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Health Disparities

HD: Food Security (2011)


Heinrich KM, Hsu LJ, Johnson CB, Jokura Y, Rider M, Maddock JE. Food security issues for low-income Hawaii residents. Asia Pac J Public Health. 2008 Oct; 20 Suppl: 64-69.

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

The purpose of the study was to examine food security issues for the Food Stamp Program (FSP) participants and eligibles in Hawaii.

Inclusion Criteria:

Eligible participants were required to be at or above 130% of the Federal Poverty Guidelines

Additional Proxy categories were used to determine eligibilty:

  • Persons participating in the FSP
  • Person who received Medicaid health insurance
  • Persons who lived in public housing
  • Persons who were consumers of food banks, food pantries and soups kitchens
  • Persons whose children receive free or reduce lunches
  • Persons who participant in the WIC Federal assistance program.
Exclusion Criteria:

Exculsion criteria were not listed.

Description of Study Protocol:


  • Potential participants were contacted by phone or in-person
  • After participants arrived to the focus groups, each provided informed consent
  • Participants were provided with a healthy meal and received a monetary incentive and parking reimbursement if necessary.


This qualitative study was cross-sectional in design.

Statistical Analysis

Statistical analysis was not discussed in the study manuscript.

Data Collection Summary:

Timing of Measurements

  • 10 study groups were conducted
  • Open-ended questions were asked about 13 different content areas:
    1. Food purchasing behaviors
    2. Knowledge and attitudes about food
    3. Food behaviors and cultural concerns
    4. Food-related bariers
    5. Knowledge of nutrition programs and resources
    6. Attitudes about nutrition programs and resources
    7. Nutrition program barriers and motivators
    8. Food stamp program barriers and motivators
    9. Physical activity barriers and motivators
    10. Attitudes about physical activity
    11. Physical activity barriers and motivators
    12. Physical activity programs
    13. Opinions about selected printed messages.

Study Variables

  • Locations were determined by the availablity of appropriate facilities and were conducted relative to the state's population distribution with six in Honolulu County
  • Focus groups were transcribed verbatim and were imported and analyzed using the NVivo 7 Software.
Description of Actual Data Sample:

Initial N

86 participants were recruited to complete the focus groups.

Attrition (Final N)

83 subjects completed a demographic questionnaire.


  • 18 to 29 years: 35%
  • 30 to 39: 28%
  • 40 to 49: 37%
  • 50 to 59: 5%
  • 60 and older: 6%.


A majority of participants were Native Hawaiian/Part Hawaiian/Pacific Islander (N=53)

  • White: 17% (N=14)
  • Asian: 9.6% (N=8)
  • African-American: 3.6% (N=3)
  • Other ethnicities: 6% (N=5).

Other Relevant Demographics

  • Female: 73.5% (N=61)
  • Male: 26.5% (N=22)
  • Average household size was 4.07±2.89 (range, one to 14 people)
  • 63% reported high school education or more.


All focus groups took place in Hawaii.

Summary of Results:

Key Findings

Five key themes were jointly decided based on the transcript:

  1. Amount of food stamps
    • Vast majority of participants reported that the amount of food stamps received was not adequate and many reported running out by mid-month
    • Inadequate food stamps also made the purchase of healthier foods more challenging for the participant.
  2. Alternative food resources: Participants were able to receive food through a variety of other sources when they ran out of food stamps including FoodBank, Salvation Army, churches, family members and friends
  3. Food security strategies
    • Participants employed a variety of stategies to help sustain the food stamps they had at their disposal. These included: Budgeting carefully, shopping for sales and shopping in bulk.
    • Some participants grew their own produce, while others purchased food from fast food establishments to supplement their food stamps.
  4. Lack of facilities
    • Participants made mention of not having adequate food storage and preparation areas
    • Many participants used "improvised" food storage such as ice, coolers and sharing with other families.
  5. High cost of living
    • Numerous reference were made in regards to the high cost of living in Hawaii
    • High costs were mentioned regarding gas, rent and groceries.
Author Conclusion:
  • Similar to other studies performed on populations with food security issues, FSP assistance was found inadequate and many participants reported running low before the end of the month
  • Participants were faced the challenge of budgeting their resources and many reported making choices that were not considered healthy when faced with lack of resources.
Funding Source:
Government: State of Hawaii Department of Health, Tobacco Settlement Fund
Reviewer Comments:
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? No
  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? ???
  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? ???
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) No
  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? No
  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? No
  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? ???
  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? 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? ???
  7.1. Were primary and secondary endpoints described and relevant to the question? N/A
  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? ???
  7.6. Were other factors accounted for (measured) that could affect outcomes? ???
  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? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? No
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  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)? ???
  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? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
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? No
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