Symposium

Development of Indicators to Assess Hunger1234 KATHY L RADIMER,5 CHRISTINE M. OLSON,

AND CATHY C. CAMPBELL

Division of Nutritional Sciences, Cornell (Jniuersity, Ithaca, NY 14853 posed generally include one or more of the following three components: the physical sensation of hunger, the interruption of a socially-accepted eating pattern (either going without food or not getting a complete meal), and inadequate food. Inadequate has been used to refer to food quality, to food consumption, and to the food supply and it has been qualified by its peri odicity—chronic, intermittent, or occasional. In some reports, there is a lack of congruence between the def inition of hunger and the measures used to indicate its presence (1-3). The measurements of hunger are diverse (1-4). Be cause direct indicators of hunger are not readily avail able, a wide variety of indirect measures of the pres ence of hunger have often been used. These indirect measures include indicators of income, unemploy ment, food assistance program participation, dietary intake, and health and nutritional status. Behaviors associated with hunger have sometimes been reported as if they were direct indicators of hunger. These be-

ABSTRACT Despite widespread concern about hunger in America, efforts to monitor and assess the extent of hunger have been hampered by lack of consensus on an appropriate meaning for the term hunger and by the lack of valid indicators to assess it. The first phase of the research used qualitative methods to derive a so cially-appropriate definition of hunger. Thirty-two women in Upstate New York were interviewed regarding their experience with food problems and hunger. The interviews were analyzed using the constant compar ative method. Results indicated that women had a nar row and a broad concept of hunger. The narrow concept focused on going without food for a specified period of time and the physical sensation of hunger. The broad one included two dimensions: household and individual hunger. Each had quantitative, qualitative, psycholog ical, and social components. The second phase of the research used survey methodology to examine the va lidity and reliability of items designed to measure the conceptual definition of hunger. The survey was ad ministered to 189 women in Upstate New York who participated in programs designed for low-income households or households in need of food. The second phase confirmed the conceptualization of hunger de veloped in the first phase. A subset of valid and reliable items that represented each of the major dimensions and components of hunger was identified as being use ful for monitoring and assessing hunger. J. riulr. 120: 1544-1548, 1990.

1 Presented as part of a conference, "Nutrition Monitoring and Nutrition Status Assessment", at the first fall meeting of the Amer ican Institute of Nutrition, Charleston, South Carolina, December 8-10, 1989. The conference was supported in part by cooperative agreement HPU880004-02-1 with the DHHS Office of Disease Pre vention and Health Promotion, the USDA Human Nutrition In formation Service, the DHHS National Center for Health Statistics, and the International Life Sciences Institute-Nutrition Foundation. 2 The Planning Committee for the meeting consisted of Drs. He

INDEXING KEY WORDS:

•hunger •nutrition monitoring •nutrition status assessment

len A. Guthrie, Roy J. Martin, Linda D. Meyers, James A. Olson, Catherine E. Woteki, and Richard G. Allison (ex-officio). The sym posium papers were edited by a committee consisting of Dr. James Allen Olson (coordinator], Dept. of Biochemistry & Biophysics, Iowa State University, Ames, IA; Dr. Cathy C. Campbell, Division of Nutritional Sciences, Cornell University, Ithaca, NY; Dr. Roy J. Martin, Dept. of Foods & Nutrition, University of Georgia, Athens, GA; and Dr. Catherine E. Woteki, Food & Nutrition Board, National Academy of Sciences, Washington, DC. 3 This research was approved by Cornell University Committee on Human Subjects. 4 The research was supported in part by contract C-001038 with

A REVIEW OF CURRENT DEFINITIONSAND THE ASSESSMENT OF HÃœNGER Hunger is a term that must be defined within a social context. In the United States in the 1980s, there has been a great deal of debate but little consensus about what hunger is and how it should be assessed. Most documents concerning hunger never explicitly define hunger. Those definitions that have been pro 0022-3166/90

S3.00 ©1990 American Institute of Nutrition.

the New York State Department of Health, Bureau of Nutrition and by the Small Grants Program of the Division of Nutritional Sciences, Cornell University. 5 During her graduate studies, Ms. Radimer was supported through a fellowship from the National Science Foundation.

Received 10 December 1989. Accepted 11 July 1990.

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INDICATORS TO ASSESS HUNGER

haviors include seeking food from abnormal sources, changing shopping behaviors, changing meal compo sition, and cutting down on food intake in various ways. Self-reports and perceptions of hunger have also occasionally been reported. These direct indicators of hunger query going or being hungry, sufficiency of in take quantity, going without food, and running out of food. Some studies have asked about running out of food money or food stamps rather than food. Thus, the current status of hunger assessment can be described as follows: hunger definitions vary widely, measures of hunger are generally indirect, di rect measures are uncommon, and definitions and measures may lack congruence. This has meant that estimates of hunger prevalence are rare and generally based on indirect, rather than direct, measures of hunger. OVERVIEW OF METHODS The first phase of this research used a phenomenological or naturalistic approach to collect qualitative data. The data collected were statements made by women who said they had experienced, or nearly ex perienced, hunger. The analysis consisted of a cate gorization of these statements into a conceptual framework that represents the phenomenon of hunger from these women's point of view. The conceptual ization of hunger thus developed is grounded in the experiences and the perceptions of those who have ex perienced hunger. This research was done with 32 white and black women between the ages of 18 and 55 in rural and urban areas of Upstate New York. Data were collected with open-ended personal interviews with women about their hunger experiences and those of their children. The interviews were audiotaped, tran scribed, and analyzed using the constant comparative method (5). The second phase of the research consisted of de veloping survey items to assess the concept of hunger in a population of women and children. Items were developed to investigate each of the major components of hunger identified in the qualitative phase of the research. The items were based on actual statements made by the women interviewed in the first phase of the research. A survey using this questionnaire was then under taken to test the validity and reliability of the items developed. The questionnaire was administered to 189 women who were identified through programs de signed to help people with low incomes or in need of food in rural and urban Upstate New York. CONCEPTUAL FRAMEWORK FOR HÃœNGER Based on the women's descriptions of the hunger experience, the following conceptualization of hunger Downloaded from https://academic.oup.com/jn/article-abstract/120/suppl_11/1544/4738653 by Kaohsiung Medical University user on 18 April 2018

is proposed (Table 1). There are two dimensions to hunger: household and individual. Household hunger has four major components: food depletion (running out of one's usual food supply), food unsuitability (not being able to buy the quality and kinds of food con sidered appropriate), and food anxiety (uncertainty about whether one's food supply would last). Whether these components were interpreted as a problem by an interviewee was influenced by whether the house hold food was acquired in socially accepted ways (the fourth component) such as with income or food stamps, but not through charity. Individual hunger also has four major components: intake insufficiency (a problem of intake quantity), diet inadequacy (a problem of intake quality), and disrupted eating pat terns (not eating the socially prescribed three meals a day). Whether these components were interpreted as a problem by interviewees was influenced by psychological considerations (the fourth component): whether a person felt deprived and/or without choice about eating this way. The women described many other aspects of their hunger experience. These were considered to be risk factors for hunger (low, unstable, or lost income; in adequate, delayed, or improperly adjusted food stamp receipt), coping tactics used to deal with the threat of hunger (obtaining additional food, stretching one's food and food money, and restricting food intake), and physical consequences of hunger (weight loss). An important part of the conceptual framework is the depiction of hunger as a managed process. Women used coping tactics to avoid or delay some components of hunger, especially running out of food or children going without food. This use of coping tactics to man age hunger was different in different households. Thus, the household and individual dimensions of hunger were not necessarily experienced simultaneously nor was there a uniform order in which the components occurred. In general, household hunger, specifically food anxiety, occurred first. But women often re stricted their own intake when their food supply be came insecure, causing them to experience hunger soon afterward. Hunger generally did not occur in

TABLE 1

Dimensions and components of a conceptual definition of hunger Dimension Component

Household

QuantityQualityPsychologicalSocialFood depletionUnsuitable foodFood anxietyUnacceptable

Individual

intakeInadequate dietFeeling deprived;lack choiceDisrupted of meansof eatingpattern food acquisitionInsufficient

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children until some time after this, but there was greater variation in the occurrence and experience of hunger in children than in women. Based on this research, a definition of hunger is pro posed: hunger is the inability to acquire or consume an adequate quality or sufficient quantity of food in socially acceptable ways, or the uncertainty that one will be able to do so. The risk factors, coping tactics, and physical consequences are related to hunger and therefore part of the conceptual framework for hunger, but not part of hunger, per se. It is this definition that is the basis for the development of indicators to mea sure hunger.

DEVELOPING SURVEY ITEMS TO ASSESS HÃœNGER Hunger is a difficult phenomenon to assess. It is a sensitive topic and one that people are unlikely to readily discuss. In addition, some of those going hun gry have a limited capacity to comprehend and express themselves. Hunger may also be experienced episod ically (e.g., a few weeks in a year) or chronically (e.g., every month). Different components are experienced in different ways and at different times in the house hold and individuals. In addition, assessment must ensure that the hunger results from limited resources, not time constraints or explicit choice. Open-ended questions are an amenable format to address some of the difficulties inherent in assessing hunger that are outlined above. But open-ended ques tions are often not feasible in large scale surveys and thus close-ended survey items were the goal of this project. The following procedures were used in de veloping survey items. To overcome any reluctance to discuss the experi ence of hunger, most items were designed to allow an affirmative response if the respondent had experienced hunger. Many items were phrased as statements made by other women, so that a woman was agreeing with something another woman had said. Using statements rather than questions facilitated the use of the present tense and simple sentence structure. Statements were said to be clearer than questions by many of the re spondents. To make responses applicable to both chronic and episodic hunger, generic response choices, rather than time-referenced response choices (e.g., once a month) were used. These were "never, hardly ever, sometimes, almost always, always" for questions, and "not true, hardly ever true ..." for statements. To assure that the experience was the result of lim ited resources, all items contained a qualifying phrase such as "because I can't afford more food," even though this addition makes the item more compli cated. Downloaded from https://academic.oup.com/jn/article-abstract/120/suppl_11/1544/4738653 by Kaohsiung Medical University user on 18 April 2018

ET AL.

Separate items were used to query each of the major components of household and individual hunger, and women's and children's intake were queried sepa rately. Items queried food supply directly, not food money, ways to get food, or restrictions in intake. To incorporate a sense of deprivation, items allowed for some interpretation by the respondent, by the use of phrases such as "should," "properly," and "not enough." Using the above procedures, survey items were de signed to measure the components of household hun ger, women's hunger, and children's hunger. In this paper, these are referred to as hunger items. Items for food unsuitability were not included.

FORMING AND EVALUATING HUNGER SCALES

j

The items were assessed for face, content, and con struct validity. Items that caused confusion or were clearly misunderstood by respondents (e.g., the phrases "nutritious diet" and "skip meals"), or did not assess a component properly were eliminated. Factor and cluster analysis were used to assess the dimensionality of the items as part of the construct validation process. The dimensions resulting from the survey analysis were similar to those derived from the first phase of the research. Specifically, they were: 1) household hunger, with subdimensions of food depletion and food anxiety; 2) women's intake and 3) children's in take, each of which had quantity and quality subdimensions; 4) women's interrupted eating pattern; and 5) children's interrupted eating pattern. To improve reliability and decrease the number of survey items needed to assess hunger, scales composed of a selected number of the items were formed for three dimensions: household hunger, women's hunger, and children's hunger. The interrupted eating pattern dimensions were not included in the scales because the analyses indicated that they didn't group with the other intake items. They do refer to very specific ways of accomplishing the general behavior of eating less. The hunger scales were unweighted, summative scales, formed by adding the selected items. Each of the three scales consisted of four items, with two items for each subdimension. Items were selected based on their reliability coefficient. The reliability of the scale was assessed with a coefficient alpha and the correla tion of the item with the scale. The former should be at least 0.90 for applied research; the latter should be at least 0.50 (Dr. J. Francis, personal communication). The items selected for each scale are listed in Table 2. Reliability was 0.91 for the household hunger scale, 0.92 for the women's hunger scale, and 0.89 for the children's hunger scale. All item-to-scale correlations were >0.5.

INDICATORS

TO ASSESS HUNGER

TABLE 2 Items used to form hunger scales Household hunger 1. Do you worry whether your food will run out before you get money to buy more? 2. The food that I bought just didn't last, and I didn't have money to get more. 3. I ran out of the foods that I needed to put together a meal and I didn't have money to get more food. 4. I worry about where the next day's food is going to come from. Women's hunger 1. I can't afford to eat the way I should. 2. Can you afford to eat properly? 3. How often are you hungry, but you don't eat because you can't afford enough food? 4. Do you eat less than you think you should because you don't have enough money for food? Children's hunger 1. I cannot give my child(ren) a balanced meal because I can't afford that. 2. I cannot afford to feed my child(ren| the way I think I should. 3. My child(ren) is/are not eating enough because I just can't afford enough food. 4. I know my child(ren) is/are hungry sometimes, but I just can't afford more food.

In comparing the similarities across the scales in who is designated as hungry, it was found that house hold hunger was most common. In households des ignated as hungry, 81% of the women and 66% of the children were designated as hungry by their respective scales. Children were least likely to be designated as hungry by their scale and if they were, their mothers and households were also very likely to be designated so. If a woman was hungry, so was her household. The construct validity of the scales was assessed by comparing them with risk factors for hunger and with each other. All hunger risk factors related significantly to all three scales. Using the criterion for hunger as any response above "never" or "not true" for either the household, women, or children scales resulted in significant differences in group means for income, food expenditures, and coping tactic usage between the hungry and nonhungry.

EVALUATING THE USE OF INDIRECT INDICATORS TO ASSESS HÃœNGER Many indirect indicators have been used to docu ment hunger, as described in the introduction. In comparison to the hunger scales, indirect indicators were either insensitive (that is, they did not identify as hungry many who were so identified by the scales) or nonspecific or both. Virtually all coping tactics and all physical consequences of hunger were insensitive, Downloaded from https://academic.oup.com/jn/article-abstract/120/suppl_11/1544/4738653 by Kaohsiung Medical University user on 18 April 2018

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meaning that assessing hunger with emergency food demand, missing meals, going a day without food, or weight loss misses many of the hungry. Several coping tactics were also nonspecific: getting family help with food, limiting food intake, and preparing poor quality meals included people or households that were not hungry.

RECOMMENDATIONS FOR ASSESSING HÃœNGER The items in Table 2 are recommended as indicators for measuring hunger in households, women, and children in social contexts similar to the context of this research. It is strongly recommended that the household and individual dimensions of hunger, and hunger in women and children be assessed separately, as they are experienced at different times and to dif ferent degrees. Combining the individual and house hold dimensions into one scale may appear to increase reliability, but if this is done, one cannot discern whether it is a household, woman, or child who has experienced hunger. For policy-making and program reasons, it may be important to be able to distinguish between the three. The measurement of risk factors, coping tactics, and physical consequences to measure hunger is not rec ommended; however, it may be very useful to monitor some of these in order to improve planning and im plementation of programs to alleviate and eliminate hunger. Indicators querying "skipping meals" or "going days without food" are often used as measures of hun ger. These are included in the conceptual framework as subcomponents of hunger, but they should not be used alone as hunger indicators. These items are very specific indicators of intake quantity. More general items are more widely applicable and preferable. The indicators developed in this research are con sidered an improvement over most existing ones, but they are not perfect. Several suggestions for modifi cations to the items and cautions about them may be useful. First, three response categories "never, some times, often" for questions and "not true, sometimes true, often true" for statements are probably adequate and easier for respondents to remember than the five choices necessary for the analytical purposes of this survey. Second, respondents said statements were eas ier to understand than questions. Thus, transforming items phrased as questions into statements may im prove them. Third, the issue of food quality at the household level was not addressed in these scales ex cept indirectly, with items about intake quality and depletion of food for making meals. An item such as "I can't afford to buy the foods that I think I should to feed my household," based on one of the coping

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tactics that was fairly sensitive and specific, may be a worthwhile addition to the household scale. Fourth, the "negative loading" of some items caused a problem of double negatives. For example, a woman responded "never" to "How often would you say you don't eat balanced meals?" Using items in a statement format and a response choice of "not true" rather than "never" minimized this problem. Items that caused confusion were not selected for the scales in this study. But to ensure that an item is correctly understood, it is a good practice for the interviewer to repeat the response and item: "So that never happens, that you don't eat balanced meals" to verify the response. For monitoring hunger, the frequency distributions of scale scores are probably the easiest and most useful forms of data. It may also be useful to monitor re sponses to each of the components separately. If one is trying to estimate the prevalence of hunger based on these indicators, a simple distribution of responses is not adequate. There is no objective guideline for determining what scale score to equate with hunger. These authors' recommendation is to use any scale score above the minimum value (i.e., any score above a consistent "never" or "not true" response) as indic ative of hunger.

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ET AL.

SUMMARY This paper illustrates the use of scientific methods of inquiry to understand and define the experience of hunger, and, on this basis, to develop indicators of hunger in populations of women and children. The result is a set of valid, reliable, and practical items representing the major dimensions and components of hunger that can be used for nutrition monitoring and surveillance.

LITERATURE 1. PHYSICIANS' TASK

FORCE ON

CITED HUNGER

IN

AMERICA.

(1985) Hunger in America: The Growing Epidemic. Harvard University School of Public Health, Boston. 2. FOOD RESEARCHAND ACTION CENTER.Hunger in the Eighties: A Primer. (1984) Food Research and Action Center, Washing ton, D.C. 3. The President's Task Force on Food Assistance. (1984) U.S. Government Printing Office, Washington, D.C. 4. Community Childhood Hunger Identification Project. (1987) Connecticut Association for Human Services, Hartford, CT. 5. GLASER, B. G. & STRAUSS,A. L. (1967) The Discovery of Grounded Theory, Strategies for Qualitative Research. Aldine, Chicago.

Development of indicators to assess hunger.

Despite widespread concern about hunger in America, efforts to monitor and assess the extent of hunger have been hampered by lack of consensus on an a...
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