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.

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 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

Prevalence of Perceived Food and Housing Security -15 States, 2013
Rashid Njai, PhD 1 ; Paul Siegel, MD 2 ; Shaoman Yin, PhD 3 ; Youlian Liao, MD 4 * Arkansas, California, Connecticut, District of Columbia, Georgia, Iowa, Kansas, Louisiana, Maine, Minnesota, Nebraska, Nevada, New Jersey, New Mexico, Virginia. † https://www.cdc.gov/brfss/. 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 singlequestion 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 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.
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 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). 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).