Development of a Comprehensive Household Food Security Tool for Families with Young Children and/or Pregnant Women in High Income Countries
Abstract
:1. Introduction
2. Materials and Methods
- Stage 1
- Stage 2
- Stage 3
- Stage 4
- Stage 5
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A
Question Item | Responses Options | Feedback from Cognitive Interviews | Changes Made to Survey |
---|---|---|---|
If you are not an Australian Citizen, what visa are you on? Leave blank if not applicable. | Free Text | Interview 1: Could just have ‘yes’ as an option: reword ‘are you an Australian citizen’? Yes, No. If not, add in what visa question; if yes, skip this question | Change as suggested to “are you an Australian citizen or permanent resident”? Yes/No options (A) Follow up question if “No” is selected; “What visa are you on?” free text response option (Q) |
Which of the following best describes your housing or living situation? Tick one: | Living with children and partner/spouse Living with children Living with partner/spouse Living with parents/extended family Living by myself Living with flatmates/friends Other (please specify) | Interview 1: For option 2, ‘living with children’ add in ‘without spouse’. Could add into question ‘own or foster’ children Interview 4: Hard to locate answer (living with children) | Changed second response option to “living with children without partner/spouse” (R) Changed wording of question item to “Which of the following best describes who you live with? Choose one”. (Q) Removed wording ‘living with’ from responses as question item wording changed (O) |
What is your current living arrangement? | Homeowner Renting (privately) Renting (public housing or community housing) Boarding house or caravan park Temporary accommodation (staying with family or friends, shelters, hostel) Living on the street Other | Interview 1: Add ‘living with parents/family’ as an option as this may be a permanent situation and therefore doesn’t come under the temporary accommodation option Interview 5: Have two options for homeowner: with mortgage and without mortgage | Added new response option “Permanently staying with family or friends” (R) Changed homeowner response options to “Homeowner no mortgage” or “Homeowner with mortgage” (R) |
What is your main source of income? | Wages or salary Any government pension or allowance Self funded retirement Nil or negative Don’t know Any other regular source—please answer 14a | Interview 5: Add in an additional question ‘are you the main income earner in the home’ Interview 7: Answer for self or partner? | Changed question item wording to include household so the question now reads “What is your main source of household income”? (Q) |
Which category listed below represents the total combined income of all members of your family who are 15 years of age or older. Please include money from things such as jobs, net income from business, pensions, social security payments, and any other income received. Was it… | No income $1–$119 per week ($1–$6239 annually) $120–$299 per week ($6240–$15,999 annually) $300–$499 per week ($16,000–$25,999 annually) $500–$699 per week ($26,000–$36,999 annually) $700–$999 per week (37,000–$51,999 annually) $1000–$1499 per week ($52,000-$77,999 annually) $1500 or more per week ($78,000 or more annually) | Interview 1: What about if living with housemates or parents? Are these included? Word ‘family’ may be confusing as may word ‘household’ Interview 2: Does this include family tax benefit? Would interpret answering this question pre-tax/gross but doesn’t specify Interview 4: Had to stop and really think Interview 6: Most payments are fortnightly Interview 7: Pre or post tax? Interview 8: Do I include child support? Interview 11: Like how there was an annual, this helped to work out more so than the weekly total | Changed wording in this question to include the text “members of your household who you share finances with” (Q) Added text “before tax is taken out” to question (Q) Added text “child support” into question (Q) |
Do you receive any government benefits? Yes/No If yes, which ones do you receive? Tick all that apply: | JobSeeker Austudy/abstudy Disability support pension Carer payment Parenting payment Aged pension Rent assistance Other | Interview 1: Add parenting payment? Interview 2: Does parenting payment cover part parenting payment? What about family tax benefit, also under parenting payment? Interview 5: Add in ‘family tax benefit as an option Interview 7: What about childcare subsidy? Does this come under family tax benefit? Interview 11: Think childcare should be here | Included “family tax benefit” as a response option (R) Allow free text if the “other” response option is selected (R) |
For the following statements please choose the answer that best fits for the past year: My family has enough money to afford the kind of home we would like to have We have enough money to afford the kind of clothing we should have We have enough money to afford the kind of furniture or household equipment we should have We have enough money to afford the kind of car we need We have enough money to afford the kind of food we should have We have enough money to afford the kind of medical care we should have My family has enough money to afford the kind of leisure and fun activities we want to participate in | Strongly disagree Disagree Neutral Agree Strongly agree | Interview 5: Have ‘adequate’ but not ‘ideal’ for most of these questions Most interviewees struggled to answer this scale as they found it hard to distinguish between essential items (i.e., any home) and what they would like (i.e., a home they would like) | Scale removed (D) |
In the last 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? | No Yes—please answer 3a. Don’t know | Interview 2: Asks about adults | Added in an additional eight USDA questions specific to children for respondents who indicate they have children (8A) Added four new questions on children’s health (4A) Added question about children’s awareness of the food insecurity experience (A) |
What kind of transport do you usually use to purchase food/groceries? Tick one only | I drive my own car I ride with friends or family I borrow a car I take public transport (train, tram, bus, or combination) I take a taxi or app-based ride like Uber I walk or take my bicycle Other, please specify | Interview 1: What about online grocery delivery (Coles online, Woolworths online)? Interview 2: Would tick two options if could Interview 7: Add in online delivery as option | Created a new question about where people shop that precedes this question about transportation to purchase food/groceries. The new question includes online shopping (A) |
Using this usual form of transport listed in the previous question, about how long would it take to get from your home to the nearest local grocery store or supermarket? | 1–10 min 11–30 min 31–45 min 46 min–1 h Over an hour Don’t know | Interview 11: In cities most people are going to be less than 5 min, so maybe have 1–5 and 6–10 min | Changed response options: “Less than 5, 5–15, 16–30, 31–45, 46–1h” (R) |
For the following questions choose the answer which best fits. How often during the past month did you or anyone in your household have to …. choose between paying for food and paying for medical care? choose between paying for food and paying for utilities? choose between paying for food and paying for rent or mortgage? choose between paying for food and paying for transportation or gas for a car? choose between paying for food and paying for school loans, tuition, or other education expenses? stretch the amount of food in your home by limiting the amount of food people in your home could eat? avoided inviting guests into your home when you would be expected to serve them food? eaten meals or snacks after your children finished to ensure they had enough? visited a food bank, pantry, or other emergency food relief service | Never Rarely Sometimes Often Always | Interview 5: Does this include medication? Interview 11: Should there be a not applicable here and for all? For us, this question is not relevant for the last month Interview 2: Could include cost of childcare in this question Interview 5: Would include question on pets as often chose to feed pets before self when things were tight with money and cost of their food impacts budget. Also include question on medical expenses (GP/medicine) and allied health (dentist/physiotherapist, etc.) | Added in the text “medication” to the first line item so question item now reads “medicine and/or medical care”? (Q) Added in “not applicable” to response options (R) Added in the text on childcare or after school care (Q) Added in the text about nappies and infant food/formula to be more relevant to children (Q) Added in the text on feeding pets (Q) Added in the text on allied health care (dentist, physiotherapist, psychologist, etc.) (Q) Split question item into two separate items (A) |
For the following statements/questions choose the answer which best fits: Meals are an important part of the day for me/my household I am able to cook healthy foods for my family on a budget I am able to cook from basic ingredients I plan meals ahead (e.g., for the day/week ahead) I use leftovers to create another meal I buy food in season to save money I purchase healthy food, even if I have limited money? (e.g., fruit and vegetables) I compare prices between products in order to get the best value food | Strongly disagree Somewhat disagree Neutral Somewhat agree Strongly agree | Interview 1: Don’t create another meal with leftovers but eat leftovers; how to answer this question? Interview 1: Don’t always know what is in season but just buy cheapest foods. Interview 11: What about buying in bulk? | Changed question item wording from “I use leftovers to create another meal” to “I use leftovers” (Q) Added in new free text item “Are there any other food budgeting strategies you use (e.g., couponing, buying in bulk)? Please write below:” (A) |
Are there times of the year or events where buying food for your household is more difficult due to competing expenses? Please tick any of the below that makes it more difficult for you to purchase food for your household. | Christmas/Ramadan/other religious festivals School holidays Start of school year/term Birthdays Towards the end of the pay cycle Loss of job Moving house Unexpected car issues Other (please specify) | Interview 2: Add in Easter to first response item, also include winter and increased heating expenses as an option Interview 3: Add in medical care/expenses. Interview 4: Would tick all answers here Interview 5: Include ‘unpaid sick leave’ and also ‘COVID/lockdown’ Interview 6: Could also include homelessness/loss of home Interview 9: Also include reduced work hours as event Interview 11: Not school but when daycare is closed, we do spend more money on feeding my daughter because she is at homeilot C: | Changed first response option to “religious festivals” and provided examples (R) Added in new response options; “Increased heating in winter or cooling in summer, Reduction in work hours, Medical care/medical expenses, Recent death/bereavement, End of a relationship, Delays in Centrelink payments, COVID-19 restrictions, Homelessness, loss of home” (R) Added in new free text item to describe other events or times when buying food is more difficult (A) |
Do you currently smoke? | No Yes—please answer 2a | Interview 5: Include question on if partner or other household members smoke | Changed question item wording to “Do you or anyone in your household smoke cigarettes or purchase other tobacco products?” (Q) |
If yes, do you currently smoke regularly, that is at least once per day? | No Yes | Added question about frequency of smoking “Do you or your household member currently smoke or vape regularly, that is at least once per day? (Q) | |
Are you currently pregnant? | No Yes—please answer 4a. | Interview 11: This is so influential in all my answers, maybe it should go at the top? Like I want to answer this first because its context for all my other answers. Same as having a toddler, our budget has changed to ensure her diet is varied and optimal | Have moved this question to the very start of the survey as a new screener question (Q) Added new question on if this is a planned pregnancy (A) |
Have you taken any dietary supplements (e.g., multivitamins, fish oil) in the last 24 h? | No Yes Don’t know | Interview 1: Add in ‘folate’ | Added “folate” under the examples provided (Q) |
Please indicate if you have ever experienced any of the following as an adult or child? | Financial or economic abuse Emotional or psychological abuse Spiritual abuse (the denial or use of spiritual or religious beliefs and practices to control and dominate another person) Physical abuse Sexual abuse Other abuse Prefer not to answer | Interview 1: Need to add into wording ‘leave blank if none apply’ Interview 2: Think this is an important question to include Interview 5: Need to have lead into question indicating it may be sensitive and can choose to skip or not answer if prefer. Interview 11: Have a ‘none of the above’ answer | Changed question item wording to include “tick any that apply” (Q) Added in response option “none of the above” (R) Moved from the start of the survey under the ‘about you’/demographics section to near the end of the survey under the ‘health’ section so not as not to be jarring and added in text prior to the question “Some of the next questions may be sensitive and you can skip them if you prefer not to answer”. (Q) |
For the following statements choose the answer which best fits: In the past month, about how often did you… feel tired out for no good reason? | None of the time A little of the time Some of the time Most of the time All of the time | Interview 1: What does ‘not good reason’ mean? i.e., is it a health or lifestyle reason? Hard to answer; need a ‘not sure’ option Interview 4: ‘tired out’ reads strange. Does this mean exhausted? Suggest changing Interview 5: ‘no good reason’ have many reasons Interview 7: ‘no good reason’? | Changed question item wording to “feel tired for no obvious reason” (O) |
Do you consider yourself to be an acceptable weight, underweight, or overweight? | Acceptable weight Underweight Overweight Currently pregnant | Interview 5: Would answer ‘slightly’ overweight if there was this option Interview 7: Probably acceptable weight but overweight for pre-baby Interview 11: Yes, doctors tell me I am for this stage in pregnancy | Removed the question as respondents are asked to report weight and height so BMI can be calculated from this information (D) |
Over the last month, how many glasses of sugar sweetened beverages (e.g., regular soft drinks like Coca-Cola, Pepsi, Solo, lemonade, sweetened tea, and fruit drinks) did you usually drink each day? Do not include mineral or soda water. | None Less than 1 glass per day 1 glass per day 2 glasses per day (equivalent to 1 can) 3 glasses per day 4 glasses per day 5 glasses per day 6 glasses per day 7 glasses per day (equivalent to a 1.25 L bottle) 8 glasses per day 9 glasses per day 10 or more glasses per day | Interview 2: ‘Fruit drinks’ would include juice in answer for this. Interview 4: Under fruit drink would include juice in calculations Pilot | Included the line saying do not include 100% fruit juice here (Q) Added sports and energy drinks (Q) |
Over the last month, how often did you eat fresh meat (including beef, veal, chicken, lamb, pork)? | Never Less than once per month 1–3 times per month 1 time per week 2 times per week 3–4 times per week 5–6 times per week 1 time per day 2 times per day 3 or more times per day | Interview 1: Household is vegetarian so need option for this. Perhaps at the start of the survey could have a question about dietary requirements, e.g., gluten free, vegetarian/vegan, etc. Interview 2: Provide option for vegetarian, i.e., ‘never’ by choice or ‘never’ because can’t afford? Interview 4: Include frozen as well in this answer? | Added in a question prior to this; “Do you follow a vegetarian or vegan diet?” If they select no then they are asked to answer this question, if they select partly (pescatarian) then they are asked to skip this question but answer other questions on fish, if they select yes then they can skip the question (A) Have included the word “frozen” in the question item so the question now reads; “Over the last month, how often did you eat fresh or frozen meat (including beef, veal, chicken, lamb, pork)?” (Q) |
Over the last month, how often did you eat take away or fast foods (such as burgers, chips, pizza, Indian)? Include foods eaten at the restaurant or at home (e.g., Uber eats, take away) | Never Less than once per month 1–3 times per month 1 time per week 2 times per week 3–4 times per week 5–6 times per week 1 time per day 2 times per day 3 or more times per day | Interview 5: Would take out Indian as haven’t mentioned other ethnic cuisines. | Have taken out “Indian” from question item wording (Q) |
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Food Security Construct | Constructs and Outcomes Identified from Scoping Review (Stage 1) | Themes and Outcomes Identified from Qualitative Interviews (Stage 2) |
---|---|---|
Income and employment | Low income, job loss, and payment schedules; not receiving welfare; low social economic status (i.e., education, occupation, and household income); living below the poverty line; and mothers as homemakers | Employment; government assistance (e.g., accessing programs, the trade-off between earning income/losing assistance, and running out of assistance); competing expenses (e.g., other bills, children’s activities, time of year, and special occasions) |
Coping strategies | Stretching food, going without food, and skipping meals; cutting back on the variety of foods consumed; going to bed hungry; cooking whatever is available, buying cheaper food, shopping at value stores, and using coupons; reducing money spent on children’s education and activities; borrowing money; and food and social supports | Utilizing resources (e.g., food pantries, utility/bill aids, and other non-government programs); budgeting skills (e.g., couponing, bargain shopping, and buying cheaper foods); family and friend support (e.g., food, money, or other resources provided; social support); rationing (e.g., making food last all month, limiting intake); nutrition knowledge and skills (e.g., being a good home cook) |
Maternal depression/mental health | Maternal depression and poor health status; parenting stress; lack of time; lack of social support; feelings of isolation; and unwanted childbearing | Stress (e.g., financial stress, stress from children, and stress about feeding children); social factors (e.g., social support or lack thereof, self-portrayal, and stigma); declining mental health contributing to poor food choices; and depression |
Residence stability and crowding | Housing and household energy insecurity; experience greater number of moves/relocating; receiving housing subsidy; not owning land; and household crowding | Food utilization; food storage, waste, and kitchen facilities |
Education | Caregivers/mothers with lower levels of education | Social demographics (e.g., lower education) |
Parent acculturation | Immigrant status and length of time in the country; difficulty with shopping and food preparation in a foreign environment | Social demographics (e.g., foreign students) |
Ethnicity | Ethnicity, race, and ethnic minority | Social demographics (e.g., visa status and eligibility for government benefits) |
Family composition | Caregiver marital status (single/widowed/separated/divorced); larger household size; and larger number of children | Familial dynamics such as children eating first and children’s awareness of food insecurity; the age of children; and generational food insecurity experience |
Health care and Health status | Health care usage; lack of health insurance coverage; poor infant/child health status and greater hospitalizations; high prevalence of overweight/obesity among food insecure children; and children’s behavioral problems | Social demographics (e.g., visa status and eligibility for free or subsidized health care, cost of health care including allied health) |
Participation in food assistance programs | Participation in welfare programs (e.g., in federal food assistance programs such as WIC and SNAP in the U.S.); reliance on school meals | Non-traditional food sources (e.g., food pantries, community gardens) |
Smoking | Living in a house with a smoker, maternal smoking | Financial impact of competing expenses |
Food access and availability | Economic constraints and food pricing (including the cost of fruit and vegetables); choosing between food and other necessities (including medicine and bills); and lack of access to healthy food or food stores in general | Food outlet location; transportation; factors influencing store and item selection; and non-traditional food sources (e.g., dollar stores) |
Diet quality | Reduced consumption of high-cost and micronutrient-rich foods; increased consumption of low-cost traditional staple foods | Family food preferences and needs (e.g., priority foods, picky eaters, preferences, dietary needs, culturally appropriate, and pregnancy/toddler/formula needs) |
Other | Lack of urban infrastructure and exposure to environmental contaminants | Coronavirus impacts on health, employment and finances, childcare, and food sourcing |
Components of Household Food Insecurity Experience | |
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1. Individual or household risk factors for food insecurity | Economic: income and employment Health: stress and mental health, chronic health conditions Social: demographics including education, ethnicity, and household composition |
2. The four dimensions of food security | Utilization: resilience and coping strategies, kitchen facilities, nutrition skills and literacy, and participation in food assistance programs Access and availability: physical and financial access to foods and stores, food insecurity screener items Stability: annual competing expenses and challenging times of year |
3. Health outcomes or consequences of food insecurity | Health: stress and mental health, chronic health conditions Diet quality |
Type of Change | Initial Item in Household Food Security Tool | Change Made to Household Food Security Tool |
---|---|---|
Improving overall readability | In the past month, about how often did you feel tired out for no good reason? | In the past month, about how often did you feel tired for no obvious reason? |
Changes to question response to make more relevant | … about how long would it take to get from your home to the nearest local grocery store or supermarket? 1–10 min 11–30 min 31–45 min 46 min–1 h Over an hour Don’t know | Changed responses to: Less than 5 min 5–15 min 16–30 min 31–45 min 46 min–1 h Don’t know Not applicable |
Changes to question content to make clearer | Which category listed below represents the total combined income of all members of your family who are 15 years of age or older. Please include money from things such as jobs, net income from business, pensions, social security payments, and any other income received. Was it… | Which category listed below represents the total combined income of all members of your household who you share finances (include family members 15 years of age or older). Please include money from things such as jobs, net income from business, pensions, social security payments, child support and any other income received, before tax is taken out. Was it… |
Adding or deleting items to make more relevant | Are there times of the year or events where buying food for your household is more difficult due to competing expenses? Please tick any of the below that makes it more difficult for you to purchase food for your household. | Added in a separate/additional item: Please describe the other times or events when buying food is more difficult (free text response) |
Do you consider yourself to be an acceptable weight, underweight or overweight? | Deleted question as subjective and survey has question items on self-reported weight and height |
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Bastian, A.; Parks, C.; McKay, F.H.; van der Pligt, P.; Yaroch, A.; McNaughton, S.A.; Lindberg, R. Development of a Comprehensive Household Food Security Tool for Families with Young Children and/or Pregnant Women in High Income Countries. Int. J. Environ. Res. Public Health 2022, 19, 10543. https://doi.org/10.3390/ijerph191710543
Bastian A, Parks C, McKay FH, van der Pligt P, Yaroch A, McNaughton SA, Lindberg R. Development of a Comprehensive Household Food Security Tool for Families with Young Children and/or Pregnant Women in High Income Countries. International Journal of Environmental Research and Public Health. 2022; 19(17):10543. https://doi.org/10.3390/ijerph191710543
Chicago/Turabian StyleBastian, Amber, Courtney Parks, Fiona H. McKay, Paige van der Pligt, Amy Yaroch, Sarah A. McNaughton, and Rebecca Lindberg. 2022. "Development of a Comprehensive Household Food Security Tool for Families with Young Children and/or Pregnant Women in High Income Countries" International Journal of Environmental Research and Public Health 19, no. 17: 10543. https://doi.org/10.3390/ijerph191710543