key: cord-0683420-wi7ocvgt authors: Kleve, Sue; Bennett, Christie J.; Davidson, Zoe E.; Kellow, Nicole J.; McCaffrey, Tracy A.; O’Reilly, Sharleen; Enticott, Joanne; Moran, Lisa J.; Harrison, Cheryce L.; Teede, Helena; Lim, Siew title: Food Insecurity Prevalence, Severity and Determinants in Australian Households during the COVID-19 Pandemic from the Perspective of Women date: 2021-11-26 journal: Nutrients DOI: 10.3390/nu13124262 sha: f6414673e21164caec088aed0e31a67289f8eb39 doc_id: 683420 cord_uid: wi7ocvgt This study aimed to describe the prevalence, severity and socio-demographic predictors of food insecurity in Australian households during the COVID-19 pandemic in 2020, from the perspective of women. A cross-sectional online survey of Australian (18–50 years) women was conducted. The survey collected demographic information and utilised the 18-item US Department of Agriculture Household Food Security Survey Module and the Kessler Psychological Distress Scale (K10). A multivariable regression was used to identify predictors of food security status. In this cohort (n = 1005), 19.6% were living in households experiencing food insecurity; with 11.8% experiencing low food-security and 7.8% very low food-security. A further 13.7% of households reported marginal food-security. Poor mental health status (K10 score ≥ 20) predicted household food insecurity at all levels. The presence of more than three children in the household was associated with low food-security (OR 6.24, 95% CI: 2.59–15.03). Those who were renting were 2.10 (95% CI: 1.09–4.05) times likely to experience very low food-security than those owning their own home. The COVID-19 pandemic may have contributed to an increased prevalence of household food insecurity. This study supports the need for a range of responses that address mental health, financial, employment and housing support to food security in Australia. Food security is a fundamental human right and paramount to physical, mental and social health and wellbeing [1] . Yet food insecurity, defined as 'the limited or uncertain availability of nutritionally adequate and safe foods, or the ability to acquire acceptable food in socially acceptable ways' is increasing in high income countries such as Australia [2] . Food insecurity at a household and individual level is characterised by episodic and/or chronic experiences of stress, anxiety, concern, social isolation and compromise to the quantity and nutritional quality of food [3, 4] . In 2011, using a two-item measure, 4% of Australians lived in a household that reported to be food insecure [5] . Key determinants of food security status include income level, income shocks, available economic resources for purchasing food and general resources in a household [6, 7] . Some population groups for purchasing food and general resources in a household [6, 7] . Some population groups in Australia may be at greater risk of experiencing food insecurity. For example, individuals experiencing material and/or financial hardship, Aboriginal and Torres Strait Island peoples, people from a Culturally and Linguistic Diverse background including refugees and people seeking asylum, single-parent households and people experiencing homelessness [6, [8] [9] [10] [11] [12] . Due to the financial consequences of the SARS-COV2 (COVID- 19) pandemic in Australia, the prevalence and severity of food insecurity may be greater than previously documented, especially within at-risk groups. COVID-19 was first identified in Australia in January 2020 [13] . Australia consists of eight states and territories, each with individual governments who were responsible for the management of the pandemic response in each respective jurisdiction. COVID-19 related restrictions (lockdowns including business and school closures, travel restrictions, wearing masks and social distancing requirements) therefore varied across Australia throughout 2020 due to varying case numbers in states and territories ( Figure 1 ). Although COVID-19 case numbers were comparatively low in a global context, some states such as Victoria endured significant periods of lockdown [14] . The federal government provided a variety of financial support payments to buffer household income (Jobkeeper and Jobseeker). Despite the multiple economic stimuli initiated in 2020 [14] , the direct and indirect impacts of COVID-19 such as lockdowns, working from home requirements, schooling from home, loss of regular social support structures, child care closure and loss of employment and income placed many households under additional stress [15] . Women were more likely to shoulder the extra domestic burden and experienced this additional pressure on top of existing household and food provisioning demands [16] . Understanding the food experience of women is particularly important due to their unique role in the household and society. Despite increasing participation by women in the workforce, either in casual, part-time or full-time work, many continue to have the Understanding the food experience of women is particularly important due to their unique role in the household and society. Despite increasing participation by women in the workforce, either in casual, part-time or full-time work, many continue to have the primary role and investment of time in household and family food provisioning [16] . As a result of the understanding and experiences of food provisioning roles, it is suggested that women in food insecure married/partnered households may report higher levels and experiences of food insecurity [18, 19] . Unsurprisingly, due to the increased load, women have exhibited higher levels of stress during the pandemic [20] . Therefore, understanding the food insecurity experience from the perspective of the female in the household during the COVID-19 pandemic is important as women are often the gate keeper to food security. Recognition of the links between food insecurity, poor diet quality, poor mental health and chronic disease development have prompted calls for more research exploring the impact of the COVID-19 pandemic on food security worldwide [21] . The few published studies characterising the effect of COVID-19 on food insecurity have found conflicting results, with both improvements [22] and reductions [23, 24] in access to food reported. While these studies explored the impact of the pandemic on food security changes in the general population, there is a need to focus research specifically on groups at potential greater risk of food insecurity within society, such as women and children. Therefore, the aim of the study was to determine the prevalence, severity and socio-demographic predictors of household food insecurity from the perspective of women of reproductive age (18-50 years) in Australia during the COVID-19 pandemic. This study was part of a larger study to explore food intake, physical activity and mental wellbeing during COVID-19 pandemic in women of reproductive age (18-50 years) in Australia. This national cross-sectional online survey was undertaken between 15 October to 7 November 2020 during COVID-19 (see further detail below). This research captured a large sample of the female Australian population across age and residential location (state/territory and remoteness area). Women of reproductive age (age 18-50) who resided in Australia were recruited by an external cross-panel market research provider (Online Research Unit) with a wellestablished database of 400,000 members. This research provider uses multiple recruitment methods (telephone, online, print and postal) [25] . Men or women under the age of 18 or over 50 were ineligible to participate. Participants were invited to complete the online survey via targeted emails describing the content and duration of the survey. The proportion of women of reproductive age from each state and territory were recruited according to the Australian Bureau of Statistics (ABS) population characteristics [26] . Whilst this cannot be representative across all population characteristics, it is a widely accepted approach and the recruitment was designed to obtain a sample consistent with the population proportions across age, gender and residential location (state/territory) [27] . On day four and five of the survey distribution, location of residence (state/territory) of respondents were examined, and further sampling was targeted to underrepresented groups to align with population characteristics. Respondents were reimbursed in line with ISO 26362 industry requirements, and reimbursements were mailed to a residential address inside Australia, therefore ensuring that respondents were living in Australia. All data collected was anonymous. Participants provided online consent after reading the study purpose, before participating in the 10-min online survey. The study was approved by the Monash University Human Research Ethics Committee (HREC project: 25941). The survey included multiple-choice questions to assess respondents' age group, cultural or ethnic group, highest level of education completed, employment status before the pandemic, changes in employment status during the pandemic and annual household income before tax pre-pandemic and during pandemic at the time of sampling in 2020. Urban or rural/remote location was determined based on postcode. Food security status was assessed using the validated 18-item United States Department of Agriculture Household Food Security Survey Module (USDA-HFSSM), including 10 adult questions and 8 child questions [28] . The USDA-HFSSM was selected for determination of food security status because of its reliability across populations and population subgroups; and its ability to capture the severity level and continuum of experience of food security. Survey respondents were asked to consider the previous six months when answering questions to capture experience during the COVID-19 pandemic. The USDA-HFSSM protocol for households with children uses the number of affirmative responses to the 18 questions to provide a raw score categorising households' food security severity: high food security (score of 0) with no reported indications of food-access limitations; marginal food security (score of 1-2) indicating anxiety over food sufficiency or a shortage of food in the house; low food security (score of 3-7) indicating reduced quality and variety of food with little or no indication of reduced intake; and very low food security (score [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] describing multiple indications of a disrupted eating pattern and reduced food intake. For data analyses HFSSM protocol identified four categories of food security: high food security, marginal food security, low food security and very low food security. The Kessler Psychological Distress Scale (K10) was used to assess psychological distress [29] . The K10 is a validated 10-item questionnaire to measure level of distress based on questions about anxiety and depressive symptoms experienced by an individual over the last 4 weeks. A score <20 was categorised as likely to be mentally well, and ≥20 was considered likely to have mental health concerns [29, 30] . Data screening and cleaning ensured data usability and an integrity script allowed discarding of surveys with less than 10% completion (n = 508). These non-completions are mostly due to ineligibility (e.g., being male) as determined in the screening questions at the start of the survey. Descriptive statistics were calculated for all variables. Chi-squared was used to compare demographic, socioeconomic, mental health and food security variables between the four food security severity groups. Multivariable logistic regression was conducted. Covariates used in the multivariable model were those identified using descriptive statistics to be significant between food security severity groups. Covariates included state, marital status, children, education, pre-COVID-19 employment, pre COVID-19 income and change to employment status due to COVID-19. Descriptive statistics were used to report the responses to the USDA-HFSSM 18-items across the four food security groups. Data were analysed using the statistical software package IBM SPSS for Windows Version 26 (SPSS INC., Chicago, IL, USA). Significance was set at p < 0.05. A total of n = 1005 women were included in the analysis. Results are presented in accordance with the four categories of food security severity status. Two thirds of respondents were categorised as living in a household experiencing high food security (n = 670, 66.7%), 13.7% (n = 138) marginal food security, 11.8% (n = 119) low food security and 7.8% (n= 78) experiencing very low food security. Survey respondent socio-demographic characteristics across the four food security categories are presented in Table 1 . The majority of respondents (n = 847, 84.3%) reported living in a major city of Australia, aged 25-44 years (n = 678, 67.5%) and in a married or de facto relationship (n = 574, 57.1%). Forty-three percent of respondents (n = 431) reported having one or more children. With regard to education status, over half (n = 561, 55.8%) had a university education (Bachelor's degree or higher) and 42.7% (n = 429) reported a household income greater than AUD 100,000 per year [31] . Households who were classified as having low and very low food security were more likely to report mental health concerns (p < 0.001), were more likely to be renting than owning their own home (p = 0.006), be single (p < 0.005), have children (p < 0.001) and were less likely to have post-secondary education (p = 0.003) compared to households that were food secure. The proportions of responses to the 18-item USDA-HFSSM questions according to each food security category are presented in Table 2 . This data highlights the experience of food security across the different severity categories. Women who were in marginally food secure households reported that they worried whether food would run out before they had money to buy more. As the questions increased in the severity of experience, there was an increase in frequency of respondents who were classified as low and/or very low food secure. For example, in response to the question "did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food", those that responded affirmatively were experiencing low (31.5%) or very low food security (67.6%). Of households experiencing very low food security, 79.7% reduced the size of their meals either every month or 3-4 months. Similarly, 95% of respondents experiencing very low food security reported in the last 6 months that either they or other adults in the household had not eaten for a whole day because there was not enough money for food. Households responding to the initial child experience question reported that they relied on only a few types of low-cost food items to feed children because they were running out of money to buy food (28% marginal food secure, 44.8% low food security and 27% very low food security). However, as the questions increased in the severity of food security experience those with low and very low food security status were more likely to respond affirmatively. In the last 6 months did any of the children ever skip meals because there wasn't enough money for food? Socio-demographic characteristics associated with food security status are reported in Table 1 . As food insecurity severity increased, women were more likely to be employed casually, be on government disability assistance payments or a homemaker (p = 0.014) prior to the COVID-19 pandemic. There was an association between food security and changes in employment status due to COVID-19, whereby those that reported changes in their employment due to COVID-19 were more likely to experience food insecurity (p < 0.001). There was also an association between severity of food security and level of income. Women in the lowest household income brackets (