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Food security status of households in Appalachian Ohio with children in Head Start
RESEARCH Research and Professional Briefs
Food Security Status of Households in Appalachian Ohio with Children in Head Start DAVID H. HOLBEN, PhD, RD; MEGAN C. MCCLINCY, RD; JOHN P. HOLCOMB, JR, PhD; KELLY L. DEAN, RD; CAITLYN E. WALKER, RD
ABSTRACT This study measured food security and hunger of households involved in Head Start in a rural Appalachian county and assessed factors that could affect food security and hunger. A convenience sample of households with children enrolled in the Head Start program in Athens County, Ohio, were sampled (n⫽710), with adults from 297 (42%) households responding. The survey instrument included the 18-question US Household Food Security Survey Module for measuring hunger and food insecurity. Of those responding, 152 households (51.2%) were food secure and 145 (48.8%) were food insecure. Ninety (30.3%) had experienced hunger in the previous 12 months, and 41 (13.8%) households were classified as food insecure with childhood hunger. Hunger was related to a variety of household characteristics and associated with several factors, including participation in food banks, dependence on family members and friends outside of the household for food, lacking reliable transportation, and not having a garden. J Am Diet Assoc. 2004;104:238-241.
F
ood insecurity implies a limited access to or availability of food or a limited or uncertain ability to acquire food in socially acceptable ways (1,2). The effects of food insecurity may include suboptimal quality of life and health (3-6). Its effects on children can be especially grave (7-15). In 2001, 10.7% of households in the United States were food insecure at some time during the year (16). In fact, households with children experienced food insecurity
D. H. Holben is an associate professor and Director, DPD Program, Ohio University, School of Human and Consumer Sciences, Athens, OH; M. C. McClincy is a clinical dietitian, Marion General Hospital, Marion, OH; J. P. Holcomb, Jr, is an assistant professor, Department of Mathematics, Cleveland State University, Cleveland, OH; Kelly L. Dean is a graduate student at the University of Cincinnati, Cincinnati, OH; and Caitlyn E. Walker is a former student, Ohio University, School of Human and Consumer Sciences, Athens, OH. Address correspondence to: David H. Holben, PhD, RD, Ohio University, School of Human and Consumer Sciences, Grover Center W324, Athens, OH 45701. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10402-0019$30.00/0 doi: 10.1016/j.jada.2003.09.023
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(16.1%) at rates greater than the national average (16). Other characteristics of households prone to being food insecure include (a) having an income below the official poverty line, (b) being headed by a single woman with children, and (c) living in rural areas (16). The Appalachian region has a large rural population and shows high rates of poverty and unemployment, which may indicate that individuals in that region are at risk for experiencing food insecurity. Healthy People 2010 includes the goal of improving US food security status (17). The American Dietetic Association has asserted that domestic hunger and food insecurity are issues in need of immediate action and has recognized a special concern for children and adolescents to have access to food and nutrition programs (18). Head Start (HS) provides a comprehensive child development program for preschool children from families with low incomes (19). Families participating in HS are prone to experiencing food insecurity and hunger, due to their demographic characteristics. Although HS is not part of the nutrition safety net, in theory, participation may contribute to improving household food security because of the provision of supplemental resources, including nutritious meals and snacks. The purposes of this study were to (a) measure the level of food security and hunger of households involved in HS in a nonmetropolitan Appalachian county, and (b) assess factors that could affect food security and hunger. METHODS Selection of Subjects The Human Subjects Committee of the Ohio University Institutional Review Board approved this study before the collection of any data. A convenience sample of all households with children currently enrolled in HS in Athens County, Ohio, were sampled (n⫽710), with adults from 297 (42%) households responding. Athens County is a nonmetropolitan county situated in the northern Appalachian region of the United States (20-22). The Appalachian Regional Commission has classified it as a distressed county (most severe economic level category) based on the economic indicators of unemployment, per capita market income, and poverty (20). Survey Instrument The 55-item survey instrument posed questions to subjects about the previous 12 months and included the 18-question US Household Food Security Survey Module (FSSM; Figure) (1). Using standard methods (1), households were categorized regarding food security status. Using the eight FSSM questions related to children (23),
© 2004 by the American Dietetic Association
● “(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.” Was that often true, sometimes true, or never true for (you/your household) in the last 12 months? ● “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/ your household) in the last 12 months? ● “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(I/We) relied on only a few kinds of low-cost food to feed (my/our) (child/children) because (I was/we were) running out of money to buy food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we) couldn’t afford that.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(My/our) (child was/children were) not eating enough because (I/we) just couldn’t afford enough food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● In the last 12 months, since last (name of current month), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food? ● In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food? ● In the last 12 months, did you lose weight because you didn’t have enough money for food? ● In the last 12 months, did (you/you or other adults in your household) ever not eat for a whole day because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, since (current month) of last year, did you ever cut the size of (your child’s/any of the children’s) meals because there wasn’t enough money for food? ● In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, (was your child/were the children) ever hungry but you just couldn’t afford more food? ● In the last 12 months, did (your child/any of the children) ever not eat for a whole day because there wasn’t enough money for food? Figure. The US Household Food Security Survey Module (FSSM) Questions (1).
households experiencing food insecurity with hunger among children were also identified. Closed-ended questions intended to document food assistance program participation, household composition, dietary habits, and availability of resources were also included. Data Collection The survey instrument was distributed on two separate days in January 2001 by the HS Program Director to adults with children enrolled and returned to the sites by adult respondents within 1 week of distribution. The surveys were coded and not linked to the respondent in any manner. No compensation was provided for participation. Statistical Analysis Statistical analyses were performed using the Statistical Program for the Social Sciences (version 10.0.1, 1999, SPSS Inc., Chicago, IL). Descriptive statistics were calculated to summarize food security status measures. Spearman correlation was calculated to assess the relationship of food security status to the number of food assistance programs participated in. Odds ratios were calculated to compare the presence of food insecurity with hunger to the variables in the Table. Variables with the highest odds ratio results were used as predictors of hunger in a forward-stepwise logistic regression model to assess the strongest predictors of hunger. Because the sample is not a random sample of the population of interest, significance tests and confidence intervals were not calculated for the Spearman correlation coefficient or odds ratios. A P value set a priori, however, of less than .05 was used to identify variables most useful in predicting food insecurity with hunger.
RESULTS AND DISCUSSION Individuals responding (n⫽297) classified themselves as a female (n⫽222, 74.7%) or male (n⫽42, 14.2%) head-ofhousehold or other/no response (n⫽33, 11.1%). Of the 297, 152 (51.2%) were food secure, and 145 (48.8%) were food insecure. Ninety (30.3%) had experienced hunger in the previous 12 months. Forty-one (13.8%) households were food insecure with childhood hunger. These 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%). Considering only rural households with children nationally, our sample experienced food insecurity (48.8% vs 17.2%) and hunger (13.8% vs 0.2%) to a more severe degree. Supporting the trends typical of the Midwest, Ohio was below the national average for prevalence of household food insecurity (9.1%) and hunger (2.8%) during 1999 to 2001 (16). This study finds that our sample of Appalachian Ohio households with children enrolled in HS experienced a higher degree of food insecurity than what is typical for a state or region. Although our sample is not representative of households in the region or those enrolled nationally in HS, these findings suggest that rural households with children enrolled in HS may experience food insecurity and hunger at dramatically greater rates than the national averages. Poverty is higher in rural Appalachia than in other populations (20,24). Similar to other counties in the Appalachian region, Athens County is characterized by high unemployment rates and other depressed economic indicators. The geography of the region often makes it difficult and costly to develop roads, communications systems, and public works facilities that support health care delivery and other services. Although these factors also
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Table. Odds ratio analyses for the outcome variable of food insecurity with hunger Survey question
Odds ratioa
Do you have reliable transportation to get food? Do you depend on family members and friends outside of your household for food? Do you participate in food banks/food shelf programs? Do you participate in the food Stamp Program? Do you give away fresh/canned/frozen produce to friends or family? Do you participate in the National School Lunch Program (free or reduced)?b Do you participate in the School Breakfast Program (free or reduced)?b Do you have a garden in the spring and summer? Do you give away fresh/canned/frozen meats to friends or family? Do you participate in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)? Number of adults in the household Do you can or freeze vegetables?
25.6a 11.7 9.6 6.0 5.0 4.3 4.0 4.0 3.0 2.6 2.2 1.7
a
Interpretation of odds ratio example: The odds of experiencing hunger were 25.6 times higher for those without reliable transportation than for those with reliable transportation. In the original survey, subjects were asked separately whether they participated in free and reduced programs. During the analysis, subjects were classified, based on their response, as participating or not participating in the program overall.
b
affect other rural areas, they affect rural Appalachian communities to a greater extent, which may be affecting food insecurity among households. Participation in a greater number of food assistance programs was associated with poorer food security status (⫽0.519). This phenomenon, although counterintuitive, may be caused by the nature of program participation. That is, because individuals self-select to participate in both federal and nonfederal programs, only when food insecurity is severe do individuals choose to participate. The Table summarizes the odds ratios calculated for the outcome variable of food insecurity with hunger. To determine the variables that best predict household hunger, forward-stepwise logistic regression analysis was performed and showed the following: participating in food banks (P⬍.001); depending on family members and friends outside of the household for food (P⫽.001); lacking reliable transportation (P⬍.001); and lacking a garden (P⫽.009). No two-way interactions among variables were significant. Transportation, which may be a proxy for income, seems particularly vital to households in rural areas because public transportation is usually absent in communities. Although participating in assistance programs and depending on others for food were associated with hunger in our study, these and other coping strategies have been previously described in the literature (25). Having a garden can decrease the likelihood of hunger among households, according to this study. This may indicate the important role of gardening in maintaining food security and underscore the need for educational programming related to both gardening and safe preservation methods. Initiating community or school gardens may be one strategy not only to teach gardening methods and improve food security, but also to improve dietary quality and promote health (26-28). However, rural areas, because of transportation limitations primarily, may require effective partnerships and alliances, as discussed in the USDA Community Food Security Initiative, to make community gardens a feasible strategy (29). Limitations of the study include how and when the survey was administered. The literacy of the subjects may have affected the response rate, in that those who
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were unable to read the survey may not have participated. The season of the year (winter) may also have affected the results because families often make choices between buying food and paying other bills (eg, utilities). Finally, although this study is limited by its nonrandom sample, it supports the need to verify these trends in a representative sample of households in the Appalachian region and in households with children enrolled in HS nationally. CONCLUSIONS ●
●
●
This study measured the level of food security and hunger of households with children enrolled in HS in a nonmetropolitan Appalachian county and assessed factors that could affect food security and hunger. Understanding the characteristics of households that are prone to food insecurity will help dietetics professionals to be more effective in practice by considering the barriers that may prevent families from complying with the prescribed medical nutrition therapy. Providing appropriate counseling and education, which may include gardening education, to clients and communities may result in greater food security. Dietetics and nutrition professionals can play leadership roles in addressing food insecurity in their communities in collaboration with community-based agencies and organizations and in food security research related to emergency feeding programs, gardening programs/ community gardening development and outcomes.
References 1. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security, Revised 2000. Alexandria, VA: US Department of Agriculture, Food and Nutrition Service; 2000. 2. Life Science Research Office, Federation of American Societies for Experimental Biology. Core indicators of nutritional state for difficult to sample populations. J Nutr. 1990;102:1559-1660. 3. Vailas LI, Nitzke SA, Becker M, Gast J. Risk indicators for malnutrition are associated inversely with
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quality of life for participants in meal programs for older adults. J Am Diet Assoc. 1998;98:548-553. Campbell CC. Food insecurity: A nutritional outcome or a predictor variable? J Nutr. 1991;121:408-415. Pheley AM, Holben DH, Graham AS, Simpson C. Food security and perceptions of health among rural Appalachians. J Am Diet Assoc. 2000; 100(suppl 1): A-92. Hamelin A-M, Habicht J-P, Beaudry M. Food insecurity: Consequences for the household and broader social implications. J Nutr. 1999;129:525S-528S. Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency, family income, and health in US preschool and school-aged children. Am J Public Health. 2001; 91:781-786. Kleinman RE, Murphy JM, Little M, Pagano J, Wehler CA, Regal K, Jellinek MS. Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics. 1998;101:1-6. Murphy JM, Wehler CA, Pagano ME, Little M, Kleinman RE, Jellinek MS. Relationship between hunger and psychosocial functioning in low-income American children. J Am Acad Child Adolesc Psychiatry. 1998; 37:163-170. Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children’s cognitive, academic and psychosocial development. Pediatrics. 2001;108:44-53. Alaimo K, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, is associated with dysthymia and suicide symptoms in adolescents. J Nutr. 2002;132:719-725. Casey PH, Szeto K, Lensing S, Bogle M, Weber J. Children in food-insufficient, low-income families. Prevalence, health and nutrition status. Arch Pediatr Adolesc Med. 2001;155:508-514. Kaiser LL, Melgar-Quinonez H, Lamp CL, Johns MC, Sutherlin JM, Harwood JO. Food insecurity and nutritional outcomes of preschool-age Mexican-American children. J Am Diet Assoc. 2002;102:924-929. Reid LL. The Consequences of Food Insecurity for Child Well-Being: An Analysis of Children’s School Achievement, Psychological Well-Being, and Health. Chicago, IL: Joint Center for Poverty Research; 2000. JCPR Working Paper 137. Alaimo K, Olson CM, Frongillo EA Jr. Low family income and food insufficiency in relation to overweight in US children. Arch Pediatr Adolesc Med. 2001;155:1161-1167. Nord M, Andrews M, Carlson S. Household Food
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Security in the United States, 2001 (FANRR-29). Alexandria, VA: Food and Rural Economics Division, Economic Research Service, US Department of Agriculture; 2002. Healthy People 2010 website. Available at: http:// www.healthypeople.gov. Accessed January 22, 2003. Olson CM, Holben DH. Position of the American Dietetic Association on domestic food and nutrition security. J Am Diet Assoc. 2002;102:1840-1847. Head Start website. Available at: http://www.acf.dhhs. gov/programs. Accessed January 22, 2003. Appalachian Regional Commission website. Available at: http://www.arc.gov. Accessed January 22, 2003. Economic Research Service. Measuring rurality: Rural-urban continuum codes. Available at: http:// www.ers.usda.gov/briefing/Rurality/RuralUrbCon/ code93.htm. Accessed January 22, 2003. Economic Research Service. Measuring rurality: Urban influence codes. Available at: http://www. ers.usda.gov/briefing/Rurality/Urbanlnf/urbinf.htm. Accessed January 22, 2003. Nord M, Bickel G. Measuring Children’s Food Security in US, 1995-1999 (FANRR-25). Alexandria, VA: Food and Rural Economics Division, Economic Research Service, US Department of Agriculture; 2002. Deavers KL, Hoppe RA. Overview of the rural poor in the 1980s. In: Duncan M, ed. Rural Poverty in America. Westport, NY: Aurburn House; 1993. Kempson KM, Keenan DP, Sadani PS, Ridlen S, Rosato NS. Food management practices used by people with limited resources to maintain food sufficiency as reported by nutrition educators. J Am Diet Assoc. 2002;102:1795-1799. Faber M, Phungula MA, Venter SL, Dhansay MA, Benade AJ. Home gardens focusing on the production of yellow and dark-green leafy vegetables increase the serum retinol concentrations of 2-5-y-old children in South Africa. Am J Clin Nutr. 2002;76:1048-1054. Morris JL, Zidenberg-Cherr S. Garden-enhanced nutrition curriculum improves fourth-grade school children’s knowledge of nutrition and preferences for some vegetables. J Am Diet Assoc. 2002;102:91-93. Armstrong D. A survey of community gardens in upstate New York: Implications for health promotion and community development. Health Place. 2000;6: 319-327. USDA Community Food Security Initiative website. Available at: http://www.reeusda.gov/food_security/ foodshp.htm. Accessed January 22, 2003.
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Food Security Status of Households in Appalachian Ohio with Children in Head Start DAVID H. HOLBEN, PhD, RD; MEGAN C. MCCLINCY, RD; JOHN P. HOLCOMB, JR, PhD; KELLY L. DEAN, RD; CAITLYN E. WALKER, RD
ABSTRACT This study measured food security and hunger of households involved in Head Start in a rural Appalachian county and assessed factors that could affect food security and hunger. A convenience sample of households with children enrolled in the Head Start program in Athens County, Ohio, were sampled (n⫽710), with adults from 297 (42%) households responding. The survey instrument included the 18-question US Household Food Security Survey Module for measuring hunger and food insecurity. Of those responding, 152 households (51.2%) were food secure and 145 (48.8%) were food insecure. Ninety (30.3%) had experienced hunger in the previous 12 months, and 41 (13.8%) households were classified as food insecure with childhood hunger. Hunger was related to a variety of household characteristics and associated with several factors, including participation in food banks, dependence on family members and friends outside of the household for food, lacking reliable transportation, and not having a garden. J Am Diet Assoc. 2004;104:238-241.
F
ood insecurity implies a limited access to or availability of food or a limited or uncertain ability to acquire food in socially acceptable ways (1,2). The effects of food insecurity may include suboptimal quality of life and health (3-6). Its effects on children can be especially grave (7-15). In 2001, 10.7% of households in the United States were food insecure at some time during the year (16). In fact, households with children experienced food insecurity
D. H. Holben is an associate professor and Director, DPD Program, Ohio University, School of Human and Consumer Sciences, Athens, OH; M. C. McClincy is a clinical dietitian, Marion General Hospital, Marion, OH; J. P. Holcomb, Jr, is an assistant professor, Department of Mathematics, Cleveland State University, Cleveland, OH; Kelly L. Dean is a graduate student at the University of Cincinnati, Cincinnati, OH; and Caitlyn E. Walker is a former student, Ohio University, School of Human and Consumer Sciences, Athens, OH. Address correspondence to: David H. Holben, PhD, RD, Ohio University, School of Human and Consumer Sciences, Grover Center W324, Athens, OH 45701. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10402-0019$30.00/0 doi: 10.1016/j.jada.2003.09.023
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(16.1%) at rates greater than the national average (16). Other characteristics of households prone to being food insecure include (a) having an income below the official poverty line, (b) being headed by a single woman with children, and (c) living in rural areas (16). The Appalachian region has a large rural population and shows high rates of poverty and unemployment, which may indicate that individuals in that region are at risk for experiencing food insecurity. Healthy People 2010 includes the goal of improving US food security status (17). The American Dietetic Association has asserted that domestic hunger and food insecurity are issues in need of immediate action and has recognized a special concern for children and adolescents to have access to food and nutrition programs (18). Head Start (HS) provides a comprehensive child development program for preschool children from families with low incomes (19). Families participating in HS are prone to experiencing food insecurity and hunger, due to their demographic characteristics. Although HS is not part of the nutrition safety net, in theory, participation may contribute to improving household food security because of the provision of supplemental resources, including nutritious meals and snacks. The purposes of this study were to (a) measure the level of food security and hunger of households involved in HS in a nonmetropolitan Appalachian county, and (b) assess factors that could affect food security and hunger. METHODS Selection of Subjects The Human Subjects Committee of the Ohio University Institutional Review Board approved this study before the collection of any data. A convenience sample of all households with children currently enrolled in HS in Athens County, Ohio, were sampled (n⫽710), with adults from 297 (42%) households responding. Athens County is a nonmetropolitan county situated in the northern Appalachian region of the United States (20-22). The Appalachian Regional Commission has classified it as a distressed county (most severe economic level category) based on the economic indicators of unemployment, per capita market income, and poverty (20). Survey Instrument The 55-item survey instrument posed questions to subjects about the previous 12 months and included the 18-question US Household Food Security Survey Module (FSSM; Figure) (1). Using standard methods (1), households were categorized regarding food security status. Using the eight FSSM questions related to children (23),
© 2004 by the American Dietetic Association
● “(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.” Was that often true, sometimes true, or never true for (you/your household) in the last 12 months? ● “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/ your household) in the last 12 months? ● “(I/We) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(I/We) relied on only a few kinds of low-cost food to feed (my/our) (child/children) because (I was/we were) running out of money to buy food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(I/We) couldn’t feed (my/our) (child/children) a balanced meal, because (I/we) couldn’t afford that.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● “(My/our) (child was/children were) not eating enough because (I/we) just couldn’t afford enough food.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? ● In the last 12 months, since last (name of current month), did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food? ● In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food? ● In the last 12 months, did you lose weight because you didn’t have enough money for food? ● In the last 12 months, did (you/you or other adults in your household) ever not eat for a whole day because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, since (current month) of last year, did you ever cut the size of (your child’s/any of the children’s) meals because there wasn’t enough money for food? ● In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? ● In the last 12 months, (was your child/were the children) ever hungry but you just couldn’t afford more food? ● In the last 12 months, did (your child/any of the children) ever not eat for a whole day because there wasn’t enough money for food? Figure. The US Household Food Security Survey Module (FSSM) Questions (1).
households experiencing food insecurity with hunger among children were also identified. Closed-ended questions intended to document food assistance program participation, household composition, dietary habits, and availability of resources were also included. Data Collection The survey instrument was distributed on two separate days in January 2001 by the HS Program Director to adults with children enrolled and returned to the sites by adult respondents within 1 week of distribution. The surveys were coded and not linked to the respondent in any manner. No compensation was provided for participation. Statistical Analysis Statistical analyses were performed using the Statistical Program for the Social Sciences (version 10.0.1, 1999, SPSS Inc., Chicago, IL). Descriptive statistics were calculated to summarize food security status measures. Spearman correlation was calculated to assess the relationship of food security status to the number of food assistance programs participated in. Odds ratios were calculated to compare the presence of food insecurity with hunger to the variables in the Table. Variables with the highest odds ratio results were used as predictors of hunger in a forward-stepwise logistic regression model to assess the strongest predictors of hunger. Because the sample is not a random sample of the population of interest, significance tests and confidence intervals were not calculated for the Spearman correlation coefficient or odds ratios. A P value set a priori, however, of less than .05 was used to identify variables most useful in predicting food insecurity with hunger.
RESULTS AND DISCUSSION Individuals responding (n⫽297) classified themselves as a female (n⫽222, 74.7%) or male (n⫽42, 14.2%) head-ofhousehold or other/no response (n⫽33, 11.1%). Of the 297, 152 (51.2%) were food secure, and 145 (48.8%) were food insecure. Ninety (30.3%) had experienced hunger in the previous 12 months. Forty-one (13.8%) households were food insecure with childhood hunger. These 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%). Considering only rural households with children nationally, our sample experienced food insecurity (48.8% vs 17.2%) and hunger (13.8% vs 0.2%) to a more severe degree. Supporting the trends typical of the Midwest, Ohio was below the national average for prevalence of household food insecurity (9.1%) and hunger (2.8%) during 1999 to 2001 (16). This study finds that our sample of Appalachian Ohio households with children enrolled in HS experienced a higher degree of food insecurity than what is typical for a state or region. Although our sample is not representative of households in the region or those enrolled nationally in HS, these findings suggest that rural households with children enrolled in HS may experience food insecurity and hunger at dramatically greater rates than the national averages. Poverty is higher in rural Appalachia than in other populations (20,24). Similar to other counties in the Appalachian region, Athens County is characterized by high unemployment rates and other depressed economic indicators. The geography of the region often makes it difficult and costly to develop roads, communications systems, and public works facilities that support health care delivery and other services. Although these factors also
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Table. Odds ratio analyses for the outcome variable of food insecurity with hunger Survey question
Odds ratioa
Do you have reliable transportation to get food? Do you depend on family members and friends outside of your household for food? Do you participate in food banks/food shelf programs? Do you participate in the food Stamp Program? Do you give away fresh/canned/frozen produce to friends or family? Do you participate in the National School Lunch Program (free or reduced)?b Do you participate in the School Breakfast Program (free or reduced)?b Do you have a garden in the spring and summer? Do you give away fresh/canned/frozen meats to friends or family? Do you participate in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)? Number of adults in the household Do you can or freeze vegetables?
25.6a 11.7 9.6 6.0 5.0 4.3 4.0 4.0 3.0 2.6 2.2 1.7
a
Interpretation of odds ratio example: The odds of experiencing hunger were 25.6 times higher for those without reliable transportation than for those with reliable transportation. In the original survey, subjects were asked separately whether they participated in free and reduced programs. During the analysis, subjects were classified, based on their response, as participating or not participating in the program overall.
b
affect other rural areas, they affect rural Appalachian communities to a greater extent, which may be affecting food insecurity among households. Participation in a greater number of food assistance programs was associated with poorer food security status (⫽0.519). This phenomenon, although counterintuitive, may be caused by the nature of program participation. That is, because individuals self-select to participate in both federal and nonfederal programs, only when food insecurity is severe do individuals choose to participate. The Table summarizes the odds ratios calculated for the outcome variable of food insecurity with hunger. To determine the variables that best predict household hunger, forward-stepwise logistic regression analysis was performed and showed the following: participating in food banks (P⬍.001); depending on family members and friends outside of the household for food (P⫽.001); lacking reliable transportation (P⬍.001); and lacking a garden (P⫽.009). No two-way interactions among variables were significant. Transportation, which may be a proxy for income, seems particularly vital to households in rural areas because public transportation is usually absent in communities. Although participating in assistance programs and depending on others for food were associated with hunger in our study, these and other coping strategies have been previously described in the literature (25). Having a garden can decrease the likelihood of hunger among households, according to this study. This may indicate the important role of gardening in maintaining food security and underscore the need for educational programming related to both gardening and safe preservation methods. Initiating community or school gardens may be one strategy not only to teach gardening methods and improve food security, but also to improve dietary quality and promote health (26-28). However, rural areas, because of transportation limitations primarily, may require effective partnerships and alliances, as discussed in the USDA Community Food Security Initiative, to make community gardens a feasible strategy (29). Limitations of the study include how and when the survey was administered. The literacy of the subjects may have affected the response rate, in that those who
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were unable to read the survey may not have participated. The season of the year (winter) may also have affected the results because families often make choices between buying food and paying other bills (eg, utilities). Finally, although this study is limited by its nonrandom sample, it supports the need to verify these trends in a representative sample of households in the Appalachian region and in households with children enrolled in HS nationally. CONCLUSIONS ●
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This study measured the level of food security and hunger of households with children enrolled in HS in a nonmetropolitan Appalachian county and assessed factors that could affect food security and hunger. Understanding the characteristics of households that are prone to food insecurity will help dietetics professionals to be more effective in practice by considering the barriers that may prevent families from complying with the prescribed medical nutrition therapy. Providing appropriate counseling and education, which may include gardening education, to clients and communities may result in greater food security. Dietetics and nutrition professionals can play leadership roles in addressing food insecurity in their communities in collaboration with community-based agencies and organizations and in food security research related to emergency feeding programs, gardening programs/ community gardening development and outcomes.
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