Food insecurity and SNAP use among sexual minority people: analysis of a population-based sample from National Health Interview Survey, 2017.

BACKGROUND: Food insecurity is a pressing public health problem. Lesbian, gay, and bisexual (LGB) people are at increased risk for food insecurity, yet this issue remains grossly understudied among this population. The purpose of this study was to add to the existing literature surrounding food insecurity and the use of federal food assistance programs (SNAP) among LGB people. METHODS: This study used publicly available, de-identified data from the 2017 National Health Interview Survey (NHIS). Primary variables were sexual orientation, food security status, and receipt of SNAP. Food security was assessed using the 10-item USDA Family Food Security measure. RESULTS: In our sample, people who identified as bisexual had the highest rates of food insecurity (23.8%, n = 76). Female sexual minorities were 52% more likely to experience food insecurity (aOR = 1.518, 95% CI 1.105-2.087, p = .01) and 44% more likely to report household SNAP assistance than their heterosexual counterparts (aOR = 1.441, 95% CI 1.025-2.028, p = .03). SNAP partially mediated the association between sexual orientation and food insecurity for LGB females. CONCLUSIONS: Our findings add to the growing empirical evidence documenting food insecurities among sexual minority adults. Our results reiterate the need for sexual orientation to be included in nationally representative federal food security measures.

Food insecurity and food pantry use among transgender and gender non-conforming people in the Southeast United States.

BACKGROUND: Transgender and gender non-conforming (TGNC) people face high rates of poverty, joblessness, and homelessness, rendering this population vulnerable to experiencing food insecurity. Yet, there is almost no empirical evidence concerning food insecurity and the use of local and federal food assistance resources in the TGNC community. Food insecurity, the use of local and Federal food assistance resources, and associations with gender-related minority stressors and resilience using the Gender Minority Stress and Resilience (GMSR) scale among TGNC individuals living in the Southeast United States (U.S.) were documented in this study. METHODS: A cross-sectional online survey was conducted with TGNC people living in the Southeast U.S. Participants were recruited via targeted Facebook advertisements. RESULTS: In total, 105 TGNC people completed the survey; 79% of survey participants experienced food insecurity, 19% utilized Federal, and 22% utilized local food assistance resources. High levels of minority stress and community resilience were reported. The GMSR resilience scale Pride (aOR = 1.09, 95% CI 1.00-1.19, p = .04) was significantly associated with the use of local food pantries, but minority stressors were not. No significant associations were found between GMSR and food security. CONCLUSION: TGNC people living in the Southeast U.S. experienced food insecurity, unstable housing, low wages, and social stigma that were a barrier to using emergency food resources. Multi-level public health solutions that address discriminatory legislative policies and create linkages between TGNC people and local and federal food assistance are required to address issues of food insecurity in the TGNC population.

Sexual orientation disparities in food insecurity and food assistance use in U.S. adult women: National Health and Nutrition Examination Survey, 2005-2014.

BACKGROUND: Nearly 40 million American adults report past year food insecurity. This is concerning, as food insecurity is associated with chronic disease morbidity and premature mortality. Women disproportionately experience food insecurity, and sexual minority women (i.e., lesbian, bisexual, and heterosexual women reporting same-sex behavior; SMW) may be at greater risk for experiencing food insecurity disparities. The purpose of this study was to investigate patterns and prevalence of food insecurity and food assistance use in sexual minority and exclusively heterosexual women using population-level health surveillance data. METHODS: Using pooled 2004-2014 National Health and Nutrition Examination Survey data (N = 7379), we estimated weighted point prevalence of past 12-month food insecurity, severe food insecurity, Supplemental Nutrition Assistance Program (SNAP) use, and emergency food assistance use. We then used Poisson regression with robust variance to estimate prevalence ratios comparing SMW to exclusively heterosexual women on all outcomes. Women were classified by sexual identity and lifetime same-sex behavior as lesbian (n = 88), bisexual (n = 251), heterosexual and reporting same-sex behavior (heterosexual WSW; n = 366), or exclusively heterosexual women (referent; n = 6674). RESULTS: Between 20.6-27.3% of lesbian, bisexual, and heterosexual WSW reported past 12-month food insecurity (versus 13.1% of exclusively heterosexual women). All SMW reported greater prevalence of past 12-month food insecurity and severe food insecurity than exclusively heterosexual women: prevalence ratios (PR) ranged from 1.34 (95% confidence interval [CI], 1.05-1.70) to 1.84 (95% CI, 1.13-3.01). No differences were found in SNAP participation by sexual orientation, but more lesbians and heterosexual WSW reported using emergency food assistance in the past 12-months (PR = 1.89; 95% CI, 1.29-2.79 and PR = 1.43; 95% CI, 1.03-2.00 respectively). CONCLUSIONS: All SMW reported higher prevalence of food insecurity than exclusively heterosexual women. Lesbians and heterosexual WSW were also more likely to rely on emergency food assistance. This is problematic as SNAP use may reduce food insecurity over time, but emergency food resources (e.g., food pantries) do not. More evidence is needed to understand the multilevel factors driving food insecurity in this population to develop policy and community-based efforts to increase SNAP participation and decrease food insecurity.

Computerized versus hand-scored health literacy tools: a comparison of Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid in printed patient education materials.

OBJECTIVE: The research compared and contrasted hand-scoring and computerized methods of evaluating the grade level of patient education materials that are distributed at an academic medical center in east Tennessee and sought to determine if these materials adhered to the American Medical Association's (AMA's) recommended reading level of sixth grade. METHODS: Librarians at an academic medical center located in the heart of Appalachian Tennessee initiated the assessment of 150 of the most used printed patient education materials. Based on the Flesch-Kincaid (F-K) scoring rubric, 2 of the 150 documents were excluded from statistical comparisons due to the absence of text (images only). Researchers assessed the remaining 148 documents using the hand-scored Simple Measure of Gobbledygook (SMOG) method and the computerized F-K grade level method. For SMOG, 3 independent reviewers hand-scored each of the 150 documents. For F-K, documents were analyzed using Microsoft Word. Reading grade levels scores were entered into a database for statistical analysis. Inter-rater reliability was calculated using intra-class correlation coefficients (ICC). Paired t-tests were used to compare readability means. RESULTS: Acceptable inter-rater reliability was found for SMOG (ICC=0.95). For the 148 documents assessed, SMOG produced a significantly higher mean reading grade level (M=9.6, SD=1.3) than F-K (M=6.5, SD=1.3; p<0.001). Additionally, when using the SMOG method of assessment, 147 of the 148 documents (99.3%) scored above the AMA's recommended reading level of sixth grade. CONCLUSIONS: Computerized health literacy assessment tools, used by many national patient education material providers, might not be representative of the actual reading grade levels of patient education materials. This is problematic in regions like Appalachia because materials may not be comprehensible to the area's low-literacy patients. Medical librarians have the potential to advance their role in patient education to better serve their patient populations.

Librarians Promoting Changes in the Health Care Delivery System through Systematic Assessment.

Patient engagement in health care decisions largely depends on a patient's health literacy and the health literacy attributes of the health care organization. Librarians have an established role in connecting patients with health information in the context of their care. However, librarians can play a larger role in helping to make changes in their organization's health literacy attributes. This article discusses one medical library's process of leading systematic assessment of their organization's health literacy attributes. Included in this discussion is the institutional support, timeline, assessment tool, the results for five areas of health literacy, marketing and the event-planning process to disseminate results. The systematic assessment process described employs the Health Literacy Environment of Hospitals and Health Centers document, which provides assessment tools for Print Communication, Oral Communication, Navigation, Technology, and Policies and Protocols.

Farmers' markets' uptake of food assistance programmes in East Tennessee, USA.

OBJECTIVE: Limited acceptance of government food assistance programmes such as the US Department of Agriculture's (USDA) Supplemental Nutrition Assistance Program (SNAP) is a barrier that produces unequal access to market products for SNAP beneficiaries. There is a dearth of published evidence to explain the limited SNAP acceptance at farmers' markets. The current project aimed to fill this gap; to identify and describe the barriers to markets' acceptance of SNAP. DESIGN: Cross-sectional, semi-structured interviews were conducted. SETTING: All interviews were conducted via telephone. SUBJECTS: Twelve East Tennessee area market managers, vendors and other key stakeholders. RESULTS: Multiple barriers exist for SNAP implementation at markets including administrative and time limitations, prejudice from market vendors against SNAP beneficiaries, and resistance to invasive and burdensome requirements of the USDA SNAP application required for farmers' markets. CONCLUSIONS: SNAP acceptance at farmers' markets is a complex issue, especially for small, rural markets. If farmers' markets are to serve as sustainable resources to increase food access, these issues must be addressed so that SNAP can be accepted. Successful implementation of SNAP at rural markets requires increased administrative support and vendor education about SNAP and its beneficiaries. A revised USDA SNAP application process for farmers' markets should also be considered.

Disparities in food insecurity at the intersection of race and sexual orientation: A population-based study of adult women in the United States.

Food insecurity affects 1 in 8 American adults annually, and is more prevalent in Black and sexual minority women. We applied an intersectional approach to investigate food insecurity prevalence in women with intersecting minority race and sexual orientation. We used two United States surveillance systems-National Health Interview Survey (NHIS) 2013-2018 and National Health and Nutrition Examination Survey (NHANES) 2005-2014, to estimate how race and sexual orientation jointly influence food insecurity prevalence in women aged 18-59 years (NHIS: N = 47596; NHANES: N = 5106). All analyses were stratified for Supplemental Nutrition Assistance Program (SNAP) use. Relative measures estimated weighted prevalence ratios (PR) comparing Black and White sexual minority women (SMW) to heterosexual White women. Absolute prevalence measures estimated the excess prevalence of food insecurity due to multiple marginalization. Patterns of food insecurity prevalence were similar across NHIS and NHANES, and differed only for non-SNAP users. Relative prevalence of food insecurity was greater in Black SMW than heterosexual White women in NHIS (PR: 2.16; 95% confidence interval [CI], 1.41-3.30) and NHANES (PR: 2.79; 95% CI, 1.73-4.51). The strength of the association between multiple marginalization and food insecurity was stronger for Black SMW than White SMW. Absolute measures were significant only for NHIS and did not support our a priori hypothesis: For non-SNAP users, being Black and sexual minority reduced the joint disparity in food insecurity by approximately 50% (Synergy Index: 0.52; 95% CI, 0.11-0.93). Overall, our study illuminated population-level differences in food insecurity among women of diverse minority races and sexual orientations. Black SMW experienced high rates of food insecurity, which may contribute to chronic disease disparities. Yet, intersecting minority social positions (race and sexual orientation) reduced food insecurity; these findings are unexpected and must be further investigated. Increasing SNAP use among multiply marginalized women may attenuate food insecurity disparities.

Food Insecurity Among Transgender and Gender Nonconforming Individuals in the Southeast United States: A Qualitative Study.

Purpose: Transgender and gender nonconforming (TGNC) people experience high rates of poverty, joblessness, and homelessness, which drive risk for food insecurity. TGNC people also face discrimination due to transphobia and cissexism, which may contribute to these drivers. Minimal empirical evidence describes experiences with food insecurity among TGNC people. This project investigated food insecurity among TGNC people and how these experiences relate to their physical and mental health. Methods: Semistructured telephone interviews were conducted with 20 TGNC people residing in the Southeast United States (U.S.), recruited through social media. Interviews were transcribed and qualitatively coded. Results: TGNC people reported living in extreme poverty. They described how the conservative sociopolitical climate of the Southeast United States made it difficult to find and maintain employment, which was a primary driver of food insecurity. Participants experienced discomfort seeking food assistance due to discrimination and concern for reducing emergency food availability for people in greater need. Stress from unemployment and underemployment, inadequate food supplies, and discrimination was reported as a contributor to poor physical and mental health, and weakened support systems. Conclusion: Poverty and food insecurity erode TGNC people's physical and mental health and support systems. TGNC people faced substantial barriers-including unemployment and underemployment and multilevel discrimination-which prevented them from affording adequate food. Public health solutions include implementing employment nondiscrimination policy to protect TGNC people in the workplace and building relationships between local food pantries and LGBT organizations to create safer environments for all persons in need of food assistance.

Social Media Recruitment of Marginalized, Hard-to-Reach Populations: Development of Recruitment and Monitoring Guidelines.

BACKGROUND: Social media can be a useful strategy for recruiting hard-to-reach, stigmatized populations into research studies; however, it may also introduce risks for participant and research team exposure to negative comments. Currently, there is no published formal social media recruitment and monitoring guidelines that specifically address harm reduction for social media recruitment of marginalized populations. OBJECTIVE: The purpose of this research study was to investigate the utility, successes, challenges, and positive and negative consequences of using targeted Facebook advertisements as a strategy to recruit transgender and gender nonconforming (TGNC) people into a research study. METHODS: TGNC adults living in the Southeast Unites States were recruited via targeted Facebook advertisements over two cycles in April and June 2017. During cycle 1, researchers only used inclusion terms to recruit the target population. During cycle 2, the social media recruitment and monitoring protocol and inclusion and exclusion terms were used. RESULTS: The cycle 1 advertisement reached 8518 people and had 188 reactions, comments, and shares but produced cyberbullying, including discriminatory comments from Facebook members. Cycle 2 reached fewer people (6976) and received 166 reactions, comments, and shares but produced mostly positive comments. CONCLUSIONS: Researchers must consider potential harms of using targeted Facebook advertisements to recruit hard-to-reach and stigmatized populations. To minimize harm to participants and research staff, researchers must preemptively implement detailed social media recruitment and monitoring guidelines for monitoring and responding to negative feedback on targeted Facebook advertisements.

Housing and food stress among transgender adults in the United States.

PURPOSE: The purpose of the study was to assess housing and food-related stress in transgender and cisgender adults in the United States. METHODS: Data from the 2014 and 2015 Behavioral Risk Factor Surveillance System were analyzed for 53,060 adults who responded to the Sexual Orientation and Gender Identity module and the Social Context module. We used multiple logistic regression to assess the association of gender identity with housing and food-related stress. RESULTS: There were no significant differences by gender identity in the odds of experiencing housing or food-related stress. A sensitivity analysis revealed that with a broader definition of food-related stress, transgender individuals had higher odds of experiencing food-related stress compared with cisgender individuals. The sample of transgender individuals who experienced food-related stress were young, single, racially diverse, sexual minorities, and the majority had a high school degree or less. Similarly, most transgender individuals who experienced housing-related stress were single, sexual minorities, and had a high school degree or less. CONCLUSIONS: More precise assessments of housing and food insecurity among probability-based samples of transgender individuals are needed to fully understand housing and food-related instability and the stress associated with these experiences.

Assessing the Print Communication and Technology Attributes of an Academic Medical Center.

BACKGROUND: Historically, health literacy has been viewed as the patient's problem; however, it is now accepted that the responsibility for improving health literacy lies with the health care professionals and systems. An Institute of Medicine report outlines the health literacy attributes, such as printed patient education and technology, which both play a role in patient decision-making and engaging them in their health care. Research suggests that patients who are engaged in their health care have improved health outcomes. For health care organizations to accommodate the needs of all patients, it is imperative that they determine the current organizational state and discover opportunities for improvement. METHODS: The Health Literacy Environment of Hospitals and Health Centers (HLEHHC) Print Communication Rating and Technology Rating Tool were used to measure the internal aspects of organizational health literacy at The University of Tennessee Medical Center (UTMC). Included in the print assessment were the 150 most distributed patient education handouts. Researchers also used the Simple Measure of Gobbledygook and Patient Education Materials Assessment Tool to assess print material. Technology was assessed using UTMC's website as the authoritative source. KEY RESULTS: The HLEHHC was useful for assessing print material and technology. Reviewing and reporting the data question-by-question revealed more granular, actionable information on where there are opportunities to improve the health care environment for all patients. This analysis resulted in proposing actions based on best practices that UTMC could implement in the coming year. The process is replicable in other settings. IMPLICATIONS: Responsibility for improving informed medical decision-making lies with health care organizations. Low health literacy influences the effectiveness of print patient education and technology in informing patients about their health. Assessing these aspects of the health care organization as part of quality improvement provides necessary data for improvements. The Health Literacy Environment of Hospital and Health Centers was a useful tool to measure characteristics of print and technology. [HLRP: Health Literacy Research and Practice. 2018;2(1):e26-e34.]. PLAIN LANGUAGE SUMMARY: A task force at an academic medical center assessed the health literacy attributes of their organization. Researchers assessed print patient education and patient-related technology. The researchers found areas for improvements to make health information easier to understand.