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FNOA: Aging Programs (2012)

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

To determine factors associated with Food Stamp Program (FSP) participation in a potentially eligible California (CA) population.

Inclusion Criteria:

Women over age 18 participating in the California Women's Health Survey (CWHS).

Exclusion Criteria:

Based on the description of how CWHS uses a screened random digit sample, the following exclusions were made when the surveys were conducted: 

  • Women under age 18 are excluded 
  • If more than one women per household is eligible, one women is randomly selected and the others are excluded. 
Description of Study Protocol:

Recruitment

The CWHS is an ongoing annual telephone survey that collects data about health-related attitudes and behaviors from a randomly selected sample of women. The present research focused on the CWHS from 2002 to 2004.

Design

Cross-Sectional Study

Blinding used

Not applicable

Intervention

Not applicable

Statistical Analysis

  • Bivariate analysis using x2 analysis
  • Multivariate analysis using logistic regression
  • Additional x2 analysis to look at reasons for not applying and levels of perceived need among groups.

 

Data Collection Summary:

Timing of Measurements

CWHS telephone surveys conducted from 2002-2004.

Dependent Variables

  • Current FSP participation as measured by participant received FSP in the past 12 months
  • Potentially eligible for FSP as defined as household income less than 130% of the Federal Poverty Level (FPL) and not denied FSP
  • Reasons for not applying for FSP: (a) No need: 'do not need them', (b) Lack of information: 'do not think I am eligible' or 'do not know how to get them', (c) Too hard: 'too hard to apply', (d) Stigma: 'don't want government help' or 'too embarrassed', (e) US citizenship: 'worried about US citizenship status'
  • Level of need: (a) Food security level (based on six-item subset of the federal Food Security Module), (b) Considers income adequate for basic needs (yes or no), (c) Use of emergency food banks (yes or no).

Independent Variables

  • Race defined as white, black, Hispanic or other
  • Marital/child status defined as single with children, married with children, single with no children, married with no children
  • Immigrant/birthplace defined as US-born, born in Latin America, interviewed in Spanish
  • Use of public, private and other food assistance/services defined as welfare/TANF, WIC, emergency food banks, formerly in foster care, has medical insurance
  • Psychosocial and health status defined as domestic violence, poor mental/physical health, feeling overwhelmed, sadness, self-reported health (good or excellent), pregnant, has mental, physical or emotional problem that limits activities
  • Age defined as 18-24 years, 25-54 years and 55 years and older
  • Education defined as less than high school
  • Employment status defined as unemployed, full-time employed, self-employed.

 Control Variables

 None

Description of Actual Data Sample:
  • Initial N: Not provided
  • Attrition (final N): 
    • 527 FSP participants
    • 1,405 non-participants
  • Age: Over 18
  • Ethnicity: 
    • Participants: 27.6% White, 15.6% Black, 46.4% Hispanic, 10.5% Other
    • Non-participants: 26.0% White, 5.8% Black, 54.2% Hispanic, 14.0% Other
  • Other relevant demographics:
  • Anthropometrics:
  • Location: California, USA. 
Summary of Results:
  • In CWHS 2002-2004, the self-reported FSP participation rate was 0.27 among all potentially eligible households
  • When only those eligible with US-born women and/or children were considered, the participation rate was 17% higher at .317 

 The following factors are associated with FSP participation:

Characteristic P value
Unemployed  P=0.0001
Single mothers with children  P=0.0001
Receiving welfare, WIC or emergency aid  P=0.0001
Formerly in foster care  P=0.0001
Uninsured  P=0.0001
Victims of domestic violence  P=0.0001
Poor mental and physical health  P=0.01
Feel sad and overwhelmed  P=0.0001
Pregnant  P=0.0001
  • Participants are less likely to be Hispanic/Latino, have been interviewed in Spanish and to be foreign born
  • Fewer younger (<25 years) and older (55 years and above) compared to middle aged women (25-54 years) participated in FSP.

After logistic regression analysis, the following remained independently and positively related to FSP participation:

Characteristic Adjusted OR 95% CI
Single mother with children  2.28  1.68, 3.09
Unemployed  2.06  1.77, 2.44
Receiving welfare  64.10  52.2, 78.9
Enrolled in WIC  2.55  2.16, 3.02
US-born  1.77  1.46, 2.14

 Reasons why low-income women do not use the FSP:

  • The main reason cited is do not need them; however, over one-third either do not think they are eligible or do not know how to apply
  • Foreign-born women were more likely than the USA-born women to cite reasons related to stigma and worry about US citizenship
  • Younger non-participates were more likely to cite "do not need them" as a reason for not applying, compared to older women
  • Older women did not cite stigma more often than did middle-aged women
  • They also did not cite "do not need them" more often than do the youngest women
  • 31% of the women aged 55 and older think that they are not eligible compared to 17.6% for the women aged 18-25 years
  • These results were found to be significant at P=0.001 or lower.

Are women who say that they do not need FSP truly less needy?

  • Reasons for not applying were compared against indicators of need
  • Potentially eligible non-participants are less likely to be: Food-insecure, to have inadequate income and to use alternative emergency aid compared to women citing all other reasons
  • The highest level of need is among those who cite worry about US citizenship or stigma as reasons for not applying
  • These results were reported at a significance of P=0.0001.

 

 

Author Conclusion:
  • This study found that the strongest positive FSP predictors are welfare, unemployment and single motherhood. This is consistent with the view that FSP in California serves a very high need population. The profile of FSP participants matches the perceptions of previous limited income focus groups in California in the FPS is viewed as filling an important need for people who are unemployed or in a crisis situation and considered a last resort for help.
  • Lower participation among low-income Hispanic immigrant women can be partially explained by US citizenship status, but barriers to applying and stigma are reported more often among potentially eligible foreign-born women compared to the USA-born group. Spanish speaking participants find many barriers apart from US citizenship including language ability which many be a proxy for immigration status in the CWHS where birthplace is more strongly and independently related to FSP participation than language spoken.
  • "Do not need them" was the highest ranked reason why for non-participation in this study. In a California food bank study in 2005, fear that FSP would hurt immigration chances was the highest ranked reason. This difference may be related to the CWHS asking a random sample of the population why they do not apply. "Do not need them" may also be the most socially acceptable answer, finding from this study show that people who give that reason are more likely to be food secure and less likely to access emergency food banks than people giving other reasons for not applying.
  • Older women cited "lack of information" as a reason for not applying for FSP. Since women experience more health problems with age, greater FSP outreach through health providers and senior services may be helpful.
  • Many eligible women who cited 'stigma' and 'fear' as reasons for not applying for FSP have very high rates of food insecurity.  Greater FSP outreach could be provided through WIC, local health clinics, schools, churches and other community groups. The outreach should highlight the benefits of using food stamps to purchase a more healthy diet for the family. In addition to this type of outreach, steps to simplify the application process, make people aware of their eligibility and improve customer service are needed to increase participation.
Funding Source:
Government: California Department of Social Services
Reviewer Comments:

The author notes the following limitations:

  • The estimated FSP participation rate for the CWHS sample (0.27 - 0.317) is much lower than the official state Program Access Index of 0.421 for 2003. This may be due to underreporting of the FSP status and/or household income.
  • Since non-citizens are not eligible for FSP, this analysis attempted to determine potential US citizenship based on whether the respondent was us-born or had given birth to a liveborn child since immigrating to the USA. It cannot be told whether the child was born in the USA or if the woman had travelled back to her home country to give birth. An additional follow-up question would help to clarify this.
  • There are rural/urban differences in FSP participation and this variable could not be analyzed in the CWHS.
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? ???
  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? N/A
  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? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  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? 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? 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%.) ???
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  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? ???
  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.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? ???
  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? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  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? N/A
  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? N/A
  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? N/A
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)? ???
  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