EAL

HD: Food Security (2011)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To examine grocery shopping behaviors and other potential factors that could influence food choice and food stamp usage among low-income women with children in their home using both qualitative and quantitative methods of data collection.

Inclusion Criteria:

Mothers or female guardians with at least one child aged nine to 13 in their household were eligible to participate.

Exclusion Criteria:

None were listed for the survey, but pregnant women were excluded from BMI assessment and non-recipients of food stamps were excluded from another analysis.

Description of Study Protocol:

Recruitment

Flyers were posted inviting mothers or female guardians with at least one child at home aged nine to 13 were invited to participate. After providing informed consent and participating in the study, the participants were reimbursed with a cash incentive for their time.

Design

This study was a cross-sectional study.

Statistical Analysis

Demographic and grocery shopping data were analyzed using SPSS for Windows.

Data Collection Summary:

Timing of Measurements

14 focus groups were conducted. These lasted 90 minutes and were audiotaped.

Key Study Variables

Questions examined personal, behavioral and environment influences on grocery shopping and food choices and were frames in the context of Social Cognitive Theory constructs
Participants also provided demographic information and completed a written grocery shopping activity. The purpose of the activity was to transition women into talking about how they prioritize food purchases given limited resources.
Height and weight were measured following a standard protocol and used to calculate BMI.

Description of Actual Data Sample:

Initial N: 92 females participated in the study
Age: Average age was 36.6±8.0 years
Ethnicity: 51% African American, 27% Native American, 13% Caucasian
Other relevant demographics: 77 of the 92 participants were currently using food stamps. Income levels varied, but most participants had incomes less than $20,000 (N=79); 61 of those had incomes less than $10,000. Approximately 30% of participants (N=39) were currently living in homeless shelters. Most participants received a GED or high school equivalent (N=45) and the remainder of participants completed some or all of some college, technical and vocational school.
Anthropometrics: Mean BMI = 32.9±8.9
Location: Twin Cities (Minneapolis and St. Paul) Minnesota.

Summary of Results:

Key Findings

Demographics:
- Mean age: 36.6±8.0
- Mean household size: 4.4±1.9 individuals
- Race: 13% Caucasian, 51.1% African American, 27.2% American Indian, 2.2% Hispanic, and 6.6% other
- Income: 44.4% less than $5,000 per year; 23.3% = $5,000 to $9,999 per year; 20% = $10,000 to 19,999 per year; 10% = $20,000 to 39,999 per year; and 2.2% more than $40,000 per year
Major themes from focus groups included:
- Factors influencing where and when low-income women shop:
  - Participants reported shopping at a variety of places including retail grocery stores, meat markets, discount stores, wholesale stores and corner stores
  - Store location was a critical factor since most women did not have their own car and relied on alternative forms of transportation
  - Most women shopped with food stamps and limited their shopping to food stamp vendors
  - Women who shopped at meat markets perceived the meat to be fresher and of higher quality
  - Women who walked or biked to stores were limited in the amount of food they could purchase at a time since they had to carry it home
- How low-income women prioritize their food purchases:
  - Most participants cited meat as their most important food purchase and it allocated nearly 50% of their money allocated for food. Meat was the basis for most grocery shopping and meal planning.
  - Per the grocery shopping activity, participants spent most of their money on higher fat, cheaper cuts of meat such as ground beef and hot dogs
  - Other choices for food purchases were based on what the household needed and what items could be obtained through food assistance programs such as dairy from WIC and canned good from local food shelves and food pantries
  - Starches were common inexpensive purchases (potatoes, generic white bread, ramen noodles and whole wheat bread)
  - Vegetables were frequently mentioned as part of the main meal, yet foods from this food group failed to make a significant portion of the participant's budget
  - Fresh fruits and vegetables were perceived at high cost and many consumed canned versions in their place although they felt these were poor substitutes
  - Milk was another item that was perceived to be expensive and they were unable to maintain a supply over the entire month
- Strategies to stretch food dollars:
  - Most women reported that their food stamp allotments lasted two to three weeks depending on how they spent them and where they shopped
  - Purchasing generic brands and using savvy shopping skills were ways to stretch their food dollars
  - Most reported it was difficult to keep perishable items like milk or fruit around routinely because their families liked them and consumed them quickly
  - Eating leftovers was also a cost-savings measure
- The children's role in grocery shopping:
  - Many women reported that children would frequently accompany them while shopping
  - Participants reported that children would place unnecessary items in the cart
  - Women would frequently let children pick out items or purchase items such as cereal that they knew their children would like
  - In some situations children assisted with shopping by making the list or actually carrying out the shopping themselves.

Author Conclusion:

Authors concluded that low-income women's grocery shopping was driven by their families' personal preferences and by their economic and environmental situations. Despite attempts to have nutritious meals, participants felt that they could not purchase ideal foods for a good diet.
The authors believed that the participants thinking to purchase higher-fat foods like meat and less fruits and vegetables may explain the high incidence of obesity. Nutrition education that teaches food budgeting skills and meal preparation strategies involving less meat and more fruits and vegetables could be useful in assisting low-income families use their dollars wisely and could potentially have healthful impacts. It may also be helpful to start educating children about healthy dietary choices as they are also a factor in food purchase and preparation.

Funding Source:

Government:	Food Stamp Nutrition Education Program
University/Hospital:	Agricultuural Experiment Station of the University of Minnesota

Reviewer Comments:

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?	Yes
3.	Were study groups comparable?		Yes
	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?	Yes
	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")?	???
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?	Yes
	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?	No
	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?	???
	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?	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?	???
	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?	???
	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)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	???
	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?	???
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