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Health Disparities

HD: Food Security (2011)


Holben DH, McClincy MC, Holcomb JP Jr, Dean KL, Walker CE. Food security status of households in Appalachian Ohio with children in Head Start. J Am Diet Assoc. 2004 Feb; 104 (2): 238-241.

PubMed ID: 14760573
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To measure the level of food security and hunger of households involved in HS in a nonmetropolitan Appalachian county and assess factors that could affect food security and hunger.

Inclusion Criteria:

Families with children currently enrolled in HS (Head Start) in Athens County, Ohio.

Exclusion Criteria:

None noted.

Description of Study Protocol:
  • Recruitment: Recruitment was not described. The sample was a convenience sample of all households with children currently enrolled in Head Start in Athens County, Ohio. 
  • Design: Cross-sectional
  • Blinding used: N/A
  • Intervention: N/A.

Statistical Analysis

  • Spearman correlation: Used to assess the relationship of food security status to the number of food assistance programs participated in
  • Odds ratios: Used to compare the presence of food insecurity with hunger to other variables.
Data Collection Summary:

Timing of Measurements

A 55-item survey instrument posed questions to subjects about the previous 12 months and included the 18-question US Household Food Security Survey Module (FFSM). The survey instrument was distributed on two separate days in January 2001 by the Head Start Program Director to adults with children enrolled and returned to the sites by adult respondents within one week of distribution. 

Dependent Variables

  • Food security
  • Hunger.

Independent Variables

Factors affecting hunger and food security (i.e., money).

Control Variables

Geography [(non-metropolitan, distressed county (most severe economic level category)].

Description of Actual Data Sample:
  • Initial N: 710 adults
  • Attrition (final N): 297 adults (222 female, 42 male, 33 other or no response)
  • Age: Not noted
  • Ethnicity: Not noted
  • Other relevant demographics: Participants were sampled from the Appalachian region of the US, which has been classified as a distress county (most severe economic level category) based on the economic indicators of unemployment, per capita market income and poverty
  • Anthropometrics: Not noted
  • Location: Athens County, Ohio.
Summary of Results:

Key Findings

  • Of the 297 adults that responded, 152 (51.2%) were food secure and 145 (48.8%) were food insecure
  • 90 (30.3%) had experienced hunger in the previous 12 months
  • 41 (13.8%) households were food insecure with childhood hunger
  • The rates of food insecurity are three times the national average for households with children (48.8% vs. 16.1%)
  • Childhood hunger was over 20 times higher than the national average (13.8% vs. 0.6%)
  • The current sample experienced food insecurity (48.8% vs. 17.2%) and hunger (13.8% vs. 0.2%) to a more severe degree than rural households with children, nationally
  • Participation in a greater number of food assistance programs was associated with poorer food security status (P=0.519)
  • A forward-stepwise logistic regression analysis was performed and showed the following
    • Participating in food banks: P<0.001
    • Depending on family members and friends outside of the household for food: P=0.001
    • Lacking reliable transportation: P<0.001
    • Lacking a garden: P=0.009.
Author Conclusion:
  • This study finds that the sample of Appalachian Ohio households with children enrolled in Head Start experienced a higher degree of food insecurity than what is typical for a state or region
  • Although the sample is not representative of households in the region or those enrolled nationally in Head Start, these findings suggest that rural households with children enrolled in Head Start may experience food insecurity and hunger at dramatically grater rates than the national averages
  • No two-way interactions among outcome variables of food insecurity and hunger were significant.
Funding Source:
University/Hospital: Ohio University
Reviewer Comments:
  • A limitation of the study may be the literacy rates of the subjects. Those unable to read may not have participated.
  • The season of the year (Winter) may have affected the results, because families often make choices between buying food and paying other bills
  • The study was limited by its non-random sample.
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? No
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? 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? 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? ???
  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? N/A
  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? 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? ???
  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? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? ???
  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? 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? No
  10.2. Was the study free from apparent conflict of interest? Yes