HD: Food Security (2011)

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

To examine the associations of loss or reduction of welfare with food security and health outcomes among children aged 36 months or younger at six urban hospitals and clinics.

Inclusion Criteria:

Adult caregivers of accompanying children aged 36 months or younger at acute and primary care clinics and hospital emergency departments.

Exclusion Criteria:
  • Did not speak English, Spanish or Somali
  • Not knowledgeable about the child's household
  • Caregiver was interviewed in the previous six months
  • Confused consent for any reasons
  • Caregiver of critically ill or injured children were not approached.
Description of Study Protocol:

Recruitment

Adult caregivers of accompanying children aged 36 months or younger at acute and primary care clinics and hospital emergency departments were approached to participate.

Design

  • The Children's Sentinel Nutrition Assessment Project conducted household surveys and medical record audits at central city medical centers in six cities
  • Interviews took place in private settings by trained interviewers
    • Scheduled during peak patient flow times
  • Survey instrument included questions on household characteristics, food security, federal assistance, program participation, changes in benefits, and the child's hospitalization history
    • Household food security status was derived from the US department of Agriculture's Food Security Scale
    • Households were classified as food insecure if they could not afford enough nutritious food for active healthy lives.

Statistical Analysis

Logistic regression

 

Data Collection Summary:

Timing of Measurements

Between Aug 1998 and December 2000 

Dependent Variables

  • Sanctioned: Benefits terminated or reduced by full family or partial sanctions for failure to comply with behavioral requirements
  • Decreased: Benefits decreased administratively because of changes in income or expenses
  • Not Decreased: Benefits either increased or did not change.

Predictor Variable

Indicates whether a child's family has experienced a change in welfare benefits because of welfare reform policy changes

  • Age
  • Birth weight (<2,500g)
  • Insurance status (public, private, none)
  • In day care.

Independent Variables

  • Race/ethnicity
  • Birth weight
  • Age
  • Health insurance coverage
  • Day care attendance
  • Whether mother was born in the US
  • Caregivers age
  • Receipt of housing subsidy
  • Whether the child or the caregiver receives supplemental security income
  • Caregivers employment
  • Marital and educational status
  • Whether the household receives food stamps or support from special supplemental nutrition program for Women, Infants and Children.

 

Description of Actual Data Sample:
  • Initial N:
    • Adult caregivers accompanying 9,469 children were approached
    • 7% refused 
    • 15% were ineligible.
  • Attrition (final N): Analytic cohort comprises 2,718 children
  • Age: 36 months or younger
  • Ethnicity:
    • African American 1,872
    • Hispanic 607
    • White 141
    • Other 97
  • Other relevant demographics: None mentioned
  • Anthropometrics: 90% of sample currently or formerly received food stamps
  • Location:
    • Baltimore, Maryland
    • Boston, Massachusetts
    • Little Rock, Arkansas
    • Los Angeles, California
    • Minneapolis, Minnesota 
    • Washington, DC.

 

Summary of Results:
  • 1,132 (42%) of the 2,718 interviews were obtained from three sites (Boston N-683),Little Rock (N=119) and Los Angles (N=330)
  • 90% of sample currently or formerly received food stamps
  • 620 caregivers had welfare sanctioned
    • 129 (21%) also had their food stamps reduced or terminated by sanctions
  • Of the 264 caregivers whose welfare was administratively decreased because of changes in income or expenses 72 (27%) also had their food stamp benefits decreased administratively.

Food Secure or Food Insecure

Household with children aged 36 months or younger whose welfare benefits had been terminated or reduced by sanction had odds of being food insecure 1.5 times greater (95% CI 1.1-1.9) as comparable households whose benefits were not decreased.

Hospitalization 

Young children in families whose welfare benefits had been terminated or reduced by sanctions had 1.3 times the odds of having been hospitalized since birth (95% CI, 1.0-1.7) as those families whose benefits were not decrease.

Emergency Department (ED) Cohort

  • Children aged 36 months or younger exposed to termination or reduction of welfare benefits by sanctions whose caregivers were interviewed during the ED visits had odds of being admitted to the hospital the day of the visit 1.8 times as great as those families whose benefits were not decreased (95% CI, 1.1-3.0)
  • Young children in families whose welfare had been decreased administratively because of changes in household income or expenses had odds of being admitted at the time of ED visit more than 2.5 times as great as those families whose benefits had not been decreased (AOR, 2.7; 95% CI, 1.3-5.4).
Author Conclusion:

Terminating or reducing welfare benefits by sanctions, or decreasing benefits because of changes in income or expenses, is associated with greater odds that young children will experience food insecurity and hospitalizations. 

Funding Source:
Not-for-profit
WK Kellogg Foundation, MAZON:a jewish response to hunger, David B Gold Foundation, Minneapolis Foundation, Project Bread, Walk for Hunger, Anthony Spinazzola Foundation, Daniel Pitino Foundation, Eos Foundation, Susan Schiro and Peter Manus, Candle Foundation, Sandpipers Philanthropic Organization
Foundation associated with industry:
Other non-profit:
Reviewer Comments:

Good discussion section, considered a lot of realities that were not mentioned in results.

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) 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) N/A
  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.) 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? N/A
  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.) N/A
  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? N/A
  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? 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? 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)? No
  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