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Health Disparities

HD: Food Security (2011)


Zekeri AA. Livelihood strategies of food-insecure poor, female-headed families in rural Alabama. Psychol Rep. 2007 Dec; 101 (3 Pt 2): 1,031-1,036.

PubMed ID: 18361115
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Negative NEGATIVE: See Quality Criteria Checklist below.
Research Purpose:

To examine how food-insecure, poor, single mothers commonly get food for themselves and their children.

Inclusion Criteria:
  • Female
  • Single, head of household
  • Lives in a five-county area of Alabama's Black Belt
    • Bullock
    • Dallas
    • Lowndes
    • Macon
    • Wilcox
  • Classified as food-insecure using the USDA food insecurity scale.
Exclusion Criteria:

Not described in study

Description of Study Protocol:


  • Part of a larger project, Food Insecurity in Poor, Female-Headed Families in Five of Alabama's Black Belt Counties
  • 100 female headed families selected from a list of 300 families
  • 20 families selected from each county.


  • Cross sectional study
  • Interviews were done with participants in their home
  • Questions asked to determine how food-insecure mothers provide daily necessities of food for themselves and their children and make ends meet
  • A quantitative measure of depression (the Center of Epidemiological Studies on Depression Scale) used to assess depression and coping with food insecurity.

Blinding used

Not applicable


Not applicable

Statistical Analysis

Data description using percentages

Data Collection Summary:

Timing of Measurements

Participants were interviewed up to two times during a one year period (May 2005-June 2006) 

Key Study Variables

  • Livelihood strategies
  • Psychological components of food insecurity.

Other Variables

  • Race
  • Education
  • Income
  • Employment
  • Age
  • Participation in Food Stamp Program.


Description of Actual Data Sample:
  • Initial N: Not applicable
  • Attrition (final N): 100 families
  • Age:
    • 18%-19-24 years
    • 29%-25-50 years
    • 14.1%-50-70 years
    • 38.9%-70 years and older
  • Ethnicity:
    • 85.7%-African America
    • 14.3%-White 
  • Other relevant demographics:
    • Education
      • 44.3% did not complete high school
      • 31.7% completed high school or equivalent
      • 17.3% some college or post high school training
      • 6.7% completed a college degree
    • Income
      • 57.1% under $10,000
      • 13.3% made $10,000-$14,000
    • 51.1% employed (including part-time)
    • 55.9% not participating in Food Stamp Program
  • Location: Five County Region in Alabama (Bullock, Dallas, Lowndes, Macon and Wilcox).
Summary of Results:

Key Findings

  • Livelihood Strategies (percentages sum greater than zero because multiple strategies were used)
    • 51% employment
    • 44.1% government assistance
    • 45% informal support, cash assistance from others (absent fathers, boyfriends, relatives)
    • 43% help from churches and social agencies, such as food banks
    • 58% cohabitating
    • 25% co-residing with a friend or relative
    • 27% engaged in belt-tightening actions (making cheaper and smaller meals)
    • 18% used a senior meal program 
  • Psychological Components of Food Insecurity
    • 65% worried food would run out before they could get money for more
    • 47.8% felt depressed
    • 56.7% felt sad
    • 45.5% felt lonely
    • 49.6% had trouble sleeping
    • 47.7% had trouble concentrating.
Author Conclusion:
  • Network-based survival strategies are present among poor African American single mothers
  • Food stamps did not figure prominently in their actions to deal with food insecurity
  • Earning an income was preferred over living on welfare
  • New and innovative solutions may be needed to ensure food security of low-income families
    • Improving local employment and job availability
    • Psychological counseling.
Funding Source:
Government: U.S. Department of Health and Human Services, United States Department of Agriculture
University/Hospital: University of Kentucky Center for Poverty Research
Reviewer Comments:

Study states 100 African-American single mothers from rural Alabama were recruited and interviewed, data describes 85.7% of participants as African American.

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? N/A
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? N/A
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  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? 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? No
  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%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? No
  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.) 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? No
  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? 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? 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? 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? 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? N/A
  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? 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? N/A
  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)? No
  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? 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? 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