The Food and Agriculture Organisation states that food security incorporates the key dimensions of food availability, food access, food utilisation, and stability of these dimensions [1
]. Each dimension includes a range of food security determinants (FSD). At the food availability level, key FSD include availability in outlets, price, promotion, quality; location of outlets; and variety [2
]. Food access determinants include social support, household financial resources; transportation to outlets; distance to outlets; and mobility [2
]. Food utilisation determinants include nutrition knowledge and skills; food preferences; household food storage facilities; cooking and food preparation facilities; and time to procure and prepare food [2
Locations where availability and access to healthy food is difficult or absent, have been referred to as “food deserts” [5
]. The limited food resources in such locations are often unaffordable and of poor quality [7
]. These issues can negatively impact health [6
] as a result of poorer dietary intake from important food groups such as vegetables [8
Adequate vegetable consumption among children aged 9–11 and females aged 12–13 years is deemed by the 2013 Australian Dietary Guidelines (ADG) to be five or more serves, whereby a serve is equivalent to one cup of salad or half a cup of cooked vegetables. For males aged 12–13 years, the requirement increases to 5.5 serves per day [9
]. Currently in Australia, the majority (almost 97%) of children consume inadequate amounts of vegetables [10
]. Children living in Western Australia (WA) consume slightly higher amounts, however, the majority (almost 92%) do not achieve the recommended vegetable intake [11
]. While evidence demonstrates most WA children are consuming inadequate amounts of vegetables, the way in which FSD impact children’s vegetable consumption remains largely unknown.
The majority of studies investigating the association between children’s vegetable consumption and food security have been limited to examining food security status [12
] rather than FSD. Current evidence relating to FSD suggests the consumption of adequate vegetables is determined by cost, social support, location of food outlets, and transport to outlets. The cost of healthy food options has been suggested to be beyond the budget of many disadvantaged families [18
]. Further, social support significantly increased fruit and vegetable intake among adolescents [21
]. Children were also more likely to have infrequent vegetable consumption if they attend schools in locations with low supermarket density [22
]. Residents living in neighbourhoods lacking in transport may have further difficulty accessing healthy food [23
This study answers the call of previous research to examine how food security impacts dietary outcomes [3
]. The aim of the current study was to determine whether FSD were associated with adequate vegetable consumption among regional and remote WA children.
2. Materials and Methods
2.1. Sampling and Recruitment
This study was conducted in non-metropolitan, rural areas of WA. Reference in this paper to “regional WA” and “remote WA” schools include the locations defined by the Australian Statistical Geography Standard [25
]. That is, locations outside of WA’s metropolitan area encompassing “inner regional” and “outer regional” (herein referred to as “regional WA”), “remote” and “very remote” (herein referred to as “remote WA”) [25
]. In Australia, the remoteness of locations is defined by an area’s access to services [25
]. Schools who were eligible to participate in the Foodbank WA Food Sensations®
program were invited. Children aged 9–13 years and their caregivers were selected to facilitate comparisons between children’s vegetable intake and the ADG recommendations for fruit and vegetables (F & V) [26
]. The WA Department of Education (DOE) annual student census was used to inform a sample size calculation for the research question relating to this manuscript, and determined the sample required (n
= 160 children and 160 of their caregivers based on an effect size of 0.15 (small), α
= 0.05, 80% power) [27
]. School authority websites [28
] were used to compile a Master Schools Database which listed schools by WA region [31
] (e.g., Pilbara), remoteness [32
], and Socio-economic Index for Areas (SEIFA) Index of Relative Socio-economic Disadvantage (IRSD) score [33
School principals were initially engaged via an introductory telephone call to explain the study, followed by an email containing a principal Invitation Letter (IL) and Consent Form (CF), in addition to a DOE approval letter. Almost three-quarters (72%, n = 23) of the school principals invited to participate consented for their school to participate. Principals nominated classes of students aged between 9 and 13 years (n = 71 teachers of 76 classes) on their principal CF. Almost all (97%, n = 69 teachers, 74 classes) teachers invited via a teacher IL returned the signed teacher CF to the study centre. Where possible (n = 51 classes), a teacher and class briefing session was delivered, explaining the study to classes, disseminating the caregiver and child IL/CF envelopes, and providing survey packs to teachers. Teachers of the 23 classes that did not participate in a briefing session were mailed study packs for dissemination. A total of 1814 caregivers and their children were invited to participate in the study, with 347 caregivers and 340 children providing written informed consent. A child-caregiver dyad was the chosen method to facilitate comparisons between data in the wider study, and given matched caregiver and child surveys were a requirement for inclusion, a total of 256 dyads were included in the sample. Due to missing data for some study variables, a total of 187 dyads have been included in analyses.
2.2.1. Socio-Demographic Questions
The research team developed cross-sectional, self-administered, pictorial, paper-based child and caregiver surveys. Socio-demographic questions included caregiver and child age, gender, caregiver educational attainment, etc., and are summarised in Table 1
. For example, the caregiver survey enquired about caregiver educational attainment, including response options of “primary school”; “secondary school”; “apprenticeship or diploma”; “university degree” and “postgraduate university degree”.
2.2.2. Independent Variable Questions
FSD were the independent variables in this study. FSD across community-level food availability, household-level, and individual-level food access and utilisation dimensions were measured by questions underpinned by the Determinants of Food Security [2
] model. These were based on previous research [34
] and investigator-initiated questions (Table 2
). For example, transportation modes to access F & V included “car”, “bus”, “walk”, “bicycle”, “no transport”, or “other” response options. Some FSD variables were measured using a five-point Likert scale of “strongly agree”, “agree”, “unsure”, “disagree”, or “strongly disagree”. For example, caregiver knowledge and skills were measured via level of agreement with the statement: “I don’t know how to use vegetables in meals”. Number of vegetable types consumed in the previous month was measured through the question “Please tick which type of vegetables your child ate in the previous month”. Options included “fresh”, “frozen”, “tinned”, “dried”, and “juice”. All vegetable types included the response options “yes” or “no”.
2.2.3. Dependent Variable Question
“Adequate vegetable consumption” was the dependent variable in this study. The question measuring usual vegetable serves consumed by children was based on the WA Child and Adolescent Physical Activity and Nutrition Survey [35
] (used with permission). Children’s usual daily vegetable serves, as reported by their caregiver, were measured using the question “How many serves of vegetables does your child usually eat each day?” Prompts were provided to outline what constitutes a serve of vegetables (i.e., one cup of salad vegetables). Response options included: “My child doesn’t eat vegetables”; “one serve or less each day”; “2 serves each day”; “3 serves each day”; “4 serves each day”; “5 serves each day”; “6 or more serves each day”; “don’t know”. Responses were compared with the ADG recommendation [26
] to ascertain whether intake was “adequate” (≥5 serves of vegetables each day) or “inadequate” (<5 serves of vegetables each day). As these survey tools were developed prior to the release of the 2013 ADG, information relating to half serves was not collected. Therefore, male children aged 12 and 13 years were deemed to have consumed adequate vegetable serves if they consumed ≥5 serves instead of the recommended ≥5.5 serves.
2.3. Data Collection
Data collection commenced in March 2013 and concluded in December 2015. This included a pilot phase where face validity and reliability testing were conducted and confirmed in one school with 26 dyads. The child survey was completed in class with their class teacher, with completed surveys sealed by students for privacy. Caregiver surveys were completed at home, with a sealable envelope provided for privacy. Schools returned all CF and completed surveys to the study centre in a pre-paid postal envelope. Teachers and caregivers provided written feedback regarding information provided about the study, question wording, convenience of the study processes, and suggestions for improvement.
2.4. Data Analysis
A unique Identification (ID) number was allocated to each caregiver-child dyad, with child and caregiver surveys entered into separate, password-protected Microsoft Excel datasets. Datasets were imported into IBM SPSS (IBM, Armonk, NY, USA) for analyses. Any cases with missing data were excluded in analyses; only complete cases remained (n = 187). Caregiver-reported FSD and vegetable intake of their children was included in this paper.
2.4.1. Variable Recoding
Due to low cell counts, a number of socio-demographic variables required recoding, including caregiver educational attainment, caregiver employment status, SEIFA IRSD decile, and number of household residents. For example, caregiver educational attainment was recoded to “primary school or secondary school”, “diploma or apprenticeship” or “undergraduate/postgraduate university degree” (Table 1
). Independent variables that required recoding included variables with five-point response options (i.e., “Strongly agree”, “Agree”, “Unsure”, “Disagree”, or “Strongly disagree”) (Table 2
2.4.2. Simple Regression Analyses
The relationship between each of the independent variables and the outcome variable were assessed via simple logistic regression analyses. All independent variables were entered as categorical variables except for number of residents in the household, distance to food outlets, and time required to travel to food outlets, which were entered as continuous variables. Potential confounding variables including caregiver age and child age were entered as continuous variables. Inclusion criterion for entry into multivariable analyses was a conservative significance level of p
≤ 0.20. The use of a conservative inclusion criteria is a validated approach [36
] and was used to elucidate important variables for inclusion in the multivariable analyses, as has been used in other studies [37
2.4.3. Multivariable Regression Analyses
Significant FSD variables identified in the simple logistic regression analyses were entered into two multivariable models (Table 3
), the latter of which was controlled for socio-demographic factors demonstrated in the literature to be associated with adequate vegetable consumption, such as caregiver educational attainment [38
], SEIFA [39
], and child gender [39
]. Child age [22
], caregiver age [41
], caregiver gender [41
], and remoteness [42
] were also included as potential confounders. The level of significance was set at p
2.4.4. Ethical Approval
All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and was approved by the Edith Cowan University Human Research Ethics Committee (project identification code 8635).
The aim of this research was to determine whether FSD were associated with adequate vegetable consumption among regional and remote WA children. The significant determinants that predicted adequate vegetable consumption at the multivariable level were within the food availability dimension and included children’s consumption of four to five vegetable types/forms; caregiver recall of a promotional health message or slogan relating to vegetables; presence of sufficient food outlets in their town; and similar vegetable prices to other towns/communities. The number of transport options used by families to purchase vegetables was weakly associated with adequate vegetable consumption among children.
The importance of controlling for potential confounding variables was highlighted in this study. The number of transport modes was not a significant predictor in the unadjusted model, yet after adjustment, was significant at p ≤ 0.10. A number of FSD increased in significance from p ≤ 0.10 to p ≤ 0.05 between the unadjusted and adjusted models (food price, location of food outlets). FSD that remained significant between unadjusted and adjusted models included promotion and variety of vegetable types, indicating these factors are key drivers of vegetable consumption regardless of socio-demographic factors. In contrast, after adjustment, financial resources no longer significantly predicted children’s vegetable intake.
Inclusion of a range of vegetable types in the diet, such as fresh, frozen, and tinned, are all recommended for good health by the ADG [26
]. Previous research indicated availability, cost, and quality of fresh vegetables is a critical issue for regional and remote areas [4
]. Therefore ensuring a range of alternative vegetable types including frozen and tinned offers more opportunities for children to consume adequate quantities of vegetables at a more affordable cost with fewer quality issues than fresh vegetables [46
]. Further, many of these types are convenient and may be more readily available when their fresh counterparts are out of season [4
Our finding that 13.4% of children within this study sample met the ADG for vegetables was slightly higher than other Western Australian data, which found that 8.8% of children met vegetable guidelines [11
Our finding that caregiver recall of a vegetable promotional message increased the likelihood of adequate vegetable consumption was consistent with previous evidence. The “Go for 2&5®
” campaign national evaluation measured recall of campaign messages [48
]. Almost half of the parents surveyed indicated the campaign prompted them to take action to improve their family’s vegetable consumption, such as increasing the vegetable quantities their family consumed, adding an extra serve of vegetables, or employing the use of vegetable based recipes. Actions to increase their family’s vegetable consumption were significantly higher in the second follow up survey of the national evaluation, compared to the baseline survey [48
]. Among WA adults, vegetable consumption increased by 0.6 serves per person during the life of the “Go for 2&5®
” campaign [49
]. With regards to communication channels to promote health messages, recognition of vegetable promotional messages in the New South Wales “Eat It To Beat It” campaign were highest for school or other newsletter articles (44%), television or community announcement (42%), recipe cards (24%), and vegetable recipe demonstrations (14%) [51
]. Exposure to each additional promotional strategy resulted in a significant increase in vegetable serves [51
Our finding that sufficient food outlets predicted adequate vegetable consumption concurred with previous literature. Adequate food outlets located in towns are key drivers of food purchasing and consumption decisions [2
], with poor density of food outlets shown previously to be associated with inadequate vegetable consumption among adolescents [22
Strengths of this study include, to our knowledge, the first investigation in Australia to measure the relationship between a wide range of FSD and adequate vegetable consumption. This study sample also comprised participants living in all WA Remoteness Areas, and the majority of WA regions and levels of disadvantage. Additionally, the investigation of vegetable consumption through a FSD lens increases understanding about the relationship between FSD and vegetable consumption. This is particularly useful for advocacy, practice, and research efforts to improve “food deserts”, such as in some regional and remote areas. However, there were a number of limitations associated with this study. The low participation rate was suggested to be, in part, a result of the consent processes required for study approval. Active written consent was required from school principals, each class teacher, each caregiver, and each child. Further, children/caregivers were excluded from the study if their child/caregiver counterpart did not participate. This negatively impacted the sample size included in analyses.
This research highlighted the range of FSD that can affect a child’s likelihood of consuming adequate amounts of vegetables for good health. Our study findings suggest resulting points of intervention should occur primarily within the food and nutrition system, such as in food outlets (i.e., supermarkets) or direct retail options such as farmers’ markets [2
]. Recommendations relating to significant determinants identified in this study (significant at p
≤ 0.05) include (i) increasing the range and promotion of vegetable types (i.e., fresh, frozen, tinned, dried, juice) available to and within local food retail outlets across regional and remote WA. This could increase the likelihood of children living in these locations consuming adequate vegetables; (ii) long-term, consistent promotion of specific vegetable messages utilising a wide range of promotional strategies; (iii) consideration of town planning to enable multiple food retail options (i.e., supermarkets, farmers’ markets, produce stalls) [4
] for regional and remote families to source vegetables from, positioned in accessible locations within the town. In addition, consideration of community gardens or edible landscapes could increase opportunities to source and consume adequate vegetables; (iv) increased reliance on a local food supply to reduce the cost of vegetables in regional and remote locations, or core food freight subsidies. Table 4
provides detailed implementation strategies for each of the significant determinants of adequate vegetable consumption. Due to weak associations, cautious recommendations relating to the issue of “transport” could be considered and could include increasing the number of transport options available in towns to increase the potential for families to access food [2
]. For example, recommendations could be made for increasing availability or efficiency of public transport, or changes to the built environment to facilitate more active transport. As this paper only reports on investigations into vegetable consumption, further research could “complete the picture” by ascertaining which FSD impact children’s fruit consumption. Although approximately two-thirds of WA children are consuming adequate amounts of fruit [11
], further investigation of the factors that predict fruit consumption could improve intake among the current one-third of children consuming suboptimal amounts of fruit [11