Food insecurity in urban American Indian and Alaska Native populations during the COVID-19 pandemic

BACKGROUND

Food insecurity is an important social determinant of health that was exacerbated by the COVID-19 pandemic. Both food insecurity and COVID-19 infection disproportionately affect racial and ethnic minority groups, particularly American Indian and Alaska Native communities; however, there is little evidence as to whether food insecurity is associated with COVID-19 infection or COVID-19 preventive behaviors such as vaccination uptake. The purpose of this study was to evaluate associations between food insecurity, COVID-19 infection, and vaccination status among urban American Indian and Alaska Native adults seen at 5 clinics serving urban Native people.

METHODS

In partnership with health organizations in Alaska, Colorado, Kansas, Minnesota, and New Mexico, the study team conducted a cross-sectional survey in 2021 to assess food security status and attitudes, barriers, and facilitators for COVID-19 testing and vaccination. Logistic regression was used to examine the association of food security status with sociodemographic factors and COVID-19 infection and vaccination status. Marginal standardization was applied to present results as prevalence differences.

RESULTS

Among 730 American Indian and Alaska Native adults, the prevalence of food insecurity measured during the pandemic was 38%. For participants who reported persistent food security status before and during the pandemic (n = 588), the prevalence of food insecurity was 25%. Prevalence of COVID-19 infection and vaccination did not vary by food security status after adjustment for confounders.

CONCLUSIONS

High rates of food insecurity among American Indian and Alaska Native communities likely increased during the COVID-19 pandemic. However, despite the high prevalence of food insecurity, community-led efforts to reduce COVID-19 infection and increase vaccination uptake across Indian Health Service and Tribal healthcare facilities may have mitigated the negative impacts of the pandemic for families experiencing food insecurity. These successful approaches serve as an important reference for future public health efforts that require innovative strategies to improve overall health in American Indian and Alaska Native communities.

NEFPAT Plus: A Valid and Reliable Tool for Assessing the Nutrition Environment in Food Pantries

OBJECTIVE

To develop a consumer nutrition environment assessment tool to assess policy, systems, and environmental initiatives that are implemented in food pantries, which incorporates recent national guidance, and evaluate its validity and reliability.

SETTING

Illinois, US.

DESIGN

This study had 4 phases: (1) tool revision, (2) pilot testing, (3) content validity assessment, and (4) interrater and test-retest reliability assessment. The original Nutrition Environment Food Pantry Assessment Tool (NEFPAT) was revised to incorporate evidence from updated guidelines and evidence. The NEFPAT+ was pilot-tested by 9 professionals at 5 food pantries. After revisions, 18 experts rated the content validity. Interrater and test-retest reliability was based on 2-4 professionals completing independent evaluations at 21 food pantries twice, 1 month apart.

ANALYSIS

Content validity indices and intraclass correlation (ICC) coefficients for reliability estimates were compared with established thresholds.

RESULTS

The NEFPAT+ was rated content valid by 94% of experts. The ICC for NEFPAT+ scores indicated excellent interrater reliability (ICC, 0.96; 99% confidence interval, 0.75-0.97) and good test-retest reliability (ICC: 0.80; 99% confidence interval, 0.60-0.92).

CONCLUSIONS

Evidence supports the content validity, interrater reliability, and test-retest reliability of the NEFPAT+. Future studies can assess how NEFPAT+ scores relate to intervention outcomes and dietary behaviors.

Food Insecurity in Urban American Indian and Alaska Native Populations During the COVID-19 Pandemic

Background

Food insecurity is an important social determinant of health that was exacerbated by the COVID-19 pandemic. Both food insecurity and COVID-19 infection disproportionately affect racial and ethnic minority groups, particularly American Indian and Alaska Native communities; however, there is little evidence as to whether food insecurity is associated with COVID-19 infection or COVID-19 preventive behaviors such as vaccination uptake. The purpose of this study was to evaluate associations between food insecurity, COVID-19 infection, and vaccination status among urban American Indian and Alaska Native adults seen at 5 clinics serving urban Native people.

Methods

In partnership with health organizations in Alaska, Colorado, Kansas, Minnesota, and New Mexico, the study team conducted a cross-sectional survey in 2021 to assess food security status and attitudes, barriers, and facilitators for COVID-19 testing and vaccination. Logistic regression was used to examine the association of food security status with sociodemographic factors and COVID-19 infection and vaccination status. Marginal standardization was applied to present results as prevalence differences.

Results

Among 730 American Indian and Alaska Native adults, the prevalence of food insecurity measured during the pandemic was 38%. For participants who reported persistent food security status before and during the pandemic (n=588), the prevalence of food insecurity was 25%. Prevalence of COVID-19 infection and vaccination did not vary by food security status after adjustment for confounders.

Conclusions

High rates of food insecurity among American Indian and Alaska Native communities likely increased during the COVID-19 pandemic. However, despite the high prevalence of food insecurity, community-led efforts to reduce COVID-19 infection and increase vaccination uptake across Indian Health Service and Tribal healthcare facilities may have mitigated the negative impacts of the pandemic for families experiencing food insecurity. These successful approaches serve as an important reference for future public health efforts that require innovative strategies to improve overall health in AIAN communities.

Food Security and Food Sovereignty: The Difference Between Surviving and Thriving

Previous research in American Indian and Alaska Native (AI/AN) communities has documented high prevalence of food insecurity. Yet many AI/AN scholars and communities have expressed concerns that the dominant societal conceptions of food security are not reflective of the teachings, priorities, and values of AI/AN communities. Food security initiatives often focus on access to food and, at times, nutrition but little consideration is given to cultural foods, the spirituality carried through foods, and whether the food was stewarded in a way that promotes well-being not just for humans but also for plants, animals, land, and water. Despite the concerns of AI/AN communities that their needs are not centered in dominant societal food conceptualizations and food security programming, the food sovereignty efforts of AI/AN communities have captured national attention as a solution to modern food system inequities. Indigenous Food Sovereignty (IFS) is a holistic approach to food that incorporates values of relationality, reciprocity, and relationships. Fundamental differences exist between food security and food sovereignty, yet dominant society often reduces IFS as a solution to food security, rather than an entirely different food system that is predicated on values that contrast with that of dominant society. Despite calls to decolonize the definition and measurement of food security, we explore whether fixing the concept of food security is a worthy endeavor or whether efforts would be better spent supporting the resurgence and revitalization of AI/AN food values, food knowledge, and community food sovereignty initiatives.

Food Sovereignty and Health: A Conceptual Framework to Advance Research and Practice

Settler colonialism disrupted traditional Indigenous foodways and practices and created high rates of diet-related disease among Indigenous peoples. Food sovereignty, the rights of Indigenous peoples to determine their own food systems, is a culturally centered movement rooted in traditional Indigenous knowledge. This approach directly intervenes upon systems-level barriers to health, making it an important strategy for health equity. While food sovereignty initiatives can be found within many Indigenous communities, the conceptual linkages between food sovereignty and health have not been well documented within the public health literature. We present a practice-informed conceptual framework developed as part of the Center for Indigenous Innovation and Health Equity (CIIHE) initiative, a community-academic partnership with the goal of strengthening Indigenous food systems and practices to promote health and well-being. The framework emphasizes connectedness, including the transmission of knowledge across generations and the restoration of relational responsibilities, as central to Indigenous concepts of health and wellness.

Framing an Indigenous Food Sovereignty Research Agenda

Access to healthy and appealing food is essential for individuals to be able to live a healthy and quality life. For decades, food security has been a priority issue for public health professionals. Food sovereignty expands upon the concept of food insecurity (i.e., having access to nutritious and culturally relevant food) by incorporating people's rights to define their own food system. The expanded focus of food sovereignty on food systems prioritizes public health professionals' role in supporting environmental- and systems-level initiatives and evaluating their implications for health, economics, and the natural environment. Food sovereignty is of particular importance for Indigenous peoples (i.e., American Indian, Alaska Native, Native Hawaiian, and Pacific Islander communities). Colonization had demonstrable consequences, with many Indigenous communities being forcibly relocated from traditional lands, alongside the destruction of traditional food sources. Indigenous food sovereignty aligns with the sovereign nation status that American Indian tribes and Alaska Native communities have with the United States. Furthermore, the worldviews that incorporate Indigenous communities' relational responsibilities to care for their food systems, according to their traditional practices and beliefs (Coté, 2016; Morrison, 2011), uniquely positions Indigenous peoples to lead food sovereignty initiatives. In this article, we explore what is currently known regarding food sovereignty and health. We then discuss opportunities to expand the evidence on Indigenous food sovereignty's relationships with (1) health and well being, (2) economics, (3) the natural environment, and (4) programming facilitators and barriers.

Food Systems, Food Sovereignty, and Health: Conference Shares Linkages to Support Indigenous Community Health

The Center for Indigenous Innovation and Health Equity (CIIHE) at Oklahoma State University Center for Health Sciences (OSU-CHS) is a community-academic partnership with Indigenous peoples from Alaska, Hawai'i, and Oklahoma. The CIIHE supports communities to strengthen traditional food practices and food sovereignty and evaluate the impact of those efforts on health. In February 2022, the CIIHE sponsored and hosted a virtual conference to better understand how food sovereignty initiatives can improve health. More than 600 participants gathered to hear the latest research and practice in the areas of public health and agriculture, nutrition, community-based and Indigenous knowledge, and health economics. Community-led food sovereignty initiatives being implemented as part of the CIIHE were featured along with other Indigenous initiatives in urban, rural, and reservation communities. A survey was administered to conference participants to assess food sovereignty topics and priorities for future research. In this Practice Note, we describe innovative community-led initiatives presented as part of the conference and recommendations for action emerging from qualitative and quantitative data collected from conference participants.

Measuring Food Security among American Indian and Alaska Native Adults: Validity Evidence Supports the Use of the US Department of Agriculture Module

BACKGROUND

Inequities in access, availability, and affordability of nutritious foods produced by settler colonialism contribute to high rates of food insecurity among American Indian and Alaska Native (AI/AN) households. Efforts to understand the influences of food security programming among AI/AN individuals in the United States are constrained by the absence of validity evidence for food security assessments for this population.

OBJECTIVE

This study assessed whether AI/AN adult responses on the Food Security Survey Module provide an accurate assessment of food security prevalence, especially when compared with other racial and ethnic groups.

DESIGN

A correlational design with the cross-sectional 2019 National Health Interview Survey was used to address the research objective.

PARTICIPANTS AND SETTING

The 2019 National Health Interview Survey contains a sample (N = 30,052) representative of the resident civilian noninstitutionalized population.

MAIN OUTCOME MEASURES

The primary outcome was food security, as characterized by the 10-item US Department of Agriculture Adult Food Security Survey Module. The module evaluates whether insufficient finances result in perceived food shortages and a reduction in the quantity and/or quality of food intake during the prior 30 days.

STATISTICAL ANALYSES PERFORMED

Data were analyzed by racial and ethnic subsamples to assess scale dimensionality (confirmatory factor analysis), Item Response Theory item analysis, differential item functioning, and external validity (χ2 tests).

RESULTS

Results supported the use of the 10-item module for racial and ethnic groups. However, differential item functioning effect sizes exceeded criteria for the Asian, AI/AN, and Hispanic respondents when compared with White respondents. Food security was not significantly related to all expected correlates in the AI/AN subsample.

CONCLUSIONS

Compelling evidence is presented for validity of the FSSM scores in determining food security status of AI/AN adults. Qualitative inquiry that explores how culture influences the way food security is conceptualized and experienced is warranted.

Food Insecurity Screening in Primary Care: Patterns During the COVID-19 Pandemic by Encounter Modality

INTRODUCTION

Screening for food insecurity in clinical settings is recommended, but implementation varies widely. This study evaluated the prevalence of screening for food insecurity and other social risks in telehealth versus in-person encounters during the COVID-19 pandemic and changes in screening before versus after widespread COVID-19 vaccine availability.

METHODS

These cross-sectional analyses used electronic health record and ancillary clinic data from a national network of 400+ community health centers with a shared electronic health record. Food insecurity screening was characterized in 2022 in a sample of 275,465 first encounters for routine primary care at any network clinic during March 11, 2020-December 31, 2021. An adjusted multivariate multilevel probit model estimated screening prevalence on the basis of encounter mode (in-person versus telehealth) and time period (initial pandemic versus after vaccine availability) in a random subsample of 11,000 encounters.

RESULTS

Encounter mode was related to food insecurity screening (p<0.0001), with an estimated 9.2% screening rate during in-person encounters, compared with 5.1% at telehealth encounters. There was an interaction between time period and encounter mode (p<0.0001), with higher screening prevalence at in-person versus telehealth encounters after COVID-19 vaccines were available (11.7% vs 4.9%) than before vaccines were available (7.8% vs 5.2%).

CONCLUSIONS

Food insecurity screening in first primary care encounters is low overall, with lower rates during telehealth visits and the earlier phase of the COVID-19 pandemic. Future research should explore the methods for enhancing social risk screening in telehealth encounters.

Distribution of fresh foods in food pantries: challenges and opportunities in Illinois during the COVID-19 pandemic

BACKGROUND

The charitable food system distributes free food to clients across the U.S., but many nutrition and health-focused efforts encounter barriers to success, which were exacerbated during the COVID-19 pandemic. The objective of the current study was to understand barriers and facilitators to distributing nutritious, fresh foods in food pantries across Illinois during the COVID-19 pandemic.

METHODS

Forty-nine pantry representatives participated in focus groups in October 2021. A codebook was created based on relevant literature, stakeholder interests, and an initial review of the recordings. Transcripts of each group were coded and analyzed using a basic interpretive approach.

RESULTS

Pantries distribution of fresh foods was impacted by community partners, food bank policies and practices, and the quality of the donated fresh foods. Physical constraints of pantries limit fresh food storage capacity. The COVID-19 pandemic magnified stressors in the charitable food system which highlighted how community partners might improve fresh food distribution.

CONCLUSION

Focus groups with food pantry representatives across Illinois provided key insights that can inform future efforts to facilitate fresh food distribution in the charitable food system. Future studies should evaluate the effects of the suggested initiatives and changes at the food pantry, food bank, and policy levels.

Native opportunities to stop hypertension: study protocol for a randomized controlled trial among urban American Indian and Alaska Native adults with hypertension

Introduction

American Indian and Alaska Native (AI/AN) adults experience disproportionate cardiovascular disease (CVD) morbidity and mortality compared to other races, which may be partly attributable to higher burden of hypertension (HTN). Dietary Approaches to Stop Hypertension (DASH) is a high-impact therapeutic dietary intervention for primary and secondary prevention of CVD that can contribute to significant decreases in systolic blood pressure (BP). However, DASH-based interventions have not been tested with AI/AN adults, and unique social determinants of health warrant independent trials. This study will assess the effectiveness of a DASH-based intervention, called Native Opportunities to Stop Hypertension (NOSH), on systolic BP among AI/AN adults in three urban clinics.

Methods

NOSH is a randomized controlled trial to test the effectiveness of an adapted DASH intervention compared to a control condition. Participants will be aged ≥18 years old, self-identify as AI/AN, have physician-diagnosed HTN, and have elevated systolic BP (≥ 130 mmHg). The intervention includes eight weekly, tailored telenutrition counseling sessions with a registered dietitian on DASH eating goals. Intervention participants will be provided $30 weekly and will be encouraged to purchase DASH-aligned foods. Participants in the control group will receive printed educational materials with general information about a low-sodium diet and eight weekly $30 grocery orders. All participants will complete assessments at baseline, after the 8-week intervention, and again 12 weeks post-baseline. A sub-sample of intervention participants will complete an extended support pilot study with assessments at 6- and 9-months post-baseline. The primary outcome is systolic BP. Secondary outcomes include modifiable CVD risk factors, heart disease and stroke risk scores, and dietary intake.

Discussion

NOSH is among the first randomized controlled trials to test the impact of a diet-based intervention on HTN among urban AI/AN adults. If effective, NOSH has the potential to inform clinical strategies to reduce BP among AI/AN adults.

Clinical trials registration

https://clinicaltrials.gov/ct2/show/NCT02796313, Identifier NCT02796313.

Development and evaluation of the Food Bank Health and Nutrition Assessment

OBJECTIVE

Efforts to improve the nutritional quality and health promotion in the charitable food system have been undertaken. Though methods exist to track these efforts in terms of food banks' inventory, there are not research-tested tools to assess, monitor and influence policy, systems and environmental (PSE) changes. The study objective was to develop and evaluate a novel assessment tool that could be used to evaluate a food bank's efforts to improve the promotion of health and nutritious foods.

DESIGN

The study had five phases: (1) initial development; (2) iterative review and revisions; (3) pilot testing; (4) content validity assessment and (5) inter-rater and test-retest assessment. The Food Bank Health and Nutrition Assessment (FB-HANA) was drafted after reviewing existing policies, nutrition-focused charitable food systems guidance and similar tools for food pantries.

SETTING

Midwestern United States.

PARTICIPANTS

Eleven food banks.

RESULTS

Stakeholders and pilot testers provided initial feedback to refine the FB-HANA's flow, ease of completion and collection of contextual information. External experts rated the FB-HANA and each of the eight objectives as content valid. A set of two assessments completed by twenty-six community-based professionals, employed by Extension and fourteen food bank staff across eleven food banks, supported moderate to excellent inter-rater and test-retest reliability for the FB-HANA overall and each of its objectives.

CONCLUSIONS

Evidence suggests that the FB-HANA can be used by either food bank or community-based professionals, such as Extension staff, to provide a perspective on ways food banks promote health and nutrition through PSE approaches.

Impacts of COVID-19 on a Food Security Study with the Baltimore Native Community

Urban American Indian/Alaska Native peoples experience disproportionate levels of food insecurity when compared to the general US population. Through a collaborative research partnership between Native American Lifelines of Baltimore, an Urban Indian Health Program, and a Johns Hopkins Bloomberg School of Public Health student-led research team, food security was identified as a priority issue. A sequential explanatory mixed methods study was planned to explore food security and food sovereignty in the Baltimore Native community prior to the COVID-19 pandemic. Due to the local impact of COVID-19, a community-based participatory research approach guided the community-academic team to revise the original study and increase understanding of how the pandemic impacted food security in the community. This article highlights the lessons learned and strengths of using a community-based participatory approach to guide adaptations made due to COVID-19 to this research study. By utilizing a co-learning approach and emphasizing flexibility, we were able to collaboratively collect meaningful data to drive future community solutions to food insecurity while building an evidence base for policy changes to better support urban Native food security.