators.
  Frequency and Duration
  
  A variety of frequencies and duration were effective, including one-time encounters and ongoing interventions lasting six months.
  
  Settings
  - Food Stamp Program offices
  - WIC clinics
  - Schools located in low-income areas, including middle and high schools
  - Community programs serving low-income families and individuals
  - Farmers’ Markets
  - Health Clinics
  - Food banks
  - Homes.
- Grade: I
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective intervention strategies that have been identified to assist the food insecure in meeting their nutritional needs?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010
What are effective nutrition education strategies that have been identified to improve food security among limited resource populations?
- Conclusion
  Five studies (two randomized controlled trials and three cross-sectional studies) evaluated various nutrition education interventions to determine their effectiveness in improving food security among adults and children with with varying socio-economic status, racial/ethnic groups or geographic locations.
  
  Tailoring the intervention to the culture and language of the target population was a key feature of effective programs.
  
  Characteristics of effective interventions included the following:
  
  Methods
  - Based on learner-focused education and the social cognitive theory
  - Data was used to plan targeted interventions
  - Interactive group nutrition education classes, including group discussions, participatory activities, modeling by instructors of healthful food selection and other healthful behaviors
  - Cooking demonstrations, including provision of appropriate recipes
  - Written materials including worksheets, recipes, handouts and visual representations of appropriate foods and portion sizes
  - Instructor explanations, including instruction in food label reading, budgeting and thrifty food purchasing, resource management, use of MyPyramid, food safety education, appropriate shopping behaviors and wellness
  - Fruit and vegetable vouchers to be used at a traveling “store”
  - Instructional video games for children
  - Focus groups to determine targeted interventions.
  Providers
  - Registered Dietitians (RDs)
  - Graduate students supervised by RDs
  - Food Stamp Nutrition Education (FSNE) program staff
  - FSNE program trained assistants
  - Food Stamp Program staff
  - Trained peer educators
  - Paraprofessionals trained in nutrition education, group class facilitation and interviewing
  - Cooperative Extension staff.
  Frequency and Duration
  
  A variety of frequencies and duration were effective, including one-time encounters and weekly or monthly lessons ranging from five weeks to six months.
  
  Settings
  - Food Stamp Program offices
  - WIC clinics
  - Schools located in low-income areas
  - Community programs serving low-income families and individuals
  - Expanded Food and Nutrition Education Program (EFNEP) sites
  - Welfare to Work Program sites
  - Sites where low-income persons may work, including Head Start programs, day care centers and social services agencies
  - Health clinics
  - Community centers
  - Mobile "stores."
- Grade: II
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective nutrition education strategies that have been identified to improve food security among limited resource populations?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010
What are effective strategies that have been identified to improve access to supermarkets among limited resource populations?
- Conclusion
  Five studies (two descriptive, three cross-sectional) evaluated effective strategies to improve access to supermarkets among limited resource populations.
  
  In all successful interventions, proactive community-wide initiatives and identification of attractive market and location conditions were key.
  
  Characteristics of effective interventions included the following:
  
  Community Support and Advocacy
  - Strong grassroots advocacy
  - Political leadership at the highest levels.
  Community Involvement in Decision-making
  - Identification of differences in the local food environment across neighborhoods associated with varying racial, ethnic and income compositions in order to assess market demand and to identify multiple possible locations
  - Community-based participatory research to build health promotion capacity among neighborhood residents
  - Skilled public agency and non-profit agency participation with sensitivity to the grocery industry context.
  Financing and Implementation Strategies
  - Assemblage of appropriate development and financing tools, including waivers to expedite processes and other incentives
  - Development and ownership of retail facilities by community development corporations, which then leased the facilities to supermarket operators
  - Competitive recruiting of multiple operators.
- Grade: II
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective strategies that have been identified to improve access to supermarkets among limited resource populations?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010
What are effective strategies that have been identified to improve food security among limited-resource older adult populations?
- Conclusion
  Five studies (one descriptive study, two cross-sectional studies, one retrospective cohort study and one decision analysis study) evaluated various strategies to determine methods for improving food security among limited-resource older adult populations.
  
  Tailoring the intervention to the culture, language and age group of the target population was a key feature of effective programs.
  
  Characteristics of effective interventions included the following:
  - Methods:
    
    Education of public health officials and health care professionals regarding hunger-related issues and their impact on health-related decisions such as food vs. medicine choices
    
    Participation in food assistance programs for older adults, including Food Stamps, congregate meals, home-delivered meals and commodity food programs
    
    Interventions to improve food stamp use, including community education, mobile and satellite food stamp offices in lower income neighborhoods, innovative outreach programs and home visits
    
    Efforts to advocate for improvements in the application process
    
    Participation in health screenings, including oral health screenings
  - Providers:
    
    Food stamp program staff
    
    Home-delivered meal and congregate meal staff
    
    Health care professionals
    
    Dietetics students
  - Frequency and duration:
    
    Ongoing food assistance programs
    
    Periodic health screenings
  - Settings:
    
    Food Stamp Program offices
    
    Congregate meal sites
    
    Homes
    
    Community centers
    
    Health care settings.
- Grade: II
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective strategies that have been identified to improve food security among limited resource older adult populations?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010
What are effective strategies that have been identified to improve food security among limited resource adult populations?
- Conclusion
  11 studies (seven cross-sectional studies, two descriptive studies, one case series study and one cohort study) evaluated various limited resource adult population groups to determine evidence-based strategies for improving food security.
  
  Characteristics of evidence-based stategies included the following:
  
  Methods
  - Focus groups conducted by trained researchers or trained facilitators including Registered Dietitians (RD) to determine targeted interventions
  - Confidential interviews conducted by trained interviewers and researchers to ascertain interviewees' perceptions of food insecurity
  - Tailoring the intervention to the culture and language of the target population
  - Telephone surveys
  - Evaluation of existing National Health and Nutrition Examination Surveys (NHANES) data to determine effective interventions
  - Education of health care personnel regarding health choices associated with food insecurity and the association of food insecurity with poorer medical and functional outcomes
  - Education of low-income families regarding diet-disease relationships and how to implement inexpensive, healthful meal plans in a structured environment
  - Nutrition education to Food Pantry participants
  - Smoking cessation programs
  - Messages promoting the use of food stamps to assist in obtaining a healthful diet
  - Advocacy for simplification of the application process for food stamps.
  Providers
  - RDs
  - Food Stamp Nutrition Education program staff and FSNE program trained assistants
  - Expanded Food and Nutrition Education Program (EFNEP) program staff
  - Trained interviewers
  - Food pantry staff.
  Frequency and Duration
  - One-time surveys
  - Several interviews conducted over time.
  Settings
  - Food Stamp Program offices
  - Food pantry
  - Schools located in low-income areas
  - Community programs serving low-income families and individuals
  - Health clinics
  - Health fairs
  - Child immunization sites
  - EFNEP sites
  - Community centers
  - Homes of participants.
- Grade: I
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective strategies that have been identified to improve food security among limited resource adult populations?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010
What are effective strategies that have been identified to improve food security among Women, Infants and Children (WIC) populations?
- Conclusion
  14 studies (eight cross-sectional studies, three retrospective cohort studies, one prospective cohort study, one validity study, and one non-randomized controlled trial) evaluated various strategies to determine their effectiveness in improving food security among Women, Infants and Children (WIC) populations with varying socio-economic status, racial/ethnic groups or geographic locations.
  
  Tailoring the intervention to the culture and language of the target population was a key feature of effective programs.
  
  Characteristics of effective interventions included the following:
  
  Methods
  - Addressing poverty-associated food insecurity early in life and eating patterns that stem from childhood food deprivation (may be associated with prevention of adult obesity)
  - Using WIC to provide age-appropriate food and nutritional advice and to improve access to the health care system
  - Actively marketing WIC to eligible families, including families from health disparities populations
  - Participation in the WIC Farmers’ Market Nutrition program
  - Policy decisions incorporating awareness of food security issues, including the likely impact on child health of sanctioning welfare benefits/food assistance
  - Participation in the Food Stamp Program (FSP)
  - Adding fresh fruits and vegetables to the WIC package
  - Provision of subsidies for fresh fruits and vegetables at grocery stores and Farmers’ Markets
  - Provision of counseling and education to families at risk for food insecurity, including gardening education
  - Collaboration with community-based agencies and organizations in regard to emergency feeding programs and community gardening initiatives
  - Providing nutrition education regarding the importance of dietary variety
  - Focus groups to develop and validate tools to measure and describe food insecurity
  - Advocacy for improvement of local employment and job availability
  - Psychological counseling to address psychological issues associated with food insecurity.
  Providers
  - WIC program staff
  - Head Start staff
  - Trained bilingual focus group moderators.
  Frequency and Duration
  
  A variety of frequencies and duration were effective, including one-time encounters and ongoing interventions lasting six months.
  
  Settings
  - FSP offices
  - WIC clinics
  - Schools located in low-income areas
  - Community programs serving low-income families and individuals
  - WIC Program offices
  - Farmers’ Markets
  - Hospitals
  - Health Clinics
  - Pediatric Care clinics
  - Community schools
  - Food banks
  - Early intervention programs
  - Head Start programs.
- Grade: I
  - Grade I means there is Good/Strong evidence supporting the statement;
  - Grade II is Fair;
  - Grade III is Limited/Weak;
  - Grade IV is Expert Opinion Only;
  - Grade V is Not Assignable.
  - High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
  - Moderate (B) means we are moderately confident in the effect estimate;
  - Low (C) means our confidence in the effect estimate is limited;
  - Very Low (D) means we have very little confidence in the effect estimate.
  - Ungraded means a grade is not assignable.
- Evidence Summary: What are effective strategies that have been identified to improve food security among Women, Infants and Children (WIC) populations?
- Search Plan and Results: HD: Food Insecurity and Food Access 2010