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Health Disparities

HD: Food Security (2011)

Citation:

Duerr L. Prevalence of food insecurity and comprehensiveness of its measurement for older adult congregate meals program participants. J Nutr Elder. 2006; 25(3-4): 121-146.

PubMed ID: 18032220
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To investigate the issue of prevalence of food insecurity for older adults participating in the Area 7 Agency on Aging and Disabled home-delivered meals program
  • To relate the home-delivered meals program participants' food security status, as determined by the widely used standardized national Current Population Survey-Food Security Survey Module (CPS-FSSM) items, to their tentative food security status as determined by augmented items added to the CPS-FSSM items.
Inclusion Criteria:
  • Community-dwelling adults
  • 60 years of age or older
  • Required meals to be delivered to their homes
  • Lived in the area serviced by one of the 17 routes of the Area 7 Agency on Aging and Disabled home-delivered meals program.
Exclusion Criteria:
  • Institutionalized adults
  • Younger than 60 years of age
  • Did not require meals to be delivered to their homes
  • Did not live in the area served by the Area 7 Agency on Aging and Disabled home-delivered meals program.
Description of Study Protocol:

Recruitment

Convenience sample of participants were recruited by telephone from among the 17 routes of Area 7 Agency on Aging and Disabled home-delivered meals program.

  • Site directors informed their route drivers about the study
  • Route drivers encouraged the home-delivered meals program older adults to participate
  • Agency supplied the principle investigator with names and telephone numbers of potential participants
  • First-year Coordinated Program dietetics students were assigned specific older adults to contact
  • Prior to the students placing the telephone calls, a memo from the Agency was delivered to all home-delivered meals clients explaining the study, encouraging them to participate and giving them the name of the student who would be contacting them.

Design

  • Participants were called over eight consecutive weeks 
  • Study was explained and older adults were asked if they were willing to participate (verbal consent)
  • Data for the 10 CPS-FSSM items and the eight augmented items were collected on anonymous survey forms.

Blinding Used

  • Anonymous survey forms were coded to the home-delivered meals program route
  • Identity of participants was unavailable to the principal investigator and the Agency.

Intervention

Descriptive data, answers to the 10 CPS-FSSM items and the eight augmented items were obtained via telephone.

Statistical Analysis

  • Data were analyzed using the Statistical Program for the Social Sciences (SPSS)
  • 10 CPS-FSSM national survey item responses were coded (zero negative, one positive) and food-insecurity scale values were assigned, with a maximum total of 10 for the 10 items
  • Participants were grouped into one of the four food-security status categories based on the total food-insecurity score values
    • Scores of zero to two were considered food secure (coded one)
    • Scores of three to five-5 were considered food insecure without hunger (coded two)
    • Scores of six to eight were considered food insecure with moderate hunger (coded three)
    • Scores of nine to 10 were considered food insecure with severe hunger (coded four)
  • Augmented items were tallied and then each individual participant was loosely assigned to a food security status level to compare the ranking of the food security status as measured by the two methods:
    • Scores of zero to two were considered food secure
    • Scores of three to four were considered food insecure without hunger
    • Scores of five to six were considered food insecure with moderate hunger
    • Scores of seven to eight were considered food insecure with severe hunger
  • Cross-tabulation analysis was performed to summarize food security status (based on food security level) by gender, race, age, marital status, living arrangement, educational level and income level for both the national and augmented items
  • Chi-square test was used to compare how the participants varied in food security level for each of the seven variables for both national and augmented items
  • Statistical analysis were run using two levels of food security status (secure and insecure). Due to homogeneous characteristics of the study sample, the three levels of food insecurity (without hunger, with moderate hunger and severe hunger) were classified as food insecure
  • Logistic regression analysis performed using the seven variables as predictors of the two measures of food security status for both national and augmented items
  • Cox-Snell R2 and Nagelkerke R2 statistics summarized the variability in the data that was explained by the model
  • Correlation analysis performed to examine the relationship between national items scores and augmented items scores
  • P-value 0.05 was considered significant.
Data Collection Summary:

Timing of Measurements

Telephone calls were conducted over a period of eight weeks.

Dependent Variables

  • Responses to the 10 items of the CPS-FSSM
  • Responses to the eight augmented items.

Independent Variables

  • Gender
  • Race
  • Age
  • Marital status
  • Living arrangement
  • Educational level
  • Income level.
Description of Actual Data Sample:
  • Initial N: 143 home-delivered meals participants
  • Attrition (final N): 143 home-delivered meals participants
  • Age:
    • 60 to 64 years: 4.9% (N=7)
    • 65 to 74 years: 18.2% (N=26)
    • 75 to 84 years: 44.8% (N=64)
    • 85 years or over: 32.1% (N=46)
  • Ethnicity:
    • 88.1% (N=126) white or Caucasian
    • 11.9% (N=17) other
  • Other relevant demographics:
    • Gender:
      • 21% (N=30) men
      • 79% (N=113) women
    • Marital status:
      • 78.3% (N=112) not married [49.7% (N=71) widowed]
      • 21.7% (N=31) married
    • Living arrangements:
      • 69.7% (N=99) lived alone
      • 30.3% (N=43) lived with others
    • Education level:
      • 28.6% (N=41) less than high school
      • 42.0% (N=60) high school graduate
      • 29.4% (N=42) higher than high school
    • Income level:
      • 45.5% (N=65) had incomes less than $10,000
      • 32.1% (N=46) had incomes $10,000 to $19,999
      • 8.4% (N=12) had incomes $20,000 and above
      • 14% (N=20) did not respond to income question
  • Location:
    • West Central Indiana
    • Area 7 Agency on Aging and Disabled.
Summary of Results:

Key Findings

  • 74.8% of the participants were found to be food secure based on the national items
  • 55.2% of the participants were found to be food secure based on the augmented items
  • Statistically significantly more women than men (percentage) were food insecure based on the national items (chi-squared value = 4.641; P-value = 0.031) and the augmented items (chi-squared value = 5.024; P-value = 0.025)
  • There was a statistically significant difference in food security status among age groups based on national items scores with the 60 to 64 years of age group being the least secure
  • There was a statistically significant difference in food security status based on living arrangements for the augmented items scores with those who lived alone being the least secure
  • The proportion of variance in food security status accounted for by the linear combination of gender, age, race, marital status, living arrangement, educational level and income level was 27.6% (Cox and Snell R2; NagelKerte R2 = 0.400) for the national items and 13.7% (Cox and Snell R2; NagelKerte R2 = 0.183) for the augmented items:
    • Model classified 77.9% of participants into correct food security status level with 91.0% of the food secure and 42.4% of the food insecure correctly classified based on the national items. The model showed that age and gender were the only statistically significant predictors of food security status for the national items.
    • Model classified 60.7% of the participants into correct food security status level with 69.7% of the food secure and 50.0% of the food insecure correctly classified based on the augmented items. The model showed that none of the variables were statistically significant predictors of food security status.
  • Number of food secure older adults decreased by 26.2% and number of food insecure older adults increased by 77.8% when the augmented items were used
  • Correlation analysis performed between the national items and the augmented items was statistically significant (R=0.385, P≤0.001).

Other Findings

  • Food security status did not change significantly with race for either the national or augmented items
  • Food security status did not change significantly with age for the augmented items
  • Food security status did not change significantly with marital status for the national or augmented items
  • Food security status did not change significantly with living arrangements for the national items
  • Food security status did not change significantly with education level for the national or augmented items
  • Food security status did not change significantly with income level for the national or augmented items.

 

Author Conclusion:
  • Level of food security varied significantly for gender and age (national items)
  • Level of food security did not vary significantly based on race, marital status, living arrangements, educational level and income level
  • The percentages of participants who were food insecure were higher than the 2005 national percentages for a comparable population and the Indiana food-insecure rates for all households
  • For the food-secure level, almost all categories within the variables had a lower percentage for the augmented items than for the national items
  • The addition of the augmented items to the national survey would identify more older adults as being food insecure than what are currently being identified by using just the CPS-FSSM.
Funding Source:
Other: No financial support information provided.
Reviewer Comments:

Interesting study that could serve as a pilot for further research using the CPS-FSSM and augmented items questionnaire to assess food insecurity.

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? 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%.) Yes
  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? Yes
  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.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  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? 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? N/A
  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)? Yes
  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? No
  10.2. Was the study free from apparent conflict of interest? Yes