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Articles

An Assessment of Various Household Food Security Measures in Hawaiì Has Implications for National Food Security Research and Monitoring^{1 ,2}

Joda P. Derrickson^*3, Anne G. Fisher, Jennifer E. L. Anderson^** and Amy Christine Brown

^* Kaneohe, Hawaiì 96744; Departments of Occupational Therapy and ^** Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado 80523 and Department of Human Nutrition, Food and Animal Sciences, University of Hawaiì at Manoa, 1955 East West Road, Honolulu, Hawaiì 96822

³To whom correspondence should be addressed. E-mail: laniwai4{at}pixi.com

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
The Core Food Security Module (CFSM), the national food security monitoring tool, requires three affirmative responses to categorize households as food insecure. If this tool is unreliable or inaccurate, vulnerable segments of our population may be adversely affected. The objectives of the present study were to assess the credibility of applying the CFSM categorical measure to a population sample from Hawaiì and to assess the concurrent validity of the CFSM, the new face-valid measure and measures adapted from the Radimer/Cornell (RC) measure and Community Childhood Hunger Identification Project. The sample included 1469 respondents gathered through a statewide telephone sample and 144 food pantry recipients. Responses to the 18 CFSM questions were used to create all four measures. The credibility of the CFSM categorical measure was also assessed via comparisons with individual items and with the 1995 national modal CFSM response pattern. Categorical measures were compared across food security prevalence estimates and indices of income and vegetable intake and with the CFSM scale measure. Differences in the modal response pattern between samples affected CFSM categorization. Only 36% of households followed the Hawaiì modal response pattern, and categorization was not consistent with the content of key items. Although 85% of the households were classified as food secure by the CFSM, only 78% were classified as food secure with each of the other food security measures. Concurrent validity of all measures was confirmed. A reassessment of the national CFSM categorical measure appears warranted.

KEY WORDS: • hunger • household food security • food insecurity • Hawaiì

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Food insecurity occurs "whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially-acceptable ways is limited or uncertain" (Life Sciences Research Office 1990). Previous researchers have defined food insecurity as an experience of severe economizing of food resources (Bickel et al. 1996 , Radimer 1990 , Wehler et al. 1992 ). To effectively ameliorate hunger and related health problems, policymakers depend on surveillance or monitoring measures for valid and reliable information (Nord et al. 1990). If the Core Food Security Module (CFSM)⁴monitoring tool for food insecurity is unreliable or inaccurate, vulnerable segments of the population may be adversely affected.

The national food security measure called the CFSM was created by a team of experts to measure the extent and severity of household food insecurity during a 12-mo period (Carlson et al. 1999 , Hamilton et al. 1997a ). It was based on earlier research completed by the Radimer/Cornell (RC) research team and by leaders of the Community Childhood Hunger Identification Project (CCHIP) (Radimer 1990 , Radimer et al. 1992 , Wehler et al. 1992 ). The original data set used to develop the CFSM was the April 1995 food security supplement of the Current Population Survey (CPS). As indicated in Table 1 , the CFSM contains 18 items, of which 8 pertain only to households with children. The order of the items represents the "CFSM modal response pattern" of respondents who completed the 1995 food security supplement. As indicated in the first column of the table, categorization of households is based on the sum of affirmative responses. For example, responses to at least three items were required for classification as "food insecure." As explained by Carlson (1999), "Determination of the initial threshold of each designated severity range was done by identifying the second or third items in the modal response pattern sequence that conceptually indicates the continuous characterizing of the category." According to Bickel (1999 ), face validity of categorization was not a priority.

Credibility assessment was operationalized to include an assessment of reliability and validity. "Reliability refers to the consistency or reproducibility of an operational definition; validity refers to the goodness of fit between an operational definition and the concept it is purported to measure" (Singleton et al. 1993 ). Concurrent validity was also defined by Singleton et al. (1993 ) as "the ability of a measure to indicate an individual’s present standing on the criterion variable."

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Samples.

Three samples were surveyed for a total sample size of 1664, which were derived from the following:

1. A convenience sample of 144 food pantry recipients
   
2. Sixty-one of the 144 respondents who completed the survey a second time; a mean of 11 d apart
   
3. A statewide sample of 1469 respondents who completed the Hawaiì Health Survey (HHS) in 1998
   

Before data collection, all participants confirmed verbal consent as required by a university human subjects review committee. This is the same data set we used to assess the validity and reliability of the CFSM scale measure (Derrickson et al. 2000a ). The population sampled was representative of the ethnicity of Hawaiì residents: 909 (54.6%) indicated they most identified with an Asian or a Pacific Islander ethnic group (Department of Business, Economic Development and Tourism 1997).

Data collection.

All data were collected in Hawaiì between June and November 1998. Data collection began with a pilot study of food pantry respondents who completed the survey once and 61 (80%) who also completed the survey a second time at an average of 11 d later. Data were gathered by interviewers who were experienced in calling limited resource households (Derrickson et al. 1995 , SMS Research and Marketing Service, Inc. 1992 ) using standard telephone survey methods to enhance response rates and minimize interviewer bias (Lavarakas 1988 , SMS Research and Marketing Service, Inc. 1998 ). Preliminary findings indicated that the CFSM was likely to be reliable and valid to use in Hawaiì (Derrickson 1999 ).

The final data set came from food security questions that were included in the HHS between September and November 1998. HHS is a telephone interview survey of at least 3500 households each year. The survey is modeled after the National Household Interview Survey conducted by the National Center for Health Statistics (SMS Research and Marketing Service, Inc. 1998 ). Households were randomly chosen from local telephone books. Once a household was chosen, the household was sent a letter from the director of the Department of Health encouraging survey participation. Data collection was administered through telephone interview using a computer-assisted telephone interviewing system (SMS Research and Marketing Service, Inc. 1998 ). A complete description of the data collection methods used in the HHS is given elsewhere (SMS Research and Marketing Service, Inc. 1998 ).

Survey instrument.

The survey instrument included the following:

• Basic demographic questions (age, household composition and ethnicity): "With what ethnic group do you identify most?"
  
• The 18 CFSM questions preceded by the four-part food insufficiency question (Rose et al. 1995 )
  
• Eight resource augmentation questions
  
• Two diet-quality indicators
  

Specifically, the four resource augmentation questions queried whether the following coping behaviors were used to enhance either the household food supply or money for food: 1)using charitable food assistance, 2) delaying bill payments, 3) borrowing money for food, and 4) sending children over to someone else’s house (only for households with children). These questions were used by the CFSM research team (Hamilton et al. 1997a ). In addition, four follow-up questions ("How often did you [resource augmentation behavior]") were asked if the initial response was affirmative. Follow-up questions were asked to determine how reliant a household was on each particular coping behavior. Response format to the follow-up questions was consistent with that asked of the follow-up questions in the CFSM (almost every month, some months but not every month or only 1 or 2 mo). Thus, a maximum of eight resource augmentation questions were asked of households with children, and six were asked of households without children. Affirmative responses were summed to create the Resource Augmentation Index (RAI).

Previous research indicated that in Hawaiì, food insecurity often led to compromised vegetable intake and increased reliance on an inexpensive high-fat dried noodle product, locally called Saimin or Ramen, to stretch food resources (Derrickson and Anderson 2000 ). Survey respondents were specifically asked the following questions:

1. "Not counting salad or potatoes, how many servings of vegetables do you usually eat a day? Count 1/2 cup (120 mL), like the size of a pudding cup, as one serving."
   
2. "How many times last month did you or the child/children (whoever ate more) eat Saimin that was purchased dried, not frozen?"
   

Analysis of responses to the vegetable frequency question was based on the serving sizes of the Food Guide Pyramid (U.S. Department of Agriculture 1999). The vegetable frequency question was validated with a 24-h vegetable recall (Derrickson 1999 ). Values of the two vegetable indices were highly correlated (r = 0.81, P < 0.001). Mean values were not significantly different between measures (1.61 ± 1.15 for recall and 1.54 ± 1.21 for vegetable frequency; t = -0.7, P = 0.40). Responses to the Saimin question were all converted to a monthly frequency by multiplying weekly responses by 4.

Food security measures.

The food security data were collected and analyzed according to the "Guidelines for Using the Core Food Security Module" (Price et al. 1997 ). The CFSM scale measures and item calibration values were created using the Rasch FACETS software program (Derrickson et al. 2000a , Linacre 1986 , Rasch 1966 , Wright and Masters 1982 , Wright and Stone 1979 ). As indicated in Table 1 , an "item calibration value" represents the position of the item along the constructed food insecurity scale. For example, Q16, with a high positive item calibration value of 4.82, indicates a very high degree of insecurity and hunger, whereas an item with a low negative calibration, such as Q2 (-4.99), is indicative of mild food insecurity (Hamilton et al. 1997). Similarly, household "scale measures" indicate the severity of household food insecurity reported by the respondent. A higher number of affirmative responses result in a higher positive placement on the food insecurity scale. Scale measures ranged from a low of -4.5, which is indicative of less severe food insecurity, to a high of +4.5, which is indicative of severe hunger (Derrickson et al. 2000a ).

The total number of affirmative responses was called the "respondent food security sum." The algorithms outlined in Table 2 were applied to create the four food security categorical variables. Because both the CCHIP and RC measures do not contain all of the CFSM items, these measures were "adapted" to the CFSM items. They are referred to as the adapted RC and the adapted CCHIP measures. Most important, because the adapted CCHIP measure does not include Q2, "Worried food would run out," a new category of food insecurity was created. The "Only worried about food insecurity" category was created within the adapted CCHIP measure to study the responses of those who responded affirmatively to Q2 but not to any other items. Creation of the "Only worried about food insecurity" category is an applied research artifact, not in anyway meant to discredit or alter the original CCHIP measure designed to measure hunger among children (Wehler et al. 1992 ).

Data analysis.

Data analysis can be broken into two parts corresponding to our objectives

1. An evaluation of the validity and reliability of applying the CFSM categorical measure in Hawaiì
   
2. A concurrent validity comparisons of the four food security categorical measures, which included the following:
   
   1. Comparisons of food security status prevalence estimates
      
   2. Comparison of dietary measures, the RAI and the CFSM scale measure
      
   
   

The evaluation of the reliability and validity of the CFSM measure was initiated by an assessment of modal response patterns. Specifically, the Hawaiì modal response pattern was compared with the original CFSM modal response pattern (Hamilton et al. 1997a ) to assess impact on categorization. To clarify, as outlined in Table 1 , the CFSM modal response pattern is the sequence of items ranging from Q2 to Q16. It is expected that if a respondent responded in the affirmative to an item (i.e., Q10, "Respondent hungry"), then she or he also responded in the affirmative to all of the preceding items (Q2 to Q9) (Hamilton et al. 1997a ). If there were notable differences in the item hierarchy between samples, then the CFSM categorical algorithm, which is based on a set sum of affirmative responses, would not be expected to consistently categorize households.

To study the effect of modal pattern response rates on the CFSM categorical measure, a "Hawaiì modal pattern" variable was created. Specifically, those who followed the Hawaiì modal response pattern outlined in Table 3 were given a score of 1, and those who did not follow this modal pattern were given a score of 0. Adherence to the Hawaiì modal response pattern was explored across the four CFSM food security categories. Finally, an investigation of content validity of the CFSM was completed by comparing affirmative responses with key food security items (Q2, Q3, Q4, Q8, Q9, Q10, Q12 and Q14) across the four CFSM food security categories.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Assessment of the credibility of the CFSM measure.

Findings outlined in Table 3 indicated that the modal response patterns or item hierarchy differed between the national 1995 CPS sample and the Hawaiì sample. When differences in modal response pattern sequencing involves a threshold item, the reproducibility of the CFSM categorical algorithm is affected. For instance, the fifth through eighth items in both modal response patterns (Q6, Q8 and Q9) and the 15th through 17th (Q12a through Q15a) items were not in the same sequence. However, because no "threshold items" (Q4, Q8a and Q12) were affected, there was no apparent effect on CFSM categorization. Q14, "Child hungry," is 14th in the CFSM modal response pattern but 12th in the Hawaiì modal response pattern (Hamilton et al. 1997a ). Findings imply that households with children in Hawaiì who followed the Hawaiì modal response up to Q14 were classified as experiencing "moderate hunger" rather than "severe hunger." As indicated in Table 1 , "Severe hunger" is the category that is supposed to capture hunger among children. This issue would be more troublesome if hungry households did not follow the Hawaiì modal response pattern.

Response rates to the Hawaiì modal response pattern were next explored to further clarify the effect on food security categorization. Overall, only 129 (36%) of the 364 respondents with one or more affirmative responses followed the Hawaiì modal response pattern: 100 (77%) of the 129 had five or fewer affirmative responses. Also, 32 (52%) of the 62 respondents with only one affirmative response constituted 25% of the respondents who followed the Hawaiì modal response pattern. Twenty-four (39%) of these 62 respondents affirmatively answered either Q3 (12), "Food bought didn’t last," or Q4 (12), "Could not afford to eat balanced meals," not Q2, "Worried about food." Only eight (10.5%) of the 76 households with eight or more affirmative responses followed the Hawaiì modal response pattern. Four of the 31 (12.9%) households classified as experiencing severe hunger by the CFSM measure followed the Hawaiì modal response pattern. There were no statistically significant differences in modal pattern response by household family status (Pearson ² = 0.83, P = 0.36). Because of high measurement variability, these findings question the reliability of using a modal response pattern as the basis of food security categorization.

The potential issue of "misclassification" of the CFSM, or validity of applying the CFSM categorical measure to Hawaiì data, was further elucidated through comparisons of affirmative response rates to selected items across the four CFSM categories (Table 4 ). Although many findings are noteworthy, the most important findings disputing the face validity of the CFSM categories with Hawaiì data are listed below:

    Food insecure. Seventeen of the 158 (10.9%) households classified as food insecure responded affirmatively to Q10, "Respondent hungry," 5 (3.2%) to Q12, "Adults did not eat for a whole day" and 4 (2.5%) to Q14, "Child hungry."

    Moderate hunger. Thirty-two of 64 (50%) households classified as experiencing moderate hunger responded affirmatively to Q10, "Respondent hungry," and 14 (22%) responded affirmatively to Q12, "Adults not eat for a whole day," a key indicator of severe hunger (Hamilton et al. 1997a ).

    Severe hunger. Twenty-one of the 31 (67%) households classified as experiencing severe hunger responded affirmatively to Q12. Twelve of the 33 (36%) households admitting to experiencing hunger among children (Q14) were classified as experiencing food insecurity without hunger (n = 4) or food insecurity with moderate hunger (n = 8).

Comparison of various four categorical measures.

Comparisons of prevalence estimates between samples are presented in Table 5 . Although not unexpected, the 6.7% difference in the overall rate or percentage classified as food secure between the CFSM categorical measure and other measures in the total sample is perhaps most important. Also, both the adapted CCHIP and adapted RC measures classified 73 (4.4%) of the sample as experiencing hunger among children. This is more than double the 31 (1.9%) categorized as "severely hungry" by the CFSM or the 33 (2.0%) categorized as experiencing child hunger with FVFSM. The food security measure reporting the highest prevalence of hunger was the adapted RC method; 119 (7.2%) were categorized as experiencing adult hunger.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
This study marks the first independent evaluation of the CFSM categorical food security measure.

Findings confirm our hypothesis that in Hawaiì, the CFSM categorical measure does not reliably or accurately categorize food insecure households based on the face validity of affirmative responses. The CFSM modal response pattern was not reproducible. Most households did not follow a modal response pattern. These results may be due to differences in ethnic and geographical composition between samples (Hamilton et al. 1997b , State of Hawaiì, Department of Business, Economic Development and Tourism 1997). Thus, caution should be used in extrapolating these findings. However, like the CFSM scale measure (Derrickson and Anderson 2000a ), the identified weaknesses found with the CFSM categorical measure in Hawaiì are likely to exist across many samples. For instance:

1. The questionable reliability of the modal response pattern (the basis for the CFSM categorical measure) was also reported in the original CFSM work (Hamilton et al. 1997a ). In the 1995 CPS study, the authors report that 82% of households without children followed the CFSM modal response pattern. However, 65% of these households responded "no" to all items. Of the households responding to at least one item affirmatively, only 49% followed the modal pattern (Hamilton et al. 1997a ). Moreover, a majority of these respondents affirmatively answered less than four items. No data were reported on the reliability of the modal response pattern for households with children.
   
2. Radimer (1999 ) questioned the credibility of requiring three or more affirmative responses. Her field experience with food insecure households was similar to our own (Derrickson and Anderson 2000 , Radimer 1990 ). Her conceptual work contributed immensely to the CFSM operationalized framework outlined in Table 1 (Bickel et al. 1996 ).
   
3. The questionable credibility of categorization arises when a comparison of the content of affirmative responses confirms the observations of Bavier (1999 ). He inquired why the content of responses (i.e., Q10, "Respondent hungry") in national data sets do not more consistently align with the CFSM categorization (Moderate hungry).
   

Some probable causes of the uncertain aspects of the CFSM categorical measure are as follows:

1. High measurement variability affects categorization. The experience of household food insecurity reported by respondents varies. Households do not uniformly reply to food insecurity indicators in the same manner because their experience of household food insecurity varies.
   
2. The dependence on a modal response pattern for categorization is a fundamental problem. Because food insecurity is not reported in a highly consistent manner, the content of questions to which a household responds affirmatively to varies across households. Thus, face or content validity of the CFSM will always be an issue unless a high percentage of food insecure households follow the modal response pattern.
   
3. Summing ordinal scales is not a valid means of making quantitative comparisons. The same "respondent food security sum" can result for different reasons (Fisher 1993 ).
   
4. Food insecurity is a multifaceted phenomenon. Psychological (Q2) and qualitative (Q4 and Q6) items are incorporated into a measure that is primarily focused on quantitative aspects of food insecurity.
   
5. There are multiple "targets" of the questions. To clarify, there are three questions pertaining to the entire household (Q2, Q3 and Q4), four questions that pertain only to adults in the household (Q8, Q8a, Q12 and Q12), three questions that pertain only to the respondent (Q9, Q10 and Q11) and eight questions that pertain to all children in the household (Q5, Q6, Q7 and Q13–16).
   

If the face or content validity of responses to specific items is valued, then the CFSM appears to underreport the severity of food insecurity across all food security categories. Perhaps a categorical measure fundamentally based on a modal response pattern can be highly reliable only if response variance is low, the measure is narrowly focused and the survey instrument contains questions that affirm food security (Derrickson et al. 2000a ). Alternately, if a pattern of responses is valued, regardless of the face validity of categorization, the CFSM appears to accurately measure increasing severity of food insecurity.

Implications for food security monitoring.

One practical application of any food security measure is to separate food secure households from food insecure households. Notably, all three alternative food security measures require only one affirmative response, whereas the CFSM requires three affirmative responses. Furthermore, respondents with only one affirmative response to Q2 (Only worried about food insecurity) exhibited behaviors consistent with food insecurity (decreased vegetable intake, greater reliance on alternative food resources and low cost foods). This finding suggests that households with only one affirmative response to the least severe item appear to be food insecure, not food secure. If only one affirmative response was required to classify food insecure households, then the CFSM measure would underestimate the prevalence of household food insecurity across the nation. Table 5 illustrates that in food secure populations, this difference may appear to be relatively small (3–5%). However, in food insecure populations, the difference in prevalence estimates may be large (10–15%). A reassessment of the CFSM categorical measure appears warranted for the following reasons:

1. These estimates pertain to a percentage of households, not the number of people in households.
   
2. Food security is an important item of the well-being of any population.
   
3. In addition, the federal government, which oversees food security monitoring, also oversees funding and administration of food and nutrition assistance programs designed to enhance food and nutrition security.
   

If an unreliable or inaccurate food security categorical measure is used as a risk criterion for assistance, as a screening tool or even in comparative surveillance efforts, vulnerable segments of our population may be adversely affected.

Previously, Derrickson (1999 ) reported that for reasons of respondent fatigue and lower cost of administration and to minimize the loss of dignity of the respondent over sensitive questions, a smaller set of food security questions should be used). Embretson (1996 ) has argued that "shorter tests can be more reliable than longer tests." One hesitation over using a shorter set of questions, or requiring only one affirmative response to categorize households, may be the fear of increased false-positive responses (when persons respond affirmatively to having experienced a certain degree of food insecurity when they really have not). However, self-reporting of hunger-related items is a sensitive domain, one more likely to be underreported than overreported (Derrickson 1999 and 2001 , George Chee, ‘Ohana Community Food Service, personal communication, Honolulu, Hawaiì, November 5, 1999). Thus, false-negative responses will likely counter false-positive responses.

Based on the work of Blumberg and colleagues (1999 ), the federal government now offers a "standard 6-item indicators set" as an alternative to the 18 items. In previous work, we support the concept of a shorter measure, particularly because it reduces respondent burden and is less expensive to administer (Derrickson et al. 1999 ). However, the recommended set of six items (Q3, Q4, Q8, Q8a, Q9 and Q10) did not adequately meet Rasch fit statistics in Hawaiì (Derrickson et al. 1999 and 2000a ). Furthermore, this set of six questions does not capture the important element of anxiety measured by Q2 ("Worried food would run out"), nor does it capture hunger among children. Alternatively, the FVFSM may be more effective as a simple food security monitoring tool. For instance, the FVFSM relies on four CFSM items to distinguish household food security from household food insecurity (Q2, Q3, Q4 and Q9 or Q8), two items to classify adult hunger (Q10 and Q12) and one item (Q14) to identify hunger among children. Thus, only seven items would be required to implement the FVFSM. If an administration protocol is similar to that of the CFSM (Bickel et al. 2000 ), then all food secure households (80–85%) would be screened out before Q10 ("Respondent hungry"). Further verification of the criterion-mediated validity of the FVFSM has been reported by Derrickson et al. (2000b ).

Future work.

In summary, findings indicate acceptable concurrent validity of all four measures assessed. Results are consistent with previous work (Hamilton et al. 1997b , Radimer 1999 ) and are grounded in qualitative work and research with the CFSM scale measure (Derrickson and Anderson 2000 , Derrickson et al. 2000a ). Notably, findings also raise questions regarding the credibility and reproducibility of the CFSM, which indicate that further assessment of the CFSM categorical measure is warranted. Because the CFSM has provided benchmark food security prevalence estimates (Hamilton et al. 1997b , Nord et al. 1999 ), changes in the national food security categorical measure may be problematic. Nevertheless, our findings indicate that households with only one affirmative response shown signs of food insecurity. The first step then in reassessing the CFSM may be reclassifying households with one or two affirmative response as some mild form of "Food insecurity without hunger."

	ACKNOWLEDGMENTS

 
We are indebted to Gary Bickel, the Hawaiì State Department of Health, Office of Health Status Monitoring, SMS Research and Marketing Service, Inc. staff, George Chee, Dwayne Makalena, various Salvation Army staff members on O’ahu and Scott Derrickson for their constructive suggestions and editorial assistance.

	FOOTNOTES

 
¹ Findings were reported as an oral presentation at the 2000 ASNS Annual Meeting.

² Supported in part by a grant from the Institute for Research on Poverty, University of Wisconsin, Madison.

⁴ Abbreviations used: CCHIP, Community Childhood Hunger Identification Project, CFSM, Core Food Security Module, CPS, Current Population Survey, HHS, Hawaiì Health Survey, Q, Question, RC, Radimer/Cornell, RAI, Resource Augmentation Index.

Manuscript received December 17, 1999. Initial review completed February 22, 2000. Revision accepted November 28, 2000.

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