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





Please note: An erratum has been published for this report. To view the erratum, please click here.

Rashid Njai, PhD1; Paul Siegel, MD2; Shaoman Yin, PhD3; Youlian Liao, MD4 (View author affiliations)

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Summary

What is already known about this topic?

The elimination of health disparities among racial/ethnic groups will require improved ability to measure and address social determinants of health, including food and housing security, which are defined as lack of stress or worry about being able to afford nutritious food and adequate housing.

What is added by this report?

In 2013, the estimated prevalence of perceived food security ranged from 68.5% to 82.4% among adult respondents in 15 participating states, and the prevalence of housing security among adults who owned or rented ranged from 59.9% to 72.8%. Food security was reported less often by non-Hispanic blacks (68.5%) and Hispanics (64.6%) than by non-Hispanic whites (81.8%). Disparities on the basis of education were consistent across all racial/ethnic groups. Approximately one fifth of college graduates reported stress or worry about having enough money to pay their rent or mortgage.

What are the implications for public health practice?

Population-based food and housing security data can help identify populations that are at risk for health disparities. These data can be used by public health professionals, health care systems and decision makers to facilitate multisectorial collaboration to develop research, policies, and programs aimed at reducing these disparities.


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.

Discussion

This report provides population-based data, from single-question measures, that identify substantial state-to-state variation in the prevalence of reported food security and housing security in 15 states. Disparities by race, ethnicity, age, sex, and education were identified, and racial/ethnic disparities persisted across each level of education. These data on two important social determinants can help identify vulnerable populations, monitor change over time, and evaluate interventions intended to reduce health disparities in food and housing security.

Lack of food and housing security creates a social context that causes material hardship and psychosocial stress that can harm health (7). Differences in social context are related to increased risk for poor health outcomes, such as cardiovascular disease and some cancers as well as other health risk factors, including obesity, tobacco or alcohol use, and adverse childhood experiences (5,8). Food and housing security are examples of actionable social determinants. The Surgeon General’s National Prevention Council Action Plan, for instance, emphasizes that increasing access to affordable healthy foods and safe, affordable housing are important strategies to support sustainable healthy communities. Establishing farmers’ markets, farm stands, and community gardens in disadvantaged neighborhoods can improve food security by increasing access to affordable healthy foods at lower cost or with alternative payment options (e.g., electronic benefits transfer discounts) and alleviating the costs associated with traveling to obtain these foods (9). These community-level interventions can be implemented in concert with policy-level improvements; for example, electronic benefits transfers can be used to provide beneficiaries of the Women, Infants and Children and Supplemental Nutrition Assistance programs with greater access and incentives to purchase healthy and nutritious foods (3,9). Coordination of investments, such as the Social Innovation Fund, AmeriCorps, and Partnership for Sustainable Communities, to provide vulnerable communities with access to affordable and safe housing is an example of a policy intervention to support housing security and prevent homelessness (3). The National Prevention Council Action Plan states that public health initiatives related to both food and housing security should be conducted in concert with other relevant lead agencies such as the USDA and the Department of Housing and Urban Development.

Achieving health equity by improving food and housing security is a major objective of CDC’s Division of Community Health (DCH) programs, such as Partnerships to Improve Community Health and Racial and Ethnic Approaches to Community Health.§ With support from DCH, many communities are working to make healthy food choices easier for persons who live in food deserts (parts of a community offering little to no fresh fruit, vegetables, and other healthy whole foods), with emphasis on increased access to healthy, affordable foods and alternative payment options (9). These initiatives are examples of policy, systems, or environmental approaches that create opportunities for health and maximize the ability of all segments of the population to achieve optimal health. The overarching strategy is to change the community context to make the healthy choice the default choice (8).

Deciding where to target interventions and determining which interventions have the most impact on reducing health disparities will require an improved understanding of social determinants (2). The BRFSS food and housing security questions could play an important role in three ways: monitoring food and housing security over time, identifying vulnerable populations that are highest priority for intervention, and evaluating the effectiveness of these interventions. The concise nature of the Social Context Module’s single-question format for food and housing security makes it possible to incorporate these questions into large health surveys to conduct nationwide monitoring of social determinants.

The findings in this report are subject to at least five limitations. First, data are self-reported, and therefore subject to recall and social desirability biases. Second, the single-item food security question does not account for the four conceptual domains measured in the USDA food security supplement survey (i.e., anxiety about food shortages, actual food shortages, concerns about dietary quality, and differences between adult and child food quality and adequacy). Third, the study includes data from only 15 states, so the results are not necessarily nationally representative. Fourth, because response rates for all states were <60% there is possibility of nonresponse bias. Finally, no adjustment was made for income, although education and income are strongly correlated.

The critical role of social determinants of health, such as food and housing security, in the elimination of health disparities has been emphasized by the World Health Organization (1), CDC’s National Expert Panel on Social Determinants of Health Equity (2), and the Surgeon General’s National Prevention Council Action Plan (3), as well as Healthy People 2020 (10). Progress toward achieving health equity can be facilitated by initiatives to reduce disparities within and between communities in social determinants of health such as food and housing security (10).


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.


* Arkansas, California, Connecticut, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Maine, Minnesota, Nebraska, Nevada, New Jersey, New Mexico, Virginia.

https://www.cdc.gov/brfss/.

§ https://www.cdc.gov/nccdphp/dch/programs/index.htm.

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.pdf
  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. CrossRef PubMed
  5. Shavers VL. Measurement of socioeconomic status in health disparities research. J Natl Med Assoc 2007;99:1013–23. PubMed
  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-states
  7. Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099–104. CrossRef PubMed
  8. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590–5. CrossRef PubMed
  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. CrossRef PubMed
  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/
Return to your place in the textTABLE 1. Prevalence of perceived food security* and perceived housing security, by state and selected characteristics — 15 states, Behavioral Risk Factor Surveillance Survey, 2013
Characteristic Food secure Housing secure
No. % (95% CI)§ No. % (95% CI)§
Overall 95,665 76.9 (76.3–77.6) 90,291 65.6 (64.9–66.4)
Age group (yrs)
18–24 4,606 73.7 (71.3–76.0) 3,630 63.4 (60.4–66.3)
25–34 9,068 70.0 (68.0–71.8) 8,498 57.9 (55.8–60.0)
35–44 11,918 72.8 (71.1–74.4) 11,472 59.7 (57.8–61.6)
45–54 16,767 75.0 (73.7–76.4) 16,043 61.5 (59.9–63.2)
55–64 22,273 78.9 (77.3–80.3) 21,276 66.7 (65.0–68.4)
≥65 31,033 88.9 (88.0–89.7) 29,372 82.2 (80.8–83.5)
Sex
Male 38,706 80.1 (79.1–81.0) 36,548 68.8 (67.6–69.9)
Female 56,959 73.9 (73.0–74.8) 53,743 62.7 (61.7–63.7)
Race/Ethnicity
White, non-Hispanic 72,935 81.8 (81.2–82.4) 69,111 71.6 (70.9–72.3)
Black, non-Hispanic 8,936 68.5 (66.3–70.7) 8,312 56.3 (54.0–58.7)
Hispanic 7,901 64.6 (62.5–66.7) 7,449 52.7 (50.4–55.0)
Other 4,656 80.7 (77.9–83.2) 4,335 65.6 (61.8–69.2)
Education
<High school 7,527 59.9 (57.5–62.1) 6,911 48.2 (45.7–50.7)
High school to 3 yrs college 52,078 75.7 (74.8–76.6) 48,727 64.0 (62.9–65.0)
≥4 yrs college 35,861 89.0 (88.3–89.7) 34,511 78.6 (77.5–79.6)
State
Arkansas 4,638 68.5 (66.5–70.5) 4,388 59.9 (57.8–62.0)
California 5,935 77.3 (75.7–78.7) 5,682 65.1 (63.3–66.8)
Connecticut 6,784 77.2 (75.7–78.7) 6,447 67.1 (65.3–68.8)
District of Columbia 4,169 79.6 (77.4–81.7) 3,995 71.6 (69.2–74.0)
Georgia 6,864 73.8 (72.3–75.2) 6,365 62.6 (61.0–64.3)
Iowa 3,654 82.0 (80.1–83.7) 3,497 72.8 (70.7–74.8)
Kansas 9,942 80.3 (79.2–81.3) 9,375 72.7 (71.5–73.9)
Louisiana 4,845 74.3 (72.1–76.3) 4,322 67.7 (65.3–70.1)
Maine 4,636 76.3 (74.6–77.9) 4,410 65.5 (63.7–67.3)
Minnesota 12,646 82.4 (81.1–83.6) 12,118 72.7 (71.1–74.1)
Nebraska 7,828 81.0 (79.4–82.4) 7,324 71.2 (69.5–72.9)
Nevada 4,485 75.8 (73.2–78.3) 4,280 62.2 (59.3–65.0)
New Jersey 3,867 77.3 (75.2–79.4) 3,635 62.0 (59.5–64.3)
New Mexico 8,114 72.0 (70.5–73.5) 7,664 62.2 (60.6–63.8)
Virginia 7,258 76.8 (75.4–78.1) 6,789 66.3 (64.7–67.8)

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.

Return to your place in the textTABLE 2. Prevalence of perceived food security* and housing security, stratified by race/ethnicity and education — 15 states,§ Behavioral Risk Factor Surveillance Survey, 2013
Race/Ethnicity Education Food secure Housing secure
No. % (95% CI) No. % (95% CI)
White, non-Hispanic <High school 3,640 65.2 (62.3–68.1) 3,298 52.7 (49.4–55.9)
High school to 3 yrs college 39,615 79.2 (78.3–80.0) 37,202 68.6 (67.5–69.6)
≥4 yrs college 29,570 91.2 (90.5–91.7) 28,528 81.7 (80.7–82.5)
Black, non-Hispanic <High school 1,182 58.3 (52.1–64.2) 1,082 44.2 (37.7–50.8)
High school to 3 yrs college 5,245 67.3 (64.5–70.1) 4,836 55.8 (52.8–58.8)
≥4 yrs college 2,490 82.1 (79.2–84.6) 2,379 68.7 (64.8–72.4)
Hispanic <High school 2,143 55.3 (51.5–59.0) 2,016 45.3 (41.4–49.3)
High school to 3 yrs college 4,237 69.5 (66.8–72.1) 3,975 55.9 (52.9–59.0)
≥4 yrs college 1,502 79.8 (75.1–83.9) 1,441 68.0 (63.0–72.6)
Other <High school 411 77.3 (67.7–84.6) 380 61.8 (47.8–74.1)
High school to 3 yrs college 2,384 74.3 (69.3–78.8) 2,180 57.1 (50.9–63.1)
≥4 yrs college 1,848 87.8 (84.5–90.4) 1,765 75.0 (70.3–79.1)

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).

Suggested citation for this article: Njai R, Siegel P, Yin S, Liao Y. Prevalence of Perceived Food and Housing Security — 15 States, 2013. MMWR Morb Mortal Wkly Rep 2017;66:12–15. DOI: http://dx.doi.org/10.15585/mmwr.mm6601a2.

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