Food security occurs when people ‘can get enough food to eat that is safe, that they like to eat, and that helps them to be healthy. They must be able to get this food in ways that make them feel good about themselves and their families’ [1
]. Food security comprises four aspects: the availability of food, the physical and financial resources to access food, the ability to utilize food, requiring safe food and water as well as the ability to safely prepare, cook and store food, and finally, the stability of food supply [2
]. Definitions of food security highlight the fact that food security is not simply the absence of food scarcity and hunger, but also relates to broader issues of a healthy and balanced diet and, for this reason, food security is a prominent policy and public health issue in high-income countries [3
The United States has been regularly measuring hunger at the national level since the 1960s, with detailed information about food insecurity collected since the late 1980s, and further methodological improvements occurring in the 1990s with the development of the United States Department of Agriculture (USDA) Household Food Security Survey Module (HFSSM; originally the Core Food Security Module) [4
]. Canada has used the HFSSM in its nationally representative Community Health Survey since 2004 [6
]. New Zealand has used items suited to its cultural context that thematically overlap with the HFSSM, capturing the reduction of food intake and/or substitution into lower cost food, access of food banks or other relief services, and anxiety, associated with food insecurity [5
]. Though varying in line with broader economic conditions [8
], food insecurity is found among 14% of the US population, 15% of NZ, and 12.3% of Canada [9
In Australia, food insecurity has overwhelmingly been measured using a single item: ‘In the last 12 months was there any time you have run out of food and not been able to purchase more?’ In a systematic review of 57 articles on food security in Australia, McKay, Haines, and Dunn [10
] found that, of the 36 studies that directly measured food insecurity, 22 (61%) used the single item measure of food security. In population-representative surveys, the single item consistently estimates the prevalence of food insecurity among the Australian population to be approximately 5% [3
]. Relative to multi-item measures, single item measures of food security underreport rates of food insecurity [13
]. However, even the arguably conservative estimate of 5% of the population translates to 1 million Australians affected by food insecurity. Therefore, the prevalence, predictors, and impacts of food insecurity in this context remain important and relevant avenues for research.
Prevalence of food insecurity varies by substrata of the population of high-income countries, such as ethnic minorities, the homeless, tertiary students, single parents and refugees [14
]. In the Australian context, a study of Victorian university students using the FSSM found that 18% had low and 30% had very low food security [17
], while a study in Queensland found that 12.7% of a university student sample were food insecure using the single item measure, and 71.8% were food insecure using the FSSM [18
]. Studies of refugees using the single item measure find that between 71% [19
] and 90% [20
] were food insecure. Studies of older Australians, also using the single item, find lower prevalence than in the general population at 2% of Australians aged over 65 years [21
] and 3% of Australians aged over 55 years [22
In terms of predictors, while low income is the strongest and most consistent predictor of food insecurity, higher income is not a proxy for food security as income level does not always reflect the economic conditions of the household [9
]. For example, households can experience significant, unexpected changes to their economic circumstances, such as the loss of an income or large household bills, which have lagged effects on household income and/or require temporary reallocation of financial resources, resulting in food insecurity. On the other hand, income does not necessarily reflect assets held, nor levels of access to other supports that prevent food insecurity. As such, while the relationship between low income and food insecurity is strong, the factors that lead to food insecurity in developed countries, particularly those with strong social safety nets, are more complex [23
]. Lower education levels, single-parent household composition, unemployment, and social isolation are associated with higher food insecurity in Australia, the UK, and the US [4
Food insecurity has significant short- and long-term impacts on physical health and social and economic participation [3
]. Food insecurity often leads to stress, cycles of fasting and bingeing, and the substitution of relatively higher cost, higher nutrition food with lower cost, higher energy food, resulting in nutrient deficiencies, metabolic changes, weight loss or, seemingly paradoxically, overweight and obesity [13
]. Children in food insecure households in Australia were more likely to miss days of school, miss out on school activities, and more likely to have emotional and behavioral issues [25
]. Eighty percent of food insecure university students reported that their studies were negatively affected by their food insecurity. They were also three times more likely to have deferred study due to financial difficulties and twice as likely to report poor or fair health [26
]. Food insecure adults are more likely to have lower self-assessed health status, higher prevalence of chronic disease such as diabetes, cardiovascular disease and depression, and lower rates of social and economic participation [13
]. Elderly food insecure people were six times more likely to rate their lifestyle as unhealthy than healthy, five times less likely to have private health insurance, and four times more likely to report needing household help [21
]. Therefore, although there is an inverse relationship between food insecurity and age, food insecurity exists in populations at all stages of the life course and results in significant health, social and economic consequences.
The present study examines food security among a cohort of non-government service users assessed by service users as experiencing hardship and entrenched disadvantage in the city of Perth, Australia (population two million people). Entrenched disadvantage is not just characterized by low income. It comprises long-term, often intergenerational exclusion from social and economic opportunities, including higher education, employment, and positive social and community based relationships, that affects all domains of wellbeing [27
]. Previous research reveals that, in addition to income, demographic characteristics such as household composition, educational attainment, country of birth, and employment status significantly predict food insecurity. Acknowledging this previous research and the low-income nature of our sample, we explore whether there are differences in levels of food security between groups with different demographic characteristics. Further, given that the sample use community services in one way or another, we examine the relationship between people’s access of food-related services and food insecurity. Finally, this paper examines social, health and economic outcomes related to food insecurity.
This paper contributes to the food security literature by adding to the evidence base on the prevalence of food insecurity in high-income countries using a multi-item, validated tool. Further, it sheds light on some of the nuances of the relationship between income and food security by examining differences in levels of food security between groups within a low-income sample. Additionally, effectiveness of responses to food insecurity is explored through analysis of the relationship between service use and food insecurity. Finally, acknowledging the different impact of food insecurity in high-income nations relative to the famine and chronic undernourishment that characterize food insecurity in countries with high rates of extreme poverty [28
] and the seemingly contradictory outcomes that food insecurity can bring about, such as underweight and obesity [13
]; this paper contributes to the literature on the impacts of food insecurity by exploring the relationships between food insecurity and health, mental health and quality of life outcomes.
Data were collected as part of a collaborative research, policy and practice project between non-government service providers and university researchers. The non-government service providers covered a broad range of service delivery domains including financial counselling programs, community mental health services, homelessness and housing support services, out-of-home care services and emergency relief services. Participants in the study were 400 family representatives that were identified by partner non-government service delivery agencies as having two or more of the following ‘eligibility criteria’ for hardship and entrenched disadvantage: reliance on welfare payments, unstable housing, unemployment or underemployment, physical or mental disability, or mental health issues, inadequate social support, and low education. These criteria were selected as known correlates of entrenched disadvantage that could be ascertained by service workers with relatively minimal burden on the worker or the potential participant. The study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by The University of Western Australia Human Research Ethics Committee (Ref: RA/4/20/4793). Written informed consent was obtained from all subjects.
Participants referred by service delivery agencies that were interested in participating in the study presented at their most conveniently located agency. An interviewer on the research team explained the study in full, provided each participant with a Participant Information Form for their records, and sought informed consent. Consenting participants then completed a survey on the Qualtrics survey software platform, guided by the interviewer. The survey was approximately one hour in length and covered several domains of socioeconomic wellbeing.
Survey data were analyzed using SPSS version 25.0 (IBM Corp. Armonk, NY, USA). Relationships between food insecurity and demographic characteristics were assessed using Pearson chi-square tests. Distributions for household size and service use were not sufficiently normal for parametric analysis based on Curran, West and Finch’s guidelines [29
]. Accordingly, Spearman correlations between food security and household size and service use were performed. To examine the relationships between mental health, quality of life, and health and food security, a series of Pearson correlations were conducted. p
-values ≤ 0.05 were considered statistically significant for all analyses.
Socio-demographic variables collected include date of birth, sex, Aboriginal or Torres Strait Islander identification, country of birth, marital status, employment status and educational attainment.
Food security was assessed using a modified version of the 18 item United States Department of Agriculture (USDA) Food Security Survey Module (FSSM). Questions pertaining to child food security were asked to participants that indicated they had a child in their household or in their care. The FSSM produces raw scores of food insecurity at the household level, among adults, and among children. Scores are then used to categorize respondents as having high, marginal, low or very low food security at the household-level and among adults, and high or marginal, low, and very low food security among children. In the FSSM version used in this study, the word “household” was replaced with “family unit”. This is because the study sought to examine entrenched disadvantage beyond the boundary of the household to account for the fact that very low-income individuals may not in fact have a dwelling, or may have a non-traditional family structure in which resources are shared across households. Consequently, we amended the standard approach and refer to food security in the family unit, in order to account for variations between household and family structures and so that scores for those experiencing homelessness include people that they are living with (perhaps sleeping rough with), and are comparable to those in stable housing.
In addition to demographic characteristics, we examine the relationship between food security and household size; food emergency relief related-service use; and mental health, wellbeing and physical health outcomes. In relation to household size, acknowledging that self-identified family structures are not restricted to those living in the same dwelling and those usually in the household may not always represent the full set of family members that one shares food with; we asked participants to identify those people that they considered part of their family unit and, for each person, how many nights that person spent in their dwelling. The sum of nights spent in the dwelling across all members of the family unit, including the participant, was calculated to create ‘total person nights’, the sum of all of the nights that people stay with the participant per week. The total person nights were then divided by the number of days in the week to derive the ‘mean person nights’—the average number of people staying in the participant’s dwelling per night. We also determine household size using the standard approach by adults and children that usually stayed in the participant’s dwelling.
Service use was identified by asking participants to indicate whether they had accessed non-government services across a range of different categories, for example, food emergency relief, mental health services, financial counselling services, emergency accommodation, in the 12 months prior to survey. For each type of service accessed, participants were asked to identify the number of different services that they accessed. For the purposes of the current study, only food emergency relief related-service use is reported.
We use a number of measures of mental health and wellbeing and physical health. Loneliness was measured using the UCLA 3 item loneliness scale [30
]. This is an indirect measure of loneliness, asking participants how often they feel they lack companionship, left out, and isolated from others. Depression, anxiety and stress were measured using the Depression Anxiety Stress Scale (DASS-21) [31
]. The World Health Organization (WHO)-5 Wellbeing Index [32
] was also used as a measure of current mental wellbeing. The WHO Quality of Life—Brief (WHOQOL-BREF) [33
], measuring wellbeing in the domains of physical health, psychological, social relationships, and environment, was administered. Physical health was assessed through participants’ self-reporting of receiving a diagnosis from a medical professional of long-term health conditions that are considered chronic in nationally representative studies and reports [34
This paper has examined the prevalence and correlates of food insecurity within a cohort of socioeconomically disadvantaged Australian service users. Using the multi-item FSSM, we find that the rate of food insecurity is markedly higher among this cohort than among the general population, for which the rate of food insecurity, albeit measured with a single item, has been consistently estimated to be approximately 5% [3
]. The rate of food insecurity in this cohort (80.8% among adults and 58.3% among children) is extremely high and, in light of the relationships between food insecurity and decreased economic, social, and health outcomes [13
], carries with it significant public health and public policy implications.
Despite low income being the strongest and most consistent predictor of food insecurity in the international literature, previous studies have found that demographic characteristics such as age, marital status, household composition, and type of housing tenure have effects on food insecurity independent of income [11
]. This was not the case for our sample; no significant differences in food insecurity were found between those of different sexes, cultural identification, education levels, household compositions, labor force participation status, nor income source. A small significant effect was present for food insecurity among children for those that were welfare dependent, such that those that were welfare dependent reported higher food security than those that had some form of wage or salary based income.
Given that the sample of this study comprised service users identified as experiencing entrenched disadvantage there are a couple of potential explanations for the lack of effect of socio-demographic characteristics on food security. It may be that there is a very low-income threshold, under which, a person is very unlikely to experience food security. Prior examinations of food insecurity and demographic characteristics in Australia have examined a particular income segment, such as low to middle income earners [11
] or have dealt with population representative data and thus a representative distribution of income [23
]. As average income in Australia is quite high, population-representative studies will not provide accurate insight into the prevalence and correlates of food insecurity in the very low-income margins. Moreover, low income in itself is neither a necessary nor sufficient condition for entrenched disadvantage, though it is clearly correlated with hardship and disadvantage. A family may be in a low-income position but may have assets or have strong family and community support networks, decreasing their need relative to a family in a low-income position without these supports.
Another potential explanation for the lack of variance in levels of food insecurity between different socio-demographic groups is that the sample were those accessing non-government services, which may well include food emergency relief. Thus, food insecurity may be a driver of service use that precipitated recruitment into the study. This is supported by the result that food insecurity was positively correlated with the number of food emergency relief services the participant had accessed in the 12 months prior to the survey. This result indicates that people with low food security are accessing a greater number of services in order to acquire food. Booth and Whelan [37
] comment on the massive expansion of the food banking industry in Australia. They note that, though it is essential that those that are hungry are provided with food, and the provision of food often serves as an entry into other, much-needed services, the stated goal of the food banking industry is to address (immediate) hunger, rather than to address the issues that create demand for food relief. This suggests that some of the participants in this study are relying on food-related services to address their food insecurity, and this explains why these supports are not effectively reducing that food insecurity and may in fact be maintaining their food insecurity.
In examining the impact of household size, firstly, the traditional method whereby participants are asked to report the number of people that usually stay in their dwelling was used. Secondly, a new method was employed to determine the household reference point, whereby the concept of “mean person nights” was introduced. Participants were asked to report the average number of nights per week that people they identified as being part of their family (that is, those that rely on each other for day to day living and may share resources and/or social support) stayed with them. This novel method sought to address some of the limitations of measuring solely a count of usual household members. The number of people who usually stay in the dwelling does not account for cases where participants are sharing with roommates who do not regularly share resources. In these cases, individuals within the same household may have different levels of food security and, therefore, it is not meaningful to compare the food security of one individual in a share house with the food security of individual in a household of the same size, but within a family. Additionally, participants may have custody arrangements where their children regularly stay with their other parent. In these cases, participants may or may not include these children in the number of people that usually stay in their dwelling. There are also cases where other family members, who are members of other households, may regularly stay at the dwelling of the participant, which would not be included in the number of people that usually stay in their dwelling.
Although there was a strong, positive correlation between mean person nights and household size, only mean person nights and adult food insecurity yielded a statistically significant, negative correlation, albeit a small effect. This negative correlation suggests that larger families have higher food security. This may indicate that larger families pool their resources; indeed, the pooling of resources may be why family members that are not usually in one’s household are temporarily but frequently joining the household. The greater number of people staying in the household may also increase the ability to access emergency relief, including food emergency relief, both in terms of an increased number of people who are ‘eligible’ for emergency relief, and an increased number of people that can visit services, which are often spread throughout the metropolitan area. The statistical significance of the correlation between mean person nights and adult food security suggests that mean person nights is a more accurate measure of the number of people supported by a family unit. It is not surprising that the correlation was weak, as single person families comprised a large proportion of the sample, so it is likely that there is a great deal of variability in food security within single person families.
Increased food insecurity was associated with reduced scores on the WHO-5 Wellbeing Index, as well as on the physical health, social relationships, environment and psychological domains of the WHOQOL-BREF. Food insecurity was also positively associated with loneliness, depression, anxiety, and stress DASS21 scores, and the number of reported chronic health conditions. Though using a different set of instruments to measure physical and mental health, these findings support several previous studies in Australia and other high-income countries that find that the food insecure are more likely to self-assess their health as poor [18
], more likely to experience stress related to food [9
], as well as generally high stress and anxiety levels [3
]. There are several theories regarding the relationship between food security and physical and mental health outcomes [13
]. It is proposed that the inability to meet nutritional needs leads, in the short-to-medium term, to nutrient deficiencies, metabolic changes, and stress which, in turn, lead to increased prevalence of chronic disease among the food insecure in the long term. An alternative theory is that poor general health, poor mental health, and chronic disease lead to debilitation, decreased economic participation, and lower income, which increases the incidence of food insecurity [13
Irrespective of the nature of the relationship between food insecurity and physical and mental health, the findings of this study have significant implications for public health practice and policy. We find that access to food emergency relief access is very prevalent, however, access to food emergency relief did not result in higher food security, indicating that food emergency relief is not addressing the underlying causes of food insecurity.
Food insecurity in developed countries is often driven by the increasing cost of food [12
] and several practitioners have called for increased study into the monetary and time costs of maintaining a healthy diet in Australia, including variations between States and Territories and between urban and regional/remote areas [37
]. There are substantial inequalities in the costs of maintaining an acceptable diet between those facing hardship and more affluent people; relative to households with middle or high income, those facing hardship spend less money but a larger proportion of household budget on food, and spend more time preparing and cooking food, but less time eating [24
]. Further, as food is the most elastic component of the poor household’s budget, it is often the area that is sacrificed in the face of other expenses, such as debts or unexpected household bills [28
]. In order to address food insecurity, national nutrition policy and welfare policy must take these inequalities into account and focus on increasing reliable access to nutritional food, such as through the provision of food vouchers additional to welfare payments and subsidised groceries. Moreover, there is a need to address the underlying structural drivers of entrenched disadvantage and deficiencies in social protection which result in government income support payments below poverty line levels [41
In addition, though our study did not find significant differences between demographic characteristics, past studies in Australia find that being born outside of Australia is negatively related to food insecurity, which may be a result of cooking and budgeting skills being taught and/or prioritized more in other cultures [13
]. Therefore, there is a role for education in increasing food security in Australia, both in formal education, and through the teaching of these skills in programs designed to alleviate food insecurity.
The impetus for these policy and practice changes is clear. In addition to the human suffering associated with food insecurity, the poor health and mental health outcomes associated with food insecurity affect one’s ability to participate socially and economically which, in turn, results in negative economic consequences, in the form of increased service use and decreased productivity, as well as negative cultural consequences in the form of increased inequality and decreased quality of life.
The present study examines the prevalence and correlates of food insecurity among a cohort of disadvantaged service users in metropolitan Australia. Using the USDA Household Food Security Survey Module, we find that the prevalence of food insecurity among our cohort greatly exceeds Australian population estimates derived from the single-item measure of food insecurity. Contrary to existing literature, we do not find any significant difference in levels of food insecurity between groups of different demographic characteristics, which may indicate that there is a lower threshold of income, under which food security cannot be achieved, irrespective of other factors that usually enhance food security. These results also reflect that recruitment into the study was via contact with community services and thus the established existence of hardship and need.
We also find that food insecurity is negatively related to household size, measured by the mean number of ‘person nights’ spent in the household. This may indicate that larger families stay together, outside of their usual households, in order to pool resources. Finally, in line with other studies, we find that food insecurity is related to increased depression, stress, and anxiety, poorer wellbeing and quality of life, and increased incidence of chronic health conditions. Though not without limitations, for instance, the use of self-report measures and the measurement of correlation which does not indicate the direction of relationships between variables, the study reveals a strong need for increased access and stability of access to adequate quantities and quality of food among low-income Australians.