International Journal of

Environmental Research
and Public Health

Article
Development of a Comprehensive Household Food Security
Tool for Families with Young Children and/or Pregnant Women
in High Income Countries
Amber Bastian 1 , Courtney Parks 2 , Fiona H. McKay 3 , Paige van der Pligt 1 , Amy Yaroch 2 ,
Sarah A. McNaughton 1 and Rebecca Lindberg 1, *

1 Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences,
Deakin University, Locked Bag 2000, Geelong, VIC 3220, Australia
2 Gretchen Swanston Centre for Nutrition, 8401 W Dodge Rd., Omaha, NE 68114, USA
3 Institute for Health Transformation, School of Health and Social Development, Deakin University,
Locked Bag 2000, Geelong, VIC 3220, Australia
* Correspondence: r.lindberg@deakin.edu.au; Tel.: +61-3-9246-8947

Abstract: Despite increasing rates of food insecurity in high income countries, food insecurity and
its related factors are inconsistently and inadequately assessed, especially among households with
young children (0–6 years) and pregnant women. To fill this gap, researchers from the U.S. and
Australia collaborated to develop a comprehensive household food security tool that includes the
known determinants and outcomes of food insecurity among parents of young children and pregnant
women. A five-stage mixed methods approach, including a scoping literature review, key informant
interviews, establishing key measurement constructs, identifying items and scales to include, and
Citation: Bastian, A.; Parks, C.;
conducting cognitive interviews, was taken to iteratively develop this new comprehensive tool. The
McKay, F.H.; van der Pligt, P.; Yaroch, resulting 78-item tool includes the four dimensions of food security (access, availability, utilization,
A.; McNaughton, S.A.; Lindberg, R. and stability) along with known risk factors (economic, health, and social) and outcomes (mental and
Development of a Comprehensive physical health and diet quality). The aim of this novel tool is to comprehensively characterize and
Household Food Security Tool for assess the severity of determinants and outcomes of food insecurity experienced by households with
Families with Young Children young children and pregnant women.
and/or Pregnant Women in High
Income Countries. Int. J. Environ. Res. Keywords: food insecurity; survey; pregnancy; young children
Public Health 2022, 19, 10543. https://
doi.org/10.3390/ijerph191710543

Academic Editor: Paul B.

Tchounwou 1. Introduction

Received: 28 July 2022

Food insecurity impacts millions of people globally; nearly one in three people did
Accepted: 22 August 2022
not have access to adequate food in 2020; an increase of 320 million people in just one
Published: 24 August 2022
year [1]. While there has been a significant focus on hunger and food insecurity in low- and
middle-income countries, there is an increasing recognition that ‘hidden hunger’ and food
Publisher’s Note: MDPI stays neutral
insecurity also exist in high income countries (HICs). In Australia, an estimated 3.4 million
with regard to jurisdictional claims in
people (13.5% of the population) experience food insecurity [2]. In the United States
published maps and institutional affil-
(U.S.), an estimated 13.8 million households (10.5% of the population) are impacted [3].
iations.
In both countries, there is an inconsistent and inadequate assessment of food insecurity
and related factors that families experience which hampers effective programmatic and
policy responses.
Copyright: © 2022 by the authors.
According to the Food and Agricultural Organization of the United Nations (FAO),
Licensee MDPI, Basel, Switzerland. achieving food security rests on four dimensions. The first is the provision of enough
This article is an open access article food to support a healthy lifestyle (availability), the second is food being economically
distributed under the terms and and physically accessible to all people (accessibility), the third is whether people are able
conditions of the Creative Commons to utilize the food they acquire (utilization), and the fourth is how stable the availability,
Attribution (CC BY) license (https:// accessibility, and utilization of food is (stability).
creativecommons.org/licenses/by/ There is considerable interest, debate, and uncertainty surrounding the best way to
4.0/). measure food insecurity in HICs. Ashby et al. examined food insecurity measurement

Int. J. Environ. Res. Public Health 2022, 19, 10543. https://doi.org/10.3390/ijerph191710543 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 10543 2 of 17

tools utilized in this context, assessing the extent to which these tools capture the four
dimensions of food security: access, availability, utilization, and stability [4]. The review
found that most tools only measured the access dimension, meaning that existing tools are
unable to determine the ability of a household to be food secure beyond their ability to
physically access and financially afford food. McKay et al. examined how food insecurity
has been measured in the Australian context over the last fifteen years, revealing that
most tools utilized only measured the access dimension of food insecurity [5]. The U.S.
Department of Agriculture (USDA) Household Food Security Survey Module is widely
used and validated in the U.S. context, however, this tool is limited as it also only assesses
the financial access dimension of food security [4].
The determinants of food insecurity are multifactorial and can occur across multiple
levels of the social-ecological model: intrapersonal, interpersonal, organizational, commu-
nity, and public policy [6]. Determinants of food insecurity include poverty, social and
economic disadvantage, individual characteristics (e.g., gender, ethnicity), and the impact
of the political and social environment [7]. However, given the limited focus on the access
dimension of food insecurity in the most common measurement tools, many estimates of
food security do not capture these additional determinants. In addition, most research to
date has focused on the general population and, as a result, an understudied population
with regard to food insecurity are the parents of young children (ages 0–6) and pregnant
women, who are known to experience negative consequences of food insecurity [8,9].
With a global focus on improving maternal and child nutrition through the 2030
Sustainable Development Goals, it is important to understand the experience of food
insecurity among pregnant women and families with young children, as food insecurity
during these life stages can have ongoing negative health consequences. Women are at risk
of becoming food insecure due to entrenched societal power inequality and a range of socio-
economic conditions such as domestic violence, poor employment, and education [10,11].
Households with children are at increased risk of food insecurity, as such, mothers and,
in particular, single mothers experience a higher rate of food insecurity compared to
women without children [11]. Living in a food insecure household during pregnancy may
increase the risk of excess gestational weight gain, disordered eating, chronic disease, and
various pregnancy complications [12]. The impact of food insecurity on young children is
particularly concerning given they are at a key stage of growth and development which can
influence health during adolescence and even adulthood [13]. It is important to understand
food insecurity among families with young children and pregnant women in HICs as
there is limited evidence that examines factors associated with food insecurity among these
populations. Identifying such factors is essential to understanding how and when strategies
that specifically target food insecurity in this population group may be implemented.
To fill this gap, researchers from the U.S. and Australia collaborated to develop a
comprehensive household food security tool that includes the known determinants of food
insecurity among parents of young children and pregnant women and to extend existing
tools that measure the access dimension of food security. The aim of this study was to
develop a new comprehensive household food security tool to characterize and assess the
severity of determinants and outcomes of food insecurity experienced by households with
young children and pregnant women.

2. Materials and Methods

A five-stage mixed methods approach was undertaken to iteratively develop a com-
prehensive household food security tool. Deakin University provided human research
ethics approval (2020-038) and included the University of Nebraska (0642-20-EX). The
study was designed and has been reported in accordance with the COREQ checklist for
qualitative studies [14]. The first two stages of this study are summarized below and have
been published with full details available [15,16] with the next three stages reported in full
detail for the first time below.
Int. J. Environ. Res. Public Health 2022, 19, 10543 3 of 17

Stage 1
In Stage 1, a scoping literature review was conducted to identify the factors associated
with food insecurity among pregnant women and households with young children aged
0–6 years living in HICs. Scoping reviews can be used to identify knowledge gaps, scope a
body of literature, and identify key characteristics or factors related to a concept [17]. The
scoping review was conducted to investigate factors that influence food insecurity among
pregnant women and households with young children (aged 0–6 years) in HICs.
A comprehensive systematic search informed by Peters et al. [18] was conducted in
four databases: Medline complete, Embase, Global Health, and CINAHL. These databases
were chosen to provide coverage of public health nutrition and nursing and allied health
literature in HICs. Search terms were relevant to food insecurity, determinants, pregnancy,
and family. The search strategy involved combining the search terms and all terms were
searched in the title and/or abstract.
Inclusion criteria were original research articles published in peer reviewed journals
in the English language conducted with families or households incorporating pregnant
women and/or caregivers of young children aged 0–6 years in high income countries
(defined by the Human Development Index). Outcome measures included food security
(measured in any way) and/or other aspects of food security as defined by the Food and
Agriculture Organization (FAO) such as affordability, access, utilization, or stability.
Relevant information was extracted using predetermined categories including country
of study, setting/population, study design, food insecurity measurement tool(s) utilized,
and outcomes. Consistent with the approach taken in scoping reviews, articles were not
assessed for quality [17]. The range of factors was identified and grouped into 13 overarch-
ing constructs. Detailed methods and findings of this scoping review have been published
elsewhere [15].
Stage 2
In Stage 2, qualitative interviews were conducted with 41 pregnant women or house-
holds with young children under 6 years of age who were experiencing or who were
at risk of food insecurity in Omaha, U.S. (n = 19) and Melbourne, Australia (n = 22). A
detailed description of the methods and results for these qualitative interviews have been
reported [16].
A multi-faceted approach was used to recruit participants. Nutrition and food or-
ganizations in Melbourne and Omaha were invited as recruitment sites. One maternity
hospital in each city was also approached along with federally subsidized preschools in
Omaha and online groups for Melbourne mothers. For those willing to assist with recruit-
ment, fliers were provided to distribute via social media platforms and/or in hard copy.
Potential participants contacted the researchers and were provided further information
and telephone/online interviews via Zoom [19] were arranged when convenient.
A semi-structured interview guide was based on the findings of the scoping review
(stage 1) and designed to gain perspectives on the constructs that influence household
food security, key coping strategies, and social, economic, and health conditions that buffer
from or exacerbate the experiences of food insecurity. The questions invited participants
to provide information about their households (including children, partners, and other
household members) and their experiences of feeding a family on a budget. Additional
probes were used for pregnant women to elicit pregnancy-specific outcomes.
NVivo 12-assisted coding [20] was completed to establish themes and subthemes
from the data, informed by Braun and Clarke’s six-step process [21]. First, all interviews
were transcribed iteratively by professional services in each city and checked for accuracy.
Secondly, initial codes were developed in line with the interview guide topics and with
input from all authors. Authors met regularly to discuss coding and emerging insights and
to identify data saturation.
Int. J. Environ. Res. Public Health 2022, 19, 10543 4 of 17

Stage 3
Stage 3 involved mapping the themes and subthemes from the qualitative interviews
to the constructs found within the scoping review. One researcher (A.B.) conducted the
initial mapping which was reviewed by co-authors (C.P., F.H.M., P.v.d.P., and S.M.). Further
analysis of the food insecurity themes and constructs was conducted by comparison with
known food security frameworks [15,22] to explore how the themes and constructs aligned.
Discussion and a consensus on themes and constructs were reached amongst co-authors.
A conceptual basis for the tool was agreed upon by organizing the mapped food
security constructs and themes into three components of the household food insecurity
experience relevant to families with young children and pregnant women. These were
(i) individual or household risk factors for food insecurity (e.g., economic, health, and
social), (ii) the four dimensions of food security (e.g., access, availability, utilization, and
stability), and (iii) the health outcomes or consequences of food insecurity.
Stage 4
In Stage 4, a comprehensive multi-dimensional measurement tool was drafted based
on approaches used previously in public health, allied health, and medicine, including
reviewing the literature, identifying and/or writing items, and subsequent field testing [23].
Using the agreed conceptual basis (i.e., risk factors, dimensions, and outcomes), ap-
propriate items to include in the tool were identified from reviewing the literature and
current measurement tools. These items were then reviewed against the following criteria
for selection: use of validated instruments for the risk factors, dimensions, and outcomes
of interest; use of brief or short items to reduce participant burden; and use of items used
commonly in Australia or the U.S. and/or tested in this population group and/or would
allow comparison with national health surveillance.
An extensive list of possible items to include in the tool was drafted and refined by
assessing each item against the selection criteria. If no existing items could be found for
a construct or theme, the research team developed item(s) taking into consideration the
factors suggested by de-Vet et al. [23] for item development, including target population,
the purpose of measurement, the difficulty of the items, the application in practice, and
response options.
Stage 5
In Stage 5, cognitive interviews using the drafted tool were conducted with pregnant
women or households with children aged 0–6 years who were experiencing or at risk of
food insecurity in Melbourne, Australia (n = 11). Budget constraints limited the piloting to
one setting. Cognitive interviewing is a psychologically oriented method for empirically
studying the ways in which individuals mentally process and respond to survey items [24].
It can be useful in pretesting items and determining how they should be modified to make
them easier to understand and answer [25].
Recruitment for the cognitive interviews included contacting participants who had
been involved in the semi-structured qualitative interviews conducted in Melbourne
(Stage 2) and who had indicated a willingness to be contacted for this additional research
component. In total, 9 out of 22 women indicated they were willing to be contacted and
4 agreed to participate in the cognitive interview. The study also was advertised on so-
cial media via new mothers’ Facebook groups, and seven women were recruited via this
method. Participants completed an online consent form and were contacted by a researcher
(A.B.) via phone or email to arrange a convenient interview time.
Interviews were conducted online via Zoom [19] during a two week period (late
May, early June 2021) and were, on average, 39 min in length (range from 23 min to
76 min). Interviews were audio recorded and cross-checked against field notes captured by
interviewers upon completion of the interview. Participants received $40 in supermarket
vouchers as compensation for their time.
During the cognitive interviews, respondents completed the comprehensive household
food security tool for families with young children and/or pregnant women with an
Int. J. Environ. Res. Public Health 2022, 19, 10543 5 of 17

interviewer while being asked open-ended and probing questions about their responses.
Respondents were asked to read and answer the questions out loud and to talk through
their decision-making process for each question. This allowed the researcher to discern the
participant’s comprehension of items and answer choices.
Respondents were also invited to give general feedback on questions and specific
probes were developed for questions by the research team. For example, at the end of the
questions on demographics, respondents were asked to reflect and answer the following
questions: How hard or easy were these questions to answer? Were any of these more
difficult? If so, why? What were you thinking about as you answered? After the question on
their main sources of income, respondents were asked: How easy or difficult was it for you
to identify your main source of income? Were any of the items confusing or needing further
explanation? This allowed for further exploration of how the questions were constructed
and suggestions for how these items could be improved.
The interviews were conducted by researchers (A.B. and R.L.). Feedback from cogni-
tive interviews was collated across each item and discussed with co-authors (C.P., F.H.M.,
and P.v.d.P.). Suggested changes resulting from this feedback were discussed by the re-
search team and the resulting changes and finalization of the tool were agreed upon by
all authors.

3. Results
The full details of the scoping literature review and qualitative interviews have been
published elsewhere (References [15,16]). In brief, findings from the qualitative interviews
identified a range of prominent themes associated with food insecurity. The constructs
from the scoping review (Stage 1) were mapped against the themes and subthemes arising
from qualitative interviews (Stage 2) to identify 13 food security constructs and themes in
pregnant women or households with young children aged 0–6 years old (Table 1).

Table 1. Constructs and themes associated with food security in pregnant women or households with
young children aged 0–6 years old.

Constructs and Outcomes Identified from Scoping Themes and Outcomes Identified from Qualitative
Food Security Construct
Review (Stage 1) Interviews (Stage 2)
Employment; government assistance (e.g., accessing
Low income, job loss, and payment schedules; not
programs, the trade-off between earning
receiving welfare; low social economic status (i.e.,
income/losing assistance, and running out of
Income and employment education, occupation, and household income);
assistance); competing expenses (e.g., other bills,
living below the poverty line; and mothers as
children’s activities, time of year, and special
homemakers
occasions)
Utilizing resources (e.g., food pantries, utility/bill
Stretching food, going without food, and skipping
aids, and other non-government programs);
meals; cutting back on the variety of foods
budgeting skills (e.g., couponing, bargain shopping,
consumed; going to bed hungry; cooking whatever is
and buying cheaper foods); family and friend
Coping strategies available, buying cheaper food, shopping at value
support (e.g., food, money, or other resources
stores, and using coupons; reducing money spent on
provided; social support); rationing (e.g., making
children’s education and activities; borrowing
food last all month, limiting intake); nutrition
money; and food and social supports
knowledge and skills (e.g., being a good home cook)
Stress (e.g., financial stress, stress from children, and
Maternal depression and poor health status; stress about feeding children); social factors (e.g.,
Maternal depression/mental
parenting stress; lack of time; lack of social support; social support or lack thereof, self-portrayal, and
health
feelings of isolation; and unwanted childbearing stigma); declining mental health contributing to poor
food choices; and depression
Housing and household energy insecurity;
experience greater number of moves/relocating; Food utilization; food storage, waste, and kitchen
Residence stability and crowding
receiving housing subsidy; not owning land; and facilities
household crowding
Education Caregivers/mothers with lower levels of education Social demographics (e.g., lower education)
Int. J. Environ. Res. Public Health 2022, 19, 10543 6 of 17

Table 1. Cont.

Constructs and Outcomes Identified from Scoping Themes and Outcomes Identified from Qualitative
Food Security Construct
Review (Stage 1) Interviews (Stage 2)
Immigrant status and length of time in the country;
Parent acculturation difficulty with shopping and food preparation in a Social demographics (e.g., foreign students)
foreign environment
Social demographics (e.g., visa status and eligibility
Ethnicity Ethnicity, race, and ethnic minority
for government benefits)
Caregiver marital status Familial dynamics such as children eating first and
Family composition (single/widowed/separated/divorced); larger children’s awareness of food insecurity; the age of
household size; and larger number of children children; and generational food insecurity experience
Health care usage; lack of health insurance coverage;
poor infant/child health status and greater Social demographics (e.g., visa status and eligibility
Health care and Health status hospitalizations; high prevalence of for free or subsidized health care, cost of health care
overweight/obesity among food insecure children; including allied health)
and children’s behavioral problems
Participation in welfare programs (e.g., in federal
Participation in food assistance Non-traditional food sources (e.g., food pantries,
food assistance programs such as WIC and SNAP in
programs community gardens)
the U.S.); reliance on school meals
Smoking Living in a house with a smoker, maternal smoking Financial impact of competing expenses
Economic constraints and food pricing (including the
cost of fruit and vegetables); choosing between food Food outlet location; transportation; factors
Food access and availability and other necessities (including medicine and bills); influencing store and item selection; and
and lack of access to healthy food or food stores in non-traditional food sources (e.g., dollar stores)
general
Family food preferences and needs (e.g., priority
Reduced consumption of high-cost and
foods, picky eaters, preferences, dietary needs,
Diet quality micronutrient-rich foods; increased consumption of
culturally appropriate, and
low-cost traditional staple foods
pregnancy/toddler/formula needs)
Lack of urban infrastructure and exposure to Coronavirus impacts on health, employment and
Other
environmental contaminants finances, childcare, and food sourcing

A conceptual basis for the tool was established by organizing the identified food
security constructs and themes into three components of the household food insecurity
experience. These were organized into: (i) individual or household risk factors for food
insecurity (economic, health, and social), (ii) four dimensions of food security (access,
availability, utilization, and stability), and (iii) health outcomes or consequences of food
insecurity (Table 2).

Table 2. The three components of the household food security experience—a conceptual basis for
comprehensively measuring household food security in families with young children and preg-
nant women.

Components of Household Food Insecurity Experience

Economic: income and employment
1. Individual or household risk factors for food
Health: stress and mental health, chronic health conditions
insecurity
Social: demographics including education, ethnicity, and household composition
Utilization: resilience and coping strategies, kitchen facilities, nutrition skills and literacy, and
participation in food assistance programs
2. The four dimensions of food security Access and availability: physical and financial access to foods and stores, food insecurity
screener items
Stability: annual competing expenses and challenging times of year
3. Health outcomes or consequences of food Health: stress and mental health, chronic health conditions
insecurity Diet quality

Using the three identified components described in Table 2, 60 suitable items were
identified from the literature and existing measurement tools: 25 items on individual or
Int. J. Environ. Res. Public Health 2022, 19, 10543 7 of 17

household risk factors for food insecurity, 13 items on the four dimensions of food security,
and 22 items on health outcomes or consequences of food insecurity.
Cognitive interviews with a sample of the population (n = 11) led to amendments, re-
sulting in 56 improvements to the measurement tool. These are documented in Appendix A,
Table A1. Changes included improving the overall readability (2), changes to question
responses offered to make them more relevant (10), changes to question content to make
them clearer (22), and adding new items (20) or deleting items (2). Examples of these types
of changes are presented in Table 3.

Table 3. Examples of changes made to the comprehensive household food security tool resulting
from cognitive interviews.

Type of Change Initial Item in Household Food Security Tool Change Made to Household Food Security Tool
In the past month, about how often did you feel tired In the past month, about how often did you feel tired for
Improving overall readability
out for no good reason? no obvious reason?
. . . about how long would it take to get from your Changed responses to:
home to the nearest local grocery store or supermarket? Less than 5 min
1–10 min 5–15 min
Changes to question response 11–30 min 16–30 min
to make more relevant 31–45 min 31–45 min
46 min–1 h 46 min–1 h
Over an hour Don’t know
Don’t know Not applicable
Which category listed below represents the total
Which category listed below represents the total
combined income of all members of your household who
combined income of all members of your family who
you share finances (include family members 15 years of age
Changes to question content are 15 years of age or older. Please include money from
or older). Please include money from things such as
to make clearer things such as jobs, net income from business,
jobs, net income from business, pensions, social
pensions, social security payments, and any other
security payments, child support and any other income
income received. Was it . . .
received, before tax is taken out. Was it . . .
Are there times of the year or events where buying
food for your household is more difficult due to Added in a separate/additional item:
competing expenses? Please tick any of the below that Please describe the other times or events when buying food is
Adding or deleting items to makes it more difficult for you to purchase food for more difficult (free text response)
make more relevant your household.
Do you consider yourself to be an acceptable weight, Deleted question as subjective and survey has question
underweight or overweight? items on self-reported weight and height

The resulting product is a comprehensive household food security tool for families
with young children and/or pregnant women that includes 78 items that span across the
three components described above. These can be grouped into 1 screening item, 27 items
on individual or household risk factors for food insecurity, 27 items on the four dimensions
of food security, and 23 items on health outcomes or consequences of food insecurity.

4. Discussion
This study developed a comprehensive household food security tool to examine social
demographics and household characteristics, food security status, health, and dietary
outcomes for parents and households with young children. The five-stage mixed method
research was designed to devise a new tool that would expand the measurement and under-
standing of household food security beyond financial access. Food security is complex, as
illustrated by the many frameworks that attempt to explain its multifactorial determinants
and the number of evolving definitions that aim to articulate its various dimensions [6,7].
With our evolving understanding of food security, there is a need to develop and refine
measurement tools that capture the diverse aspects of food security. Previous tools such as
the USDA household food security survey module, Cornell Child Food Security Measure,
Hager two-item screen, and Girard four-point tool have largely focused on the economic or
financial aspect of food insecurity [4]. While this is certainly an important pillar of food
security, it overlooks the physical accessibility to food, availability of healthy and affordable
Int. J. Environ. Res. Public Health 2022, 19, 10543 8 of 17

food, people’s ability to utilize food, and stability of this experience across weeks, months,
years, and even generations. This comprehensive household food security tool is unique
as it includes items that measure the other dimensions of food security and is specific
to households with children under the age of 6 years. Broadly speaking, questions on
food literacy and coping skills uncover the ability to utilize food, questions on fruit and
vegetable availability and the distance to nearest shops examine the availability dimension,
while questions on how various events throughout a year impact food security examine
the stability dimension.
The inter-household dynamics between parents/caregivers and their young chil-
dren are known to be complex in a food insecure context, and hence, a specific tool to
investigate these components among an understudied population is warranted. The con-
ceptual basis developed during this research and used to underpin the comprehensive
household food security tool highlights the complex nature of food security. Risk factors
for food insecurity are commonly attributed to economic variables such as low income
and unemployment [26–28]. Health risk factors such as maternal depression have also
consistently been found to be higher among women experiencing food insecurity [29].
This relationship may be bidirectional as poor mental health has been associated with
a transition into food insecurity [30] and food insecurity has been observed to precede
depression [31,32]. Further, having a household member with chronic health needs and
the associated health care costs is also a risk factor associated with food insecurity [33].
The third type of risk factor contributing to food insecurity is social and includes socio-
demographic factors such as ethnicity, education level, marital status, family size, accul-
turation, and urban life stressors [33–35]. The known consequences or outcomes of food
insecurity include poorer dietary quality [36,37], associations with diet-related chronic
conditions such as diabetes and obesity [38,39], and elevated poor mental health including
depression and anxiety [40]. This comprehensive household food security tool could be
useful in postnatal, maternal, and child health settings to explore a more comprehensive
set of components of food security. Women who report being food secure may in fact
present with several economic, health, or social risk factors that, if identified, could enable
supports to be implemented in these households to prevent the transition into food insecu-
rity. Furthermore, as the comprehensive household food security tool captures health and
dietary outcomes, the inter-relationships between food insecurity and these outcomes can
be further explored to better understand the food insecurity experience in families with
young children and/or pregnant women.
One strength of this research is that it combines multiple types of evidence into
the iterative design of the final instrument. The scoping literature review followed by
qualitative and then cognitive interviews with the target population allowed grounding
of the tool in both lived experience and evidence. Impacted populations provide their
own forms of evidence (knowledge, experience, ideas, and opinions) that aid in expanding
the understanding of a given issue [41]. The information gleaned from the qualitative
interviews helped to contextualize the constructs found within the scoping literature review
to develop the final conceptual framework that underpins the comprehensive household
food security tool. Further, the robustness of the tool comes not only from the efforts to
generate constructs grounded in people’s daily experiences but also from the efforts to
select and generate high-quality items to include in the tool [42].
This tool and study have some imitations. Firstly, the tool is in English. Populations
with English as a second language or who do not speak English at all are often at increased
risk of food insecurity. Race, ethnicity, and acculturation were identified as factors associ-
ated with food insecurity within the literature [27,43], as such, there is a need to develop
and test the tool in languages other than English so that food insecurity among diverse
populations can be better understood and addressed. Secondly, in 2020, the fifth and
sixth dimensions were proposed by the High-Level Panel of Experts on Food Security and
Nutrition and include whether people have the ability to make choices and control their
engagement with the food system (agency) and whether the food system is environmen-
Int. J. Environ. Res. Public Health 2022, 19, 10543 9 of 17

tally, economically, and socially sustainable (sustainability) (HLPE 2020). As this research
commenced prior to the FAO high-level panel of experts recommending the agency and
sustainability dimensions, the tool overlooks these two dimensions [44]. Thirdly, while the
tool is comprehensive, its length might mean its use is limited to research or to settings
where there is sufficient time available to screen.
Future research could explore agency and sustainability and incorporate items around
them into the tool to expand the understanding of how these aspects impact food security
specifically in this population group. This tool is at its prototype stage and several steps
need to be devised before implementing the tool at a population level. These include the
development of a scoring system to rate food insecurity status based on social, cultural,
and economic risk factors and the severity of food insecurity based on answers to the
availability, access, utilization, and stability dimensions of food security. The next step for
this measurement tool is reliability and validity testing. Once these steps are undertaken,
the tool could be useful in screening families at risk of food insecurity in a range of settings.
Future research may also explore how researchers and practitioners may utilize specific
scales and items from the comprehensive tool depending on their interests and goals. It
could be useful in better measuring and understanding food insecurity in this population
group so that policy and programs to address this issue can be devised.

5. Conclusions
There is a need for further research beyond the economic dimension of food security
to truly understand this complex issue and be able to better identify and support those
experiencing food insecurity. Further work is required to test the 78-item comprehen-
sive household food security tool in various settings and populations for reliability and
validity. Subsequently, the tool could be used to examine the relationship and increase
understanding between risk factors, components of the food insecurity experience, and
health outcomes. With an increased understanding of the issue, practitioners, policymakers,
and governments will be better placed to identify and implement the required solutions.

Author Contributions: All authors contributed to the development of the study design, manuscript
development, and revision. C.P. and A.Y. provided guidance on cognitive interviewing methodology,
A.B. and R.L. conducted the cognitive interviews, C.P., A.B., R.L., F.H.M. and P.v.d.P. reviewed
the results and devised the tool. All authors have read and agreed to the published version of
the manuscript.
Funding: The Eisele Family Foundation grant made this work possible. Institute for Physical Activity
and Nutrition (IPAN), Deakin University, Seed Funding, and Dean’s Faculty of Health Post-Doctoral
Research Fellowship (R.L.).
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Deakin
University (2020-038 4 May 2020) and the University of Nebraska (0642-20-EX).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The comprehensive household food security tool can be obtained from
the corresponding author upon email request.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2022, 19, 10543 10 of 17

Appendix A

Table A1. Changes made to the survey as a result of cognitive interview feedback.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
Change as suggested to “are you an Australian
Interview 1: Could just have ‘yes’ as an option:
citizen or permanent resident”? Yes/No options
If you are not an Australian Citizen, what visa are you reword ‘are you an Australian citizen’? Yes, No. If
Free Text (A)
on? Leave blank if not applicable. not, add in what visa question; if yes, skip this
Follow up question if “No” is selected; “What
question
visa are you on?” free text response option (Q)
Living with children and partner/spouse Changed second response option to “living
Living with children Interview 1: For option 2, ‘living with children’ add with children without partner/spouse” (R)
Living with partner/spouse in ‘without spouse’. Could add into question ‘own Changed wording of question item to “Which
Which of the following best describes your housing or
Living with parents/extended family or foster’ children of the following best describes who you live
living situation? Tick one:
Living by myself Interview 4: Hard to locate answer (living with with? Choose one”. (Q)
Living with flatmates/friends children) Removed wording ‘living with’ from responses
Other (please specify) as question item wording changed (O)
Homeowner
Renting (privately) Interview 1: Add ‘living with parents/family’ as an
Added new response option “Permanently
Renting (public housing or community housing) option as this may be a permanent situation and
staying with family or friends” (R)
Boarding house or caravan park therefore doesn’t come under the temporary
What is your current living arrangement? Changed homeowner response options to
Temporary accommodation (staying with family or accommodation option
“Homeowner no mortgage” or “Homeowner
friends, shelters, hostel) Interview 5: Have two options for homeowner:
with mortgage” (R)
Living on the street with mortgage and without mortgage
Other
Wages or salary
Any government pension or allowance
Interview 5: Add in an additional question ‘are you Changed question item wording to include
Self funded retirement
What is your main source of income? the main income earner in the home’ household so the question now reads “What is
Nil or negative
Interview 7: Answer for self or partner? your main source of household income”? (Q)
Don’t know
Any other regular source—please answer 14a
Int. J. Environ. Res. Public Health 2022, 19, 10543 11 of 17

Table A1. Cont.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
Interview 1: What about if living with housemates
or parents? Are these included? Word ‘family’ may
No income be confusing as may word ‘household’
Which category listed below represents the total $1–$119 per week ($1–$6239 annually) Interview 2: Does this include family tax benefit? Changed wording in this question to include
combined income of all members of your family who $120–$299 per week ($6240–$15,999 annually) Would interpret answering this question the text “members of your household who you
are 15 years of age or older. Please include money from $300–$499 per week ($16,000–$25,999 annually) pre-tax/gross but doesn’t specify share finances with” (Q)
things such as jobs, net income from business, pensions, $500–$699 per week ($26,000–$36,999 annually) Interview 4: Had to stop and really think Added text “before tax is taken out” to question
social security payments, and any other income $700–$999 per week (37,000–$51,999 annually) Interview 6: Most payments are fortnightly (Q)
received. Was it . . . $1000–$1499 per week ($52,000-$77,999 annually) Interview 7: Pre or post tax? Added text “child support” into question (Q)
$1500 or more per week ($78,000 or more annually) Interview 8: Do I include child support?
Interview 11: Like how there was an annual, this
helped to work out more so than the weekly total
JobSeeker Interview 1: Add parenting payment?
Austudy/abstudy Interview 2: Does parenting payment cover part
Disability support pension parenting payment? What about family tax benefit, Included “family tax benefit” as a response
Do you receive any government benefits? Yes/No Carer payment also under parenting payment? option (R)
If yes, which ones do you receive? Tick all that apply: Parenting payment Interview 5: Add in ‘family tax benefit as an option Allow free text if the “other” response option is
Aged pension Interview 7: What about childcare subsidy? Does selected (R)
Rent assistance this come under family tax benefit?
Other Interview 11: Think childcare should be here
For the following statements please choose the answer
that best fits for the past year:
My family has enough money to afford the kind of
home we would like to have
We have enough money to afford the kind of clothing
we should have Interview 5: Have ‘adequate’ but not ‘ideal’ for
Strongly disagree
We have enough money to afford the kind of furniture most of these questions
Disagree
or household equipment we should have Most interviewees struggled to answer this scale as
Neutral Scale removed (D)
We have enough money to afford the kind of car they found it hard to distinguish between essential
Agree
we need items (i.e., any home) and what they would like (i.e.,
Strongly agree
We have enough money to afford the kind of food we a home they would like)
should have
We have enough money to afford the kind of medical
care we should have
My family has enough money to afford the kind of
leisure and fun activities we want to participate in
Int. J. Environ. Res. Public Health 2022, 19, 10543 12 of 17

Table A1. Cont.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
Added in an additional eight USDA questions
specific to children for respondents who
In the last month did (you/you or other adults in your No indicate they have children (8A)
household) ever cut the size of your meals or skip meals Yes—please answer 3a. Interview 2: Asks about adults Added four new questions on children’s health
because there wasn’t enough money for food? Don’t know (4A)
Added question about children’s awareness of
the food insecurity experience (A)
I drive my own car
I ride with friends or family
I borrow a car Interview 1: What about online grocery delivery Created a new question about where people
What kind of transport do you usually use to purchase I take public transport (train, tram, bus, or (Coles online, Woolworths online)? shop that precedes this question about
food/groceries? Tick one only combination) Interview 2: Would tick two options if could transportation to purchase food/groceries. The
I take a taxi or app-based ride like Uber Interview 7: Add in online delivery as option new question includes online shopping (A)
I walk or take my bicycle
Other, please specify
1–10 min
11–30 min
Using this usual form of transport listed in the previous
31–45 min Interview 11: In cities most people are going to be Changed response options: “Less than 5, 5–15,
question, about how long would it take to get from your
46 min–1 h less than 5 min, so maybe have 1–5 and 6–10 min 16–30, 31–45, 46–1h” (R)
home to the nearest local grocery store or supermarket?
Over an hour
Don’t know
For the following questions choose the answer which
best fits. How often during the past month did you or
anyone in your household have to . . . .
choose between paying for food and paying for Added in the text “medication” to the first line
medical care? Interview 5: Does this include medication? item so question item now reads “medicine
choose between paying for food and paying for utilities? Interview 11: Should there be a not applicable here and/or medical care”? (Q)
choose between paying for food and paying for rent and for all? For us, this question is not relevant for Added in “not applicable” to response options
or mortgage? the last month (R)
Never
choose between paying for food and paying for Interview 2: Could include cost of childcare in this Added in the text on childcare or after school
Rarely
transportation or gas for a car? question care (Q)
Sometimes
choose between paying for food and paying for school Interview 5: Would include question on pets as Added in the text about nappies and infant
Often
loans, tuition, or other education expenses? often chose to feed pets before self when things food/formula to be more relevant to children
Always
stretch the amount of food in your home by limiting the were tight with money and cost of their food (Q)
amount of food people in your home could eat? impacts budget. Also include question on medical Added in the text on feeding pets (Q)
avoided inviting guests into your home when you expenses (GP/medicine) and allied health Added in the text on allied health care (dentist,
would be expected to serve them food? (dentist/physiotherapist, etc.) physiotherapist, psychologist, etc.) (Q)
eaten meals or snacks after your children finished to Split question item into two separate items (A)
ensure they had enough?
visited a food bank, pantry, or other emergency food
relief service
Int. J. Environ. Res. Public Health 2022, 19, 10543 13 of 17

Table A1. Cont.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
For the following statements/questions choose the
answer which best fits:
Meals are an important part of the day for me/my
household
Changed question item wording from “I use
I am able to cook healthy foods for my family on a Interview 1: Don’t create another meal with
Strongly disagree leftovers to create another meal” to “I use
budget leftovers but eat leftovers; how to answer this
Somewhat disagree leftovers” (Q)
I am able to cook from basic ingredients question?
Neutral Added in new free text item “Are there any
I plan meals ahead (e.g., for the day/week ahead) Interview 1: Don’t always know what is in season
Somewhat agree other food budgeting strategies you use (e.g.,
I use leftovers to create another meal but just buy cheapest foods.
Strongly agree couponing, buying in bulk)? Please write
I buy food in season to save money Interview 11: What about buying in bulk?
below:” (A)
I purchase healthy food, even if I have limited money?
(e.g., fruit and vegetables)
I compare prices between products in order to get the
best value food
Interview 2: Add in Easter to first response item,
also include winter and increased heating expenses Changed first response option to “religious
as an option festivals” and provided examples (R)
Christmas/Ramadan/other religious festivals
Interview 3: Add in medical care/expenses. Added in new response options; “Increased
School holidays
Interview 4: Would tick all answers here heating in winter or cooling in summer,
Are there times of the year or events where buying food Start of school year/term
Interview 5: Include ‘unpaid sick leave’ and also Reduction in work hours, Medical care/medical
for your household is more difficult due to competing Birthdays
‘COVID/lockdown’ expenses, Recent death/bereavement, End of a
expenses? Please tick any of the below that makes it Towards the end of the pay cycle
Interview 6: Could also include homelessness/loss relationship, Delays in Centrelink payments,
more difficult for you to purchase food for your Loss of job
of home COVID-19 restrictions, Homelessness, loss of
household. Moving house
Interview 9: Also include reduced work hours as home” (R)
Unexpected car issues
event Added in new free text item to describe other
Other (please specify)
Interview 11: Not school but when daycare is events or times when buying food is more
closed, we do spend more money on feeding my difficult (A)
daughter because she is at homeilot C:
Changed question item wording to “Do you or
No Interview 5: Include question on if partner or other
Do you currently smoke? anyone in your household smoke cigarettes or
Yes—please answer 2a household members smoke
purchase other tobacco products?” (Q)
Added question about frequency of smoking
If yes, do you currently smoke regularly, that is at least No “Do you or your household member currently
once per day? Yes smoke or vape regularly, that is at least once per
day? (Q)
Int. J. Environ. Res. Public Health 2022, 19, 10543 14 of 17

Table A1. Cont.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
Interview 11: This is so influential in all my answers,
Have moved this question to the very start of
maybe it should go at the top? Like I want to
No the survey as a new screener question (Q)
Are you currently pregnant? answer this first because its context for all my other
Yes—please answer 4a. Added new question on if this is a planned
answers. Same as having a toddler, our budget has
pregnancy (A)
changed to ensure her diet is varied and optimal
Have you taken any dietary No
Added “folate” under the examples
supplements (e.g., multivitamins, fish oil) in the Yes Interview 1: Add in ‘folate’
provided (Q)
last 24 h? Don’t know
Changed question item wording to include
Financial or economic abuse “tick any that apply” (Q)
Interview 1: Need to add into wording ‘leave blank
Emotional or psychological abuse Added in response option “none of the
if none apply’
Spiritual abuse (the denial or use of spiritual or above” (R)
Interview 2: Think this is an important question to
religious beliefs and practices to control and Moved from the start of the survey under the
Please indicate if you have ever experienced any of the include
dominate another person) ‘about you’/demographics section to near the
following as an adult or child? Interview 5: Need to have lead into question
Physical abuse end of the survey under the ‘health’ section so
indicating it may be sensitive and can choose to skip
Sexual abuse not as not to be jarring and added in text prior
or not answer if prefer.
Other abuse to the question “Some of the next questions may
Interview 11: Have a ‘none of the above’ answer
Prefer not to answer be sensitive and you can skip them if you prefer
not to answer”. (Q)
Interview 1: What does ‘not good reason’ mean? i.e.,
None of the time is it a health or lifestyle reason? Hard to answer;
For the following statements choose the answer which A little of the time need a ‘not sure’ option
Changed question item wording to “feel tired
best fits: In the past month, about how often did you . . . Some of the time Interview 4: ‘tired out’ reads strange. Does this
for no obvious reason” (O)
feel tired out for no good reason? Most of the time mean exhausted? Suggest changing
All of the time Interview 5: ‘no good reason’ have many reasons
Interview 7: ‘no good reason’?
Interview 5: Would answer ‘slightly’ overweight if
Acceptable weight there was this option
Removed the question as respondents are asked
Do you consider yourself to be an acceptable weight, Underweight Interview 7: Probably acceptable weight but
to report weight and height so BMI can be
underweight, or overweight? Overweight overweight for pre-baby
calculated from this information (D)
Currently pregnant Interview 11: Yes, doctors tell me I am for this stage
in pregnancy
Int. J. Environ. Res. Public Health 2022, 19, 10543 15 of 17

Table A1. Cont.

Question Item Responses Options Feedback from Cognitive Interviews Changes Made to Survey
None
Less than 1 glass per day
1 glass per day
2 glasses per day (equivalent to 1 can)
Over the last month, how many glasses of sugar Interview 2: ‘Fruit drinks’ would include juice in
3 glasses per day
sweetened beverages (e.g., regular soft drinks like answer for this. Included the line saying do not include 100%
4 glasses per day
Coca-Cola, Pepsi, Solo, lemonade, sweetened tea, and Interview 4: Under fruit drink would include juice fruit juice here (Q)
5 glasses per day
fruit drinks) did you usually drink each day? Do not in calculations Added sports and energy drinks (Q)
6 glasses per day
include mineral or soda water. Pilot
7 glasses per day (equivalent to a 1.25 L bottle)
8 glasses per day
9 glasses per day
10 or more glasses per day
Added in a question prior to this; “Do you
Never follow a vegetarian or vegan diet?” If they
Less than once per month select no then they are asked to answer this
Interview 1: Household is vegetarian so need
1–3 times per month question, if they select partly (pescatarian) then
option for this. Perhaps at the start of the survey
1 time per week they are asked to skip this question but answer
could have a question about dietary requirements,
Over the last month, how often did you eat fresh meat 2 times per week other questions on fish, if they select yes then
e.g., gluten free, vegetarian/vegan, etc.
(including beef, veal, chicken, lamb, pork)? 3–4 times per week they can skip the question (A)
Interview 2: Provide option for vegetarian, i.e.,
5–6 times per week Have included the word “frozen” in the
‘never’ by choice or ‘never’ because can’t afford?
1 time per day question item so the question now reads; “Over
Interview 4: Include frozen as well in this answer?
2 times per day the last month, how often did you eat fresh or
3 or more times per day frozen meat (including beef, veal, chicken, lamb,
pork)?” (Q)
Never
Less than once per month
1–3 times per month
Over the last month, how often did you eat take away or 1 time per week
Interview 5: Would take out Indian as haven’t
fast foods (such as burgers, chips, pizza, Indian)? 2 times per week Have taken out “Indian” from question item
mentioned other ethnic cuisines.
Include foods eaten at the restaurant or at home (e.g., 3–4 times per week wording (Q)
Uber eats, take away) 5–6 times per week
1 time per day
2 times per day
3 or more times per day
(A) added an item, (D) deleted an item, (Q) changed question content, (R) changed response option, and (O) overall readability improved.
Int. J. Environ. Res. Public Health 2022, 19, 10543 16 of 17

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