PLOS ONE

RESEARCH ARTICLE

Food insecurity among African Americans in

the United States: A scoping review
Elizabeth Dennard ID1☯*, Elizabeth Kristjansson2☯, Nedelina Tchangalova ID3☯,
Sarah Totton ID4☯, Donna Winham5☯, Annette O’Connor ID6☯
1 Office of Applied Research and Safety Assessment, Food and Drug Administration, Laurel, Maryland,
United States of America, 2 School of Psychology, University of Ottawa, Ottawa, Ontario, Canada, 3 STEM
Library, University of Maryland, College Park, Maryland, United States of America, 4 Department of
Population Medicine, University of Guelph, Guelph, Ontario, Canada, 5 Food Science and Human Nutrition,
a1111111111 Iowa State University, Ames, Iowa, United States of America, 6 College of Veterinary Medicine, Michigan
State University, East Lansing, Michigan, United States of America
a1111111111
a1111111111 ☯ These authors contributed equally to this work.
a1111111111 * Elizabeth.dennard@fda.hhs.gov
a1111111111

Abstract
In 2019, the estimated prevalence of food insecurity for Black non-Hispanic households was
OPEN ACCESS
higher than the national average due to health disparities exacerbated by forms of racial dis-
Citation: Dennard E, Kristjansson E, Tchangalova
N, Totton S, Winham D, O’Connor A (2022) Food
crimination. During the COVID-19 pandemic, Black households have experienced higher
insecurity among African Americans in the United rates of food insecurity when compared to other populations in the United States. The pri-
States: A scoping review. PLoS ONE 17(9): mary objectives of this review were to identify which risk factors have been investigated for
e0274434. https://doi.org/10.1371/journal.
an association with food insecurity, describe how food insecurity is measured across studies
pone.0274434
that have evaluated this outcome among African Americans, and determine which dimen-
Editor: Volkan Okatan, Eskisehir Osmangazi
sions of food security (food accessibility, availability, and utilization) are captured by risk fac-
Universitesi, TURKEY
tors studied by authors. Food insecurity related studies were identified through a search of
Received: July 23, 2021
Google Scholar, PubMed, CINAHL Plus, MEDLINE®, PsycINFO, Health Source: Nursing/
Accepted: August 9, 2022 Academic Edition, and Web of Science™ (Clarivate), on May 20, 2021. Eligible studies
Published: September 12, 2022 were primary research studies, with a concurrent comparison group, published in English
Peer Review History: PLOS recognizes the
between 1995 and 2021. Ninety-eight relevant studies were included for data charting with
benefits of transparency in the peer review 37 unique measurement tools, 115 risk factors, and 93 possible consequences of food inse-
process; therefore, we enable the publication of curity identified. Few studies examined factors linked to racial discrimination, behaviour, or
all of the content of peer review and author
risk factors that mapped to the food availability dimension of food security. Infrequently stud-
responses alongside final, published articles. The
editorial history of this article is available here: ied factors, such as lifetime racial discrimination, socioeconomic status (SES), and income
https://doi.org/10.1371/journal.pone.0274434 insecurity need further investigation while frequently studied factors such as age, education,
Copyright: This is an open access article, free of all race/ethnicity, and gender need to be summarized using a systematic review approach so
copyright, and may be freely reproduced, that risk factor impact can be better assessed. Risk factors linked to racial discrimination
distributed, transmitted, modified, built upon, or and food insecurity need to be better understood in order to minimize health disparities
otherwise used by anyone for any lawful purpose.
among African American adults during the COVID-19 pandemic and beyond.
The work is made available under the Creative
Commons CC0 public domain dedication.

Data Availability Statement: All relevant data are

within the paper and its Supporting information.

Funding: The authors received no specific funding

for this work.

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PLOS ONE Food insecurity among African Americans in the United States

Competing interests: The authors have declared Introduction

that no competing interests exist.
Description of the problem
As of 2019, 10.5% of United States (US) households (13.7 million households) experienced
food insecurity and 4.1% of these households (5.3 million households) experienced very low
food security at some time during the year [1]. Rates of food insecurity were significantly
higher than the national average for households with Black, non-Hispanic, household refer-
ence persons (19.1 percent) [1]. Households that experience food insecurity lack access to
enough food for an active and healthy lifestyle for all household members [2]. The COVID-19
pandemic has caused a public health and economic crisis with repercussions that have led to
an increase in the number of people experiencing food insecurity. In 2020, African Americans
experienced more negative health outcomes linked to COVID-19, the disease caused by
SARS-CoV-2, than other populations due to a combination of factors including racial discrim-
ination, disparities linked to income and health, and inconsistent access to food [2]. Further,
in the United States, individual studies have reported that African American households are
two to three times as likely to experience consistent food insecurity when compared to the gen-
eral population [3–5] These prior findings indicate that race is associated with food insecurity.
However, many individual- and group-level factors other than race have been investigated for
an association with food insecurity. A comprehensive list of studied risk factors and their rela-
tionship to food insecurity among African American households is not available. A compre-
hensive list is needed to understand which relationships exist and which intervention
opportunities need to be investigated. Diverse metrics of food security have been employed by
numerous authors across the literature. According to Ashby and colleagues [6], “accurate mea-
surement of food insecurity is imperative to understand the magnitude of the issue and to
identify specific areas of need, in order to effectively tailor policies and interventions for its
alleviation.” To understand the implications of current study findings, each citation and corre-
sponding findings must be placed in the context of other studies that assess food insecurity
among African American adults in the United States.

Objectives
The first objective of this review was to identify factors that have been investigated for an asso-
ciation with food insecurity among African American adults across the peer-reviewed litera-
ture. Knowledge of these factors will identify critical research gaps and highlight areas for
future research. The second objective was to describe how food insecurity has been measured
in studies that have evaluated this outcome among African American populations. Knowledge
of food security metrics will identify how comparable current measures and potential findings
are across the literature. The final objective was to map each risk factor identified or consid-
ered by researchers to the three primary dimensions of food security (food accessibility, avail-
ability, and utilization) to identify potential gaps across each dimension. Table 1 serves as a
glossary of terms and definitions for food security and relevant proxy variables.

Materials and methods

Protocol and registration
Registering a protocol for systematic reviews in advance promotes transparency, reduces bias,
and eliminates unintended duplication of effort [7, 8]. The PRISMA checklist was developed
by a 24-member expert panel following published guidance and contains 22 reporting items to
help readers develop a greater understanding of relevant terminology, concepts, and key items
to report for scoping reviews [9]. The protocol followed the framework set by Munn et al.

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PLOS ONE Food insecurity among African Americans in the United States

Table 1. Glossary of food security terms.

Term Definition
food security Food security refers to access by all people at all times to enough food for an active and healthy
lifestyle [1].
food insecurity Households that experience food insecurity lack access to enough food for an active and healthy
lifestyle for all household members [2].
food availability Food availability refers to a reliable and consistent source of enough quality food for an active and
healthy lifestyle (environmental factors) [6].
food Food accessibility acknowledges the resources required in order to obtain and put food on the
accessibility table (economic factors) [6].
food utilization Food utilization refers to the intake of safe food and the human resources required to transform
food into meals [6].
food stability Food stability can be achieved when all three domains (availability, accessibility, and utilization)
become sustainable over time [6].
https://doi.org/10.1371/journal.pone.0274434.t001

(2018) and Arksey and O’Malley (2005) [10, 11], as well as the guidelines in protocol was
drafted using the PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and
Explanation. The protocol was registered with the Systematic Reviews for Animals and Food
(SYREAF) on December 30, 2019 (https://syreaf.org/wp-content/uploads/2022/05/Scoping-
Review-Protocol_Signed.pdf). The methodology was informed by Munn et al. (2018)’s guid-
ance and Arksey and O’Malley (2005)’s framework [10, 11].

Eligibility criteria
The eligibility criteria for study inclusion were defined based on the population (P)—adult
African Americans, and the outcome (O)—food insecurity. Peer-reviewed articles published
in English between 1995–2021 were eligible for inclusion in this paper.

Eligible study designs

Eligible studies were primary research studies with a concurrent comparison group: observa-
tional studies (cross-sectional, cohort, and case control), randomized controlled trials, and pri-
mary research studies that evaluated risk factors between time periods (before and after).
Studies that assessed interventions were also included.

Eligible participants
Relevant participants were African American adults, 18 to 64 years of age, living in the United
States. If a study contained a subset of a sample that matched the population of interest, the
subset of participants was included if data was reported separately. One possible source of
ambiguity among identified citations included the definition and use of the term “African
American” in the literature. The United States Census Bureau adheres to the 1997 Office of
Management Budget (OMB) standards on race and ethnicity, which includes five categories:
Asian, Black or African American, Native Hawaiian or Pacific Islander, American Indian or
Alaska Native, and White [12]. According to Rastogi and colleagues, “The Black racial category
includes people who marked the ’Black or African American’ checkbox. It also includes
respondents who reported entries such as African American; Sub-Saharan African entries,
such as Kenyan and Nigerian; and Afro-Caribbean entries, such as Haitian and Jamaican”
[13]. The category for Black and African American people serves as a broad descriptor for
study participants who may not share the same ethnicity, culture, or immigration status. Ras-
togi and colleagues explain further that “these federal standards mandate that race and

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PLOS ONE Food insecurity among African Americans in the United States

Hispanic origin (ethnicity) are separate and distinct concepts and that when collecting these
data via self-identification, two different questions must be used” [13]. This distinction
between race and ethnicity is relevant to this scoping review because the intention was to
include study participants who only identify themselves as African American. Immigration
status is another key factor that may have impacted the eligible study population of interest.
For this scoping review, citations were excluded if the researcher’s study population of interest
comprised only immigrants or refugees.

Eligible outcomes
The outcome of interest was food insecurity. Some authors may have used the following terms
to describe food insecurity: food availability, food accessibility, food utilization, food supply,
food intake, undernourishment, food deprivation, hunger, malnutrition, and use of food assis-
tance programs. These proxy variables of food insecurity were also eligible for inclusion in this
study.

Search sources
The search for relevant studies was conducted in six databases: PubMed (US National Library
of Medicine), EBSCO databases (CINAHL Plus, MEDLINE1, PsycINFO, Health Source:
Nursing/Academic Edition), and Web of Science™ (Clarivate) on May 20, 2021. Both MED-
LINE (EBSCO) and legacy PubMed, the old interface, were searched due to the variations of
the database syntax and features. In addition to the databases above, Google Scholar was
searched to find additional studies that may have been missed through the database searches.
Relevant full-text publications were obtained through available subscriptions through the Uni-
versity of Maryland, University of Guelph, and Iowa State University Libraries. Reference lists
of the included primary research articles and retrieved systematic reviews were examined to
identify any relevant publications. DistillerSR1 (Evidence Partners, Ottawa, Canada) software
was used for article screening and data extraction.

Search strategy
The search strategy was designed by a public health librarian in consultation with other team
members. The search strategy was checked for comprehensiveness and errors against the
PRESS Peer Review of Electronic Search Strategies Guidelines [14]. Search strategies for each
database and corresponding results are shown in S1 Appendix (S1–S3 Tables). Results were
restricted to publication year 1995–2021, English language, and peer-reviewed publications.
The US Department of Agriculture (USDA) began collecting data annually regarding food
access, food spending, and sources of food assistance in the United States in 1995 [15]. There-
fore, this regulatory activity represents a reasonable starting point for relevant studies to be
included in this paper.

Selection of sources
Search results were uploaded into EndNote X9 Desktop and duplicate records removed. Title/
abstract screening, full-text screening, and data extraction were independently performed by
two authors in DistillerSR1. Both reviewers received training prior to the screening process
using piloted forms and discussion until agreement about interpretation was reached. The
title/abstract screening form was piloted with 100 records while the full-text screening form
was piloted with five records. Conflicts were resolved through discussion until consensus was

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PLOS ONE Food insecurity among African Americans in the United States

reached based on detailed justifications provided by each reviewer. The screening forms are
included in S3 Appendix.

Data charting and analysis

Data charting forms were developed and reviewed to determine study characteristics and data
items for extraction. Two reviewers independently captured data items, discussed findings,
and updated all forms as changes were made. Data extraction forms are included in S3
Appendix.

Data items and extraction

Data extraction captured general study characteristics, study population characteristics (state,
region, age distribution, and number of participants), study design, exposures investigated,
and relevant measures. These food insecurity metrics might be used at the individual level to
represent the experiences, behaviours, or conditions of an individual or a single household [1].
Alternatively, these metrics might be aggregated to represent a group at the ecological or
group level. For example, a study might report the proportion of households in a region that
skip meals more than twice in one week or the proportion of households in a neighbourhood
with a cut-off listed in the USDA (2018)’s 18-item questionnaire. For this scoping review, all
measures of food security described in the literature were extracted.

Risk of bias and study quality

The authors did not assess risk of bias or study quality of the included studies, as risk-of-bias
assessment is not required for scoping reviews [10]. According to Munn and colleagues (2018)
“as scoping reviews do not aim to produce a critically appraised and synthesized result/answer
to a particular question, an assessment of methodological limitations or risk of bias of the evi-
dence included within a scoping review is generally not performed unless there is a specific
requirement due to the nature of a scoping review aim” [10].

Critical appraisal of individual sources of evidence

A critical appraisal of the included studies was not conducted, consistent with Arksey and
O’Malley (2005)’s guidance [11].

Synthesis of results
After data extraction, the factors were mapped to no more than three of the four unique
dimensions of food security: food availability, food accessibility, and food utilization. Table 1
provides definitions of these proxy variables of food insecurity. The extracted risk factors were
also mapped as being at the individual or group level and whether a risk factor appeared to be
a “cause” or “possible consequence” of food insecurity. If a risk factor identified in the study
served as a “possible consequence” of food insecurity, this term was not categorized into the
food security dimensions (food availability, accessibility, and utilization) for risk factors. For
example, a study participant’s mental health status or “depression score” could serve as both a
“cause” of food insecurity due to lack of food accessibility or it could serve as a “consequence”
of experiencing food insecurity due to lack of food utilization. If the risk factor fell into the
“cause” category only, the factor was categorized based on the three food security dimensions
described above. Finally, these variables were placed into ten descriptive categories: demo-
graphic (individual characteristics such as age and sex), household (marital status and single
parent status), economic (household income and family poverty), behavioural (lifestyle habits,

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PLOS ONE Food insecurity among African Americans in the United States

actions, and behaviours), nutritional, physical environment (physical, chemical, and biological
factors external to a person), social environment (social factors external to a person), physical
health (physical and genetic health factors), mental health, and COVID-19 related risk factors.
This process was completed by two reviewers and then conflicts were resolved through discus-
sion to ensure consistent classification.

Results
Selection of citations
The results of the search and eligibility screening process are presented in Fig 1 [16].

Characteristics of included studies

The characteristics of included studies are described in S2 Appendix (S4–S6 Tables). which
provides an overview of food security measures described by authors, citation characteristics
(state, region, and study design), and study population characteristics (spread of ages, partici-
pant count, and household count).

Synthesis of results
Data were extracted from ninety-eight citations. Seventy-three studies employed a cross-sec-
tional design, while the remaining studies implemented the following study designs: cohort/
longitudinal (n = 19 studies), randomized controlled trial (n = 3 studies), qualitative (n = 2
studies), and concept mapping (n = 1 study). Studies were conducted in multiple states, but
many authors did not report a specific state (n = 35). Twenty-eight studies reported findings
from urban, both urban and rural (n = 12 studies), and rural (n = 3 studies) regions while the
remaining studies did not report a specific region (n = 55 studies).
For the 115 risk factors identified, demographic characteristics represented the majority of
factors described in the literature (n = 53 factors). Behavioural (lifestyle and nutritional habits,
n = 5 factors), environmental (physical and social environment, n = 38 factors), health-related
characteristics (physical and mental health, n = 15 factors), and COVID-19 related risk factors
(n = 4) were less commonly reported. For possible consequences of food insecurity (n = 92 fac-
tors), the following terms received the greatest number of hits across the reviewed citations:
self-reported health status (n = 16 citation hits), total number of people in household (n = 14
citation hits), SNAP recipient (n = 14 citation hits), depression or depressive symptoms
(n = 12 citation hits), and body mass index (BMI) (n = 8 citation hits). The results of the risk
factor mapping process are presented in Fig 2.
The 115 risk factors were mapped to five broad categories (demographic, behaviour, envi-
ronment, health-related factors, and COVID-19 related factors) along with ten descriptive sub-
categories for further risk factor categorization. Each subcategory was further mapped to the
three dimensions of food security (food accessibility, availability, and utilization) and each
combination available (1. Accessibility and Availability; 2. All Categories; 3. Accessibility; 4.
Accessibility and Utilization; 5. Availability (Fig 2). None of the identified risk factors mapped
to food utilization exclusively, so this category was not represented in the figure. Demographic
factors mapped most frequently to the accessibility category while household and economic
factors mapped to the food accessibility and utilization categories. Behavioural factors linked
to behaviour and nutrition mapped to all three dimensions of food security, while COVID-19
related factors and health-related factors primarily mapped to food accessibility and utiliza-
tion. Most of the physical environmental factors mapped to food accessibility and availability,
while most social environmental factors mapped to food accessibility exclusively. Ultimately,

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PLOS ONE Food insecurity among African Americans in the United States

Fig 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers
only. This diagram depicts the flow of information through different phases of a scoping review and maps the number
of records identified, included and excluded, and exclusion justifications.
https://doi.org/10.1371/journal.pone.0274434.g001

Fig 2. Dimensions of food insecurity Evidence and Gap Map (EGM). This diagram depicts the sum of citation hits (1–233) per risk factor category
(behavioural, COVID-19, demographic, environment, and health) and how each category is mapped to the dimensions of food insecurity (accessibility,
availability, and utilization).
https://doi.org/10.1371/journal.pone.0274434.g002

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PLOS ONE Food insecurity among African Americans in the United States

this scoping review provides a visual breakdown of risk factor categorization across each
dimension and possible combination of food security in all included studies.
Thirty-seven measures of food security were identified across 98 citations. Most authors
implemented the U.S. Household Food Security Survey Module (n = 16), the Six-Item Short
Form of the Food Security Survey Module (n = 16), and the Eighteen-Item Household Food
Security Scale (n = 13). The remaining studies referenced other measures of food security.
Adaptations of the USDA Food Security Survey Module included the US Adult Food Security
Survey Module, a 2-item screener derived from the 18-Item US Household Food Security
Screen, and a 3-item adaptation from the USDA Food Insecurity Scale [17–21]. Non-USDA
metrics included the National Health Interview Survey on Disability, the 2007 AIDS Alabama
Needs Assessment Survey, the Survey of Income and Program Participation (SIPP), the Food
Insufficiency Indicator (from SEED OK Survey), the Current Population Survey Food Security
Supplement (CPS-FSS), the Health and Retirement Study (HRS) Food Insecurity Question-
naire, the Radimer-Cornell Hunger and Food Insecurity Instrument, the Access to Healthy
Foods Scale, and the NHANES Food Security Module [22–31]. Remaining metrics include
Food Sufficiency Status based on four self-reported risk situations that were related to absence
of food and forced scarce-resource decisions, neighbourhood supermarket density per 10,000
people, receipt of food stamps in the past 12 months, the number of full-service retail food out-
lets (RFOs) in the neighbourhood, and WIC receipt [32–35].
Most of the demographic factors (n = 53 risk factors), including household and economic
terms, were mapped to the food access category (n = 52 risk factors) while remaining dimen-
sions of food security, food availability (n = 5 risk factors) and food utilization (n = 26 risk fac-
tors), were mapped less frequently (Table 2). Examples of identified demographic risk factors
include age, race/ethnicity, gender, number of children in household, socioeconomic status
(SES), and family poverty. All behavioural factors (n = 5), including lifestyle habits and terms
linked to nutrition, mapped to food access and food utilization (Table 3). Most of the environ-
mental factors (n = 38 factors), including physical and social environment terms, mapped to
the food access category (n = 36 factors), while food availability (n = 19 factors) and food utili-
zation (n = 10 factors), were mapped less frequently (Table 4). Examples of identified environ-
mental risk factors include geographic location, living situation, neighbourhood grocery store
availability, and neighbourhood safety from crime and violence. All health-related factors
(n = 15), including physical and mental health terms, mapped to the food access dimension of
food insecurity. Most of these terms also mapped to the food utilization category (n = 13)
while none of them mapped to food availability (Table 5). Examples of identified health-related
risk factors include human immunodeficiency virus (HIV) status, arthritis, alcoholism, liver
fibrosis, and health insurance status. All COVID-19 related risk factors (n = 4), including
impact of COVID-19 on employment, stay-at-home orders, decreased income due to COVID-
19, and unemployed prior to pandemic, mapped to the food access and utilization dimension
of food security (Table 6).

Discussion
Summary of the evidence
The findings from this scoping review suggest that a wide range of risk factors have been evalu-
ated for an association with food insecurity among African American adults across the peer-
reviewed literature. The demographic (n = 53 risk factors) and environmental (n = 38 risk fac-
tors) categories represented the greatest number of risk factors evaluated across studies, which
suggests that these categories, and relevant terms within each group, have received more

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PLOS ONE Food insecurity among African Americans in the United States

Table 2. Demographic risk factors mapped to the dimensions of food security.

Term Citation Hits Sub Category Accessibility Availability Utilization Level
Race/ethnicity 65 Demographic Accessibility Individual
Age 54 Demographic Accessibility Individual
Education 52 Demographic Accessibility Individual
Gender (social) 41 Demographic Accessibility Individual
Household income 29 Economic Accessibility Utilization Group
Employed/Unemployed 28 Economic Accessibility Utilization Individual
Marital status (partnered status) 28 Household Accessibility Utilization Group
Number of children in household 20 Household Accessibility Utilization Group
Income 15 Economic Accessibility Utilization Individual
Family poverty 11 Economic Accessibility Availability Utilization Group
Child’s age 10 Household Accessibility Utilization Group
Race 10 Demographic Accessibility Individual
Single parent (status) 6 Household Accessibility Utilization Group
Time (year) 6 Demographic Accessibility Availability Group
Mother’s age 5 Household Accessibility Utilization Group
Child’s gender 4 Household Accessibility Individual
Female-headed household 4 Household Accessibility Group
Home ownership 4 Economic Accessibility Utilization Individual
Documentation status (work permit, citizen, legal permanent resident, etc.) 3 Demographic Accessibility Individual
Poverty rate 3 Economic Accessibility Availability Utilization Group
Sexual orientation 3 Demographic Accessibility Individual
Unemployment rate 3 Economic Accessibility Group
Disability 2 Demographic Accessibility Utilization Individual
Family monthly poverty level index 2 Economic Accessibility Group
History of military service 2 Demographic Accessibility Individual
Hours of work 2 Economic Accessibility Utilization Individual
Infant/child race/ethnicity 2 Household Accessibility Individual
Maternal union transitions 2 Economic Accessibility Individual
Pregnant woman (pregnancy status) 2 Demographic Accessibility Utilization Individual
Baby’s father in household 1 Household Accessibility Utilization Group
Baby’s grandmother in household 1 Household Accessibility Utilization Group
Bank account ownership 1 Economic Accessibility Individual
Child in household on NSLP (National School Lunch Program) 1 Household Availability Both
Credit card ownership 1 Economic Accessibility Individual
Disabled adults in household 1 Household Accessibility Utilization Group
Disabled child in household (not receiving SSI) 1 Household Accessibility Utilization Group
Disabled child in household (receiving SSI) 1 Household Accessibility Utilization Group
English proficiency 1 Demographic Accessibility Individual
Financial capability 1 Economic Accessibility Utilization Both
Financial hardship from medical bills 1 Economic Accessibility Both
Gender modality (transgender or cisgender) 1 Demographic Accessibility Individual
Has dependents 1 Household Accessibility Utilization Individual
Have enough money to buy food at the hospital 1 Economic Accessibility Individual
History of incarceration 1 Household Accessibility Utilization Both
Income insecurity 1 Economic Accessibility Availability Utilization Both
Parental drug use 1 Household Accessibility Utilization Group
Parental incarceration 1 Household Accessibility Utilization Group
(Continued )

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PLOS ONE Food insecurity among African Americans in the United States

Table 2. (Continued)

Term Citation Hits Sub Category Accessibility Availability Utilization Level

Religion 1 Demographic Accessibility Individual
Senior in household 1 Household Accessibility Utilization Group
Socio-economic status (SES) 1 Economic Accessibility Individual
State welfare expenditures 1 Economic Accessibility Group
Unexpected expenses 1 Economic Accessibility Individual
Will lose income from your job because of hospital stay 1 Economic Accessibility Individual
https://doi.org/10.1371/journal.pone.0274434.t002

representation when compared to other categories (behavioural, health-related, and COVID-

19-related categories).
COVID-19 related factors (n = 4), behavioural factors (n = 5), and health related factors
(n = 15) comprised the fewest number of risk factors across included studies. This serves as a
significant data gap compared to demographic and environmental characteristics, because
these sub-categories have received less attention by authors. In future studies, it is critical for
researchers to consider risk factor representation across the literature by examining beha-
vioural and health-related risk factors among African American adults to fill current data gaps.
A few examples include sexual orientation [22], English proficiency [34], pregnancy status [36,
37], religion [38], lifetime racial discrimination [18], neighbourhood safety from crime and
violence [26], neighbourhood grocery store availability [38], impairment that limits use of
public transportation [24, 39], HIV status [40], decreased income due to COVID-19 [41], the
impact of COVID-19 on employment, and stay-at-home orders [42]. Future primary research
studies could focus on these under-represented risk factors that may perpetuate food insecu-
rity among African American adults instead of examining risk factors that have been exten-
sively evaluated by other researchers. Authors should also consider findings from multiple
publications, including similar studies, scoping reviews, and systematic reviews, instead of for-
mulating hypotheses based on a single finding or publication. The inference obtained from a
single publication is limited; therefore, authors of future studies should consider findings from
multiple studies to refine metrics and improve study design for stronger inference about
described associations.
Diverse metrics of food security (n = 37 metrics) have been employed across this body of
included studies to measure a single outcome. The use of multiple measures for a single out-
come presents issues for understanding the entire body of work available to readers. If
researchers and clinicians are willing to modify standardized measures of food security, then a
justification for this modification must be reported. For example, the 2-item screen derived
from the 18-Item US Household Food Security Screen could impact the accuracy of the mea-
surement of food insecurity. In addition, it is important for researchers and clinicians to con-
sider the value of individual questions within modified screeners. Variation in questions and

Table 3. Behavioural risk factors mapped to the dimensions of food security.

Term Citation Hits Sub Category Accessibility Availability Utilization Level
Drug problem 3 Behavioral Accessibility Utilization Individual
"I’m too busy to take the time to prepare healthy foods" 2 Nutrition Accessibility Utilization Individual
SNAP receipt in past year 2 Nutrition Accessibility Utilization Individual
Time since SNAP distribution 1 Nutrition Accessibility Utilization Individual
Taking prescribed medications 1 Behavioral Accessibility Utilization Individual
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PLOS ONE Food insecurity among African Americans in the United States

Table 4. Environmental risk factors mapped to the dimensions of food security.

Term Citation Hits Sub Category Accessibility Availability Utilization Level
Urbanicity 7 Physical Environment Accessibility Availability Group
Access to car 5 Physical Environment Accessibility Both
Living situation (living alone vs with spouse/family/room-mates) 4 Physical Environment Accessibility Utilization Both
Social support (to borrow money from) 4 Social Environment Accessibility Individual
Access to help from family, friends, neighbors 3 Social Environment Accessibility Utilization Individual
Geographic location 2 Physical Environment Accessibility Availability Group
State 2 Physical Environment Accessibility Availability Group
Social capital 2 Social Environment Accessibility Individual
Metropolitan residency 1 Physical Environment Accessibility Availability Group
Fruit and vegetable selection in neighborhood 1 Physical Environment Accessibility Availability Group
Have transportation to get food while at the hospital 1 Physical Environment Accessibility Individual
Neighborhood aesthetic quality 1 Physical Environment Accessibility Availability Group
Neighborhood walking/exercise environment 1 Physical Environment Accessibility Group
Neighborhood safety from crime/violence 1 Physical Environment Accessibility Availability Group
Neighborhood grocery store availability 1 Physical Environment Availability Group
Ambient (environmental temperature) 1 Physical Environment Accessibility Availability Group
Birthplace (inside vs outside US) 1 Physical Environment Accessibility Individual
Calendar month 1 Physical Environment Accessibility Individual
Patterns of food source destinations 1 Physical Environment Availability Group
Home damage 1 Physical Environment Accessibility Availability Utilization Both
Relocation 1 Physical Environment Accessibility Availability Utilization Both
Disaster assistance 1 Physical Environment Accessibility Availability Utilization Both
Spatial access 1 Physical Environment Accessibility Availability Both
Transportation mode 1 Physical Environment Accessibility Individual
Shopping distance 1 Physical Environment Accessibility Availability Utilization Both
Member of social or civic organization 1 Social Environment Accessibility Individual
Personal disparity 1 Social Environment Accessibility Individual
Number of people in social network 1 Social Environment Accessibility Utilization Individual
Church (community characteristic) 1 Social Environment Accessibility Availability Both
Neighborhood participation index 1 Social Environment Accessibility Utilization Group
Neighborhood social cohesion 1 Social Environment Accessibility Utilization Group
Neighborhood problems index 1 Social Environment Accessibility Availability Group
Lifetime racial discrimination 1 Social Environment Accessibility Individual
Neighborhood congruence 1 Social Environment Accessibility Group
Neighborhood SES 1 Social Environment Accessibility Availability Group
Neighborhood race/ethnic statuses 1 Social Environment Accessibility Availability Group
Sense of community 1 Social Environment Accessibility Utilization Group
SNAP policy change 1 Social Environment Accessibility Group
https://doi.org/10.1371/journal.pone.0274434.t004

similar themes could lead to distinct differences between metrics of food security. The authors
of this scoping review encourage researchers to utilize standardized metrics, in addition to any
questionnaire modification they desire, so that the body of work has a standard for compari-
son. Efforts such as the Core Outcome Measures in Effectiveness Trials Initiative (COMET)
have been working towards standardizing outcomes as a means of reducing research wastage
[43]. The rationale for using standard outcomes is that this approach facilitates comparison
between studies. Inclusion of a standard outcome, like the USDA 18-item questionnaire, is not
a barrier to adding additional outcomes that researchers are interested in investigating.

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PLOS ONE Food insecurity among African Americans in the United States

Table 5. Health-related risk factors mapped to the dimensions of food security.

Term Citation Hits Sub Category Accessibility Availability Utilization Level
Health insurance status 4 Physical Health Accessibility Utilization Both
Impairment that limits/prevents use of public transportation 2 Physical Health Accessibility Utilization Individual
Alcoholism 2 Mental Health Accessibility Utilization Individual
Cancer type 1 Physical Health Accessibility Utilization Individual
Time since cancer diagnosis 1 Physical Health Accessibility Utilization Individual
Difficulty walking 1 Physical Health Accessibility Individual
Difficulty sitting 1 Physical Health Accessibility Individual
Difficulty standing 1 Physical Health Accessibility Utilization Individual
Difficulty lifting/carrying (10lbs) 1 Physical Health Accessibility Utilization Individual
Length of time on dialysis 1 Physical Health Accessibility Utilization Individual
HIV status 1 Physical Health Accessibility Utilization Individual
Arthritis 1 Physical Health Accessibility Utilization Individual
Joint pain 1 Physical Health Accessibility Utilization Individual
Liver fibrosis 1 Physical Health Accessibility Utilization Individual
Mastery score 1 Mental Health Accessibility Utilization Individual
https://doi.org/10.1371/journal.pone.0274434.t005

Results from this scoping review also suggest that the three unique dimensions of food secu-
rity (food accessibility, availability, and utilization) are represented by distinct risk factor cate-
gories across the peer-reviewed literature and are not equally evaluated by authors. It is critical
for researchers to acknowledge that risk factors linked to food accessibility have received more
risk factor representation across the published literature and that other dimensions of food
security, food availability and food utilization, must be explored to better serve African Ameri-
can adults who experience barriers linked to food insecurity.
Another gap includes the absence of synthesized results for risk factors that have received
the most study representation across the peer-reviewed literature. Multiple demographic risk
factors including education, age, race/ethnicity, and gender were assessed for an association
with food insecurity among most of the included studies. Currently, there is a potential to con-
duct systematic reviews on extensively evaluated demographic risk factors (age, gender, and
race/ethnicity) and summarize the associations found across populations. A systematic review
of these risk factors might expose which demographic factors are associated with the highest
risk of food insecurity among African American adults in the United States.
Another characteristic includes the frequent use of cross-sectional study designs (n = 73)
compared to cohort or longitudinal study designs (n = 19) and randomized controlled trials
(n = 3). As noted by multiple authors of the included studies, the use of the cross-sectional
design limits the assertion of a causal relationship between exposure variables and outcomes of
interest [24]. However, there is an opportunity to consider the implementation of other
designs such as cohort study designs. The value that could be obtained from studying groups
that do not experience food insecurity and then become food insecure would eliminate many

Table 6. COVID-19 related risk factors mapped to the dimensions of food security.
Term Citation Hits Sub-category Accessibility Availability Utilization Level
Impact of COVID-19 on Employment 1 COVID-19 Accessibility Utilization Individual
State stay-at-home orders 1 COVID-19 Accessibility Utilization Group
Decreased income (COVID-19) 1 COVID-19 Accessibility Utilization Both
Unemployed (prior to pandemic) 1 COVID-19 Accessibility Utilization Individual
https://doi.org/10.1371/journal.pone.0274434.t006

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PLOS ONE Food insecurity among African Americans in the United States

of the limitations of trying to understand the cause and effect presented across the peer-
reviewed literature.

Limitations
The focus of this scoping review was on peer-reviewed literature, and it is unclear if inclusion
of grey literature would have impacted review findings.

Conclusions
The findings from this scoping review suggest that metrics of food security and risk factors
associated with food insecurity among African American adults have received variable levels
of representation across the literature. The implementation of standardized metrics of food
insecurity across the literature would minimize research wastage and facilitate better compari-
sons between studies. In addition, it is critical for researchers to consider the wide range of
food security metrics that are implemented by authors and how the creation of new metrics or
modification of standardized metrics could impact the ability to synthesize findings in this
critical area. It is also crucial that researchers consider extensively studied risk factors that are
eligible for systematic reviews (education, age, race/ethnicity, and gender) as they consider
current data gaps and next steps required to address them. For example, behavioural risk fac-
tors and risk factors mapped to the food availability dimension of food security require further
investigation to better assess human behaviour and environmental factors linked to food avail-
ability, and barriers that impact African American populations in the United States. The evalu-
ation of human behaviour and risk factors linked to food availability, a consistent source of
quality food, could minimize existing data gaps and the impact of food insecurity as a negative
health outcome. Other underrepresented risk factors to consider for future research include
factors linked to health disparities among African American adults: lifetime racial discrimina-
tion, neighbourhood grocery store availability, neighbourhood safety from violence, income
insecurity, and the impact of COVID-19 on employment. For example, households that expe-
rience income insecurity or fall below the federal poverty line have greater odds of experienc-
ing inability to afford food, housing insecurity, and food insecurity during the COVID-19
pandemic [41]. In addition, interventions to increase food access among minority and low-
income individuals are crucial to minimize health disparities and the economic stress linked to
the COVID-19 pandemic [42]. Overall, it is crucial for researchers and clinicians to consider
the impact of these factors and how they relate to forms of systemic racism, food insecurity,
and the COVID-19 pandemic in the United States.

Supporting information
S1 Appendix. Search strategies.
(DOCX)
S2 Appendix. Characteristics of included studies.
(DOCX)
S3 Appendix. Screening forms.
(DOCX)
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses exten-
sion for Scoping Reviews (PRISMA-ScR) checklist.
(PDF)

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PLOS ONE Food insecurity among African Americans in the United States

S1 File.
(DOCX)

Author Contributions
Conceptualization: Elizabeth Dennard, Elizabeth Kristjansson, Donna Winham, Annette
O’Connor.
Data curation: Elizabeth Dennard, Nedelina Tchangalova, Sarah Totton.
Investigation: Elizabeth Dennard, Sarah Totton.
Supervision: Annette O’Connor.
Writing – original draft: Elizabeth Dennard, Annette O’Connor.
Writing – review & editing: Elizabeth Dennard, Elizabeth Kristjansson, Nedelina Tchanga-
lova, Sarah Totton, Donna Winham, Annette O’Connor.

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