Barriers to Healthcare Seeking and Provision Among African American Adults in the Rural Mississippi Delta Region: Community and Provider Perspectives.

Barriers to health care access and utilization are likely to be perceived differently for receivers and providers of health care. This paper compares and contrasts perspectives of lay community members, volunteer community health advisors (CHA), and health care providers related to structural and interpersonal barriers to health care seeking and provision among African American adults experiencing health disparities in the rural Mississippi Delta. Sixty-four Delta residents (24 males, 40 females) participated in nine focus groups organized by role and gender. The constant comparative method was used to identify themes and subthemes from the focus group transcripts. Barriers were broadly categorized as structural and interpersonal with all groups noting structural barriers including poverty, lack of health insurance, and rurality. All groups identified common interpersonal barriers of gender socialization of African American males, and prevention being a low priority. Differences emerged in perceptions of interpersonal barriers between community members and healthcare providers. Community members and CHA fears of serious medical diagnosis, stigma, medical distrust, and racism emerged as factors inhibiting health care utilization. All groups were critical of insurance/regulatory constraints with providers viewing medical guidelines at times restricting their ability to provide quality treatment while community members and CHA viewed providers as receiving compensation for prescribing medications without regard to potential side-effects. These findings shed light on barriers perceived similarly and differently across these stakeholder groups, and offer directions for ongoing research, outreach, clinical work, and health care policy.

"We Need Help in the Delta".

The purpose of this study was to better understand the barriers to health promotion among African American older men living in the rural Mississippi Delta. A qualitative, intrinsic case study approach was used to explore the phenomenon of health and the barriers to promoting men's health within the unique context of the Delta. Data included one key informant interview and two focus group interviews with 14 men, with the majority between the ages of 41 and 55 years. Focus group participants were lay community members as well as members of a volunteer community health advisors men's group. Findings underscore the extensiveness of the term "health" and the importance of attending to structural barriers in addressing men's health. Three overarching themes emerged: "men don't talk about health," "health care is not just the issue, everything is," and "we need a strong male to lead." Implications for future research and health promotion efforts are provided.

Mississippi Communities for Healthy Living.

BACKGROUND: Improving the diet of communities experiencing health inequities can be challenging given that multiple dietary components are low in quality. Mississippi Communities for Healthy Living was designed to test the comparative effectiveness of nutrition education using a single- versus multiple-message approach to improve the diet of adult residents in the Lower Mississippi Delta. METHOD: The single-message approach targeted discretionary calories while the multiple-message approach also targeted vegetables, fruits, whole grains, and lean protein. Delta food frequency questionnaires were used to measure participants' diet, while the Healthy Eating Index-2005 (HEI-2005) was used to generate diet quality scores. Generalized linear mixed model regression was used to test for significant time, treatment, and time × treatment interaction effects in HEI-2005 component and total score changes. RESULTS: The majority of participants in the single- and multiple-message arms ( n = 114 and 127, respectively) were female (88% and 96%, respectively), African American (90% and 98%, respectively), overweight or obese (92% and 87%, respectively), and 41 to 60 years of age (57% and 43%, respectively). Significant time effects were present for HEI-2005 total and component scores, with three exceptions-whole fruit, total grains, and saturated fat. Significant treatment effects were present for two components-total and whole fruit; scores were higher in the multiple-message approach arm as compared to the single-message approach arm across time points. No interaction effects were significant for any of the HEI-2005 scores. CONCLUSION: Focusing nutrition education on the discretionary calories component of the diet may be as effective as focusing on multiple components for improving diet quality.

Psychosocial constructs and postintervention changes in physical activity and dietary outcomes in a lifestyle intervention, HUB City Steps, 2010.

INTRODUCTION: Although modifications to dietary and physical activity (PA) behavior can reduce blood pressure, racial disparities in prevalence and control of hypertension persist. Psychosocial constructs (PSCs) of self-regulation, processes of change, and social support are associated with initiation and maintenance of PA in African Americans; which PSCs best predict lifestyle behavior changes is unclear. This study's objective was to examine relationships among PSC changes and postintervention changes in PA and dietary outcomes in a community-based, multicomponent lifestyle intervention. METHODS: This study was a noncontrolled, pre/post experimental intervention conducted in a midsized, Southern US city in 2010. Primarily African American adults (n = 269) participated in a 6-month intervention consisting of motivational enhancement, social support, pedometer diary self-monitoring, and 5 education sessions. Outcome measures included pedometer-determined steps per day, fitness, dietary intake, and PSC measures. Generalized linear mixed models were used to test for postintervention changes in behavioral outcomes, identify predictors of PSC changes, and determine if PSC changes predicted changes in PA and diet. RESULTS: Postintervention changes were apparent for 10 of 24 PSCs (P < .05). Processes of change components, including helping relationships, reinforcement management, and consciousness raising, were significant predictors of fitness change (P < .05). CONCLUSION: This article is among the first to address how measures of several theoretical frameworks of behavior change influence changes in PA and dietary outcomes in a multicomponent, community-based, lifestyle intervention conducted with African American adults. Findings reported identify PSC factors on which health behavior interventions can focus.

Mississippi Communities for Healthy Living: Implementing a nutrition intervention effectiveness study in a rural health disparate region.

BACKGROUND: Intervention research in rural, health disparate communities presents unique challenges for study design, implementation, and evaluation. Challenges include 1) culturally appropriate intervention components, 2) participant recruitment and retention, 3) treatment cross-contamination, 4) intervention delivery and data collection, and 5) potential measurement reactivity. PURPOSE: The purposes of this paper are to 1) detail the methods of the MCHL study and 2) report baseline demographic characteristics of study participants. The secondary aim is to determine if study participants were engaging in behavior changes after enrollment and prior to intervention initiation. METHODS: MCHL was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). Intervention components were based on Roger's diffusion of innovation attributes that promote adoption of a new innovation as well as on the psychosocial constructs of social support, self-efficacy and decisional balance. Rolling enrollment data collection was used to acquire sufficient sample size and a second data collection just prior to intervention implementation assessed measurement reactivity effects. Participant outcomes included diet quality, blood pressure, weight status, and quality of life. Cluster stratified assignment to one of two treatment arms was utilized to minimize cross contamination. Generalized linear models were used to compare enrollment measures between the two treatment arms while mixed model linear regression was used to test for changes in diet quality outcomes from enrollment to pre-intervention baseline. RESULTS: There were no significant differences in participant demographic, anthropometric or clinical measures between the two treatment arms at enrollment. With the exception of total vegetables, none of the diet quality indicators were significantly different between enrollment and baseline timepoints. CONCLUSIONS: Conducting nutrition intervention research in a rural health disparate region requires flexibility in adapting the recruitment, retention, and data collection procedures while maintaining a high level of scientific rigor. Negligible research participation effects, such as measurement reactivity, were noted in this population. However, further research is needed to identify methods to successfully recruit and retain Caucasian females to participate in community-based nutrition interventions in this region.

Participant adherence indicators predict changes in blood pressure, anthropometric measures, and self-reported physical activity in a lifestyle intervention: HUB city steps.

The objective of this secondary analysis was to evaluate the utility of several participant adherence indicators for predicting changes in clinical, anthropometric, dietary, fitness, and physical activity (PA) outcomes in a lifestyle intervention, HUB City Steps, conducted in a southern, African American cohort in 2010. HUB City Steps was a 6-month, community-engaged, multicomponent, noncontrolled intervention targeting hypertension risk factors. Descriptive indicators were constructed using two participant adherence measures, education session attendance (ESA) and weekly steps/day pedometer diary submission (PDS), separately and in combination. Analyses, based on data from 269 primarily African American adult participants, included bivariate tests of association and multivariable linear regression to determine significant relationships between seven adherence indicators and health outcome changes, including clinical, anthropometric, dietary, fitness, and PA measures. ESA indicators were significantly correlated with four health outcomes: body mass index (BMI), fat mass, low-density lipoprotein (LDL), and PA (-.29 ≤ r ≤ .23, p < .05). PDS indicators were significantly correlated with PA (r = .27, p < .001). Combination ESA/PDS indicators were significantly correlated with five health outcomes: BMI, percentage body fat (%BF), fat mass, LDL, and PA (r = -.26 to .29, p < .05). Results from the multivariate models indicated that the combination ESA/PDS indicators were the most significant predictors of changes for five outcomes--%BF, fat mass, LDL diastolic blood pressure (DBP), and PA--while ESA performed best for BMI only. For DBP, a one-unit increase in the continuous-categorical ESA/PDS indicator resulted in 0.3 mm Hg decrease. Implications for assessing participant adherence in community-based, multicomponent lifestyle intervention research are discussed.

Using the RE-AIM Framework in formative evaluation and program planning for a nutrition intervention in the Lower Mississippi Delta.

OBJECTIVE: Identification of prominent themes to be considered when planning a nutrition intervention using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. DESIGN: Qualitative formative research. SETTING: Women's social and civic organizations in the Lower Mississippi Delta. PARTICIPANTS: Thirty-seven (5 white and 32 black) women with a college degree or higher. PHENOMENON OF INTEREST: Impact of dietary and contextual factors related to the Lower Mississippi Delta culture on intervention planning. ANALYSIS: Case analysis strategy using question-by-question coding. RESULTS: Major themes that emerged were "healthy eating focus" and "promoting a healthy lifestyle" when recruiting organizations (Reach); "positive health changes" as a result of the intervention (Effectiveness); "logistics: time commitment, location, and schedule" to initiate a program (Adoption); "expense of healthy foods" and "cooking and meal planning" as barriers to participation (Implementation); and "resources and training" and "motivation" as necessary for program continuation (Maintenance). The "health of the Delta" theme was found across all dimensions, which reflected participants' compassion for their community. CONCLUSIONS AND IMPLICATIONS: Results were used to develop an implementation plan promoting optimal reach, effectiveness, adoption, implementation, and maintenance of a nutrition intervention. This research emphasizes the benefits of formative research using a systematic process at organizational and individual levels.

Several steps/day indicators predict changes in anthropometric outcomes: HUB City Steps.

BACKGROUND: Walking for exercise remains the most frequently reported leisure-time activity, likely because it is simple, inexpensive, and easily incorporated into most people's lifestyle. Pedometers are simple, convenient, and economical tools that can be used to quantify step-determined physical activity. Few studies have attempted to define the direct relationship between dynamic changes in pedometer-determined steps/day and changes in anthropometric and clinical outcomes. Hence, the objective of this secondary analysis was to evaluate the utility of several descriptive indicators of pedometer-determined steps/day for predicting changes in anthropometric and clinical outcomes using data from a community-based walking intervention, HUB City Steps, conducted in a southern, African American population. A secondary aim was to evaluate whether treating steps/day data for implausible values affected the ability of these data to predict intervention-induced changes in clinical and anthropometric outcomes. METHODS: The data used in this secondary analysis were collected in 2010 from 269 participants in a six-month walking intervention targeting a reduction in blood pressure. Throughout the intervention, participants submitted weekly steps/day diaries based on pedometer self-monitoring. Changes (six-month minus baseline) in anthropometric (body mass index, waist circumference, percent body fat [%BF], fat mass) and clinical (blood pressure, lipids, glucose) outcomes were evaluated. Associations between steps/day indicators and changes in anthropometric and clinical outcomes were assessed using bivariate tests and multivariable linear regression analysis which controlled for demographic and baseline covariates. RESULTS: Significant negative bivariate associations were observed between steps/day indicators and the majority of anthropometric and clinical outcome changes (r = -0.3 to -0.2: P < 0.05). After controlling for covariates in the regression analysis, only the relationships between steps/day indicators and changes in anthropometric (not clinical) outcomes remained significant. For example, a 1,000 steps/day increase in intervention mean steps/day resulted in a 0.1% decrease in %BF. Results for the three pedometer datasets (full, truncated, and excluded) were similar and yielded few meaningful differences in interpretation of the findings. CONCLUSIONS: Several descriptive indicators of steps/day may be useful for predicting anthropometric outcome changes. Further, manipulating steps/day data to address implausible values has little overall effect on the ability to predict these anthropometric changes.

Academic partnerships and key leaders emerging from communities in the lower Mississippi Delta (LMD): a community-based participatory research model.

Collaboratively, the nutritional health problems of the Lower Mississippi Delta (LMD) region were examined and opportunities identified for conducting research interventions. To combat the nutritional health problems in the LMD, community residents yielded to a more comprehensive and participatory approach known as community-based participatory research (CBPR). Community residents partnered with academic researchers and other organizational entities to improve the overall quality of diet and health in their respective communities using CBPR. The collaborative work in the LMD focused on interventions conducted in each of three specific communities across three states: Marvell, Arkansas (Marvell NIRI), and its surrounding public school district; Franklin Parish in Louisiana (Franklin NIRI); and the city of Hollandale, Mississippi (Hollandale NIRI). This paper examined some of the research interventions conducted in Franklin, Hollandale, and Marvell NIRI respectively, how leadership emerged from each of these communities, and lessons learned as a result of the CBPR model.

Simulated reductions in consumption of sugar-sweetened beverages improves diet quality in Lower Mississippi Delta adults.

BACKGROUND: Although the effects of replacing sugar-sweetened beverages (SSBs) with water on energy intake and body weight have been reported, little is known about how these replacements affect diet quality. OBJECTIVE: To simulate the effects of replacing SSBs with tap water on diet quality and total energy intake of Lower Mississippi Delta (LMD) adults. DESIGN: Retrospective analysis of cross-sectional dietary intake data using a representative sample of LMD adults (n=1,689). Diet quality was measured using the Healthy Eating Index-2005 (HEI-2005) scores that were computed using the population ratio method. The effects of substituting SSBs with water on diet quality were simulated by replacing the targeted items' nutrient profile with tap water's profile. RESULTS: Simulating the replacement of SSBs with tap water at 25, 50, and 100% levels resulted in 1-, 2.3-, and 3.8-point increases, respectively, in the HEI-2005 total score. Based on a mean daily intake of 2,011 kcal, 100% substitution of SSBs with tap water would result in 11% reduction in energy intake. CONCLUSIONS: Replacing SSBs with water could substantially improve the diet quality of the LMD adult population and potentially lead to significant weight loss overtime. Prioritizing intervention efforts to focus on the replacement of SSBs with energy-free drinks may be the most efficacious approach for conveying potentially substantial health benefits in this and similar disadvantaged populations.

A simulation study of the potential effects of healthy food and beverage substitutions on diet quality and total energy intake in Lower Mississippi Delta adults.

The majority of adult diets in the United States, particularly the South, are of poor quality, putting these individuals at increased risk for chronic diseases. In this study, simulation modeling was used to determine the effects of substituting familiar, more healthful foods and beverages for less healthy ones on diet quality and total energy intake in Lower Mississippi Delta (LMD) adults. Dietary data collected in 2000 for 1689 LMD adults who participated in the Foods of Our Delta Study were analyzed. The Healthy Eating Index-2005 (HEI-2005) was used to measure diet quality. The effects of substituting targeted foods and beverages with more healthful items on diet quality were simulated by replacing the targeted items' nutrient profile with their replacements' profile. For the single food and beverage groups, 100% replacement of grain desserts with juice-packed fruit cocktail and sugar-sweetened beverages with water resulted in the largest improvements in diet quality (4.0 and 3.8 points, respectively) and greatest decreases in total energy intake (98 and 215 kcal/d, respectively). The 100% substitution of all food and beverage groups combined resulted in a 12.0-point increase in HEI-2005 score and a decrease of 785 kcal/d in total energy intake. Community interventions designed to improve the diet of LMD adults through the use of familiar, healthy food and beverage substitutions have the potential to improve diet quality and decrease energy intake of this health disparate population.

Food and beverage choices contributing to dietary guidelines adherence in the Lower Mississippi Delta.

OBJECTIVES: The objectives of the present study were to evaluate diet quality among Lower Mississippi Delta (LMD) residents using the Healthy Eating Index-2005 (HEI-2005) and to identify the top five dietary sources contributing to HEI-2005 components. Demographic differences in HEI-2005 scores were also explored. DESIGN: Diet quality was evaluated using HEI-2005. Demographic differences in HEI-2005 scores were investigated using multivariable regression models adjusting for multiple comparisons. The top five dietary sources contributing to HEI-2005 components were identified by estimating and ranking mean MyPyramid equivalents overall and by demographic characteristics. SETTING: Dietary data, based on a single 24 h recall, from the Foods of Our Delta Study 2000 (FOODS 2000) were used in the analyses. SUBJECTS: FOODS 2000 adult participants 18 years of age or older. RESULTS: Younger age was the largest determinant of low diet quality in the LMD with HEI-2005 total and seven component scores declining with decreasing age. Income was not a significant factor for HEI-2005 total or component scores. The top five dietary sources differed by all five of the demographic variables, particularly for total vegetables and energy from solid fats, alcoholic beverages and added sugars (SoFAAS). Soft drinks were the leading source of SoFAAS energy intake for all demographic groups. CONCLUSIONS: The assessment of diet quality and identification of top dietary sources revealed the presence of demographic differences for selected HEI-2005 components. These findings allow identification of food patterns and culturally appropriate messaging and highlight the difficulties of treating this region as a homogeneous population.

Perceptions of community-based participatory research in the Delta Nutrition Intervention Research Initiative: an academic perspective.

Lower Mississippi Delta Nutrition Intervention Research Initiative (Delta NIRI) is an academic-community partnership between seven academic institutions and three communities in Mississippi, Arkansas, and Louisiana. A range of community-based participatory methods have been used to develop sustainable nutrition intervention strategies. Focus groups were conducted with 22 faculty and staff members from the academic partners on the project to document their perceptions of community-based participatory processes in a federally funded, multi-academic-community partnership spanning a decade. Focus groups were conducted to glean insights or lessons from the experiences of academic personnel. Focus groups were transcribed and analyzed using the constant comparative method. Two researchers analyzed each transcript independently and reached consensus on the consistent themes. Participants candidly shared their experiences of working with community members to devise research plans, implement programs, and evaluate outcomes. The majority of faculty and staff members were attracted to this project by an excitement for conducting a more egalitarian and potentially more successful type of research. Yet each academic partner voiced that there was an underlying disconnect between community practices and research procedures during the project. Additional barriers to collaboration and action, located in communities and academic institutions, were described. Academic partners stressed the importance of open and ongoing communication, collective decision-making strategies, and techniques that support power sharing between all parties involved in the project. Findings from this research can inform academic-community partnerships and hopefully improve the community-based participatory research process implemented by academic institutions and communities.

Capacity building for health through community-based participatory nutrition intervention research in rural communities.

Since its inception, capacity building has been a stated goal of the Delta Nutrition Intervention Research Initiative, a tri-state collaboration in the Lower Mississippi Delta to address high rates of chronic disease. Textual analysis of project documents identifies and describes strategies carried out to foster capacity building. Strategies to build community capacity include fostering participation, cultivating leadership opportunities, training community members as co-researchers, securing community resources, and implementing the intervention together. Incorporating capacity-building approaches in health promotion and nutrition-intervention programming in rural communities provides a means to enhance potential for sustainability of health outcomes and developed effectiveness.

Does a six-month pedometer intervention improve physical activity and health among vulnerable African Americans? A feasibility study.

BACKGROUND: Race/ethnic-specific physical activity patterns and biological responses to physical activity is one of the most understudied, yet critical aspects related to the development and adoption of physical activity recommendations. METHODS: In this 6-month community walking intervention targeting African Americans, participants wore a pedometer and maintained a pedometer diary for the study duration. Outcome measures included height, weight, percent body fat, waist circumference, blood pressure, lipids and glucose. ANOVA, Pearson Correlations, and Kruskal-Wallis tests were used to examine changes in steps/day over each month of the intervention and explore associations among pedometer-determined physical activity and anthropometric/biological change scores from month 1 to 6. RESULTS: The 83 participants were primarily African American (98%) women (94%). There was a significant increase in the average step/day beginning with 6665 (SD = 3396) during month 1 and increasing to 9232 (SD = 3670) steps/day during month 6 (F = 4.5, P < .0001). Associations among step counts and anthropometric/biological change scores were not significant. CONCLUSIONS: While this intervention resulted in significant increases in steps/day; it exemplifies that physical activity standards may be unachievable for some vulnerable, minority communities. Methodological considerations for exploring associations between changes in pedometer-determined step counts and anthropometric/biological outcomes are emphasized through this study.

Compliance and acceptability of maintaining a 6-month pedometer diary in a rural, African American community-based walking intervention.

BACKGROUND: Limited research has been done on the compliance and acceptability of maintaining pedometer diaries for an extensive time frame in community-based interventions targeting minority populations. METHODS: Community "coaches" led participants in a 6-month community-based walking intervention that included wearing pedometers and maintaining pedometer diaries for the study duration. Descriptive statistics and ANOVA tests were used to evaluate compliance rates for maintaining diaries and daily step counts. After the intervention, focus groups were used to explore opinions regarding pedometers. Audiotapes were transcribed and evaluated using systematic content analysis. RESULTS: The 8 coaches and 75 enrolled walking participants were primarily African American (98%) women (94%). Overall, the group (N = 83) submitted 85% of all possible pedometer diaries and recorded 73% of all possible daily step counts. Walking-group members were significantly (P < .01) more compliant if their coach was also compliant. Identified benefits of wearing pedometers and maintaining diaries outnumbered the barriers. Participants were enthusiastic about wearing the pedometers and indicated that the weekly diaries provided a source of motivation. CONCLUSIONS: This research suggests pedometer diaries are a viable intervention tool and research method for community-based physical activity interventions targeting African Americans and highlights the need for social support to promote pedometer diary compliance.

Nutrition literacy status and preferred nutrition communication channels among adults in the Lower Mississippi Delta.

INTRODUCTION: The objective of this cross-sectional study was to examine the nutrition literacy status of adults in the Lower Mississippi Delta. METHODS: Survey instruments included the Newest Vital Sign and an adapted version of the Health Information National Trends Survey. A proportional quota sampling plan was used to represent educational achievement of residents in the Delta region. Participants included 177 adults, primarily African Americans (81%). Descriptive statistics, chi2 analysis, analysis of variance, and multivariate analysis of covariance tests were used to examine survey data. RESULTS: Results indicated that 24% of participants had a high likelihood of limited nutrition literacy, 28% had a possibility of limited nutrition literacy, and 48% had adequate nutrition literacy. Controlling for income and education level, the multivariate analysis of covariance models revealed that nutrition literacy was significantly associated with media use for general purposes (F = 2.79, P = .005), media use for nutrition information (F = 2.30, P = .04), and level of trust from nutrition sources (F = 2.29, P = .005). Overall, the Internet was the least trusted and least used source for nutrition information. Only 12% of participants correctly identified the 2005 MyPyramid graphic, and the majority (78%) rated their dietary knowledge as poor or fair. CONCLUSION: Compared with other national surveys, rates of limited health literacy among Delta adults were high. Nutrition literacy status has implications for how people seek nutrition information and how much they trust it. Understanding the causes and consequences of limited nutrition literacy may be a step toward reducing the burden of nutrition-related chronic diseases among disadvantaged rural communities.

Community--academia partnerships to promote nutrition in the lower Mississippi delta: community members' perceptions of effectiveness, barriers, and factors related to success.

This study examined the perceptions of community members' engaged in community-academia partnerships involved in developing nutrition interventions in three communities in the Lower Mississippi Delta. Perceptions on effectiveness of the partnerships were investigated. Six focus group interviews were conducted, with 33 participants that included 27 females and 6 males. The data were analyzed by content coding. Emerging themes were identified and related to accomplishments, barriers to success, and factors related to success of the partnerships. Accomplishments included the establishment of active committees, positive changes in health behavior related to food choices, and participation in community events. Barriers to success included the slow pace of intervention implementation, difficulties with understanding the role of the community in the participatory research process, the decision-making processes, and project name recognition. Factors related to success were tangible benefits to the community, participation that was representative, simplification of the research process, and the decision-making processes.

Children's experiences of food insecurity can assist in understanding its effect on their well-being.

An understanding of the experience of food insecurity by children is essential for better measurement and assessment of its effect on children's nutritional, physical, and mental health. Our qualitative study explored children's perceptions of household food insecurity to identify these perceptions and to use them to establish components of children's food insecurity experience. Children (n = 32; 11-16 y old) from after school programs and a middle school in low-income areas participated in individual semistructured in-depth interviews. Children as young as 11 y could describe behaviors associated with food insecurity if they had experienced it directly or indirectly. Using the constant comparative method of qualitative data analysis, children's descriptions of behaviors associated with food insecurity were categorized into components of quantity of food, quality of food, psychological aspects, and social aspects described in the household food insecurity literature. Aspects of quantity included eating less than usual and eating more or eating fast when food was available. Aspects of quality included use of a few kinds of low-cost foods. Psychological aspects included worry/anxiety/sadness about the family food supply, feelings of having no choice in the foods eaten, shame/fear of being labeled as poor, and attempts to shield children. Social aspects of food insecurity centered on using social networks to acquire food or money and social exclusion. These results provide valuable information in understanding the effect of food insecurity on children's well-being especially relative to the social and emotional aspects of well-being.

Food security of older children can be assessed using a standardized survey instrument.

Cognitive interviewing methods were used to adapt questions from the U.S. Food Security Survey Module for administration to children. Individual concurrent probing techniques using standardized probes were utilized to assess understanding of the items with 20 African American children (10 males, 10 females, aged 11-13 y). Item wording and response sets were revised, and small groups of boys (n = 5) and girls (n = 14) aged 12-15 y were asked to complete the 9-item survey. Retrospective probing techniques were then used to assess comprehension of items and response sets. Nine items were then piloted in a middle school using a self-administered format. Three hundred forty-five surveys were returned. The majority of the students were between 12 and 15 y (n = 215). Scaling analysis of the 345 completed surveys using statistical methods based on the Rasch measurement model indicated that the module measured a single underlying phenomenon (food insecurity) with sufficient reliability to be a useful tool. The measurable range of food insecurity was about 6 times the estimated measurement error, indicating that the scale could identify 3 categories of food security with reasonable reliability. A survey instrument that reliably measures food security status of individual children can provide researchers with an important tool to assess more accurately the individual-level effects of food security on nutritional status and mental and physical health among this population.