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Health needs and neighbourhood concerns of low income households vulnerable to food insecurity E.M. Vivian a,*, J. Le b,e, P. Ikem a,f, Y. Tolson c a

University of Wisconsin-Madison, School of Pharmacy, 777 Highland Avenue, Madison, WI 53705, USA University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, USA c St. Vincent de Paul Charitable Pharmacy, 2033 Fish Hatchery Road, Madison, WI 53725, USA b

article info Article history: Received 15 November 2013 Received in revised form 2 May 2014 Accepted 6 May 2014 Available online 13 August 2014

Introduction In 2010, an estimated 32.6 million adults in the United States experienced food insecurity.1 Food insecurity, defined as the limited or uncertain availability of healthy and nutritious foods is increasing among low income households. Lack of access to a nutritious and adequate food supply has implications not only for the development of physical and mental disease, but also behaviours and social skills.1,2 Health disparities related to food have a disproportional impact on low-income households, placing them at increased risk for developing obesity, heart disease, diabetes, and other chronic diseases.3 Poor access to healthy foods has been found to be strongly associated with adverse health outcomes; therefore, a person's diet becomes a predictable health indicator, turning food access into a public health issue.4

Households at risk of food insecurity often lack environmental resources such as adequate housing, safe walking paths and working conditions, which can also have a negative impact on their health.3e5 Individuals from low income households may also face financial and life stress which can compromise their health.4,5 Continual exposure to stress, as well as a lack of resources, skills, social support, and connection to the community can contribute to less healthy coping skills and poorer health behaviours such as smoking, over-consumption of alcohol and less healthy eating habits.5 Preventive and management programs which focus on developing sustainable healthy lifestyles are important to improve the health of individuals and families at risk of food insecurity. A short needs assessment survey was developed and distributed to a sample of clients who utilize a food pantry in an underserved community to help identify their health needs and neighbourhood concerns and learn the best way to design health promotion strategies within the community. St. Vincent de Paul (SVdP) located in Madison, WI operates the largest food pantry in Dane County. The SVdP food pantry is a client choice model, where clients select their own food choices, like shopping in a grocery store. The SVdP food pantry serves nearly 22,000 households and donated over $1,300,000 in 2013. SVdP has an ethnically-diverse clientele that consists of 35% whites, 33% African Americans, 20% Hispanics/Latino Americans, 10% Asians, and 2% American Indians and/or Alaska Natives. Individuals and families who participate in the food pantry program are below the 185% federal poverty line.

* Corresponding author. Tel.: þ1 608 263 1779 (office). E-mail addresses: [email protected] (E.M. Vivian), [email protected] (J. Le), [email protected] (P. Ikem), [email protected] (Y. Tolson). e Tel.: þ1 858 534 3692. f Tel.: þ1 608 263 1779 (office). http://dx.doi.org/10.1016/j.puhe.2014.05.005 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

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Five pharmacy students administered a survey instrument on health-related needs and neighbourhood concerns to clients waiting in line to register for the food pantry. The survey instruments were administered six of the 12 days the food pantry was open from July 18, 2013 to August 8, 2013. The students spoke with clients individually, providing each with a brief, standardized explanation of the study. The survey instrument contained 16 short closed-ended questions and sections for additional comments. The survey instruments were available in both English and Spanish. The Institutional Review Board at the University of Wisconsin determined that the project did not fit the federal definition of research; therefore, informed consent was not required. A total of 566 of the 1463 clients who attended the food pantry within a 3-week period were invited to complete the survey instrument. Twenty-two clients declined because they could not read English or Spanish and 42 refused because they were not interested in completing the survey instrument. The response rate was 89% of the 566 clients surveyed. The mean age of the 502 participants was 42 years ± 12.95 (ages ranging from 18 to 77 years). Mean ages stratified by race/ethnicity ranged from 43.11 ± 14.10 years among White Americans, 42.94 ± 13.20 among African Americans, 36.2 ± 10.14 years among Asian Americans to 28.0 ± 4.63 among American Indians. More than half of the respondents were women (68%, n ¼ 342) and 79% had graduated from high school or completed GED equivalent. Those who reported being Hispanic or Latino (regardless of other race) were counted as such and removed from any other category; making up 15% (n ¼ 77) of the sample (Table 1).

Health conditions and neighbourhood concerns Most of the participants (96% of 502) reported at least one health condition. The five most frequently reported health conditions were obesity, depression, hypertension, diabetes and asthma. High blood pressure was the most prevalent condition reported among African Americans (n ¼ 70, 44.87%) while the most prevalent conditions reported among whites was obesity (n ¼ 93, 45.6%) and depression (n ¼ 90, 44.1%). Of the 178 participants who reported being obese, 43% reported concurrent depression, 41% hypertension, and 35% diabetes. Ninety eight percent (n ¼ 492) of all participants reported at least one neighbourhood concern. Respondents from all zip codes identified safety and crime as the most salient neighbourhood concern (n ¼ 289, 58.7%). Other neighbourhood concerns include housing (n ¼ 165, 33.5%), recreational drugs (n ¼ 143, 29.1%), unemployed youth (n ¼ 134, 27.2%), and transportation (n ¼ 127, 25.8). Fifty-nine percent of participants (n ¼ 292) identified physical activity classes in safe environments as the top neighbourhood need. Other reported needs included nutrition classes (n ¼ 167), and diabetes self-care management education (n ¼ 106). A unique feature of this study was surveying clients at a food pantry, an understudied setting among low income households. In addition, food pantries are an ideal venue to assess the health needs of those at risk of food insecurity. In

Table 1 e Characteristics and concerns of study participants (n ¼ 502). Parameter Mean Age Female Gender Race/Ethnicity White American African American Hispanic/Latino Asian/Pacific Islander Native American Biracial/Multicultural No response Marital Status Single Married Divorced Housing (place of residence) House Apartment Shelter Street Education Less than high school Some High school High School or G.E.D. Some College or technical school Completed technical school Completed Bachelor's degree Graduate study/advanced degree Top Health Concerns (n ¼ 480) Obesity/Overweight Depression Hypertension Diabetes Asthma Top Neighbourhood Concerns (n ¼ 492) Safety/Crime Housing Problems Drugs (illegal) Unemployed Youth Transportation Grocery Stores

Number (%)a 42.0 ± 13.0 343 (68) 204 (41) 156 (31) 77 (15) 14 (3) 3 (1) 23 (5) 21 (4) 250 (50) 151 (30) 84 (17) 128 (25) 318 (63) 18 (3) 14 (3) 35 (7) 68 (14) 138 (27) 141 (28) 57 (11) 31 (6) 22 (4) 178 (37.1) 169 (35.2) 159 (33.1) 129 (26.9) 89 (18.5) 289 165 143 134 127 119

(58.7) (33.5) (29.8) (27.9) (25.5) (24.8)

a

Numbers represent number and percentage of subjects (%), except for mean age ± standard deviation. All values were derived according to the number of respondents to a particular question.

this study, an overwhelming 96% of SVdP food pantry participants reported at least one health condition. The frequency of the most common health conditions reported (including obesity, hypertension and depression) are consistent with national prevalence rates of these conditions.6,7 African Americans had the highest self-reported rate of hypertension, which is consistent with national prevalence rates among different races/ethnicity groups.8 Interestingly, self-reported obesity rates among white Americans was higher than African Americans, which is contrary to national statistics8 and may indicate that weight perception contributed to the possible underreporting of obesity in the African American group.9 Not surprisingly, most (98%) respondents had neighbourhood concerns, which were consistent across race/ethnicity. Safety and crime ranked as the top concern, followed by

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housing and illegal drugs. Participants identified the need for crime and violence prevention measures to make their neighbourhoods feel safer, thus removing a major barrier to exercise or being active outdoors. Participants recommended increasing community policing to ensure safe environments for physical activity and providing low- or no-cost physical activity programs, facilities, or equipment (e.g. bicycles) for children, families, and adults of all ages to increase social networking and help families feel more comfortable with outdoor activities.10 Current knowledge underscores the importance of programs and policies that influence the choices available to individuals and the contexts in which those choices occurdincluding conditions in homes, schools, workplaces and neighbourhoodsdthat can constrain or enable healthier living.10 More than simply making health information available, effective strategies that focus on strengthening individuals' abilities to use information to make healthy choices, by ensuring access to healthy options and removing barriers to leading a healthy lifestyle, particularly for groups whose abilities have been severely constrained, is needed. The high number of health conditions and neighbourhood concerns perceived by food pantry clients underscores the need to develop and implement community-sensitive programs for health promotion with the goal of containing chronic diseases related to food insecurity. Findings from this needs assessment will be useful for designing health promotion programs in this community where there are limited health services and few existing social support networks. The primary limitation of the present study is the nonrandom sample and self-reported health conditions. While the authors successfully recruited a representative group of white Americans and African Americans, language and literacy barriers limited our ability to recruit more Hispanic/ Latinos Americans, Asian Americans, and Native Americans. However this study's unique data collection strategies and findings will be helpful to others working to engage families in much needed health promotion and prevention efforts.

Author statements Special thanks to Ralph Middlecamp, Christopher Kane, Josie  ez-Tyler, and the staff at St. Vincent de Paul. Montan

Ethical approval The Institutional Review Board at the University of Wisconsin reviewed this project and determined that the project did not

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fit the federal definition of research; therefore, informed consent was not required.

Funding This project was not funded.

Competing interests None.

references

1. Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household food security in the United States in 2010. U.S.: USDA ERS; 2011. 2. Center for Disease Control and Prevention. Adult obesity facts. Available at: http://www.cdc.gov/obesity/data/trends. html#State (13.10.01). 3. Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966e2007. Prev Chronic Dis(3):A105. Available at: http://www.cdc.gov/pcd/issues/2009/jul/08_0163.htm, 2009;6 (13.10.01). 4. Koh KA, Hoy JS, O'Connell JJ, Montgomery P. The hungerobesity paradox: obesity in the homeless. J Urban Health 2012;89(6):952e64. 5. Berkowitz SA, Seligman HK, Choudhry NK. Treat or eat: food insecurity, cost-related medication underuse, and unmet needs. Am J Med 2014;127(4):303e10. 6. Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the U.S.: what the patterns tell us. Am J Public Health 2010;(Suppl. 1):S186e96. 7. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095e105. 8. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone G, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM, Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statisticsd2011 update: a report from the American Heart Association. Circulation 2011;123(4):e18e209. 9. Befort CA, Thomas JL, Daley CM, Rhode PC, Ahluwalia JS. Perceptions and beliefs about body size, weight, and weight loss among obese African American women: a qualitative inquiry. Health Educ Behav 2008;35(3):410e26. 10. National Prevention Council. National prevention strategy. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.

Health needs and neighbourhood concerns of low income households vulnerable to food insecurity.

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