Prevalence of Perceived Food and Housing Security — 15 States, 2013

Recent global (1) and national (2,3) health equity initiatives conclude that the elimination of health disparities requires improved understanding of social context (4,5) and ability to measure social determinants of health, including food and housing security (3). Food and housing security reflect the availability of and access to essential resources needed to lead a healthy life. The 2013 Behavioral Risk Factor Surveillance System (BRFSS) included two questions to assess perceived food and housing security in 15 states.* Among 95,665 respondents, the proportion who answered “never or rarely” to the question “how often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?” ranged from 68.5% to 82.4% by state. Among 90,291 respondents living in housing they either owned or rented, the proportion who answered “never or rarely” to the question, “how often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?” ranged from 59.9% to 72.8% by state. Food security was reported less often among non-Hispanic blacks (blacks) (68.5%) and Hispanics (64.6%) than non-Hispanic whites (whites) (81.8%). These racial/ethnic disparities were present across all levels of education; housing security followed a similar pattern. These results highlight racial/ethnic disparities in two important social determinants of health, food and housing security, as well as a substantial prevalence of worry or stress about food or housing among all subgroups in the United States. The concise nature of the BRFSS Social Context Module’s single-question format for food and housing security makes it possible to incorporate these questions into large health surveys so that social determinants can be monitored at the state and national levels and populations at risk can be identified.

BRFSS is an ongoing surveillance system designed to measure behavioral risk factors for the noninstitutionalized adult population aged ≥18 years residing in the United States.^† Two questions on perceived food and housing security were added to the BRFSS in 15 states in 2013. Respondents were asked how often they were worried or stressed in the last 12 months about having enough money to buy nutritious meals or pay rent or mortgage. Persons who responded “never or rarely” were considered secure; persons who responded “sometimes,” “usually,” or “always” were considered insecure. The food security question is a simplified version of the U.S. Department of Agriculture’s (USDA’s) Current Population Survey food security supplement (CPS-FSS) measure that has been used by USDA since 1995 to measure national estimates of food security (6). The BRFSS-based measure of food security was compared with the CPS-FSS measure by calculating the correlation between the estimated prevalence of food security in the 12 states that implemented the Social Context Module in 2009 with the average estimated prevalence of food security in those same states during 2008–2010. These two measures were highly correlated (r = 0.71; p<0.01; Mark Nord, USDA, personal communication, June 6, 2012). The 2009 state-specific BRFSS-measured estimates were lower on average by approximately 5 percentage points than the 2008–2010 CPS-FSS estimates for food security; the BRFSS estimates show slightly higher perceptions of stress from being food insecure. The 2009 BRFSS-based measure of housing security in the 12 states was compared with the U.S. Census Bureau’s measure of housing affordability during 2007–2011 (i.e., the percentage of households with housing costs <30% of income). These two measures correlated highly (r = 0.71; p<0.01). Prevalence estimates were weighted to the age, sex, and racial/ethnic distribution of the 2013 intercensal estimates.

The 15 states included in this study represent approximately one third of the total U.S. population. Response rates for the 15 states ranged from 35.2% to 54.3% (median = 46.5%). BRFSS estimates of the prevalence of perceived food security varied by state, ranging from 68.5% (Arkansas) to 82.4% (Minnesota). Estimates of the prevalence of perceived housing security among respondents who owned or rented the housing in which they were living ranged from 59.9% (Arkansas) to 72.8% (Iowa) (Table 1); this variation persisted after controlling for age, education, and race and ethnicity. Disparities were also evident on the basis of age, sex, education level, and race and ethnicity. For example, the prevalence of food security was highest among whites (81.8%, CI = 81.2%–82.4%), lower among blacks (68.5%, CI = 66.3%–70.7%), and lowest among Hispanics (64.6%, CI = 62.5%–66.7%). The prevalence of food security was highest among persons with ≥4 years of college education (89.0%, CI = 88.3%–89.7%), lower among persons with a high school education and <4 years of college (75.7%, CI = 74.8%–76.6%), and lowest among persons with less than a high school education (59.9%, CI = 57.5%–62.1%). For each racial/ethnic group, the prevalence of food security was highest among persons with ≥4 years of college and lowest among persons with less than a high school education (Table 2). Patterns for housing security were similar.

Corresponding author: Rashid S. Njai, rnjai@cdc.gov, 770-488-5215.

¹Office of Noncommunicable Diseases, Injury and Environmental Health, CDC; ²Center for Surveillance, Epidemiology and Laboratory Services, CDC; ³Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; ⁴Division of Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

1. World Health Organization Regional Office for Europe. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008.
2. National Expert Panel on Social Determinants of Health Equity. Report of the National Expert Panel on Social Determinants of Health Equity: recommendations for advancing efforts to achieve health equity. Atlanta, GA: National Expert Panel on Social Determinants of Health Equity; 2009.
3. Office of the Surgeon General. National prevention council action plan: implementing the national prevention strategy. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2012. http://www.surgeongeneral.gov/initiatives/prevention/2012-npc-action-plan.pdfCdc-pdfExternal
4. Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic status in health research: one size does not fit all. JAMA 2005;294:2879–88. CrossRefExternal PubMedExternal
5. Shavers VL. Measurement of socioeconomic status in health disparities research. J Natl Med Assoc 2007;99:1013–23. PubMedExternal
6. Economic Research Service. Food security in the United States: data access to the current population survey food security supplement (used by USDA to monitor food security). Washington, DC: US Department of Agriculture, Economic Research Service; 2016. https://www.ers.usda.gov/data-products/food-security-in-the-united-statesExternal
7. Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099–104. CrossRefExternal PubMedExternal
8. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590–5. CrossRefExternal PubMedExternal
9. Lindsay S, Lambert J, Penn T, et al. Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities. Prev Chronic Dis 2013;10:E188. CrossRefExternal PubMedExternal
10. Office of Disease Prevention and Health Promotion. Healthy people 2020. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion; 2016. http://www.healthypeople.gov/2020/External

TABLE 1. Prevalence of perceived food security* and perceived housing security,^† by state and selected characteristics — 15 states, Behavioral Risk Factor Surveillance Survey, 2013

Abbreviation: CI = confidence interval.
* Responded “never” or “rarely” to the question, “How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?”
^† Responded “never” or “rarely” to the question, “How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?”
^§ Prevalence (%) and 95% CI were calculated using sampling weights.

TABLE 2. Prevalence of perceived food security* and housing security,^† stratified by race/ethnicity and education — 15 states,^§ Behavioral Risk Factor Surveillance Survey, 2013

Abbreviation: CI = confidence interval.
* Responded “never” or “rarely” to the question, “How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?”
^† Responded “never” or “rarely” to the question, “How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?”
^§ The 15 states include Arkansas, California, Connecticut, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Maine, Minnesota, Nebraska, Nevada, New Jersey, New Mexico, and Virginia.
^¶ Sample size is smaller than that for food security: some respondents were not asked the housing security question because they reported living in housing that did not require them to pay either rent or mortgage (e.g., living with family).