Matern Child Health J DOI 10.1007/s10995-015-1735-9
Increased Food Insecurity Among Mothers of 2 Year Olds with Special Health Care Needs Elizabeth J. Adams • Laurel M. Hoffmann • Kenneth D. Rosenberg • Dawn Peters • Melissa Pennise
Ó Springer Science+Business Media New York 2015
Abstract The objective of this study is to explore the association between having a child with special health care needs (CSHCN) and food insecurity when the child is 2 years old. We studied women who had a live birth in 2004–2005 and responded to Oregon’s Pregnancy Risk Assessment Monitoring System (PRAMS) survey 3 months postpartum (Time 1) and the follow-up survey (PRAMS-2), when the child was 2 years old (Time 2). Women answering affirmatively to the PRAMS-2 question, ‘‘In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?’’ were considered food insecure. CSHCN status was identified by affirmative responses to questions about needs for ongoing services (Time 2). PRAMS and PRAMS-2 responses were weighted for study design and nonresponse. Results report weighted analyses, unless noted. Among 1812 mothers completing PRAMS-2, 13.6 % (unweighted) had a 2-year-old CSHCN and 11.9 % (unweighted) were food insecure at Time 2. The estimated prevalence of food insecurity at 2-year follow-up was 20.7 % among families of CSHCN and 9.7 % for others. After adjustment for Time 2 marital status, education, lifetime U.S. residence, income and health conditions, multivariable logistic regression revealed that odds of food
E. J. Adams (&) L. M. Hoffmann K. D. Rosenberg D. Peters M. Pennise Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] K. D. Rosenberg Oregon Public Health Division, Portland, OR, USA Present Address: M. Pennise University of Rochester, Rochester, NY, USA
insecurity were more than two times as great for CSHCN mothers 2 years post-partum compared to non-CSHCN mothers (adjusted odds ratio 2.6, 95 % confidence interval 1.3, 4.6). Families of CSHCN face increased risk for food insecurity. Improved understanding of causal determinants of food insecurity among households of CSHCN is needed. Keywords Food security Children with special health care needs (CSHCN) Social determinants of health PRAMS Oregon
Introduction Food insecurity, the ‘‘limited or uncertain availability of nutritionally adequate and safe foods,’’ is associated with adverse health and developmental outcomes for children and caregivers [1]. It is a recognized public health problem in the U.S. [2, 3] and other countries [4]. In the U.S., food security is assessed annually by the U.S. Department of Agriculture using the 18-question U.S. Household Food Security Survey Module (FSSM) [5]. In 2013, 14.3 % of the U.S. population lived in food insecure households, an increase from 11.0 % in 2005 [5]. The prevalence of food insecurity in Oregon was 15.2 % in 2011–2013 [5] and 11.9 % in 2004–2006 [6]. Oregon had among the highest proportion (27.3 %) of children under 18 years old living in households that experienced food insecurity in 2012, as compared to 21.6 % of children under 18 years old nationally [7]. Food insecurity is not evenly distributed in the population. Young children living in low income, Black, American Indian, or Hispanic households are at increased risk for food insecurity compared to other children [5]. Food insecurity among families that include young children has
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also been related to nonfinancial factors such as maternal mental health problems including depression, alcohol or drug abuse, psychiatric disorders, or domestic violence [8], parental burdens such as low income [13] or disability [5], and to community factors including social deprivation, lack of social cohesion, and high social disorder [9]. Families of children with complex health conditions such as diabetes [10] or cystic fibrosis [11] are also at increased risk for food insecurity; social and economic stresses related to having a child with special health needs may contribute to increase risk. Cross-sectional studies from the U.S. and Canada using the 18-question FSSM, or a subset of FSSM questions [5], document the link between food insecurity and compromised child health and well-being including poor or fair general health [12, 13], low school achievement [14], compromised diet [15, 16], and behavioral problems [17]. Longitudinal studies also identify relationships between household food insecurity in infancy or early childhood and compromised subsequent health and development [8, 9, 12, 18]. Children with special health care needs (CSHCN) are ‘‘those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally’’ [20]. Food insecurity may further complicate any health challenges faced by CSHCN. CSHCN are identified by U.S. public health surveillance systems using a five-item, parent-reported tool designed to reflect the federal Maternal and Child Health Bureau’s consequences-based definition of CSHCN [21]. In 2005–2006, the prevalence of CSHCN among children 0–5 years old was 8.8 % in the U.S., and 8.6 % in Oregon [22]. Caring for CSHCN can cause financial and parenting stress for families, with up to 20 % of CSHCN families reporting financial struggles related to their child’s condition and 22.5 % reporting ‘‘usually or always feeling stress from parenting’’ [23–27]. It is not known how often financial and other stresses related to parenting CSHCN manifest as food insecurity. Although diagnosis-specific conditions have been associated with increased risk for food insecurity [10, 11] the relationship between the more broadly defined CSHCN status and food insecurity is not well described. A better understanding about the relationship between food insecurity and CSHCN status, and determinants of food insecurity among CSHCN families is needed to inform strategies to prevent and mitigate food insecurity in this broader population. This investigation quantifies the association between food insecurity and having a child with special health care
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needs when the child is 2 years old, controlling for food security before the child’s birth.
Methods Instrument Data were obtained from the 2004–2005 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) and the 2 year follow-back survey (PRAMS-2). PRAMS and PRAMS-2 are surveillance projects of the U.S. Centers for Disease Control and Prevention (CDC) and state health departments. These surveys are used to monitor pregnancy and early childhood risks and outcomes in order to inform public health decisions and improve health outcomes of mothers, infants and children [28, 29]. Subjects Participants included in this study delivered a live birth in Oregon, completed PRAMS and PRAMS-2 surveys, and provided complete data for the variables used in these analyses. Stratified random sampling from birth certificates was used to identify the PRAMS sample, with oversampling of mothers who are Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Asian/Pacific Islander, and Non-Hispanic Black to ensure reliable estimates for these groups. All responses in PRAMS and PRAMS-2 were weighted for oversampling, non-response and non-coverage of births omitted from the state birth certificate files to allow for population-based estimates representative of all Oregon births. Birth certificate, PRAMS, and PRAMS-2 data were linked to each other to create the final data set [28]. Oregon PRAMS and PRAMS-2 have been reviewed by, and were conducted under the supervision of, the Oregon State Public Health/Multnomah County Public Health Institutional Review Board (IRB). The protocol for this study was also reviewed and approved by the Oregon Health and Science University IRB. Procedure Oregon PRAMS surveys are mailed to identified mothers at 2–6 months post-partum (Time 1). PRAMS-2 provides information about early childhood health issues at 2 years of age (Time 2) for children in the PRAMS cohort. Participants are contacted by phone and mail for PRAMS. For PRAMS-2, participants are contacted by mail only (for 2004 births) or mail and phone (for 2005 births), depending on the birth year. PRAMS-2 is sent to all women who
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completed PRAMS unless the PRAMS index child had died or the mother had opted out of the follow-back. Measures Dependent Variable The dependent variable of interest was food security at Time 2 (PRAMS-2). Food security at Time 2 was identified on PRAMS-2 by asking, ‘‘In the past 12 months, did you ever eat less than you felt you should because there was not enough money to buy food?’’ Women with affirmative responses were classified as food insecure at Time 2. Independent Variables Children with special health care needs (CSHCN) were identified at Time 2 (PRAMS-2) by response to a 10-item question about ongoing health needs of their 2-year-old lasting 6 months or more for specific services: specialty health care, behavioral health or mental health services, physical therapy, occupational therapy, speech services, medication, home health services, special diet, use of assistive devices, or durable medical equipment. Mothers who responded ‘‘yes’’ to one or more of the ten items were classified as having a CSHCN. This 10-item question, modeled after the national CSHCN screener, collectively identifies children classified as CSHCN rather than identifying need for distinct services [21]. Demographic and health variables were gathered from birth certificates and PRAMS-2 surveys. Maternal race/ ethnicity (Non-Hispanic White, Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Asian/ Pacific Islander, and Non-Hispanic Black) was obtained from the birth certificate. The variables from the PRAMS-2 survey included maternal employment, education, lifetime U.S. residence, marital status, poverty status (B100 % federal poverty level (FPL)) and health conditions (nonpregnancy diabetes, and asthma), as well as spouse employment. Baseline food security at Time 1 (PRAMS) was identified on PRAMS by asking, ‘‘During the 12 months before your new baby was born, did you ever eat less than you felt you should because there was not enough money to buy food?’’ Women with affirmative responses were classified as food insecure at Time 1. Data Analysis Descriptive statistics were used to summarize demographic and health characteristics of the sample. Logistic regression was carried out to estimate the association between Time 2 food security and CSHCN status. Only women with
complete data for all study variables were included in the multivariable logistic regression analyses. The odds of experiencing food insecurity at Time 2 was estimated for participants with CSHCN compared to those without CSHCN. Predictors of interest were identified based on the literature concerning child health and food insecurity; these included variables related to income, employment, marital status, education, race and ethnicity, and health status (as shown in Table 1). Predictors were assessed for multicollinearity with each other and as confounders of the primary association of interest before being assessed for inclusion in the final model. Multicollinearity was evaluated using variable inflation factors (VIF). Variables with VIF values [2.0 were considered to have high multicollinearity and were excluded from the final multivariable model. Bivariate models quantified the relationship between each predictor variable and food insecurity (Time 2). Predictor variables were incorporated into a multivariable model with the CSHCN variable one at a time to assess confounding. The beta value from the multivariable logistic regression model was compared to that from the crude bivariate model; variables with values that differed by over 10 % were considered to be important confounders, as described in Applied Logistic Regression [30]. Candidate predictors were considered for the full model based on this statistical evaluation for confounding, evidence of association with food insecurity identified by Wald test statistic results of p \ 0.20, and association with food insecurity as described in the literature. The Hosmer– Lemeshow goodness-of-fit test for weighted data was used to assess the multivariable model’s overall fit with the data. A second multivariable regression model was applied to estimate the odds of experiencing food insecurity at Time 2 among families with and without CSHCN, adjusting for food insecurity at Time 1, and for potential confounding variables identified, as described above. All analyses were performed using STATA 11 [31]. Results report weighted analyses, unless otherwise noted.
Results Characteristics of the Sample The weighted response rate for Oregon PRAMS was 75.2 % and for PRAMS-2 was 43.5 % of the original Oregon PRAMS sample. A total of 2027 participants replied to both surveys. Of these, 1661 had complete data for all study variables and are included in the first multivariable analysis, as reported in Table 3. Demographic characteristics of participants as assessed at Time 1 (PRAMS) and Time 2 are summarized in Table 1. Mean
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Matern Child Health J Table 1 Demographic characteristics of participants, frequency, actual percent and weighted percent, Oregon PRAMS-2, 2004–2005 births
Frequency
Actual (%)
Weighted (%)
Food insecurity Food insecure at Time 1a (n = 1768)
169
9.6
9.7
Food insecure at Time 2b (n = 1812)
216
11.9
11.2
181
10.2
1.9
Maternal race/ethnicitya Non-Hispanic Black Non-Hispanic American Indian/Alaskan Native
213
11.8
1.4
Non-Hispanic Asian/Pacific Islander
284
15.2
5.3
Hispanic
325
18.0
16.3
Non-Hispanic White
804
44.5
75.1
Marital statusb Not married Married
498
27.5
27.5
1315
72.5
72.5
Annual household incomeb At or below 100 % FPL Above 100 % FPL Maternal employment statusb Not employed
470
27.5
23.7
1242
72.6
76.3
802
44.4
45.4
1006
55.6
54.6
No
547
30.2
23.4
Yes
1264
69.8
76.6
B12th grade
643
35.5
35.2
[12th grade
1166
64.5
64.8
Yes
303
16.8
15.1
No
1504
83.2
84.2
Employed Lived in US entire lifeb
Maternal education
b
Maternal asthmab
Frequency and actual % are unweighted a b
PRAMS variable PRAMS-2 variable
Maternal diabetesb Yes No
child age at the time of PRAMS survey completion was 14 weeks, and mean child age at the time of PRAMS-2 survey completion was 25 months (unweighted). The estimated percentage of 2-year-olds with one or more special health needs, and therefore classified to be CSHCN, was over 10 % (11.6 %). The distribution of special health care needs estimated in this population at Time 2 (PRAMS-2) is presented in Table 2.
Food Security Status at Time 1 and Time 2 At Time 1 (PRAMS), 9.7 % of participants were estimated to be food insecure, and at Time 2 (PRAMS-2), 11.2 % were estimated to be food insecure, as shown in Table 1. Food security was not constant over the study. The greatest proportion (84.7 %) were food secure at Time 1 and Time 2; 5.5 % were food insecure at both times.
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56
3.1
2.5
1751
96.9
97.2
Food Insecurity and CSHCN Status Table 3 presents the results of bivariate and multivariable logistic regression analyses evaluating the cross-sectional relationship between food insecurity and CSHCN status at Time 2. In the bivariate analyses, having a CSHCN, being unmarried, of low education, income B100 % FPL, not having lived entire life in the U.S., and having asthma or diabetes were each associated with food insecurity at Time 2. In the multivariable analysis without including food insecurity at Time 1 (see Table 3, Model 1), CSHCN status, marital status, education, having lived entire life in U.S., income B100 % FPL, and having diabetes or asthma were all associated with the Time 2 food insecurity (p \ 0.1) and were retained in the model. The odds of reporting food insecurity at Time 2 was more than two times as great for households of CSHCN compared to families without CSHCN, as shown in both the bivariate
Matern Child Health J Table 2 Number and type of special health care needs (SHCN) reported for children with special health care needs, frequency and weighted percent Oregon PRAMS-2, 2004–2005 births
Frequency
Actual (%)
Weighted (%)
1534
86.4
88.4
241
13.6
11.6
Specialty health care
86
4.8
4.4
Behavioral and mental health care
12
0.7
0.8
Physical therapy
41
2.3
1.7
Occupational therapy
32
1.7
0.8
Number of special health care needs None One or more Type of special health care needa
Speech services
60
3.3
2.2
132
7.3
6.3
Home health services
30
1.7
1.1
Special diet
57
3.2
2.1
Use of assistive devices
23
1.6
1.0
Durable medical equipment
36
2.0
1.8
Medication
Frequency and actual % are unweighted a
PRAMS-2 variable
(OR 2.4; 95 % CI 1.3, 4.6) and multivariable analyses (AOR 2.9; 95 % CI 1.4, 6.0), respectively. When food insecurity at Time 1 was included in the model (see Table 3, Model 2), baseline food security was significantly related to odds of Time 2 food security in the bivariate (OR 19.7; 95 % CI 10.9, 35.5) and multivariable models (AOR 13.1; 95 % CI 6.6, 26.3). The odds of food insecurity at Time 2 remained more than two times as great for families of CSHCN compared to others, even after controlling for baseline food security in the multivariable model (AOR 2.6; 95 % CI 1.2, 5.4).
Discussion This investigation explored the association between food insecurity and having a child who has special health care needs at 2 years of age. In bivariate and multivariable analyses, there was a positive association between food insecurity at Time 2 and having a child who has had one or more ongoing health service needs at 2 years (Time 2). As shown in Table 3, this association remained statistically significant after controlling for maternal characteristics associated with food insecurity, including marital status, employment, lifetime U.S. residence, health conditions, and baseline food insecurity (Time 1). Results of this study support the hypothesis that there is a positive association between having a CSHCN and experiencing food insecurity when the CSHCN is 2 years old, even after controlling for food insecurity before the child’s birth. Findings complement the current literature that links diagnosis of specific chronic conditions such as diabetes to increased risk of food insecurity [10]. However, unlike studies focusing on specific diagnoses, our investigation is unique in identifying children with special health needs
based on functioning and service needs. This approach is consistent with the approach of U.S. federal and state governments to identify CSHCN across public agencies, health care plans, and other settings [32]. Findings of this study may be relevant to populations of children with special health care needs and complex care needs in the U.S. and many countries. Recent longitudinal studies relate early childhood experiences of food insecurity to disadvantage in later outcomes including poor health, anxiety and insecure attachment, all of which suggest an early impact of food insecurity on child health and development [8, 11, 19]. These studies raise concern that early exposure of CSHCN to food insecurity could augment challenges to achieving optimal health and development. In light of potential risks identified [8, 11, 18, 19] our novel finding, that households including 2- year-old CSHCN are more likely to experience food insecurity, supports the importance of routine screening for early detection of food insecurity by healthcare providers and others who work with young children and their families, especially families of CSHCN. Upon recognizing food insecurity, providers can connect families with resources and education to prevent food insecurity and its adverse effects. Health care providers do not routinely screen for food insecurity although it is associated with adverse health outcomes for children and families. A survey of Oregon pediatric health care providers revealed that most do not routinely screen for food insecurity; however 88 % expressed willingness to screen if a standardized screening tool were available to them [33]. A validated rapid screening tool is now readily accessible [34]. This work can inform policymakers about the need for additional supports (including food but also other supports)
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Matern Child Health J Table 3 Prevalence of food insecurity at Time 2, bivariate and adjusted multivariable odds ratios (OR) with 95 % confidence intervals (CI) for the relationship between Time 2 food insecurity Characteristic
and special health care needs (SHCN) status, adjusted for maternal characteristics not including (Model 1a) or including Time 1 food insecurity (Model 2b)
Food insecure at Time 2 (weighted %)
Bivariate OR (95 % CI)
Model 1a multivariable OR (95 % CI)
Model 2a multivariable OR (95 % CI)
20.7
2.4 (1.3, 4.6)
2.9 (1.4, 6.0)
2.6 (1.2, 5.4)
Referent
Referent
Referent
SHCN status One or more None
9.7
Marital status Not married
21.6
3.57 (2.2, 5.8)
2.6 (1.4, 4.7)
1.8 (0.9, 3.7)
7.2
Referent
Referent
Referent
B12th grade
7.5
2.7 (1.7, 4.4)
2.2 (1.9, 4.2)
2.3 (1.1, 4.6)
[12th grade
18.0
Referent
Referent
Referent
Married Maternal education
Lived in US entire life No
7.5
Yes
12.3
1.7 (1.1, 2.8)
2.6 (1.4, 4.9)
2.5 (1.3, 5.0)
Referent
Referent
Referent
Annual household income B100 % FPL
8.3
2.8 (1.7, 4.6)
1.8 (0.9, 3.4)
1.2 (0.5, 2.8)
[100 % FPL Maternal asthma
20.1
Referent
Referent
Referent
Yes
20.4
2.4 (1.4, 4.3)
2.3 (1.2, 4.3)
1.9 (0.9, 4.0)
No
9.5
Referent
Referent
Referent
Maternal diabetes Yes
28.5
3.31 (1.4, 8.0)
4.0 (1.5, 10.3)
4.0 (1.7, 9.8)
No
10.7
Referent
Referent
Referent
Yes
56.5
19.7 (10.9, 35.5)
–
13.1 (6.6, 26.3)
No
6.2
Referent
–
Referent
Food insecurity (Time 1)
a
Multivariable Model 1 adjusts for maternal marital status, education B12th grade, income B FPL, lived entire life in US, asthma, and diabetes (not in pregnancy); 1661 participants had complete data for all variables used in Model 1 and are included in results reported b Multivariable Model 2 adjusts for maternal marital status, education B12th grade, income B FPL, lived entire life in US, asthma, diabetes (not in pregnancy) and food insecurity at Time 1; 1622 participants had complete data for all variables used in Model 2 and are included in results reported
for mothers/families of CSHCN; it highlights the increased risk of food insecurity faced by families of CSHCN. Although not investigated by this study, financial and nonfinancial strains placed on families whose children may require more time commitment, health care expenditures, and other stresses than children without special health care needs are likely to contribute to increased risk for food insecurity. While many children with special health care needs have health insurance, as many as 15.1 or 20.3 % of families with privately or publicly insured CSHCN, respectively, report that out of pocket medical costs caused family financial problems [35]. In the U.S., financial instability, such as unemployment and home foreclosure, has impacted many families. Mothers of CSHCN are less likely to be employed outside the home, and so in many cases a single income must provide for the family [36]. This
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employment and care-giving balance leaves families with CSHCN vulnerable to financial challenges. Strengths This study is strengthened by the population focus and study design of PRAMS and PRAMS-2. These surveys draw on large population-based samples; PRAMS and PRAMS-2 methodology and weighting allow investigators to make inferences about Oregon populations. In addition, the PRAMS and PRAMS-2 surveys provide a unique combination of both food security and CSHCN data. While forty states and New York city currently participate in PRAMS, Oregon is one of four states with a PRAMS follow-back survey in early childhood [37–39]. Only Oregon’s PRAMS/PRAMS-2 collects data about food
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security before birth as well as food security and CSHCN status at 2 years of age. These data make it possible to study the relationship between CSHCN status and food security at 2 years, and to control for food security before birth. Evidence of a positive association highlights the need to better understand the impact on food security of caring for a CSHCN from birth to 2 years, and the impact of food insecurity on families. Weaknesses Limitations are introduced by data available to identify CSHCN and food insecurity. Although the PRAMS-2 questions applied to identify CSHCN were modeled after the national CSHCN Screener and designed to collect information about the presence of chronic conditions with ongoing need for services, the wording and format of the PRAMS-2 CSHCN items differed from the national Screener. The CSHCN Screener includes 6 items instead of 10, and asks about the need for services expected to last at least 12 months instead of six. It is possible that use of the PRAMS-2 questions about need for services to identify CSHCN, rather than the validated CSHCN Screener, resulted in misclassification of CSHCN. Despite differences with the CSHCN Screener, use by PRAMS-2 of a parentreported tool to identify increased service needs is consistent with use of a parent-reported tool for national assessments. Similarly, the PRAMS-2 question used to identify food security represents one question from the validated 18-question U.S. FSSM and is likely to less completely identify food insecurity than the full tool. The FSSM addresses four domains of food security: anxiety about the food supply, perception the quality or quantity of foods is not adequate, reduced adult intake, and reduced intake by children [40]. In contrast, the PRAMS-2 question used in this study reflects a single domain, ‘‘reduced adult food intake’’. This may in part explain why the prevalence of food insecurity estimated in this study (11.2 %) is less than the Oregon 2004–2006 prevalence estimated using the full 18-item tool (14.6 %). However, reduced sensitivity to identify food insecurity would bias our findings towards the null, and is not likely to explain the statistically significant positive associations observed. Current food security monitoring tools do not capture experiences such as shame or alienation that may relate to food insecurity for subgroups [40], such as families of CSHCN. Research to improve understanding of these experiences is needed. The investigation is also limited by loss of participants to follow-up for Oregon PRAMS-2 during 2006–2007. Out of 3883 women who responded to PRAMS in 2004 and 2005, 2027 also responded to PRAMS-2 for a weighted
response proportion of 43.5 %. Our study sample includes only women who responded to both PRAMS and PRAMS2. To assess the effect of loss to follow up, participants who responded only to PRAMS were compared to participants who responded to both PRAMS and PRAMS-2 using unweighted data. The prevalence of food insecurity in the past year was 14.5 % for women who responded only to PRAMS and 12.4 % for women who responded to both PRAMS and PRAMS-2 (p B 0.40). Mothers responding to both surveys had similar characteristics compared to women who responded only to PRAMS. However, women who responded only to PRAMS were more likely to have completed the survey in Spanish (18.3 %) instead of English, compared to women who responded to both surveys (14.7 %) (p \ 0.003). Although differences were evident only for language of survey completed, it is not possible to definitively assess whether the mothers who were lost to follow-up in PRAMS-2 were at increased or decreased risk for food insecurity. Summary Despite these limitations, this study suggests that having a child with special health care needs increases the risk of being food insecure. Families of CSHCN need support from health care and other service providers and the community to help address needs and prevent food insecurity. Community-based organizations like local food banks and advocacy groups may use the findings of this investigation to target outreach activities to specific populations at increased risk for food insecurity. On the local, state and national levels, this investigation highlights the need for policies that support all families to reduce risk of food insecurity. Targeted strategies are needed to address increased risks to families of CSHCN. This investigation provides evidence for policy-makers to use as they craft policies to support families at risk for conditions recognized to stress family resources and threaten the health of household members. Food insecurity is a preventable experience and this investigation highlights the higher risk for it in the vulnerable population of CSHCN and their families. Acknowledgments We would like to acknowledge PRAMS and PRAMS-2 participants as well as Al Sandoval for providing technical assistance related to use of PRAMS and PRAMS-2 data and Tina Kent and Caitlyn Howell for their work in data collection. This work would not have been possible without their contributions. Funding for the PRAMS and PRAMS-2 surveys comes from the Oregon Health Authority; Oregon Office of Children and Youth with Special Health Needs (at Oregon Health & Science University); the Centers for Disease Control and Prevention (US Department of Health and Human Services (HHS)); and the Maternal and Child Health Bureau (Health Resources and Services Administration, HHS).
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American Dietetic Association, 109(12), 2001–2009. doi:10. 1016/j.jada.2009.09.004. Slopen, N., Fitzmaurice, G., Williams, D. R., & Gilman, S. E. (2010). Poverty, food insecurity, and the behavior of childhood internalizing and externalizing disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 444–452. Ryu, J.-H., & Bartfeld, J. S. (2012). Household food insecurity during childhood and subsequent health status: the early childhood longitudinal study—Kindergarten cohort. American Journal of Public Health, 102(11), e50–e55. doi:10.2105/AJPH.2012.300971. Zaslow, M., Bronte-Tinkew, J., Capps, R., Horowitz, A., Moore, K. A., & Weinstein, D. (2008). Food security during infancy: Implications for attachment and mental proficiency in toddlerhood. Maternal and Child Health Journal, 13, 66–80. doi:10. 1007/s10995-008-0329-1. McPherson, M., Arango, P., et al. (1998). A new definition of children with special health care needs. Pediatrics, 102(1), 137–139. CSHCN screener—(Children with Special Health Care Needs (CSHCN) Screener, the Child and Health Measurement Initiative. Retrieved December 27, 2014, from http://www.cahmi.org/pro jects/children-with-special-health-care-needs-screener/. National Survey of Children with Special Health Care Needs 2005–2006: Oregon CSHCN Data. (2011). Retrieved December 6, 2011, from http://mchb.hrsa.gov/cshcn05/SD/oregon.htm. Van Dyck, P. C., Kogan, M. D., McPherson, M. G., Weissman, G. R., & Newacheck, P. W. (2004). Prevalence and characteristics of children with special health care needs. Archives of Pediatric Adolescent Medicine, 158(9), 884–890. doi:10.1001/ archpedi.158.9.884. Kuhlthau, K., Hill, K. S., Yucel, R., & Perrin, J. M. (2005). Financial burden for families of children with special health care needs. Maternal and Child Health Journal, 9, 207–218. doi:10. 1007/s10995-005-4870-x. Bumbalo, J., Ustinich, L., Ramcharran, D., & Schwalberg, R. (2005). Economic impact on families caring for children with special health care needs in New Hampshire: The effect of socioeconomic and health-related factors. Maternal and Child Health Journal, 9, S3–S11. doi:10.1007/s10995-005-4350-3. Viner-Brown, S. I., & Kim, H. K. (2005). Impact of caring for children with special health care needs on the family: Rhode Island’s experience. Maternal and Child Health Journal, 9, S59– S66. doi:10.1007/s10995-005-4483-4. Porterfield, S. L., & DeRigne, L. (2011). Medical home and outof-pocket medical costs for children with special health care needs. Pediatrics, 128(5), 892–900. doi:10.1542/peds.2010-1307. CDC—Methodology—Pregnancy Risk Assessment Monitoring System—Reproductive Health. (n.d.). Retrieved February 18, 2013, from http://www.cdc.gov/prams/methodology.htm. Oregon PRAMS (Pregnancy Risk Assessment Monitoring System). Retrieved November 30, 2011, from http://public.health. oregon.gov/HealthyPeopleFamilies/DataReports/prams/Pages/ index.aspx. Hosmer, D. W., & Lemeshow, S. (2013). Applied logistic regression. Oxford: Wiley-Blackwell. StataCorp. (2009). Stata statistical software: Release 11. College Station, TX: StataCorp LP. Bethell, C. D., Reed, D., Stein, R. E., Blumberg, S. J., Wells, N., & Newacheck, P. W. (2002). Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambulatory Pediatrics, 2(1), 38–48. Hoisington, A. T., Braverman, M. T., Hargunani, D. E., Adams, E. J., & Alto, C. L. (2012). Health care providers’ attention to food insecurity in households with children. Preventive Medicine. doi:10.1016/j.ypmed.2012.06.007.
Matern Child Health J 34. Hager, E. R., Quigg, A. M., Black, M. M., et al. (2010). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126(1), e26–e32. doi:10.1542/ peds.2009-3146. 35. Yu, H., Dick, A. W., & Szilagyi, P. G. (2008). Does public insurance provide better financial protection against rising health care costs for families of children with special health care needs? Medical Care, 46, 1064–1070. doi:10.1097/MLR.0b013e3181 85cdf2. 36. Thyen, U., Kuhlthau, K., & Perrin, J. M. (1999). Employment, child care, and mental health of mothers caring for children assisted by technology. Pediatrics, 103(6), 1235–1242. 37. Association of Maternal and Child Health Programs, Innovation Station. Alaska Childhood Understanding Behavior Survey (CUBS). Retrieved January 9, 2015, from http://www.amchp.org/ programsandtopics/BestPractices/InnovationStation/ISDocs/AKCUBS.pdf.
38. Rosenberg, K. D., Hembroff, L., Drisko, J., Viner-Brown, S., Decker, K., & Lichter, E. (2011). New options for maternal and child health surveillance by state health departments. Maternal and Child Health Journal, 15(3), 302–309. doi:10.1007/s10995010-0589-4. 39. Oklahoma State Department of Health, Maternal and Child Health. The Oklahoma Toddlers Survey (TOTS). Retrieved January 18, 2015, from http://www.ok.gov/health/Child_and_ Family_Health/Maternal_and_Child_Health_Service/Data_and_ Evaluation/The_Oklahoma_Toddler_Survey_(TOTS)/index.html. 40. Jones, A. D., Ngure, F. M., Pelto, G., & Young, S. L. (2013). What are we assessing when we measure food security? A compendium and review of current metrics. Advances in Nutrition, 4(5), 481–505. doi:10.3945/an.113.004119.
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Increased Food Insecurity Among Mothers of 2 Year Olds with Special Health Care Needs Elizabeth J. Adams • Laurel M. Hoffmann • Kenneth D. Rosenberg • Dawn Peters • Melissa Pennise
Ó Springer Science+Business Media New York 2015
Abstract The objective of this study is to explore the association between having a child with special health care needs (CSHCN) and food insecurity when the child is 2 years old. We studied women who had a live birth in 2004–2005 and responded to Oregon’s Pregnancy Risk Assessment Monitoring System (PRAMS) survey 3 months postpartum (Time 1) and the follow-up survey (PRAMS-2), when the child was 2 years old (Time 2). Women answering affirmatively to the PRAMS-2 question, ‘‘In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?’’ were considered food insecure. CSHCN status was identified by affirmative responses to questions about needs for ongoing services (Time 2). PRAMS and PRAMS-2 responses were weighted for study design and nonresponse. Results report weighted analyses, unless noted. Among 1812 mothers completing PRAMS-2, 13.6 % (unweighted) had a 2-year-old CSHCN and 11.9 % (unweighted) were food insecure at Time 2. The estimated prevalence of food insecurity at 2-year follow-up was 20.7 % among families of CSHCN and 9.7 % for others. After adjustment for Time 2 marital status, education, lifetime U.S. residence, income and health conditions, multivariable logistic regression revealed that odds of food
E. J. Adams (&) L. M. Hoffmann K. D. Rosenberg D. Peters M. Pennise Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] K. D. Rosenberg Oregon Public Health Division, Portland, OR, USA Present Address: M. Pennise University of Rochester, Rochester, NY, USA
insecurity were more than two times as great for CSHCN mothers 2 years post-partum compared to non-CSHCN mothers (adjusted odds ratio 2.6, 95 % confidence interval 1.3, 4.6). Families of CSHCN face increased risk for food insecurity. Improved understanding of causal determinants of food insecurity among households of CSHCN is needed. Keywords Food security Children with special health care needs (CSHCN) Social determinants of health PRAMS Oregon
Introduction Food insecurity, the ‘‘limited or uncertain availability of nutritionally adequate and safe foods,’’ is associated with adverse health and developmental outcomes for children and caregivers [1]. It is a recognized public health problem in the U.S. [2, 3] and other countries [4]. In the U.S., food security is assessed annually by the U.S. Department of Agriculture using the 18-question U.S. Household Food Security Survey Module (FSSM) [5]. In 2013, 14.3 % of the U.S. population lived in food insecure households, an increase from 11.0 % in 2005 [5]. The prevalence of food insecurity in Oregon was 15.2 % in 2011–2013 [5] and 11.9 % in 2004–2006 [6]. Oregon had among the highest proportion (27.3 %) of children under 18 years old living in households that experienced food insecurity in 2012, as compared to 21.6 % of children under 18 years old nationally [7]. Food insecurity is not evenly distributed in the population. Young children living in low income, Black, American Indian, or Hispanic households are at increased risk for food insecurity compared to other children [5]. Food insecurity among families that include young children has
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also been related to nonfinancial factors such as maternal mental health problems including depression, alcohol or drug abuse, psychiatric disorders, or domestic violence [8], parental burdens such as low income [13] or disability [5], and to community factors including social deprivation, lack of social cohesion, and high social disorder [9]. Families of children with complex health conditions such as diabetes [10] or cystic fibrosis [11] are also at increased risk for food insecurity; social and economic stresses related to having a child with special health needs may contribute to increase risk. Cross-sectional studies from the U.S. and Canada using the 18-question FSSM, or a subset of FSSM questions [5], document the link between food insecurity and compromised child health and well-being including poor or fair general health [12, 13], low school achievement [14], compromised diet [15, 16], and behavioral problems [17]. Longitudinal studies also identify relationships between household food insecurity in infancy or early childhood and compromised subsequent health and development [8, 9, 12, 18]. Children with special health care needs (CSHCN) are ‘‘those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally’’ [20]. Food insecurity may further complicate any health challenges faced by CSHCN. CSHCN are identified by U.S. public health surveillance systems using a five-item, parent-reported tool designed to reflect the federal Maternal and Child Health Bureau’s consequences-based definition of CSHCN [21]. In 2005–2006, the prevalence of CSHCN among children 0–5 years old was 8.8 % in the U.S., and 8.6 % in Oregon [22]. Caring for CSHCN can cause financial and parenting stress for families, with up to 20 % of CSHCN families reporting financial struggles related to their child’s condition and 22.5 % reporting ‘‘usually or always feeling stress from parenting’’ [23–27]. It is not known how often financial and other stresses related to parenting CSHCN manifest as food insecurity. Although diagnosis-specific conditions have been associated with increased risk for food insecurity [10, 11] the relationship between the more broadly defined CSHCN status and food insecurity is not well described. A better understanding about the relationship between food insecurity and CSHCN status, and determinants of food insecurity among CSHCN families is needed to inform strategies to prevent and mitigate food insecurity in this broader population. This investigation quantifies the association between food insecurity and having a child with special health care
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needs when the child is 2 years old, controlling for food security before the child’s birth.
Methods Instrument Data were obtained from the 2004–2005 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) and the 2 year follow-back survey (PRAMS-2). PRAMS and PRAMS-2 are surveillance projects of the U.S. Centers for Disease Control and Prevention (CDC) and state health departments. These surveys are used to monitor pregnancy and early childhood risks and outcomes in order to inform public health decisions and improve health outcomes of mothers, infants and children [28, 29]. Subjects Participants included in this study delivered a live birth in Oregon, completed PRAMS and PRAMS-2 surveys, and provided complete data for the variables used in these analyses. Stratified random sampling from birth certificates was used to identify the PRAMS sample, with oversampling of mothers who are Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Asian/Pacific Islander, and Non-Hispanic Black to ensure reliable estimates for these groups. All responses in PRAMS and PRAMS-2 were weighted for oversampling, non-response and non-coverage of births omitted from the state birth certificate files to allow for population-based estimates representative of all Oregon births. Birth certificate, PRAMS, and PRAMS-2 data were linked to each other to create the final data set [28]. Oregon PRAMS and PRAMS-2 have been reviewed by, and were conducted under the supervision of, the Oregon State Public Health/Multnomah County Public Health Institutional Review Board (IRB). The protocol for this study was also reviewed and approved by the Oregon Health and Science University IRB. Procedure Oregon PRAMS surveys are mailed to identified mothers at 2–6 months post-partum (Time 1). PRAMS-2 provides information about early childhood health issues at 2 years of age (Time 2) for children in the PRAMS cohort. Participants are contacted by phone and mail for PRAMS. For PRAMS-2, participants are contacted by mail only (for 2004 births) or mail and phone (for 2005 births), depending on the birth year. PRAMS-2 is sent to all women who
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completed PRAMS unless the PRAMS index child had died or the mother had opted out of the follow-back. Measures Dependent Variable The dependent variable of interest was food security at Time 2 (PRAMS-2). Food security at Time 2 was identified on PRAMS-2 by asking, ‘‘In the past 12 months, did you ever eat less than you felt you should because there was not enough money to buy food?’’ Women with affirmative responses were classified as food insecure at Time 2. Independent Variables Children with special health care needs (CSHCN) were identified at Time 2 (PRAMS-2) by response to a 10-item question about ongoing health needs of their 2-year-old lasting 6 months or more for specific services: specialty health care, behavioral health or mental health services, physical therapy, occupational therapy, speech services, medication, home health services, special diet, use of assistive devices, or durable medical equipment. Mothers who responded ‘‘yes’’ to one or more of the ten items were classified as having a CSHCN. This 10-item question, modeled after the national CSHCN screener, collectively identifies children classified as CSHCN rather than identifying need for distinct services [21]. Demographic and health variables were gathered from birth certificates and PRAMS-2 surveys. Maternal race/ ethnicity (Non-Hispanic White, Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Asian/ Pacific Islander, and Non-Hispanic Black) was obtained from the birth certificate. The variables from the PRAMS-2 survey included maternal employment, education, lifetime U.S. residence, marital status, poverty status (B100 % federal poverty level (FPL)) and health conditions (nonpregnancy diabetes, and asthma), as well as spouse employment. Baseline food security at Time 1 (PRAMS) was identified on PRAMS by asking, ‘‘During the 12 months before your new baby was born, did you ever eat less than you felt you should because there was not enough money to buy food?’’ Women with affirmative responses were classified as food insecure at Time 1. Data Analysis Descriptive statistics were used to summarize demographic and health characteristics of the sample. Logistic regression was carried out to estimate the association between Time 2 food security and CSHCN status. Only women with
complete data for all study variables were included in the multivariable logistic regression analyses. The odds of experiencing food insecurity at Time 2 was estimated for participants with CSHCN compared to those without CSHCN. Predictors of interest were identified based on the literature concerning child health and food insecurity; these included variables related to income, employment, marital status, education, race and ethnicity, and health status (as shown in Table 1). Predictors were assessed for multicollinearity with each other and as confounders of the primary association of interest before being assessed for inclusion in the final model. Multicollinearity was evaluated using variable inflation factors (VIF). Variables with VIF values [2.0 were considered to have high multicollinearity and were excluded from the final multivariable model. Bivariate models quantified the relationship between each predictor variable and food insecurity (Time 2). Predictor variables were incorporated into a multivariable model with the CSHCN variable one at a time to assess confounding. The beta value from the multivariable logistic regression model was compared to that from the crude bivariate model; variables with values that differed by over 10 % were considered to be important confounders, as described in Applied Logistic Regression [30]. Candidate predictors were considered for the full model based on this statistical evaluation for confounding, evidence of association with food insecurity identified by Wald test statistic results of p \ 0.20, and association with food insecurity as described in the literature. The Hosmer– Lemeshow goodness-of-fit test for weighted data was used to assess the multivariable model’s overall fit with the data. A second multivariable regression model was applied to estimate the odds of experiencing food insecurity at Time 2 among families with and without CSHCN, adjusting for food insecurity at Time 1, and for potential confounding variables identified, as described above. All analyses were performed using STATA 11 [31]. Results report weighted analyses, unless otherwise noted.
Results Characteristics of the Sample The weighted response rate for Oregon PRAMS was 75.2 % and for PRAMS-2 was 43.5 % of the original Oregon PRAMS sample. A total of 2027 participants replied to both surveys. Of these, 1661 had complete data for all study variables and are included in the first multivariable analysis, as reported in Table 3. Demographic characteristics of participants as assessed at Time 1 (PRAMS) and Time 2 are summarized in Table 1. Mean
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Matern Child Health J Table 1 Demographic characteristics of participants, frequency, actual percent and weighted percent, Oregon PRAMS-2, 2004–2005 births
Frequency
Actual (%)
Weighted (%)
Food insecurity Food insecure at Time 1a (n = 1768)
169
9.6
9.7
Food insecure at Time 2b (n = 1812)
216
11.9
11.2
181
10.2
1.9
Maternal race/ethnicitya Non-Hispanic Black Non-Hispanic American Indian/Alaskan Native
213
11.8
1.4
Non-Hispanic Asian/Pacific Islander
284
15.2
5.3
Hispanic
325
18.0
16.3
Non-Hispanic White
804
44.5
75.1
Marital statusb Not married Married
498
27.5
27.5
1315
72.5
72.5
Annual household incomeb At or below 100 % FPL Above 100 % FPL Maternal employment statusb Not employed
470
27.5
23.7
1242
72.6
76.3
802
44.4
45.4
1006
55.6
54.6
No
547
30.2
23.4
Yes
1264
69.8
76.6
B12th grade
643
35.5
35.2
[12th grade
1166
64.5
64.8
Yes
303
16.8
15.1
No
1504
83.2
84.2
Employed Lived in US entire lifeb
Maternal education
b
Maternal asthmab
Frequency and actual % are unweighted a b
PRAMS variable PRAMS-2 variable
Maternal diabetesb Yes No
child age at the time of PRAMS survey completion was 14 weeks, and mean child age at the time of PRAMS-2 survey completion was 25 months (unweighted). The estimated percentage of 2-year-olds with one or more special health needs, and therefore classified to be CSHCN, was over 10 % (11.6 %). The distribution of special health care needs estimated in this population at Time 2 (PRAMS-2) is presented in Table 2.
Food Security Status at Time 1 and Time 2 At Time 1 (PRAMS), 9.7 % of participants were estimated to be food insecure, and at Time 2 (PRAMS-2), 11.2 % were estimated to be food insecure, as shown in Table 1. Food security was not constant over the study. The greatest proportion (84.7 %) were food secure at Time 1 and Time 2; 5.5 % were food insecure at both times.
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56
3.1
2.5
1751
96.9
97.2
Food Insecurity and CSHCN Status Table 3 presents the results of bivariate and multivariable logistic regression analyses evaluating the cross-sectional relationship between food insecurity and CSHCN status at Time 2. In the bivariate analyses, having a CSHCN, being unmarried, of low education, income B100 % FPL, not having lived entire life in the U.S., and having asthma or diabetes were each associated with food insecurity at Time 2. In the multivariable analysis without including food insecurity at Time 1 (see Table 3, Model 1), CSHCN status, marital status, education, having lived entire life in U.S., income B100 % FPL, and having diabetes or asthma were all associated with the Time 2 food insecurity (p \ 0.1) and were retained in the model. The odds of reporting food insecurity at Time 2 was more than two times as great for households of CSHCN compared to families without CSHCN, as shown in both the bivariate
Matern Child Health J Table 2 Number and type of special health care needs (SHCN) reported for children with special health care needs, frequency and weighted percent Oregon PRAMS-2, 2004–2005 births
Frequency
Actual (%)
Weighted (%)
1534
86.4
88.4
241
13.6
11.6
Specialty health care
86
4.8
4.4
Behavioral and mental health care
12
0.7
0.8
Physical therapy
41
2.3
1.7
Occupational therapy
32
1.7
0.8
Number of special health care needs None One or more Type of special health care needa
Speech services
60
3.3
2.2
132
7.3
6.3
Home health services
30
1.7
1.1
Special diet
57
3.2
2.1
Use of assistive devices
23
1.6
1.0
Durable medical equipment
36
2.0
1.8
Medication
Frequency and actual % are unweighted a
PRAMS-2 variable
(OR 2.4; 95 % CI 1.3, 4.6) and multivariable analyses (AOR 2.9; 95 % CI 1.4, 6.0), respectively. When food insecurity at Time 1 was included in the model (see Table 3, Model 2), baseline food security was significantly related to odds of Time 2 food security in the bivariate (OR 19.7; 95 % CI 10.9, 35.5) and multivariable models (AOR 13.1; 95 % CI 6.6, 26.3). The odds of food insecurity at Time 2 remained more than two times as great for families of CSHCN compared to others, even after controlling for baseline food security in the multivariable model (AOR 2.6; 95 % CI 1.2, 5.4).
Discussion This investigation explored the association between food insecurity and having a child who has special health care needs at 2 years of age. In bivariate and multivariable analyses, there was a positive association between food insecurity at Time 2 and having a child who has had one or more ongoing health service needs at 2 years (Time 2). As shown in Table 3, this association remained statistically significant after controlling for maternal characteristics associated with food insecurity, including marital status, employment, lifetime U.S. residence, health conditions, and baseline food insecurity (Time 1). Results of this study support the hypothesis that there is a positive association between having a CSHCN and experiencing food insecurity when the CSHCN is 2 years old, even after controlling for food insecurity before the child’s birth. Findings complement the current literature that links diagnosis of specific chronic conditions such as diabetes to increased risk of food insecurity [10]. However, unlike studies focusing on specific diagnoses, our investigation is unique in identifying children with special health needs
based on functioning and service needs. This approach is consistent with the approach of U.S. federal and state governments to identify CSHCN across public agencies, health care plans, and other settings [32]. Findings of this study may be relevant to populations of children with special health care needs and complex care needs in the U.S. and many countries. Recent longitudinal studies relate early childhood experiences of food insecurity to disadvantage in later outcomes including poor health, anxiety and insecure attachment, all of which suggest an early impact of food insecurity on child health and development [8, 11, 19]. These studies raise concern that early exposure of CSHCN to food insecurity could augment challenges to achieving optimal health and development. In light of potential risks identified [8, 11, 18, 19] our novel finding, that households including 2- year-old CSHCN are more likely to experience food insecurity, supports the importance of routine screening for early detection of food insecurity by healthcare providers and others who work with young children and their families, especially families of CSHCN. Upon recognizing food insecurity, providers can connect families with resources and education to prevent food insecurity and its adverse effects. Health care providers do not routinely screen for food insecurity although it is associated with adverse health outcomes for children and families. A survey of Oregon pediatric health care providers revealed that most do not routinely screen for food insecurity; however 88 % expressed willingness to screen if a standardized screening tool were available to them [33]. A validated rapid screening tool is now readily accessible [34]. This work can inform policymakers about the need for additional supports (including food but also other supports)
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Matern Child Health J Table 3 Prevalence of food insecurity at Time 2, bivariate and adjusted multivariable odds ratios (OR) with 95 % confidence intervals (CI) for the relationship between Time 2 food insecurity Characteristic
and special health care needs (SHCN) status, adjusted for maternal characteristics not including (Model 1a) or including Time 1 food insecurity (Model 2b)
Food insecure at Time 2 (weighted %)
Bivariate OR (95 % CI)
Model 1a multivariable OR (95 % CI)
Model 2a multivariable OR (95 % CI)
20.7
2.4 (1.3, 4.6)
2.9 (1.4, 6.0)
2.6 (1.2, 5.4)
Referent
Referent
Referent
SHCN status One or more None
9.7
Marital status Not married
21.6
3.57 (2.2, 5.8)
2.6 (1.4, 4.7)
1.8 (0.9, 3.7)
7.2
Referent
Referent
Referent
B12th grade
7.5
2.7 (1.7, 4.4)
2.2 (1.9, 4.2)
2.3 (1.1, 4.6)
[12th grade
18.0
Referent
Referent
Referent
Married Maternal education
Lived in US entire life No
7.5
Yes
12.3
1.7 (1.1, 2.8)
2.6 (1.4, 4.9)
2.5 (1.3, 5.0)
Referent
Referent
Referent
Annual household income B100 % FPL
8.3
2.8 (1.7, 4.6)
1.8 (0.9, 3.4)
1.2 (0.5, 2.8)
[100 % FPL Maternal asthma
20.1
Referent
Referent
Referent
Yes
20.4
2.4 (1.4, 4.3)
2.3 (1.2, 4.3)
1.9 (0.9, 4.0)
No
9.5
Referent
Referent
Referent
Maternal diabetes Yes
28.5
3.31 (1.4, 8.0)
4.0 (1.5, 10.3)
4.0 (1.7, 9.8)
No
10.7
Referent
Referent
Referent
Yes
56.5
19.7 (10.9, 35.5)
–
13.1 (6.6, 26.3)
No
6.2
Referent
–
Referent
Food insecurity (Time 1)
a
Multivariable Model 1 adjusts for maternal marital status, education B12th grade, income B FPL, lived entire life in US, asthma, and diabetes (not in pregnancy); 1661 participants had complete data for all variables used in Model 1 and are included in results reported b Multivariable Model 2 adjusts for maternal marital status, education B12th grade, income B FPL, lived entire life in US, asthma, diabetes (not in pregnancy) and food insecurity at Time 1; 1622 participants had complete data for all variables used in Model 2 and are included in results reported
for mothers/families of CSHCN; it highlights the increased risk of food insecurity faced by families of CSHCN. Although not investigated by this study, financial and nonfinancial strains placed on families whose children may require more time commitment, health care expenditures, and other stresses than children without special health care needs are likely to contribute to increased risk for food insecurity. While many children with special health care needs have health insurance, as many as 15.1 or 20.3 % of families with privately or publicly insured CSHCN, respectively, report that out of pocket medical costs caused family financial problems [35]. In the U.S., financial instability, such as unemployment and home foreclosure, has impacted many families. Mothers of CSHCN are less likely to be employed outside the home, and so in many cases a single income must provide for the family [36]. This
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employment and care-giving balance leaves families with CSHCN vulnerable to financial challenges. Strengths This study is strengthened by the population focus and study design of PRAMS and PRAMS-2. These surveys draw on large population-based samples; PRAMS and PRAMS-2 methodology and weighting allow investigators to make inferences about Oregon populations. In addition, the PRAMS and PRAMS-2 surveys provide a unique combination of both food security and CSHCN data. While forty states and New York city currently participate in PRAMS, Oregon is one of four states with a PRAMS follow-back survey in early childhood [37–39]. Only Oregon’s PRAMS/PRAMS-2 collects data about food
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security before birth as well as food security and CSHCN status at 2 years of age. These data make it possible to study the relationship between CSHCN status and food security at 2 years, and to control for food security before birth. Evidence of a positive association highlights the need to better understand the impact on food security of caring for a CSHCN from birth to 2 years, and the impact of food insecurity on families. Weaknesses Limitations are introduced by data available to identify CSHCN and food insecurity. Although the PRAMS-2 questions applied to identify CSHCN were modeled after the national CSHCN Screener and designed to collect information about the presence of chronic conditions with ongoing need for services, the wording and format of the PRAMS-2 CSHCN items differed from the national Screener. The CSHCN Screener includes 6 items instead of 10, and asks about the need for services expected to last at least 12 months instead of six. It is possible that use of the PRAMS-2 questions about need for services to identify CSHCN, rather than the validated CSHCN Screener, resulted in misclassification of CSHCN. Despite differences with the CSHCN Screener, use by PRAMS-2 of a parentreported tool to identify increased service needs is consistent with use of a parent-reported tool for national assessments. Similarly, the PRAMS-2 question used to identify food security represents one question from the validated 18-question U.S. FSSM and is likely to less completely identify food insecurity than the full tool. The FSSM addresses four domains of food security: anxiety about the food supply, perception the quality or quantity of foods is not adequate, reduced adult intake, and reduced intake by children [40]. In contrast, the PRAMS-2 question used in this study reflects a single domain, ‘‘reduced adult food intake’’. This may in part explain why the prevalence of food insecurity estimated in this study (11.2 %) is less than the Oregon 2004–2006 prevalence estimated using the full 18-item tool (14.6 %). However, reduced sensitivity to identify food insecurity would bias our findings towards the null, and is not likely to explain the statistically significant positive associations observed. Current food security monitoring tools do not capture experiences such as shame or alienation that may relate to food insecurity for subgroups [40], such as families of CSHCN. Research to improve understanding of these experiences is needed. The investigation is also limited by loss of participants to follow-up for Oregon PRAMS-2 during 2006–2007. Out of 3883 women who responded to PRAMS in 2004 and 2005, 2027 also responded to PRAMS-2 for a weighted
response proportion of 43.5 %. Our study sample includes only women who responded to both PRAMS and PRAMS2. To assess the effect of loss to follow up, participants who responded only to PRAMS were compared to participants who responded to both PRAMS and PRAMS-2 using unweighted data. The prevalence of food insecurity in the past year was 14.5 % for women who responded only to PRAMS and 12.4 % for women who responded to both PRAMS and PRAMS-2 (p B 0.40). Mothers responding to both surveys had similar characteristics compared to women who responded only to PRAMS. However, women who responded only to PRAMS were more likely to have completed the survey in Spanish (18.3 %) instead of English, compared to women who responded to both surveys (14.7 %) (p \ 0.003). Although differences were evident only for language of survey completed, it is not possible to definitively assess whether the mothers who were lost to follow-up in PRAMS-2 were at increased or decreased risk for food insecurity. Summary Despite these limitations, this study suggests that having a child with special health care needs increases the risk of being food insecure. Families of CSHCN need support from health care and other service providers and the community to help address needs and prevent food insecurity. Community-based organizations like local food banks and advocacy groups may use the findings of this investigation to target outreach activities to specific populations at increased risk for food insecurity. On the local, state and national levels, this investigation highlights the need for policies that support all families to reduce risk of food insecurity. Targeted strategies are needed to address increased risks to families of CSHCN. This investigation provides evidence for policy-makers to use as they craft policies to support families at risk for conditions recognized to stress family resources and threaten the health of household members. Food insecurity is a preventable experience and this investigation highlights the higher risk for it in the vulnerable population of CSHCN and their families. Acknowledgments We would like to acknowledge PRAMS and PRAMS-2 participants as well as Al Sandoval for providing technical assistance related to use of PRAMS and PRAMS-2 data and Tina Kent and Caitlyn Howell for their work in data collection. This work would not have been possible without their contributions. Funding for the PRAMS and PRAMS-2 surveys comes from the Oregon Health Authority; Oregon Office of Children and Youth with Special Health Needs (at Oregon Health & Science University); the Centers for Disease Control and Prevention (US Department of Health and Human Services (HHS)); and the Maternal and Child Health Bureau (Health Resources and Services Administration, HHS).
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