Ability to afford enough food
The United States Department of Agriculture defines food security as regular access to enough food to lead a healthy and active life. In contrast, individuals who experience food insecurity may cut the size of their meals, be unable to eat balanced meals, forgo eating when hungry, or eat less than needed because of an inability to afford or access food. Inadequate diets can impair intellectual performance and have been linked to more frequent school absence and poorer educational achievement in children. Nutrition also plays a significant role in causing or preventing a number of illnesses, such as cardiovascular disease, some cancers, obesity, type 2 diabetes, and anemia. Inadequate food intake can also adversely affect learning, development, and physical and psychological health.
At least two factors influence the affordability of food and the dietary choices of families—the cost of food and family income. The inability to afford food is a major factor in food insecurity, which has a spectrum of effects including anxiety over food sufficiency or food shortages; reduced quality or desirability of diet; and disrupted eating patterns and reduced food intake.
Low-income, ethnic minority, and female-headed households are at the highest risk for food insecurity. In 2011, approximately 15% of U.S. households were food insecure at some time during the year, meaning that the food intake of one or more household members was reduced and eating patterns were disrupted because the household lacked money and other resources for food. Inadequate diet and physical inactivity are responsible for approximately 17% of deaths in the United States.
The steps outlined here to analyze survey data about food insecurity are part of the service diagnose and investigate. Completion of this step allows a health department to identify the priority populations where to focus other essential public health services primarily: evaluate, monitor health, and mobilize community partnerships. Based on the results of this analysis, a health department can identify the community organizations and stakeholders working with priority populations to mobilize into a partnership first. Once created, the first crucial outcome of this partnership is the inter-agency sharing of data about programmatic and health outcomes of the priority populations. This partnership can then specifically identify the needs of the priority populations through sharing this data, which this broad SDOH-LC indicator cannot capture. The partnership can then design policies, programs, and other interventions tailored to the priority populations identified in the “diagnose and investigate” step from this collaboratively-created needs assessment. The partnership, after implementation of an intervention, can use this SDOH-LC indicator to evaluate the progress and to monitor the health and quality of life in priority populations over time.
There are two sources of data for health departments in California—the California Health Interview Survey (CHIS) and the California Department of Public Health’s Healthy Communities Data and Indicator (HCI) project.
CHIS collects data on food insecurity from adults with household incomes that are less than 200% of the federal poverty level (FPL) (i.e., lower-income households). Ideally, in order to identify disparities in food security, it is best to look at differences among adults from lower- and higher-income households. However, the CHIS data can be used to identify lower-income adults who are most at risk of food insecurity, such as those from disadvantaged racial/ethnic groups or older adults. Considering the limitations of CHIS (and phone-based surveys in general), BARHII suggests that health departments always triangulate estimates from CHIS with other SDOH-LCs and other neighborhood-level data. In the case of the food insecurity indicator, we can assume that areas with a higher prevalence of people living below 200% FPL also face a higher prevalence of food insecurity. Based on this assumption, further assessment about food insecurity in high-poverty areas (as shown on the poverty map in the introduction) can occur to mitigate the limitations of phone-based surveys such as CHIS. For a detailed set of instructions with screen shots of how to access these data, see Appendix C.
In addition, HCI has developed their own data for this indicator for California, which can be found at http://www.cdph.ca.gov/programs/Pages/HealthyCommunityIndicators.aspx. For the detailed instructions on how to download and filter data from the HCI, see Appendix D.
Each of these methods is outlined below.
The method outlined for CHIS to identify priority places and populations for a health outcome or social determinant of health can be applied to local surveys or others outside of California.
CHIS asked a series of five questions developed by the USDA about nutrition in the past 12 months, such as whether the food that the household bought lasted, or whether they had enough money to purchase more to measure food security. These questions can be found on the CHIS adult questionnaire at http://healthpolicy.ucla.edu/chis/design/Pages/questionnaires.aspx.
For more information on how the responses to these five questions were combined into a single overall measure of household food security that can be viewed on AskCHIS, see http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/measurement.aspx
Use the method from Appendix C to identify disparities in food security by race/ethnicity among adults from low-income households. In this case, we used the BARHII region (the Bay Area plus Santa Cruz) as the geography, comparing food security by race/ethnicity over time.
Interpret the trend chart to determine priority populations among race and ethnicities with statistically stable estimates. Race/ethnicities (with statistically stable estimates) among people living below 200% FPL with the highest prevalence of food insecurity have seen an increase or no change in food insecurity over time should be designated as intervention priorities. Based on this procedure, recommended ranked priority populations of people living below 200% FPL by race and ethnicity for food-security interventions include those of two or more races, African American/Black and Hispanic/Latino (tie), Asian, and White. Because Native Hawaiian and American Indian population responses were unstable, their rank could not be determined from these data, although they could experience food insecurity greater than or equal to other race/ethnicities. Right now, this can only be determined with local-level assessment or oversampling of these populations by CHIS, which can be cost prohibitive. In late 2014, CHIS will release the CHIS Neighborhood Edition, which will allow geographies including zip codes to be grouped together for analysis.
An interpretation of the trend chart would be that, in 2009, food insecurity among those living below 200% FPL in the BARHII region increased since 2001 with the most significant change after 2007. In 2009, Multirace individuals living below 200% FPL had the most significant increase in food insecurity since 2001, followed by Hispanic/Latinos and African Americans/Blacks (tie), Asian, and White populations. Although sometimes reported, data on food insecurity for Native Hawaiian/Pacific Islander, and Native Americans could not be determined with CHIS because of unstable data. Although the data from CHIS cannot determine food insecurity for Native Americans and Native Hawaiian populations living below 200% FPL, these populations may still experience food insecurity equal to or greater than race/ethnicities identified in this analysis. This can be examined more closely with local-level assessment or oversampling of these populations by CHIS.
Figure 23: Food Insecurity, BARHII Region
Identify the potential community-based organizations in priority areas to mobilize community partnerships to increase food security.
Use the method from Appendix D to download data from the California Department of Public Health’s Healthy Communities Data and Indicator (HCI) project.
The HCI presents the ratio of dollars to purchase an annual market basket of foods for a female-headed household with children less than 18 years, relative to her annual inflation-adjusted income. The cost of food is based on the USDA’s low-cost food plan, which includes a market basket of items that families would have to purchase to provide a nutritious diet for each family member. To determine the costs, the USDA conducts a monthly national market basket survey of food items. The USDA tabulates per person costs by age for children less than 11 years, and age and gender for those 12 years to those 71 years and older. For the HCI project, family costs were the sum of costs for the female head of household and the per child-cost multiplied by the area average number of children under 18 years, taking into account their age distribution. The USDA annual costs were expressed in constant 2010 dollars and adjusted for regional differences (Los Angeles, Bay Area, San Diego, California average) based on the Consumer Price Index food at home.
STEP 02. Open the “Food Affordability” Microsoft Excel sheet (xls).
STEP 03. Choose filters based on your analysis. For this example, we will be comparing race/ethnicities in the entire state of California. So under ‘geotype’ choose “CA.” This will bring up each race/ethnicity category as rows.
STEP 04. The affordability shown is for a female-headed household with children under 18 years. The affordability ratio is the food cost divided by median income for that race/ethnicity. Copy the data into a new Excel sheet.
STEP 05. Create a visual representation.
Figure 24: Affordability Ratio, California, By Race/Ethnicity
III. BAY AREA LOCAL HEALTH DEPARTMENT EXAMPLES
In 2011, Marin County convened a CalFresh collaborative to address the low penetration of CalFresh enrollment in Marin, as Marin has one of the lowest in the state. The collaborative convened representatives from the local food bank; the director of Health and Human Services and Social Services; policy analysts; Community Health and Prevention staff; Women, Infants, and Children (WIC) staff, and Epidemiology Program staff. A data presentation on food insecurity, food stamp gaps, and needs in Marin was provided by the epidemiologists.
In 2012, as a direct outcome of the collaborative, a CalFresh application assister was hired by the Division of Social Services, and located at the WIC office to assist WIC clients with completing CalFresh applications. It was clear from this pilot that the assister was able to effectively reach CalFresh eligible families, dispel myths about the program, and be a friendly and accessible face of the program.
Later in 2012, the recently convened Marin Food Policy Council chose CalFresh enrollment as a program goal and explored opportunities to support CalFresh outreach and enrollment activities and the systems and policy changes that were required to make an impact on this issue. The council drafted a resolution to the board of supervisors recognizing May as Marin’s first ever CalFresh Awareness Month, and supported a range of awareness activities for the month, including:
+ Coordinating a CalFresh application assister training in which 30 community-based application assisters were trained to complete CalFresh applications. These CBO staff are now poised to do outreach and enrollment in the community and can better address myths about the program.
+ Developing a plan for a community advisory board comprised of low-income residents to guide healthcare reform and other public assistance enrollment efforts, including CalFresh.
+ Strengthening CalFresh outreach and promotion materials. These materials include a CalFresh insert that was printed in English and Spanish and was distributed in the Sunday Marin Independent Journal and will be available for future community events. They also produced a CalFresh video.
+ Coordinating Marin’s first CalFresh in a Day outreach event, in which applicants bring their applications and are certified as eligible on the same day.
Increasing access to farmers’ markets and community-supported agriculture projects in communities can promote the consumption of fruits and vegetables. However, since low-income residents must often purchase food with CalFresh Electronic Benefits Transfer/Food Stamps, access may be limited if farmers’ markets do not accept CalFresh. To promote increased access to healthy foods and beverages among low-income families, the Santa Clara County Public Health Department (SCCPHD) worked with farmers’ markets, farmers’ market associations, city officials, and a local coalition of stakeholders to increase acceptance of CalFresh at farmers’ markets. The work was supported by a Center for Disease Control and Prevention Communities Putting Prevention to Work grant. SCCPHD staff provided one-on-one guidance to the cities, towns, farmers’ markets, and farmers’ market associations on the application process to offer CalFresh, as well as on building community support and utilizing marketing materials to promote the use of markets by low-income families. Since the work began, ten markets have completed the application to accept CalFresh, obtained a wireless point-of-sale machine, and promoted CalFresh acceptance. Farmers’ markets that successfully implemented market acceptance of CalFresh were in locations of the county with high populations of low-income residents. Through partnerships with local cities and farmers’ markets associations, 23 farmers’ markets now accept CalFresh in Santa Clara County.
In addition, The Health Trust (a local foundation) with funds from CPPW and in collaboration with key stakeholders advocated for the adoption of an ordinance streamlining the process for new certified farmers’ markets in the City of San Jose. The ordinance eliminates barriers to San Jose’s farmers’ market permitting process and creates a requirement that all new farmers’ markets accept food assistance benefits, CalFresh and WIC.
Through CPPW funding, SCCPHD also worked with food retailers to apply to the USDA’s Restaurant Meals Program. This program allows CalFresh-approved clients that are disabled, homeless, or elderly to purchase prepared meals at participating retailers. SCCPHD and the Santa Clara County Social Services Agency (SSA) identified and prioritized regions in the county to target, providing technical assistance to retailers in completing Restaurant Meals Program (RMP) applications and assisted with marketing efforts. For example, SSA provided a venue for promotion of retailers participating in the RMP on their website and at their monthly Safety Net meetings. As a result, 14 additional restaurant retail locations in Santa Clara County in geographic areas with high need accept CalFresh.
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Harrison GG, Sharp M, Manalo-LeClair G, Ramiriez A, McGarvey N. 2007. Food Security Among California’s Low-Income Adults Improves. But Most Severely Affected Do Not Share Improvement. Los Angeles: UCLA Center for Health Policy Research.
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