Proposal of a short-form version of the Brazilian Food Insecurity Scale

Rev Súde Públic 2014;48(5):783-789 Originl Articles DOI:10.1590/S0034-8910.2014048005195 Leonrdo Pozz dos Sntos I Ivn Lorine Lindemnn II Jnín Vieir dos Sntos Mott I,III Gicele Mintem II Elin Bender II Denise Petrucci Gignte I Proposl of short-form version of the Brzilin Food Insecurity Scle Propost de versão curt d Escl Brsileir de Insegurnç Alimentr ABSTRACT I Progrm de Pós-Grdução em Epidemiologi. Universidde Federl de Pelots. Pelots, RS, Brsil II Fculdde de Nutrição. Universidde Federl de Pelots. Pelots, RS, Brsil III Progrm de Pós-Grdução em Súde e Comportmento. Universidde Ctólic de Pelots. Pelots, RS, Brsil Correspondence: Leonrdo Pozz dos Sntos Ru Mrechl Deodoro, 1160 3 piso Centro Cix Postl 464 96020-220 Pelots, RS, Brsil E-mil: leonrdo_pozz@yhoo.com.br OBJECTIVE: To propose short version of the Brzilin Food Insecurity Scle. METHODS: Two smples were used to test the results obtined in the nlyses in two distinct scenrios. One of the studies ws composed of 230 low income fmilies from Pelots, RS, Southern Brzil, nd the other ws composed of 15,575 women, whose dt were obtined from the 2006 Ntionl Survey on Demogrphy nd Helth. Two models were tested, the first contining seven questions, nd the second, the five questions tht were considered the most relevnt ones in the concordnce nlysis. The models were compred to the Brzilin Food Insecurity Scle, nd the sensitivity, specificity nd ccurcy prmeters were clculted, s well s the kpp greement test. RESULTS: Compring the prevlence of food insecurity between the Brzilin Food Insecurity Scle nd the two models, the differences were round 2 percentge points. In the sensitivity nlysis, the short version of seven questions obtined 97.8% nd 99.5% in the Pelots smple nd in the Ntionl Survey on Demogrphy nd Helth smple, respectively, while specificity ws 100% in both studies. The five-question model showed similr results (sensitivity of 95.7% nd 99.5% in the Pelots smple nd in the Ntionl Survey on Demogrphy nd Helth smple, respectively). In the Pelots smple, the kpp test of the seven-question version totled 97.0% nd tht of the five-question version, 95.0%. In the Ntionl Survey on Demogrphy nd Helth smple, the two models presented 99.0% kpp. CONCLUSIONS: We suggest tht the model with five questions should be used s the short version of the Brzilin Food Insecurity Scle, s its results were similr to the originl scle with lower number of questions. This version needs to be dministered to other popultions in Brzil in order to llow for the dequte ssessment of the vlidity prmeters. DESCRIPTORS: Food Security. Scles. Questionnires, utiliztion. Vlidtion Studies. Received: 10/18/2013 Approved: 5/12/2014 Article vilble from: www.scielo.br/rsp

784 Reduced food insecurity scle Sntos LP et l RESUMO OBJETIVO: Propor versão curt d Escl Brsileir de Insegurnç Alimentr. Form nlisdos dois estudos constituídos por mostr de 230 fmílis de bix rend, de Pelots, RS, e de 15.575 mulheres com bse nos ddos d Pesquis Ncionl de Demogrfi e Súde, de 2006. MÉTODOS: Form utilizds dus mostrs pr testr os resultdos obtidos ns nálises em dois cenários distintos. Um dos estudos foi composto por 230 fmílis de bix rend, de Pelots, RS, e o outro, por 15.575 mulheres, cujos ddos form obtidos n Pesquis Ncionl de Demogrfi e Súde de 2006. Form testdos dois modelos, o primeiro contendo sete questões e o segundo s cinco considerds mis relevntes n nálise de concordânci. Os modelos form comprdos à Escl Brsileir de Insegurnç Alimentr, clculndo-se os prâmetros de sensibilidde, especificidde e curáci e o teste de concordânci de kpp. RESULTADOS: Comprndo s prevlêncis de insegurnç limentr entre Escl Brsileir de Insegurnç Alimentr e os dois modelos, s diferençs ficrm em torno de dois pontos percentuis. N nálise de sensibilidde, versão curt de sete questões obteve 97,8% e 99,5% n mostr de Pelots e d PNDS, respectivmente, enqunto especificidde foi de 100% em mbos os estudos. O modelo de cinco questões mostrou resultdos semelhntes (sensibilidde de 95,7% e 99,5% n mostr de Pelots e d PNDS, respectivmente). A versão de sete questões presentou teste de kpp de 97,0% e versão de cinco questões, de 95,0%, n mostr de Pelots. Já n mostr d PNDS, os dois modelos presentrm kpp de 99,0%. CONCLUSÕES: Sugere-se o modelo com cinco questões pr ser utilizdo como versão curt d Escl Brsileir de Insegurnç Alimentr, visto que presentou resultdos semelhntes à escl originl com menor número de questões. É necessário que ess versão sej plicd em outrs populções do Brsil, de form permitir dequd vlição dos prâmetros de vlidde. DESCRITORES: Segurnç Alimentr e Nutricionl. Escls. Questionários, utilizção. Estudos de Vlidção. INTRODUCTION The fulfilment of the right to regulr nd permnent ccess to sufficient mounts of high-qulity foods without hindering the ccess to other essentil needs is known s food security. Food insecurity levels rnge from worry nd nguish brought by the uncertinty of hving food regulrly to lck of food.,b An instrument tht ssesses food insecurity ws developed in the 1990s in the United Sttes. 7 Subsequently, it ws modified nd dpted in mny countries. 1,2,6,8 To id studies of shorter durtion nd/or lower finncil resources, Blumberg et l developed scle with six questions, bsed on the originl North Americn version. 4 Brzil lso hs n dpttion of the scle, known s Escl Brsileir de Insegurnç Alimentr (EBIA Brzilin Food Insecurity Scle), which hs been duly vlidted for the popultion nd brodly used. 3,9,16 However, some surveys do not use the EBIA due to the lrge number of questions nd to the cost involved in dministering them. Ntionl surveys hve proposed to use the North Americn scle with six questions to investigte the food insecurity sitution, 11,12 but Lei nº 11.346, de 15 de setembro de 2006. Cri o Sistem Ncionl de Segurnç Alimentr e Nutricionl SISAN com vists em ssegurr o direito humno à limentção dequd e dá outrs providêncis. Brsíli (DF); 2006. Artigo 3. [cited 2014 Jul 6]. Avilble from: http://www.plnlto.gov.br/ccivil_03/_to2004-2006/2006/lei/l11346.htm b Bickel GW, Nord M, Price C, Hmilton W, Cook J. Mesuring food security in the United Sttes: guide to mesuring household food security. Rev. ed. Alexndri: U. S. Deprtment of Agriculture; 2000 [cited 2014 Jul 7]. Avilble from: http://www.fns.usd.gov/fsec/files/fsguide.pdf

Rev Súde Públic 2014;48(5):783-789 785 study crried out in the city of Pelots, RS, Southern Brzil, verified tht there is no stisfctory concordnce between the EBIA nd this scle. 13 This study imed to propose short version of the Brzilin Food Insecurity Scle. METHODS Two smples were used in this study. The first ws composed of 230 low income fmilies living in the city of Pelots nd the second ws composed of 15,575 women of childbering ge, ged 15 to 49 yers, whose dt were obtined from the 2006 Pesquis Ncionl de Demogrfi e Súde (PNDS Ntionl Survey on Demogrphy nd Helth). c The Pelots smple is prt of cross-sectionl study crried out between April nd October 2011 in the ctchment re of the Unidde de Súde d Fmíli (USF Fmily Helth Unit) of neighborhood locted on the periphery of the city. 13 This study imed to vlidte the short version of the food insecurity scle proposed by Bickel et l b (2000) nd it ws trgeted t the fmilies tht lived in tht neighborhood. The second smple (PNDS) nlyzed the helth of women of reproductive ge nd of children younger thn five yers. Complementry informtion on the methodology cn be obtined from the bove-mentioned studies. 13,c The two smples were used to test the results of the nlysis in different scenrios, which mde the conclusions more robust. In both smples, the EBIA ws dministered to the person responsible for food in the household. The questions referred to the period of three months prior to the interview. To ech ffirmtive nswer, the vlue 1 ws ssigned. The scle dministered in PNDS ws different from the originl EBIA in terms of the number of questions: 16 in the PNDS nd 15 in the originl one. This did not influence the nlysis, s this chnge originted from the division of question 5 in two questions, which were subsequently regrouped in the nlysis. In both studies, to clssify food security/insecurity, the score ws clculted by considering the number of positive nswers in ech item of the scle, ccording to the household s ge composition. Only eight questions pplied to households without individuls younger thn 18 yers. Therefore, the mximum score tht could be chieved would be eight. For households with individuls younger thn 18 yers, the complete questionnire ws dministered, with mximum score of 15. The EBIA s score criterion nd cut-off point llows for the division in four ctegories nd three levels of intensity food security (FD), mild, moderte nd severe food insecurity, ttributed ccording to the presence or bsence of individuls younger thn 18 yers in the household. As the short version proposed here must serve s food insecurity trcker mong fmilies nd must function in the sme wy for households with nd without individuls younger thn 18 yers, the questions of the scle referring to this ge group were excluded from the proposed scle. In the lst Technicl Workshop for the Anlysis of the Household Mesurement Scle of Food Insecurity, d the exclusion of the ssocition between weight loss nd food insecurity ws pproved, s well s the exclusion of repetitive item: question 9. After these exclusions, seven questions remined from the originl scle. Bsed on these seven questions, two short-scle models for food insecurity ssessment were tested. The first contined the seven questions (Tble 1A). To construct the second model, concordnce nlysis ws performed with the full scle, tht is, we investigted which questions hd the highest proportions of positive nswers mong fmilies with food insecurity. After the nlysis, the second model ws composed of the five questions tht were considered most relevnt regrding concordnce with the full scle (Tble 1B). To compre the proposed models with the full version of the EBIA, initilly, the concordnce of positive nswers of fmilies with food insecurity ws nlyzed in ech remining question, so s to detect the most relevnt questions in the identifiction of food insecurity. Subsequently, the models (of seven nd five questions) were compred to the EBIA, which is considered the gold stndrd. The following prmeters were clculted: sensitivity proportion of individuls with food insecurity, through the EBIA, with positive result in the short versions, specificity proportion of individuls without food insecurity nd with negtive result in the short versions, nd ccurcy the proposed model s probbility of being in ccordnce with the gold stndrd for ll the studied individuls. In ddition, n greement test (kpp index) ws performed. 5 The nlyses were crried out in the Stt progrm, version 12.0 (Stt Corp., College Sttion, United Sttes). Due to the fct tht the PNDS dtbse hs complex smple design, ll the estimtes were weighted, considering the design effect nd lso the clibrtion ccording to estimtes of the Brzilin popultion, by mens of the svy commnd. c Ministério d Súde, Centro Brsileiro de Análise e Plnejmento. Pesquis Ncionl de Demogrfi e Súde d Crinç e d Mulher. Brsíli (DF); 2008. Avilble from: http://bvsms.sude.gov.br/bvs/pnds/img/reltorio_finl_pnds2006.pdf d Ministério do Desenvolvimento Socil e Combte à Fome, Secretri de Avlição e Gestão d Informção. Reltório d Oficin Técnic pr Análise d Escl de Medid Domicilir d Insegurnç Alimentr. Brsíli (DF); 2010. (Not Técnic, 128).

786 Reduced food insecurity scle Sntos LP et l Tble 1. Proposls for food insecurity scle tht is reduced version of the Brzilin Food Insecurity Scle. Pelots, RS, Southern Brzil, 2013. (A) Proposl with seven questions 1) In the lst 3 months, were you worried tht the food in your home would end before you could buy, receive or produce more food? 2) In the lst 3 months, did the food end before you hd money to buy more? 3) In the lst 3 months, did you run out of money nd you could not hve helthy nd vried diet? 4) In the lst 3 months, did you or n dult in your home reduce the mount of food in your mels, or skip mels, becuse there ws not enough money to buy food? 5) In the lst 3 months, did you et less thn you thought you should becuse there ws not enough money to buy food? 6) In the lst 3 months, did you feel hungry but did not et becuse you could not buy enough food? 7) In the lst 3 months, did you or ny other dult in your home spend one entire dy without eting or hd only one mel per dy becuse there ws no money to buy food? (B) Proposl with five questions 1) In the lst 3 months, were you worried tht the food in your home would end before you could buy, receive or produce more food? 2) In the lst 3 months, did the food end before you hd money to buy more? 3) In the lst 3 months, did you run out of money nd could not hve helthy nd vried diet? 4) In the lst 3 months, did you or n dult in your home reduce the mount of food in your mels, or skip mels, becuse there ws not enough money to buy food? 5) In the lst 3 months, did you et less thn you thought you should becuse there ws not enough money to buy food? RESULTS In the Pelots smple, 58.3% of the heds of households who were interviewed were men. Less thn 20.0% hd nine or more yers of schooling nd lmost 75.0% ws younger thn 60 yers. In the PNDS smple, lmost hlf lived in the Southest of Brzil nd pproximtely 40.0% hd nine or more yers of schooling. As for food insecurity mesured by the EBIA, we observed prevlence of more thn 60.0% in the first smple nd pproximtely 40.0% in the PNDS smple. Figure A shows the questions with the highest number of positive nswers in fmilies with food insecurity (questions 1, 2, 3, 5 nd 6). When this nlysis ws performed in the PNDS dtbse, the sme result ws obtined (Figure B). Bsed on these results, we rrived t the five-question version composed of questions 1, 2, 3, 5 nd 6 of the EBIA. Tble 1 shows the short version bsed on seven questions of the EBIA (A) nd the short version bsed on five questions (B). When we compred the prevlence of food insecurity tht ws found using the two proposed models with the EBIA, we observed tht, while the full scle found prevlence of pproximtely 60.0% in the Pelots smple, the short version with seven questions showed prevlence of 59.0% nd the version with five questions, 58.0%. In the PNDS smple, the following prevlences were found: 39.0% by the full scle, 38.8% by the one with seven questions nd 38.1% by the version with five questions (Tble 2). In the sensitivity nd specificity nlysis, the short version with seven questions presented excellent results when the sme cut-off point dopted by the EBIA to clssify food insecurity ws considered (one positive nswer or more). Sensitivity ws close to 98.0% for the Pelots smple nd lmost 100% for the PNDS. In ddition, the result with highest ccurcy is the cut-off point equl to 1, which clssified correctly lmost 100% of the individuls in both smples (Tble 3). Similr results were found in the proposed model with five questions. The cut-off point with best results ws, once gin, the sme recommended by the trditionl version. Furthermore, it ws verified tht, for the Pelots nd the PNDS smples, sensitivity ws 95.7% nd 98.1%, respectively, nd specificity ws 100% in both. Once more, for this cut-off point, ccurcy ws very high: 97.0% for the Pelots smple nd close to 100% for the PNDS smple (Tble 4). In the kpp sttisticl nlysis, both the proposed models presented high greement with the full version of the food insecurity scle, both in the Pelots smple nd in the 2006 PNDS smple. In the former, the sevenquestion version presented n greement of 97.0%, nd the five-question version, of 95.0%. In the PNDS, both proposls presented n greement of 99.0%. DISCUSSION Independently of the size of the proposed short version, both models showed high sensitivity nd specificity when compred to the EBIA, method tht is considered the gold stndrd. In ddition, the proposed models were ccurte when they mesured the prevlence of food insecurity, nd their results were similr to those found by the originl version. We highlight tht this is the first study tht proposes short version to mesure food insecurity bsed on the EBIA. Since its vlidtion in 2004, the EBIA hs been used in ntionl surveys to mesure fmilies food insecurity level. 15,c,e This scle ids policies tht fight hunger e Instituto Brsileiro de Geogrfi e Esttístic. Pesquis Ncionl por Amostr de Domicílios: 2006. Rio de Jneiro; 2007. v.27.

Rev Súde Públic 2014;48(5):783-789 787 100 A 100 B 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Question 1 Question 2 Question 3 Question 5 Question 6 Question 7 Question 9 See Tble 1. Question 1 Question 2 Question 3 Question 5 Question 6 Question 7 Question 9 Figure. Percentge of positive nswers mong fmilies with food insecurity in the questions tht remined in the proposl for short version bsed on the Brzilin Food Insecurity Scle; (A) Pelots smple, (B) smple of the 2006 Ntionl Survey on Demogrphy nd Helth. Pelots, RS, Southern Brzil, 2013. Tbel 2. Prevlence of food insecurity ccording to the Brzilin Food Insecurity Scle nd to the two short version proposls in two smples. Pelots, RS, Southern Brzil, 2013. Vrible Pelots smple PNDS-2006 smple n % n % EBIA Food security 91 39.6 8,998 61.0 Food insecurity 139 60.4 6,577 39.0 EBIA b Food security 94 40.9 9,034 61.2 Food insecurity 136 59.1 6,541 38.8 EBIA c Food security 97 42.2 9,121 61.9 Food insecurity 133 57.8 6,454 38.1 EBIA: Escl Brsileir de Insegurnç Alimentr (Brzilin Food Insecurity Scle) Full scle. b Seven questions (see Tble 1). c Five questions (see Tble 1). nd ssesses people s perception of foods nd lso the vilbility of foods in the household. 14,15 Considering the importnce of verifying nd/or monitoring the food sitution, 14 using shorter scle bsed on the EBIA itself nd not on instruments tht hve not been vlidted for the Brzilin popultion cn fcilitte the mesurement of food insecurity nd the development of studies tht hve little time or insufficient resources to dministrte the full scle. However, food insecurity is not esily mesured, s diverse fctors re ssocited with this condition, such s skin color, level of schooling nd gender of the person of reference in the household, f,g nd must be considered in the ssessment. The short version models proposed here do not im to replce the EBIA, s they do not mesure the degrees of intensity of food insecurity nd do not detect fmilies tht live in hunger sitution, which is chrcterized by scenrio of f Instituto Brsileiro de Geogrfi e Esttístic. Pesquis Ncionl de Amostr de Domicílios 2009: Segurnç Alimentr 2004/2009. Rio de Jneiro: IBGE; 2010. g Ministério do Desenvolvimento Socil. Plno Ncionl de Segurnç Alimentr e Nutricionl: 2012/2015. Brsíli (DF): Câmr Interministeril de Segurnç Alimentr e Nutricionl; 2011.

788 Reduced food insecurity scle Sntos LP et l Tble 3. Sensitivity nd specificity of the short version of the Brzilin Food Insecurity Scle, with seven questions. Pelots, RS, Southern Brzil, 2013. Cut-off points Sensitivity Specificity Accurcy % % % Pelots smple 1 97.8 100 98.7 2 65.5 100 79.1 3 48.2 100 68.7 4 19.4 100 51.3 5 12.2 100 46.9 6 5.8 100 43.0 7 0 100 39.6 PNDS 1 99.5 100 99.8 2 77.7 100 90.6 3 59.9 100 83.1 4 31.9 100 71.3 5 21.9 100 67.0 6 12.9 100 63.2 7 0 100 57.8 See Tble 1. severe food insecurity. The first scle tht proposed to mesure the household food insecurity level ws creted t the beginning of the 1990s in the United Sttes of Americ. h Constituted of 18 questions, it encompsses ll the food insecurity severity levels observed in households with nd without children. f Subsequently, in 1999, short version of the North Americn scle ws developed contining six questions, with the im of building quicker nd cheper lterntive to ssess food insecurity. 4 The differentil of the present study ws the use of two smples, one from poor re of medium-sized city in Brzil, nd the other, representtive of Brzilin women of childbering ge, which mde the nlysis become more robust. However, some limittions of the proposed instrument re: the impossibility of cpturing other cuses of food insecurity, such s the unvilbility of dequte mounts of food in certin community, neighborhood nd/or region; the beliefs tht restrict the consumption of vilble foods or some people s lower ccess to foods; 4 incpcity for distinguishing between households with nd without individuls younger thn Tble 4. Sensitivity nd specificity of the short version of the Brzilin Food Insecurity Scle, with five questions. Pelots, RS, Southern Brzil, 2013. Cut-off points Sensitivity Specificity Accurcy % % % Pelots smple 1 95.7 100 97.4 2 58.9 100 75.2 3 29.5 100 57.4 4 12.2 100 46.9 5 0 100 39.6 PNDS 1 99.5 100 99.7 2 77.5 100 90.5 3 59.2 100 82.8 4 25.7 100 68.6 5 0 100 57.8 See Tble 1. 18 yers; higher risk of food insecurity; nd, like the EBIA, incpcity for cpturing the food insecurity mesure in n individul wy, s it reflects reltive mesure of the sitution experienced by ll the individuls in the sme household. Given the bove-mentioned circumstnces nd resons, we suggest the use of the proposed model with five questions, s its results were very similr to the originl scle but with lower number of questions compred to the proposed model with seven questions. In certin cses, like studies with very lrge smples, 14 questions increse the nswering time; thus, the short version of the instrument will llow trcking the fmilies in food insecurity sitution. If there is interest in verifying the food insecurity intensity degrees, the full scle cn be subsequently dministered only to the fmilies clssified with food insecurity by the short version. Furthermore, mny studies hve used food insecurity in dichotomous wy (presence or bsence), nd, long this line, the short version is lso n option of instrument. To conclude, it is necessry to pply the short version with five questions to popultion-bsed studies, in popultions from different regions of Brzil, in order to ttest its use s food insecurity trcker nd id studies tht investigte this condition, s well s the progrms tht im to combt this problem. h Hmilton WL, Cook JT, Thompson WW, Buron LF, Frongillo EA, Olson CM, et l. Household food security in the United Sttes in 1995: technicl report of the Food Security Mesurement Project. Alexndri (VA): US Deprtment of Agriculture, Food nd Consumer Service; 1997.

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