EAL

HD: Food Security (2011)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To examine the relationship between past food deprivation and child feeding practices in a Latino immigrant population
To describe the development and validation of a tool to measure the degree of past food insecurity in a Latino population.

Inclusion Criteria:

Low-income
Mothers of children aged four or five years
Lived in Calaveras, Sacramento, Solano or Tulare counties
Participants in the food assistance, nutrition education (including the Expanded Food and Nutrition Education Program), Head Start or migrant pre-school programs.

Exclusion Criteria:

Mothers of children less than four or older than five years
Did not live in one of the targeted counties listed in the inclusion criteria
Did not participate in one of the programs listed in the inclusion criteria.

Description of Study Protocol:

Recruitment

First phase:
- Participants recruited by Cooperative Extension advisors in Solano and San Joaquin counties from Head Start, local food pantries, health fairs and Cooperative Extension nutrition programs
Second phase:
- Participants recruited by two bilingual interviewers from a convenience sample of participants in food assistance, nutrition education (including the Expanded Food and Nutrition Education program), Head Start or migrant preschool programs.

Design

First phase:
- Bilingual moderator and co-moderator conducted four focus groups in community settings, including Head Start, a school, and a clinic
- Focus groups were conducted among low-income Latino parents of young children to explore their life experiences with past food deprivation and how these experiences might influence current food behaviors
Second phase:
- A tool to measure past food insecurity was developed and validated.

Blinding used

Not applicable

Intervention

Before the focus groups were conducted, a set of open-ended questions were drafted and tested in five in-depth structured interviews
Using the results of the focus group research, an eight-item tool was developed to measure past food insecurity which was tested and the wording of the questions modified
After attending a one-day workshop to standardize interviewing procedures, two bilingual interviewers recruited a convenience sample and interviewed them using the modified eight-item tool.

Statistical Analysis

First phase:
- Two researchers independently analyzed the transcripts and determined the emerging themes
- Researchers used constant comparative analysis and NUD*IST software, version 4.0 (Qualitative Solutions and Research Pty, Ltd., Melbourne, Australia, 1997) to assist in coding and sorting of text
Second phase:
- Cronbach α test was used to examine internal reliability of the past food insecurity items
- After establishing reliability, summative scales were constructed where affirmative responses indicating limited access to food ("yes", "sometimes", "usually") were scored as "1" and negative responses ("no", "hardly ever") were scored as "0"
- Spearman rank-order correlations of past food insecurity with mother's education and past food insufficiency were examined to assess convergent validity of the scale to capture past deprivation
- Chi-square was used to compare differences in past food insecurity between mother born in the United States and those born in Latin America for each of the seven categorical items
- Kruskal-Wallis test for nonparametric data was used for the summative total past food insecurity scale
- All analysis were conducted using SAS for Windows software (Release 8.01, SAS Institute, Cary NC, 1999).

Data Collection Summary:

Timing of Measurements

All interviews were conducted between August and November, 2004

Dependent Variables

Seven-item past food insecurity tool

Independent Variables

Language preference
Ethnicity
Birth country
Maternal age
Years of residence in the United States
Maternal education
Child's age
Child's gender
Child's health.

Control Variables

None

Description of Actual Data Sample:

Initial N:
- First phase:
  - 22 women
- Second phase:
  - 85 women
Attrition (final N):
- First phase:
  - 22 women
- Second phase:
  - 85 women
Age:
- First phase:
  - Maternal age 32.5±5.8 years
- Second phase: Not provided
Ethnicity:
- First phase:
  - Mexican-born Latino women
- Second phase:
  - 77% born in Mexico or Guatemala (N=64, N=2, respectively)
  - 23% born in United States (N=19)
  - 86% self-identified as Mexican, Hispanic or Latina (N=73)
  - 14% self-identified as white, non-Latina (N=12)
Other relevant demographics:
- First phase:
  - Spanish-speaking=100%
- Second phase:
  - Spanish-speaking only=66% (N=56)
  - English-speaking only=22% (N=19)
  - Bilingual (Spanish, English)=12% (N=10)
  - Mean monthly income=$1,125
Anthropometrics:
- First phase:
  - Length of residency in the United States 7.5±4.5 years
  - Food insufficiency reported in 40.9% (nine) of participants
- Second phase: None provided
Location:
- First phase: Solano and San Joaquin counties, California
- Second phase: Calaveras, Sacramento, Solano or Tulare counties, California.

Summary of Results:

Key Findings

Second Phase:
- Reliability and validity
  - Original past food security tool included eight items
  - Internal reliability of scale improved when one item (did your family produce your own food through a garden, fruit trees or raising animals) was deleted
  - Cronbach α for remaining seven items was 0.84, indicating internal consistency or reliability of the past food security scale
  - Past food insecurity was significantly correlated with
    - Lower maternal education (r= -0.45, P=0.0001)
    - Greater crowding in mother's childhood household (r= +0.30, P=0.006)
    - Greater past food insufficiency (r= +0.74, P=0.0001)
- Past food insecurity
  - Foreign-born mothers reported significantly higher levels of past food insecurity than US-born women (mean±SD: 3.7±2.3 compared to 1.9±2.2, P<0.02)
  - Foreign-born mothers reported a significantly greater level of past food insufficiency than the US-born women (P<0.0005).

Percent (N) Responses

Foreign-born

N=66

US-born

N=19

Statistical Significance of Group Difference for Affirmative Responses

1) Do you feel you need to give your child certain foods that you didn't have as a child?

Yes

30.3% (20)

69.7% (46)

63.2% (12)

36.8% (9)

P<0.01

2) Did your family eat the same foods every day because there was not enough money or resources for other foods?

Yes

34.8% (23)

65.2% (43)

68.4% (13)

31.6% (6)

P<0.01

3) Were there times of the month or year when your family ran low on food?

Yes

40.9% (27)

59.1% (39)

42.1% (8)

57.9% (11)

P=Not significant

4) Did you have to divide very small amounts of meat among family members, because there wasn't enough for everyone?

Yes

34.8% (23)

65.2% (43)

68.4% (13)

31.6% (6)

P<0.01

5) Did you work as a child to earn money to help your family buy food?

Hardly ever

Sometimes or usually

57.6% (38)

42.4% (28)

94.7% (18)

5.3% (1)

P<0.01

6) When you were a child, were there times when your parents did not have enough to eat?

Hardly ever

Sometimes or usually

75.8% (50)

24.2% (16)

84.3% (16)

15.7% (3)

P=Not significant

7) When you were a child, were there times when you did not have enough to eat?

Hardly ever

Sometimes or usually

60.6% (40)

39.4% (26)

84.3% (16)

15.7% (3)

P=Not significant

Other Findings

Second Phase:
- No significant differences in monthly income or current food security levels between foreign-born and US-born mothers
- Foreign-born mothers had significantly lower levels of education compared to US-born mothers (median: 6.0 compared to 14.0 years, P<0.0001)
- Foreign-born mothers had lived in more crowded households as children compared to US-born mothers (mean±SD: 8.7±2.4 compared to 6.4±2.5 people, P<0.0005).

Author Conclusion:

The seven-item tool tested in this study has validity and reliability in measuring past food insecurity among immigrants from Latin America
Focus group findings point to some food-related behaviors that may be influenced by past food insecurity
- Compared to immigrants who were food secure during childhood, those who experienced greater past deprivation:
  - May choose to eat out more often
  - May serve their children larger portions of food
  - May replace nutritious staples such as beans with less nutrient-dense foods.

Funding Source:

University/Hospital:

Jastro-Shields Graduate Research Fund; Body Weight and Health workgroup of the University of California Division of Agriculture and Natural Resources

Reviewer Comments:

Food insecurity tool was developed using appropriate procedures and validated in a well-conducted study
Sample size for validation was relatively small; tool should be utilized on a larger population to validate 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)	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)	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?		???
	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?	???
3.	Were study groups comparable?		No
	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?	No
	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?		No
	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%.)	N/A
	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?		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?	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?		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?	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?	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)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	N/A
	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