Association and disparities of food insecurity and exposure to violence: analysis of the National Survey of Children’s Health

Food insecurity

To identify children who experienced food insecurity, we utilized the survey question, “Which of these statements best describes your household’s ability to afford the food you need during the past 12 months?” [15] Respondents’ answers included: “We could always afford to eat good nutritious meals”; “We could always afford enough to eat but not always the kinds of food we should eat”; “Sometimes we could not afford enough to eat”; and “Often we could not afford enough to eat.” [19].

Experiences of violence: abuse and domestic or community violence

The NSCH collected adverse childhood experiences with a broad spectrum of factors. To identify children who experienced parent-reported exposure to violence, we extracted data from two potential responses to the prompt, “To the best of your knowledge, has this child EVER experienced any of the following?,” which were: “was a victim of violence or witnessed violence in their neighborhood,” and “saw or heard parents or adults slap, hit, kick, or punch one another in the home.” [19].

Demographic factors

For age, we re-coded and combined the age groups into the following: 0–4, 5–10, 11–14, and 15–17 years. To identify the race/ethnicity of each child, we utilized the survey question, “What is this child’s race/ethnicity?” The self-identified responses included: “Hispanic; White, non-Hispanic; Black, non-Hispanic; Asian, non-Hispanic; American Indian/Alaska Native, non-Hispanic; Native Hawaiian/Other Pacific Islander, non-Hispanic; Two or More Races, non-Hispanic.” [19] NSCH data for White, Black, Asian, and Hispanic races are nationally representative. However, American Indian or Alaska Native (AIAN), Native Hawaiian and Other Pacific Islander (NHPI), and “Two or More Races” are not controlled independently, and thus may not constitute national estimates. To assess socioeconomic status, the percent of the federal poverty guidelines (% FPG) that the household income was categorized as was utilized. Urbanicity was defined as households in metro vs. nonmetro areas, according to the National Center for Health Statistics urban-rural classifications.

Statistical analysis

For this study, survey weights provided by the NSCH were employed and adjusted to account for multiple cycles of data [19]. First, we reported the sample size and demographics, and the population estimates. Next, we determined the rate of children with parent-reported exposure to violence overall and food insecurity status. We then constructed logistic regression models to assess associations, through odds ratios (ORs), between food security groups and whether the child experienced exposure to violence.

To assess disparities with respect to children experiencing food insecurity and exposure to violence, we combined the six annual cycles of data from 2016 to 2021. Weights were adjusted according to the NSCH guidebook [19]. We then constructed logistic regression models through ORs to assess food security and violence exposure by demographic factors. The reported demographic factors included age and race/ethnicity, in addition to household variables, including food security, federal poverty level (FPL), and urbanicity.

Analyses were conducted utilizing Stata 16.1 MP (StataCorp, LLC, College Station, TX), with alpha set at 0.05 and confidence intervals (CIs) of 95 %. This study did not meet the requirements for human subjects research according to the regulatory definition of human subject research as defined in 45 CFR 46.102(d) and (f) of the Department of Health and Human Services’ Code of Federal Regulations (https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/), and therefore was not submitted for ethics review. Results were reported according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Recommendations

There are many hunger-relief organizations with a shared mission to decrease food insecurity, including Feeding America, the nation’s largest [28]. Despite the altruistic mission to reduce hunger, these organizations are often criticized for providing nutritionally empty, energy-dense foods, and a continuously insufficient supply to meet the demand of families experiencing food insecurity [29]. Further, delivery of food is typically made by whatever means of transportation agencies can provide, which has forced agencies to utilize personal vehicles that often lack refrigeration – posing a great challenge for agencies in rural areas [29]. The shortcomings displayed by these organizations provide significant evidence for the need of greater funding, resources, and policies addressing food insecurity. Because osteopathic physicians are more likely to work in these rural communities, upholding osteopathic values through providing patient-centered care that considers both the community and environmental impact is essential [30]. This includes increased screenings for food insecurity, providing nutritional education to patients as well as patient advocacy and outreach for greater nutritional support for rural areas.

State-funded and regulated farm-to-food bank programs offer a potential strategy to address insufficient supplies and a lack of quality nutrients in the foods typically donated. In 2018, the Growing Together Illinois program was implemented across Illinois, which utilized fresh produce donations for 17 participating food pantries [31]. The program received not only positive feedback regarding the high quantity and quality of food provided but also an overall increase in the nutrition assessment score at participating pantries [31]. The Agriculture Improvement Act of 2018 was recently amended to allocate funding for Farm to Food Bank Projects for State Emergency Food Assistance Program agencies for the 2023 fiscal year [32]. This will not only alleviate the lack of nutritious foods but also provide funding for the harvesting, processing, packaging, and transportation of foods, as well as building relationships between agricultural producers and processors with local food banks [32].

In addition to organizations that directly distribute food, food assistance programs, including the Supplemental Nutrition Assistance Program (SNAP), are aimed at reducing food-related hardships [33]. Unfortunately, the current program requirements for SNAP exclude many individuals who would benefit from the program. While the exact qualifications for SNAP vary by state-specific regulations, the general criteria are based on income and work requirements [33]. Although poverty and food insecurity are highly correlated, they are not synonymous, and many household variables may contribute to food insecurity despite adequate income. Additionally, numerous barriers prevent many eligible households from applying or recertifying for SNAP benefits [33, 34]. Limited transportation or lack of the necessary technology to apply disproportionately affects disadvantaged individuals living in rural areas, further from SNAP offices [34]. An analysis funded by the Robert Wood Johnson Foundation found that with just two policy adjustments, one in 11 SNAP households would lose eligibility, and the ramifications would disproportionately affect groups of children in rural communities and children of color [35]. This prompted the recommendations to utilize more objective data and economic realities to determine eligibility, expansion of SNAP-Ed, and financial incentive programs, as well as to ensure that any changes made to SNAP policy do not disproportionately affect certain groups [35]. In addition to these recommendations, we urge policymakers and program administrators to expand enrollment for SNAP participation through the adaptation of more lenient program rules [33].

Culture plays a role in the evaluation of food security in many ways: the classification of nutritious food sources, and the traditionally produced crops of that region, among others [36]. Implementing culturally competent initiatives is essential to the success of food-insecurity prevention programs, which may secondarily lower child abuse rates. For example, the Culturally Responsive Food Initiative (CRFI), implemented in August 2020 by the Food Bank of the Rockies, ran a pilot study aiming to overcome barriers experienced by food bank clients of different cultural backgrounds [37]. The program identified cultural barriers and developed customized food lists offering culturally responsive foods for their clients [37]. By implementing strategies that similarly address cultural variations, it is possible to address disparities created by structural and systemic racism contributing to food availability and utilization, and as an indirect result, child abuse [38].

Finally, additional research is needed to create a more robust analysis of the barriers to food security among historically disempowered groups. Previous studies have identified low native food security – the accessibility to the desired native foods – as a predictor to food insecurity [39]. Therefore, we urge policymakers and state and federal stakeholders to expand funding and develop collaborative research partnerships with tribal leaders and scholars that integrate native food security measures. Additional research and policy is also necessary for understanding and addressing the racialized patterning of food insecurity in the United States. Black communities experience a significant food store shortage, directly contributing to food accessibility. We urge policymakers, community leaders, and business owners to develop food-related policies and practices directed toward addressing the disparities in minority communities [40]. Partnerships between local government and supermarket leaders should be developed to increase access to food within neighborhoods that have been historically overlooked by food retailers [40].

Limitations

A significant limitation is that all data are based on parental or primary caregiver responses that have not been independently verified. Additionally, it is important to note the nature of reporting food insecurity and bias. Studies have found food insecurity to be a recurrent state but not a constant [41]. Another limitation is that the survey includes noninstitutionalized children only and excludes families experiencing homelessness or children residing in group homes. Therefore, food insecurity and exposure to violence rates are likely underestimated. It is probable that certain ethnic populations, including Indigenous populations, are underrepresented due to being identified as Multiracial in the NSCH survey. Therefore, it is possible that the impact of exposure to violence and food insecurity in these populations is greater than what is reported within the dataset. Additionally, other studies have shown that reports of child abuse substantiation differ between races [42].