Essay Grade

This week, you will submit the annotation of a qualitative research article on a topic of
your interest
8
•
Annotate one qualitative research article from a peer-reviewed journal on a topic of your
interest.
•
Provide the reference list entry for this article in APA Style followed by a threeparagraph annotation that includes:
o
A summary
o
An analysis
o
An application as illustrated in this example
•
Format your annotation in Times New Roman, 12-point font, double-spaced. A separate
References list page is not needed for this assignment.
•
•
Submit your annotation.
ARTICLE
Child Health-Related Quality of Life
and Household Food Security
Patrick H. Casey, MD; Kitty L. Szeto, MS; James M. Robbins, PhD; Janice E. Stuff, PhD;
Carol Connell, PhD; Jeffery M. Gossett, MS; Pippa M. Simpson, PhD
Objective: To examine the association of household food
insecurity with child self- or proxy-reported healthrelated quality of life (HRQOL).
Design: Cross-sectional telephone survey from January 1, 2000, through June 30, 2000.
Participants: Three hundred ninety-nine children who
live in 36 counties of the Delta region of Arkansas, Louisiana, and Mississippi.
Main Outcome Measures: Household food insecurity status was measured using the US Household Food
Security Scale. Child HRQOL was measured by the Pediatric Quality of Life Inventory, QL version 4.0.
Analysis: Summary statistics, linear and logistic regressions, incorporating survey weights, performed with
SUDAAN version 8.
Results: Household food insecurity was significantly associated with total child HRQOL (P⬍.05) and physical
function (P⬍.05), adjusted for child age, ethnicity, gender, and family income. Children aged 3 through 8 years
in food insecure households were reported by parents to
have lower physical function (P=.001), while children
aged 12 through 17 years reported lower psychosocial
function (P=.007). Black males in food insecure households reported lower physical function (P⬍.05) and lower
total HRQOL (P⬍.05).
Conclusions: Children who live in food insecure households have poorer HRQOL. The effect on physical or psychosocial function may differ by age, ethnicity, and gender. Food security should be considered an important risk
factor for child health.
Arch Pediatr Adolesc Med. 2005;159:51-56
H
Author Affiliations:
Departments of Pediatrics,
University of Arkansas for
Medical Sciences, Little Rock
(Drs Casey, Robbins, and
Simpson and Ms Szeto and
Mr Gossett); Children’s
Nutrition Research Center,
Baylor College of Medicine,
Houston, Tex (Dr Stuff ); and
Nutrition and Food Systems,
College of Health, the
University of Southern
Mississippi, Hattiesburg
(Dr Connell).
OUSEHOLD FOOD INSECUrity is defined by national
experts as limited or uncertain availability of nutritionally adequate and
safe foods, and limited or uncertain ability
to acquire acceptable foods in socially acceptable ways. As measured by the US
Household Food Security Module, food security is considered a marker of the adequacy and stability of a household’s food
supply over the preceding 12 months for active healthy living of all household members.1,2 The most recent national data in
2002 indicate that 11.1% of all households
(12.1 million) were food insecure.3 Sixteen percent of households with children
were food insecure at some time during the
preceding year. The prevalence of food insecurity is higher in African American (22%)
and Hispanic households (21.7%) than in
households of other racial groups. The
prevalence is even higher in households with
family incomes below the federal poverty
line (38.1%).
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Earlier national surveys measured food
insufficiency, a single question that assessed the quantity of food available at the
household level, but not the quality, uncertainty, or psychological components as
measured by the Food Security Scale.4
Food insufficiency or other brief measures of hunger have been found to be related to low nutrient intake and poor selfreported health status in adults.5-9 Similar
associations have been found in adults
(particularly women) when food security is measured by the US Household Food
Security Scale.10-12
Independent of demographic characteristics, children in food insufficient
households have lower general health status and more negative symptoms when
compared with children in food sufficient households.13,14 In a study of more
than 11000 children participating in the
National Health and Nutrition Examination Survey III (NHANES III,19881994), children in food insufficient households (measured by 1 question) were more
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likely to have poor/fair general health status (also measured by a single question), and were more likely to report stomach aches, headaches, and colds, after adjusting for poverty, past health risk, and other family and
environmental characteristics.14 Food insufficiency and
hunger have also been associated with mental health problems and academic difficulties among school-aged children.13,15-17 To our knowledge, no research has been published using the US Food Security Household Scale with
measures of child health status.
People who live in poverty, those from specific ethnic groups such as African Americans or Hispanics, or
those of a lower educational level are known to be at increased risk for physical and mental health problems.18-22 Similarly, families who live in rural areas where
access to medical care may be limited are at increased
health risk.23,24 Thus, it is important to consider these factors when examining the association between food insecurity with child health.
Measures of general health and functional status, or
health-related quality of life (HRQOL)25 are increasingly used to assess child health function in general populations26,27 or in relation to specific conditions like childhood obesity or other chronic conditions. 28-30 This
multidimensional construct includes physical, emotional, social, and school functioning and allows measurement of function that transcends the presence of
symptoms or specific conditions. To our knowledge,
HRQOL measures have not been previously used to evaluate the association of household food insecurity with the
health and functional status of children.
In prior research with residents of the Lower Mississippi Delta, we have demonstrated that HRQOL is lower
among adults from food insecure households than food
secure households.31 Further, residents of this region have
twice the rate of household food insecurity compared with
the US population32 and higher self-reported rates of obesity, hypertension, and diabetes mellitus than national
estimates.33 In this article we address the association of
food insecurity and child HRQOL (CHRQOL) among children and adolescents in this economically depressed region of the country. We hypothesize that youth from food
insecure households will have lower HRQOL than other
youth after controlling for social and demographic characteristics known to influence child well-being.
METHODS
stratum in the telephone survey. List-assisted random digitdialing method was used to select a random sample of telephone numbers from the eligible blocks of numbers in these
counties. Of the 3455 eligible households, 1293 households
(37.4%) refused to participate. This participation rate reflects
the increasing difficulty in recruiting participants in scientific
surveys, particularly in low-income minority populations.34
A computer-assisted telephone interview was conducted to
determine the eligibility of the household. An eligible household was one that had at least one member aged 18 years or
older; the telephone number was not for business use only; and
the household was located in 1 of the 18 Delta sample counties. During this initial interview, information on age, sex, ethnicity of household members, and the presence of children in
the household was determined. All members of the household
were enumerated and 1 adult per household was selected randomly using the Kish tables.35 One child was selected from singlechild households and randomly selected from households with
more than 1 child. A second nonscheduled telephone call was
made to households who agreed to participate to collect information regarding dietary intake, height and weight, and
CHRQOL. Approximately 1 to 2 weeks later, the adult in the
household who had completed the dietary interview was interviewed again with questions including the food security status of the household.
Data on 485 children aged 3 to 17 years were collected in
the first follow-up interview, and 465 completed the next interview (adult-reported household food security). Three hundred ninety-nine children had complete data for all study variables needed to compute food security and CHRQOL, and these
constituted the final sample for these analyses.
ASSESSMENT OF FOOD SECURITY
Food security status was evaluated using the US Household Food
Security Scale.1,36 The responses to this 18-item food security
survey module were used to classify households into 3 categories of food security status:
• Food secure: households that show no or minimal evidence of food insecurity.
• Food insecure without hunger: food insecurity is evident
in the household concerns and in adjustments to household
food management including reduced-quality diets. Little or no
reduction in the household members’ food intake was reported.
• Food insecure with hunger: the food intake for adults and
children in the household has been reduced to the extent that
they have repeatedly experienced the physical sensations of hunger.
Because of limited observations, the latter 2 categories were
combined, resulting in food secure and food insecure groups.
PEDIATRIC HRQOL
DATA COLLECTION
We conducted a cross-sectional telephone survey of a representative sample of the population aged 3 years and older in
36 Delta counties of Arkansas, Louisiana, and Mississippi between January 1, 2000, and June 30, 2000. This research was
reviewed and approved by the institutional review board of each
partner university and Westat. A 2-stage stratified cluster sampling plan was used to assign the 36 Delta Nutrition Intervention Research Initiative counties to 9 strata according to population size, percentage of population who were black, and
percentage of persons living below the federal poverty level.
Eighteen counties (2 counties from each stratum) were selected with probability proportional to size to represent that
The Pediatric Quality of Life Initiative (PEDS QL) version 4.0
was used to assess CHRQOL.25 The Peds QL consists of 23 items
with 5 response selections that range from “never” to “almost
always.” The Peds QL has a total score and 2 subscale scores—
physical and psychosocial function. The psychosocial subscale has questions that assess the domains of emotional, social, and school function. Scores were transformed to a 0 to 100
scale so that higher scores indicate better health-related QOL.
The Peds QL has 4 different versions; Parent Report for Toddlers (aged 3-4 years); Parent Report for Young Children (aged
5-8 years); Child Report with parent assistance as needed (aged
9-11 years); and Teen Report (aged 12-17 years). The reliability and validity of the Peds QL has been demonstrated in both
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healthy children and children with physical illness who range
in age from 2 to 18 years.30
Table 1. Characteristics of Children and Their Families
Characteristic
CATEGORIZATION OF VARIABLES
Total income for the previous 12 months was self-reported in
increments of $5000 or $10 000 ranging from less than $5000
to $50000 or more. For the present analyses, income was stratified into the following 3 categories: $0 to $14999, $15000 to
$29999, and greater than $30000. Child age was categorized into
3 groups: 3 to 8 years; 9 to 11 years; and 12 to 17 years. Ethnicity was categorized as white and black of non-Hispanic origin.
ANALYSIS
A household base weight equal to the inverse of the probability of selection was assigned to each sampled telephone number. Data were adjusted to compensate for telephone numbers
with unknown residential status or eligibility, the number of
residential telephone numbers in the household, and nonresponse to the screener interview. To account for nonresponse
in the second interview, the weight of the nonparticipant was
distributed to the participants within adjustment cells defined
by age, race, and sex. Finally, estimates were calibrated to 1990
US Census Bureau37 estimates of the total households by state.
All analyses were done using SUDAAN version 8.0 (Research Triangle Institute, Research Triangle Park, NC). Continuous variables were compared using t test comparing the
weighted means. The association of CHRQOL with household
food security status was determined for the entire sample, and
stratified by the child’s age, gender, ethnic groups, and family
income. Linear regression analyses were conducted with
CHRQOL physical, psychosocial, and total scores as the dependent variable and food security status as the independent
variable. Covariates included were the child’s age, race, gender, and family income, all variables that may be associated with
food security or CHRQOL. Race was retained in these analyses as African Americans in this region have traditions and culture, which stem from the history of slavery and discrimination, that may result in differences in diets, access to safe and
healthy food, and lifestyle.38 These differences between ethnic
groups, independent of education or income, may directly or
indirectly influence health status.
RESULTS
Demographic and food security status of the children and
families are described in Table 1. Most children were
black, and genders were equally represented. More than
25% had a family income less than $15000, and less than
half had a family income greater than $30 000. Twentyfive percent of the households with children were food
insecure.
The CHRQOL by household food security status is
given in Table 2. Children in food insecure households scored significantly lower on physical (P=.006) and
psychosocial function (P = .017) and on total CHRQOL
(P=.005) than children in food secure households.
The CHRQOL by household food security status for
3 child age groups is listed in Table 3. The youngest
children (aged 3-8 years) in food insecure households
scored significantly lower in physical functioning
(P=.001). In contrast, the teenagers (aged 12-17 years)
in food insecure households scored lower in psychosocial functioning (P = .007). The youngest children
No. (%) of Participants
Sex
Male
Female
Race
Black
White
Age group, y
3-8
9-11
12-17
Annual income, $
ⱕ14 999
15 000-29 999
ⱖ30 000
Food security
Secure
Insecure
192 (48.1)
207 (51.8)
232 (58.1)
167 (41.8)
149 (37.3)
67 (16.8)
183 (45.9)
105 (26.3)
109 (27.3)
185 (46.4)
297 (74.4)
102 (25.6)
(P=.022) and teenagers (P=.03) in food insecure households were lower in the total health-related QOL. Among
children in the middle-age group (aged 9-11 years), neither physical or psychosocial function nor total CHRQOL
scores differed by food security status.
The CHRQOL of male children is given separately for
black and white participants by household food security status in Table 4. Black males, but not white males,
in food insecure households scored significantly lower
on physical function (P⬍.05) and total CHRQOL (P⬍.05).
Black males in food insecure households scored lower
in psychosocial function that approached statistical significance (P =.07). In separate analyses, black females,
but not white females, in food insecure households scored
somewhat lower in psychosocial (P = .08) and total
CHRQOL (P = .06). (Data not shown.) When comparing CHRQOL within 3 income categories, there were no
differences between food secure and food insecure household status in the child’s physical function, psychosocial function, or total CHRQOL.
The results of the linear regression of CHRQOL on
household food insecurity status, controlling for the child’s
age, gender, and race, and household income, is given
in Table 5. Independent of the demographic variables,
food insecurity status was significantly associated with
total CHRQOL and physical function (Pⱕ.05). The association of food insecurity with psychosocial function
approached significance (P=.06).
COMMENT
In this representative sample of children from the Delta
region of Arkansas, Louisiana, and Mississippi, household food insecurity status was associated with lower reported physical and psychosocial function and lower total
CHRQOL. Food insecurity status was associated with
poorer physical function and lower total CHRQOL independent of the child’s gender, ethnicity, and age, and
household income. The youngest children (aged 3-8 years)
in food insecure households were reported by their par-
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Table 2. Health-Related Quality of Life of Children by Household Food Security Status*
Variable
Physical functioning
Psychosocial functioning
Total score
Food Secure
(n = 297)
Food Insecure
(n = 102)
Mean Difference,
95% (CI)
P Value
90.9 (0.6)
80.8 (0.7)
84.4 (0.6)
86.9 (1.5)
76.7 (1.6)
80.3 (1.4)
4.0 (1.17 to 6.79)
4.1 (0.78 to 7.56)
4.1 (1.29 to 6.99)
.006
.02
.005
Abbreviation: CI, confidence interval.
*Data are given as mean (SE) unless otherwise indicated.
Table 3. Health-Related Quality of Life by Age of Children and Household Food Security Status*
Variable
Physical functioning
Age group, y
3-8
9-11
12-17
Psychosocial functioning
Age group, y
3-8
9-11
12-17
Total score
Age group, y
3-8
9-11
12-17
Food Secure
Food Insecure
Mean Difference (95% CI)
P Value
94.4 (0.6) [111]
88.6 (2.0) [51]
88.1 (0.9) [135]
88.3 (1.7) [38]
83.0 (4.8) [16]
87.2 (2.1) [48]
6.1 (2.55 to 9.67)
5.6 (−4.6 to 15.74)
0.9 (−3.50 to 5.33)
.001
.28
.68
83.6 (0.9) [111]
78.1 (2.4) [51]
79.1 (1.1) [135]
79.6 (2.3) [38]
79.7 (3.2) [16]
71.8 (2.3) [48]
4.0 (−1.17 to 9.10)
−1.6 (−9.30 to 6.03)
7.3 (2.07 to 12.50)
.13
.67
.007
87.5 (0.6) [111]
81.7 (2.0) [51]
82.2 (0.8) [135]
82.7 (1.9) [38]
80.9 (3.7) [16]
77.2 (2.0) [48]
4.8 (0.73 to 8.92)
0.8 (−7.15 to 8.90)
5.0 (0.52 to 9.54)
.02
.83
.03
Abbreviation: CI, confidence interval.
*Data are given as mean (SE) [sample size] unless otherwise indicated.
Table 4. Health-Related Quality of Life of Male Children by Ethnicity and Household Food Security Status*
Black
Variable
Physical functioning
Psychosocial functioning
Total score
White
Food Secure
(n = 68)
Food Insecure
(n = 44)
Mean Difference
(95% CI)
Food Secure
(n = 76)
Food Insecure
(n = 4)
Mean Difference
(95% CI)
92.3 (1.1)
81.0 (1.3)
85.0 (1.1)
87.9 (1.8)†
76.5 (2.1)
80.5 (1.8)†
4.4 (0.47 to 8.19)
4.5 (−032 to 9.39)
4.5 (0.68 to 8.48)
93.2 (0.7)
79.8 (1.2)
84.6 (0.8)
92.9 (6.5)
74.8 (4.7)
81.1 (5.2)
0.3 (−12.77 to 13.45)
5.0 (−4.71 to 14.76)
3.5 (−7.08 to 14.04)
Abbreviation: CI, confidence interval.
*Data are given as mean (SE) unless otherwise indicated.
†P⬍.05.
ents to have lower physical functioning while the teenagers reported lower psychosocial functioning. Black
males in food insecure households had lower physical
function and lower total CHRQOL.
On average, children from food insecure households
scored about 4 units below children from food secure
households on scales of the Peds QL. This difference approximates the difference between healthy children and
acute and chronically ill children on scales as reported
by the developer of the Peds QL.30 The Peds QL total scores
of children from food insecure families in this sample were
somewhat lower than a sample of healthy children and
similar to scores of children with types 1 and 2 diabetes
mellitus and certain chronic conditions.30,39 Scores from
this sample from food insecure households were higher
than those for children with cancer40 and obesity.28
This study advances the understanding of the association of food insecurity and child health in several
important ways. To our knowledge, this is the first
report to use the US Household Food Security Scale to
categorize household food insecurity status while
assessing child health status. We used a well-validated
measure to document CHRQOL across the age span. In
addition, the association was examined in multiple subgroups and consistent differences were found between
age groups and gender. The direction of effects is consistent, with the food insecure groups scoring lower in
the CHRQOL measure in almost all comparisons, even
when differences between food secure and insecure
groups were not statistically significant. Finally, the
sample was randomly collected and is reasonably representative of the population from which it was drawn
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Table 5. Adjusted Health-Related Quality of Life by Household Food Security Status*
Variable
Physical functioning
Psychosocial functioning
Total score
Food Secure
Food Insecure
Mean Difference (95% CI)
P Value
90.7 (0.66)
80.7 (0.80)
84.2 (0.64)
87.4 (1.64)
77.1 (1.64)
80.7 (1.53)
3.3 (0.11 to 6.39)
3.6 (−0.04 to 7.40)
3.5 (0.39 to 6.75)
.046
.06
.03
Abbreviation: CI, confidence interval.
*Data are adjusted for the child’s age, race, gender, and household income and are given as the score (SE) unless otherwise indicated.
compared with convenience samples used in much previous research.
There are also limitations of this study. It is possible
that unmeasured covariates might influence the risk of
food insecurity and CHRQOL and their relationship.
While both household food security status and reported
CHRQOL are self- or proxy-reported, both of these measures have demonstrated acceptable reliability and validity. Participation in our telephone survey was not uniform. Subjects were lost in every phase of telephone survey
data collection, and it is unclear how this subject loss affects our results. Data in this study were adjusted in an
attempt to compensate for nonresponse and unanswered telephone calls. The sample size in some stratified cells was small and likely did not provide adequate
power to detect true differences. Sample participants live
in a very rural area of the United States with a high poverty rate and poor access to health care. This may exaggerate the association of food insecurity and CHRQOL.
It is also possible that poorer families may not have had
telephones, which may result in underestimating the
prevalence of the conditions. We previously conducted
a validation study in this population to evaluate the possibility of differential reporting of health and nutrition
data in households with or without telephones.41 Nine
percent of the households did not have telephones. No
differences were found in reported health or food intake
in households with or without telephones, in face-toface or telephone interviews. For all the aforementioned reasons, caution should be taken in generalizing
our results to the population of US children.
Given the cross-sectional design, these data do not allow for a conclusion regarding causality between household food security status and CHRQOL. However, plausible conceptual models assume food insecure status
would result in lower intake of healthy foods and nutrients, which would ultimately result in changes in child
health status.42 Families of limited income have no flexible financial resources to deal with unexpected changes
in monthly expenses.43 Weekly household spending is
much lower in food insecure households ($28.57 vs $40).3
Families with restricted income may thus ration food,
regulate frequency of meals, and/or use low-cost energydense foods at times of financial constraints, particularly at the end of the month.44 Hispanic children from
food insecure households have been found to have significant decreases in energy and meat intake as payday
approached.45 Future research is required to understand the causal pathway of food insecurity to CHRQOL.
Household food insecurity is a common condition
among African American and Hispanic American chil-
dren, particularly those who live in female-headed households with income below the federal poverty line. The
prevalence of food insecurity in the United States increased from 10.1% in 1999 to 11.1% in 2002, an increase of more than 1.5 million households.3 There is concern among child advocates and child health clinicians
that this trend will worsen as a result of the downswing
in the US economy and changes in welfare programs.46
A recent report demonstrated that children in families
whose benefits were terminated or reduced had greater
likelihood of being food insecure.47 The loss of food stamps
in this context is of particular concern as food stamps
have been shown to increase the nutrient intake of children in impoverished families.48
While research to date does not allow understanding
as to whether food insecurity is an independent cause of
negative CHRQOL, one can conclude that food insecurity is independently associated with negative CHRQOL.
For this reason, researchers, clinicians, and policymakers should consider food insecurity as an important
risk factor for children, particularly those who live in
poverty.
Accepted for Publication: August 9, 2004.
Correspondence: Patrick H. Casey, MD, Arkansas Children’s Hospital, 800 Marshall St, Slot 512-26, Little Rock,
AR 72202 (CaseyPatrickH@uams.edu).
Funding/Support: This study was funded by Agricultural Research Service, US Department of Agriculture,
Project No. 6 251-53000-002-00D.
Acknowledgment: This research was conducted by the
Lower Mississippi Delta Nutrition Intervention Research Initiative [NIRI] Consortium. Executive Committee and Consortium partners included: Margaret L.
Bogle, PhD, RD, executive director, Delta NIRI, Agricultural Research Service of the US Department of Agriculture, Little Rock, Ark; Ross Santell, PhD, RD, Alcorn State
University, Alcorn State, Lorman, Miss; Patrick H. Casey, MD, Arkansas Children’s Hospital Research Institute, Little Rock; Donna Ryan, MD, Pennington Biomedical Research Center, Baton Rouge, La; Bernestine McGee,
PhD, RD, Southern University and A & M College, Baton Rouge; Edith Hyman, PhD, University of Arkansas
at Pine Bluff; Kathleen Yadrick, PhD, RD, University of
Southern Mississippi, Hattiesburg.
We acknowledge and thank Margaret Parker for her
assistance in manuscript preparation. Jacqueline Horton, ScD, Gary Shapiro, MS, and Annie Lo, MS, of Westat,
Rockville, Md, are acknowledged for their study design
and statistical expertise.
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