Primary ovarian insufficiency quality of life scale
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Sahyoun-Food_Security_Scale-Lebanon.pdf
N THE JOURNAL OF NUTRITION
(:__~
S upplem
entalM aterial can be found at:
http://jn.nutrition.org/content/suppl/2014/04/10/jn.113.18711 2.D
C S
upplem ental.htm
l
T h e J
o u rn a l o
f N u tritio
n C o m m u n ity a
n d
In te rn a tio
n a l N
u tritio
n
D e v e lo p m e n t a
n d
V a lid
a tio
n o f a
n A
ra b
F a m ily
F o o d
S e c u rity
S c a le
1 – 4
N ad
in e R
. Sah yo
u n , 5* M
ark N o rd , 6
A n n ieb
elle J. Sassin e, 7
K arin Seyfert, 8
N ah
la H w alla, 7
an d H
ala G h attas
7
5D ep
a rtm
en t o
f N u tritio
n a n d
F o o d
S cien
ce, U n iv ersity o
f M a ry la n d , C
o lleg
e P a rk , M
D ; 6E
co n o m ic R
esea rch
S erv
ice, U S D A ,
W a sh in g to n , D
C ; 7D
ep a rtm
en t o
f N u tritio
n a n d
F o o d
S cien
ces, A m erica
n U
n iv ersity o
f B eiru
t, B eiru
t, L eb
a n o n ; a
n d
8D ep
a rtm
en t o
f E co
n o m ics, S
ch o o l o
f O rien
ta l a
n d
A frica
n S tu d ies, U
n iv ersity o
f L o n d o n , L
o n d o n , U
K
A b s tra
c t
T h e o
b je c tiv
e o f th
is a rtic
le w a s to d
e s c rib
e 1 ) th
e v a lid a tio
n o f 2 s
im ila r b
u t n
o t id
e n tic
a l fo
o d s
e c u rity m
o d u le s u
s e d to
c o lle c t d
a ta fro
m 2 v
u ln e ra b le p
o p u la tio
n s , s o u th e rn L
e b a n o n re
s id e n ts (n =
8 1 5 ) a n d P
a le s tin
ia n re
fu g e e s in L
e b a n o n (n =
2 5 0 1 ), a
n d 2
) th e d
e v e lo p m e n t a
n d v
a lid a tio
n o f a
n A ra b F
a m ily F
o o d S
e c u rity S
c a le (A
F F S S ). T
h e s
u rv e y s u
s e d a c
lu s te r-
ra n d o m ize
d s a m p lin g d
e s ig n . T
h e 2 fo
o d s
e c u rity s
u b s c a le s u
n d e rw
e n t fa
c e a
n d c
o n s tru
c t v
a lid ity
. In a d d itio
n , b
o th o
f
th e s e to
o ls a
n d th
e A F F S S
u n d e rw
e n t p
s y c h o m e tric a
s s e s s m e n t fo
r in te rn a l v a lid ity b
y u s in g s
ta tis
tic a l m
e th o d s b
a s e d o
n
Ite m
R e s p o n s e T
h e o ry . T
h e fo
o d s
e c u rity q
u e s tio
n s te
s te d b
y fo c u s g
ro u p s w
e re u
n d e rs to o d a
n d a
c c e p te d in a
ll re g io n s o
f
L e b a n o n . T
h e fo
o d s
e c u rity s
u b s c a le s a
n d th
e A F F S S
h a d a
c c e p tab
le le v e ls o
f in te rn a l c
o n s is te n cy . T
h e p
s y c h o m e tric
a s s e s s m e n t c
o n fi rm
e d th
a t th
e 7 ite m s o
f th e A
F F S S
h a d g
o o d in
te rn a l v a lid ity a
n d re
a s o n a b le re
lia b ility w
ith ite m
in -fi ts
fro m
0 .7 3 to 1
.1 6 . F
o o d in
s e c u rity w
a s id
e n tifi
e d a
m o n g 4
2 %
o f s
o u th e rn L
e b a n e s e a
n d 6
2 %
o f P
a le s tin
ia n re
fu g e e
h o u s e h o ld s . T
h e d
e te rm
in a n ts a
n d c
o n s e q u e n ce
s o f fo
o d s
e c u rity m
e a s u re d in th
is s tu d y p
ro v id e a
d d itio
n a l s
u p p o rt fo
r
th e v
a lid ity o
f th e m
o d u le s . U
s in g m
u ltiv
a ria
te lo g is tic re
g re s s io n , th
e h ig h e r th
e m e a n m
o n th ly in
c o m e p
e r h
o u s e h o ld
m e m b e r a
n d th
e h ig h e r th
e e d u c a tio
n a l a
tta in m e n t o
f th e h
e a d o
f h o u s e h o ld , th
e lo w e r th
e ris k o
f fo o d in
s e c u rity [O
R s
(9 5 %
C Is ): 0
.9 9 (0
.9 8 , 0
.9 9 ) a
n d 0
.6 6 (0
.5 4 , 0
.8 0 ), re
s p e c tiv
e ly ]. T
h e re w
a s a s
tro n g s
ig n ifi c a n t a
s s o c ia tio
n b e tw
e e n fo
o d
in s e c u rity a
n d lo
w e r fo
o d e
x p e n d itu
re a n d lo
w e r in
ta k e o
f a ll fo
o d c
a te g o rie
s e x c e p t fo
r le g u m e s , w
h ic h w
a s s
ig n ifi c a n tly
a s s o c ia te d in th
e o p p o s ite d
ire c tio
n (P <
0 .0 0 1 ). T
h e o
d d s o
f b o rro
w in g m
o n e y a
n d a
c c e p tin
g g ifts
/d o n a tio
n s w
e re
s ig n ifi c a n tly h
ig h e r a
m o n g m
o d e ra te ly a
n d s
e v e re ly fo
o d -in
s e c u re h
o u s e h o ld s (P
< 0 .0 0 0 ). T
h e A
F F S S
h a s b
e e n v
a lid a te d
w ith
in L e b a n o n an
d c an p
o te n tia
lly b e e
xte n d e d to o
th e r A
rab -sp
e a kin
g p o p u latio
n s .
J. N u tr. 1
4 4 : 7
5 1 –7
5 7 , 2
0 1 4 .
Downloaded from jn.nutrition.org by guest on March 15, 2016
In tro
d u c tio
n
F o o d
secu rity is a co
m p lex
p h en
o m en
o n
th a t in
clu d es so
cia l,
b io lo g ic, n
u tritio
n a l, a
n d
eco n o m ic in
fl u en
ces (1 ). T
h e F
A O
d efi
n es fo
o d
secu rity a
s ex istin
g ‘‘w h en
a ll p
eo p le a
t a ll tim
es h a v e p
h y sica
l, so cia
l a n d
eco n o m ic a
ccess to su
ffi cien
t, sa fe
a n d
n u tritio
u s fo o d
to
m eet
th eir
d ieta
ry n eed
s a n d
fo o d
p referen
ces fo r a
n a ctiv
e, h ea lth
y life’’ (2 ). In
d irect m
ea su res
o f fo
o d
secu rity, su
ch a s d
ieta ry in
ta k e a
n d
a n th ro p o m etric
m ea su rem
en ts,
h a v e b een
u sed
to
d escrib
e th e n u tritio
n a l
1 C o m p o n e n ts o
f th is s
tu d y w
e re s
u p p o rte
d b y a E
u ro p e a n U
n io n g
ra n t to th
e U n ite
d N a tio
n s R
e lie f a
n d W
o rk s A
g e n c y fo
r P a le s tin
ia n R
e fu g e e s in th
e N e a r
E a s t (U
N R W
A ); a g
ra n t a
w a rd e d b
y th e W
H O , E
a s te rn M
e d ite
rra n e a n R
e g io n a l
O ffi c e (W
H O -E M R O ; R
P P H
1 0 -5 3 ); a
n d th
e F a c u lty o
f A g ric
u ltu
ra l a
n d F
o o d
S c ie n c e s a
t th e A
m e ric
a n U
n iv e rs ity o
f B e iru
t. 2
A u th o r d
is clo
s u re s : N
. R . S
ah yo
u n , M
. N o rd , A
. J . S
as sin
e , K
. S e y fe rt, N
. H w alla
, a n d H
. G h a ttas
, n o c
o n fl ic ts o
f in te re st.
3 T h e v
ie w s e
x p re s s e d a
re th o s e o
f th e a
u th o rs a
n d m
a y n
o t b
e a ttrib
u te d to th
e U n iv e rs ity o
f M a ry la n d , th
e A m e ric
a n U
n iv e rs ity o
f B e iru
t, o r th
e E c o n o m ic
R e s e a rc h S
e rv ic e o
r U S D A .
4 S u p p le m e n ta l T
a b le 1 is a
v a ila b le fro
m th
e "O n lin e S
u p p o rtin
g M a te ria
l" lin k in
th e o
n lin e p
o s tin
g o f th
e a rtic
le a n d fro
m th
e s a m e lin
k in th e o
n lin e ta
b le o
f c o n te n ts a
t h ttp
://jn .n u tritio
n .o rg .
* T o w
h o m
c o rre
s p o n d e n c e s
h o u ld b
e a d d re s s e d . E
-m a il: n
s a h y o u n @ u m d .e d u .
ã 2 0 1 4 A
m e ric
a n S
o c ie ty fo
r N u tritio
n .
sta tu s o
f th e p
o p u la tio
n in
L eb
a n o n
(3 ). D
irect m ea su res o
f fo o d
secu rity, h
o w ev er, p
a rticu
la rly in
v u ln era
b le su
b p o p u -
la tio
n s in
L eb
a n o n , a
re n o t a
v a ila
b le. T
h is is p
a rtly d
u e to
th e
la ck
o f reco
g n itio
n in
th a t p
a rt o
f th e w
o rld
o f fo
o d
secu rity a
s a d
irectly m ea su ra b le p
h en
o m en
o n . C
o n seq
u en
tly, th ere is n
o
v a lid
a ted
to o l in
th e A
ra b ic la
n g u a g e to
a ssess its p
resen ce
a n d
sev erity in
co m m u n ities in
th e a
rea .
A v a lid
a ted
, cu ltu
ra lly a
p p ro p ria
te fo o d secu
rity a ssessm
en t
to o l th
a t ca
n b e u
sed in A ra b ic-sp
ea k in g co
u n tries fo
r a ssessin
g a n d m
o n ito
rin g th
e ex ten
t o f th
e p ro b lem
is essen tia
l to d eter-
m in e th
e im p a ct o
f in terv
en tio
n p ro g ra m s in
ten d ed to a
llev ia te
th is
p ro b lem
. T h is
is p a rticu
la rly
im p o rta
n t in
lig h t o f th e
g ro w in g n
u m b ers o
f refu g ees in th
e reg io n . A
d irect, ex
p erien
tia l
m ea su re o
f fo o d in
secu rity is u
sefu l b
eca u se it is q
u ick a
n d
rela tiv
ely in ex p en siv
e to a d m in ister a
n d is n
o n in v a siv
e (4 ). It
m in im
izes th e b
u rd en o
n resp o n d en ts a
n d th
e co st a
n d co
m -
p lex
ity o f tra
in in g in
terv iew
ers. M ea su rem
en t to
o ls o
f th is ty
p e
h a v e b
een v a lid
a ted in m
a n y p
o p u la tio
n s a
n d a
re in reg u la r u
se fo r m
o n ito
rin g a
n d fo
r resea rch in a n
u m b er o
f co u n tries in
-
clu d in g th
e U n ited States, C
an ad
a, B razil, M
ex ico
, an d C
o lo m b ia
(5 – 8 ). A
lth o u g h fo
o d secu
rity su rv ey s h
a v e b
een co n d u cted in
sev era
l A ra b
co u n tries,
in clu
d in g
Y em
en (9 ),
th e P a lestin
ia n
M a n u s c rip
t re c e iv e d O
c to b e r 1
8 , 2
0 1 3 . In
itia l re
v ie w
c o m p le te d D
e c e m b e r 2
2 , 2
0 1 3 . R
e v is io n a
c c e p te d F
e b ru a ry 1
0 , 2
0 1 4 .
F irs
t p u b lis h e d o
n lin e M
a rc h 5
, 2 0 1 4 ; d
o i:1
0 .3 9 4 5 /jn
.1 1 3 .1 8 7 1 1 2 .
7 5 1
THE JOURNAL OF NUTRITION
T errito
ries (1 0 ), Jo
rd a n , a
n d S
y ria (1
1 ,1 2 ), to o
u r k
n o w led
g e th
e m ea su rem
en t to
o ls u
sed th ere h
a v e n
o t b
een v a lid
a ted fo
r u se in
th e M
id d le E
a st. In a
d d itio
n , th
e to o ls u
sed fo r th
ese su rv ey s
d iffered in ea
ch co u n try a
n d in so
m e ca
ses w ere d
ev elo
p ed to
m ea su re
fo o d
secu rity
u n d er
sp ecifi
c situ
a tio
n s,
su ch
a s th e
P a lestin
ia n u
p risin
g in th e W
est B a n k o
r th e G
a za W
a r (1
3 ).
In 2 0 1 0 , resea
rch ers fro
m th
e A m erica
n U n iv ersity o
f B eiru
t an
d th e U
n iversity o
f M arylan
d d evelo
p ed a to
o l to assess h
o u se-
h o ld fo
o d secu
rity am o n g vu
ln erab
le p o p u latio
n s in L
eb an o n . T
h e
to o l, d
eriv ed fro
m q u a lita
tiv e resea
rch o n fo
o d secu
rity in th e
a rea a
n d fro
m co
n cep
ts g lea
n ed fro
m o th er a
lrea d y u
tilized to o ls
(5 ,9 ), w
as fi rst u
sed in th e so
u th o
f L eb an
o n , a regio
n p articu
larly ex p o sed to d
isru p tio
n an d m
igratio n d
u e to w
ar. A fter a sligh
t m o d ifi catio
n , th
is to o l w
as th en ad
m in istered to P
alestin ian refu
- gees th
ro u gh
o u t L
eb an
o n . T
h e o
b jective o
f th is article is to d
escrib e
th e valid
atio n o
f th e to
o ls u
sed an d th
e d evelo
p m en t an
d valid atio
n o f a n
A ra b
F a m ily
F o o d
S ecu
rity S ca le
(A F F S S ) th a t co u ld
p o ten
tia lly b
e u sed in th
e M id d le E
a st reg
io n .
P a rtic
ip a n ts a
n d
M e th
o d s
In 2 0 1 0 , su
rv ey s w
ere co n d u cted in L
eb a n o n to a
ssess th e fo
o d secu
rity sta
tu s o
f m a rg in a lized p
o p u la tio
n s. A
fo o d secu
rity to o l w
a s d
ev elo
p ed
a n d a
d m in istered to rep
resen ta tiv
e sa m p les o
f resid en ts in th
e so u th o
f L eb a n o n (T
y re R
esid en t S
u rv ey ) a
n d to P
a lestin
ia n refu
g ees liv
in g in
ca m p s a
n d in g
a th erin
g s th
ro u g h o u t L
eb a n o n (P
a lestin
ia n R
efu g ee S
u r-
v ey ). T
h e fo
llo w in g is a d
escrip tio
n o f th
e d esig
n o f th
ese 2 su rv ey s, th
e d ev elo
p m en t a
n d v
a lid
a tio
n o f th
e fo o d secu
rity to o ls, a
n d th
e d ev elo
p -
m en t a
n d v
a lid
a tio
n o f a fi
n a l a
n d reco
m m en d ed 7
-item fo
o d secu
rity m ea su re, th
e A F F S S .
S u rv e y d
e sig
n
T y re
R e s id e n t S u rv e y . T h is cro
ss-sectio n a l h
o u seh
o ld
su rv ey w
a s
co n d u cted
in th
e so u th ern
g o v ern
o ra te o
f T y re in
L eb
a n o n , w
h ich
in -
clu d es th
e city o f T
y re a
n d
6 7
su rro
u n d in g to
w n s a
n d
v illa
g es. B
y u sin
g a clu
ster-ra n d o m ized
sa m p lin
g d esig
n , th
e city o f T
y re a
n d
2 9
v illa
g es
w ere
selected . T y re
a n d
th e
v illa
g es
w ere
sa m p led
b y
p ro b a b ility
p ro p o rtio
n a l
to estim
a ted
size. H o u seh
o ld s
w ith
in v illa
g es
w ere
sa m p led b
y u sin
g a ra n d o m
w a lk . A
to ta l o
f 8 1 5 h
o u seh
o ld s p
a rticip
a ted
in th e su
rv ey.
P a le s tin
ia n
R e fu g e e S
u rv e y . T
h is su
rv ey w
a s co
n d u cted fo
r th e U
n ited
N a tio
n s R
elief a n d W
o rk s A
g en cy fo
r P a lestin
ia n R
efu g ees in th
e N ea r
E a st
(U N R W A ) a n d
w a s ca rried
o u t in
a ll
1 2
P a lestin
ia n ca
m p s in
L eb a n o n a
n d in 2
0 g a th erin
g s in th
e 5 a d m in istra
tiv e a
rea s o
f L eb a n o n .
T h e su
rv ey, d
escrib ed in d
eta il elsew
h ere (1
4 ), w
a s a m
u ltista
g e sa
m p lin
g o f clu
sters. W ith
in clu sters, h
o u seh
o ld s w
ere selected a t ra
n d o m . A
to ta l
o f 2
5 0 1 h
o u seh
o ld s p
a rticip
a ted in th
e su rv ey.
In b o th
th e T y re
R esid
en t a n d
P a lestin
ia n
R efu
g ee
S u rv ey s,
th e
in d iv id u a l resp
o n sib
le fo r fo
o d p
rep a ra tio
n w ith
in ea ch h
o u seh
o ld w
a s
id en tifi
ed a n d in
v ited to p
a rticip
a te in th
e stu d y. T
h e in
terv iew
ees g a v e
eith er o
ra l o
r w ritten in
fo rm
ed co n sen
t if th ey w
ere w illin
g to p a rtici-
p a te. If a
n in d iv id u a l d
eclin ed to p
a rticip
a te, d
a ta co
llecto rs m
o v ed to th
e a d jo in in g a
p a rtm
en t/h
o u se. T
h e resp
o n se ra
te a m o n g P
a lestin
ia n refu
- g ees w
a s 9
7 .1 %
a n d w
a s 8
5 .1 %
a m o n g so
u th ern L
eb a n ese. T
h e resea
rch d esig
n fo r b
o th su
rv ey s w
a s a
p p ro v ed b
y th e in
stitu tio
n a l rev
iew b o a rd
o f th
e A m erican U
n iv ersity o
f B eiru
t.
M e a s u re m e n t o
f k e y
c o n stru
cts T h e q
u estio
n n a ires u
sed in b o th su
rv ey s co
n ta in ed sim
ila r q
u estio
n s a
n d
co llected
in fo rm
atio n
o n
g en d er,
a g e,
em p lo y m en t,
a n d
ed u ca tio
n a l
a tta
in m en t o
f th e h
ea d o
f h o u seh
o ld . A
lso co llected w
ere to ta l h
o u seh
o ld
in co m e, ex
p en d itu
re o n fo
o d , h
o u seh
o ld freq
u en cy o
f co n su m p tio
n o f
certa in fo
o d g
ro u p s, a
n d co
p in g stra
teg ies. S
ta tu s o
f fo o d secu
rity w a s
o b ta in ed b
y u sin
g 2 slig h tly d
ifferen t q
u estio
n n a ires fo
r b o th su
rv ey s.
D escrib
ed b elo
w a re th
e to o ls u
sed to a ssess fo
o d secu
rity a n d to co
llect h o u seh
o ld fo
o d co
n su m p tio
n p a ttern
s a n d co
p in g stra
teg ies.
7 5 2
S a h y o u n e
t a l.
D e v e lo p m e n t o
f th e fo
o d
s e c u rity to
o l
T h e
h o u seh
o ld
fo o d
secu rity
to o l d ev elo
p ed
fo r u se
in su rv ey s o f
v u ln era
b le
p o p u la tio
n s in
L eb a n o n
o rig
in a lly
in clu
d ed
1 6
q u estio
n s
d eriv
ed fro m
th e U
.S . H
o u seh
o ld F
o o d S
ecu rity S
u rv ey M
o d u le (5
) a n d
th e Y
em en i N
a tio
n a l F
o o d S
ecu rity S
u rv ey (9
). T h e fo
o d secu
rity to o l
w a s tra
n sla
ted b y n
a tiv
e sp ea k ers in
to S ta n d a rd M
o d ern A
ra b ic a
n d in
to L eb a n ese a
n d P
a lestin
ia n d
ia lects a
n d tested o
n k ey in
fo rm
a n ts fro
m th
e co m m u n ities to b
e su rv ey ed . T
h e q
u estio
n s u
n d erw
en t fa
ce v a lid
ity a n d
p relim
in a ry
in tern
al v a lid
a tio
n a s d escrib
ed b elo
w . A s a
resu lt,
th e
q u estio
n s th
at w ere an
alyzed an d u
sed to d eterm
in e fo
o d secu
rity statu s in
th is
stu d y w ere
red u ced
to 6 in
each su rvey.
T h e 6 q
u estio
n s ad
m in istered in each o
f th e su
rveys w ere sim
ilar b u t n
o t
id en tical. F
o u r o
f th e q
u estio
n s w
ere in clu
d ed in b
o th su
rveys an d w
ere id en tical ex
cep t fo
r d ifferen
ces in th e referen
ce p erio
d (1 2 m
o in th e T
yre R esid
en t Su rvey
an d
6 m o
in th e P alestin
ian R efu
gee Su rvey).
T h ese
q u estio
n s in
clu d ed th
e fo llo
w in g item
s: ‘‘in ad eq u ate q
u ality o
f fo o d ,’’ ‘‘cu
t size o
f m eal,’’ ‘‘sk
ip p ed m
eal,’’ ‘‘d id n
o t eat w
h o le d
ay o r w
en t to b
ed h u n gry.’’ O
n e q
u estio
n in q u irin
g ab o u t ‘‘n
o t en
o u gh o
f so m e fo
o d s’’ w
as in clu
d ed in b
o th su
rveys an d w
as sim ilar in co
gn itive co
n ten
t b u t w
o rd ed
so m ew
h at d
ifferen tly. O
n e ad
d itio
n al q
u estio
n w as u
n iq u e to each o
f th e
su rveys: th
ese in clu
d ed a q
u estio
n ab o u t ‘‘co
n cern
ed fo o d w
o u ld ru
n o u t’’ in
th e T
yre R esid
en t Su
rvey an d a q
u estio
n o n ‘‘fo
o d s b
o u gh t d
id n o t last’’ in th
e P alestin
ian R efu
gee Su rvey. T
h ese q
u estio
n n aires are sh
o w n in Su
p p lem
en tal
T ab le 1
. T o assess th
e level o f fo
o d secu
rity o f p
articip atin
g h o u seh
o ld s, th
e 6 item
s o f each to
o l w
ere co d ed b
y assign in g 1 p
o in t to each p
o sitive resp
o n se.
T h e q
u estio
n n aires w
ere assessed fo r face valid
ity, an d th
e m easu
res b ased
o n th
em w ere assessed fo
r co n stru
ct an d in
tern al valid
ity as d escrib
ed b elo
w .
H o u s e h o ld
fo o d
g ro
u p
c o n su
m p tio
n
F o o d g
ro u p co
n su m p tio
n b y h
o u seh
o ld w
a s m
ea su red b
y u sin
g a sh o rt
fo o d g
ro u p freq
u en cy q
u estio
n n a ire. R
esp o n d en ts w
ere a sk ed if h
o u se-
h o ld m
em b ers co
n su m ed m
ilk a n d d
a iry p
ro d u cts, m
ea t a
n d p
o u ltry,
leg u m es, v
eg eta
b les, fru
it, ch o co la te/sw
eets/ca n d ies, a
n d so
d a s/b
o ttled
b ev era
g es, a
n d if so
, h o w
o ften p
er d a y, w
eek , o
r m o n th . R
esp o n ses w
ere co n verted to w
eek ly co
n su m p tio
n . B
ecau se freq
u en cies o
f fo o d co
n su m p -
tio n a
re n o t n
o rm
a lly d
istrib u ted
, lo g-tran
sfo rm
ed va riab
les w ere u
sed in th e a
n a ly sis, w
ith resu lts b
ack -tran
sfo rm
ed to facilitate in terp
retatio n .
C o p in g
stra te g ie s
In th
e 2 su
rv ey
s, if in d iv id u a ls resp
o n d ed
p o sitiv
ely to th
e q u estio
n
‘‘W a s th
ere a tim e w
h en
y o u
w ere co
n cern
ed th
a t y
o u
w o u ld
ru n
o u t
o f fo
o d
fo r y
o u r h
o u seh
o ld
fo r th
e n ex
t m o n th ?’’ (T
y re R
esid en
t S u rv ey
) o r ‘‘T
h e fo
o d
th a t I b
o u g h t ju
st d id
n o t la
st a n d
w e d
id n o t
h a v e m
o n ey to
g et m
o re’’ (P
a lestin
ia n
R efu
g ee S
u rv ey
), th ey w
ere th en
a sk ed
a series o f q
u estio
n s o
n co
p in g stra
teg ies. T
h ese q
u estio
n s
w ere d
eriv ed
a n d
a d a p ted
fro m
th e C
o p in g S
tra teg
ies In d ex
(1 5 ) to
a scerta
in w
h eth
er th e resp
o n d en
ts o r o
th er m
em b ers o
f th e h
o u se-
h o ld
en g a g ed
in $
1 o f th
e fo llo
w in g a
ctio n s: w
o rk ed
m o re to
o b ta in
fo o d , b
o rro
w ed
m o n ey, b
o rro
w ed
fo o d , a
ccep ted
g ifts/d
o n a tio
n s, o
r co
u ld
d o
n o th in g a
b o u t th
e situ a tio
n . T
h e a
n sw
ers w ere co
d ed
a s
‘‘y es’’ o
r ‘‘n o .’’
V a lid
a tio
n o f fo
o d
s e cu
rity m e a su
re s
F a c e
v a lid
ity . W e
co n d u cted
a q u alitative
stu d y
u sin
g fo cu s gro
u p
in terview
s in 7 go vern
o ra tes in L
eb an
o n to en
su re th
a t th
e q u estio
n s as
stated w ere u
n d ersto
o d as in
ten d ed , th
e la n g u a ge w
as cu ltu
rally ap p ro -
p riate in th
e d ifferen
t reg io n s o
f L eb a n o n , a
n d th
e ra n g e o
f b eliefs,
o p in io n s, a
n d b
eh a v io rs rep
resen ted th
o se o
f th e ta
rg et p
o p u la tio
n .
O n e m
u n icip
ality fro m
each o f th
e 7 go vern
o rates o
f L eb an
o n w
as ran
d o m ly selected
. M u n icip
ality lead ers an
d so cial w
o rk ers id
en tifi
ed 8 –1 2
in d ivid
u als in each go
vern o rate to p
articip ate in th
e fo cu s gro
u p s w
ith th e
research team . A
to tal o
f 5 7 in
d ivid
u als p
articip ated in th
e 7 fo cu s gro
u p
sessio n s. T
h e in
d ivid
u als selected rep
resen ted vario
u s so
cio eco
n o m ic statu
s gro
u p s, w
ere o f b
o th gen
d ers an
d d ifferen
t age catego ries, an
d rep resen
ted th e d
ifferen t b
ack gro
u n d s an
d religio n s o
f each area. T h e fo
cu s gro
u p s
in clu
d ed
lab o rers,
farm ers,
so cial
w o rk ers,
teach ers,
h o u sew
ives, an d
sh o p k eep
ers. F o cu s gro
u p d
iscu ssio
n s w
ere tap e reco
rd ed an
d tran scrib
ed verb
atim in A
rab ic. T
h em
atic an alysis w
as u sed fo
r th e an
alysis o f th
e tran
scrib ed fo
cu s gro
u p d
iscu ssio
n s.
Downloaded from jn.nutrition.org by guest on March 15, 2016
70
60
50
~ 40 C: QI
cii e 30 a.
20
10
0
■ Palestinian Refugees (n=2493)
□ Tyre Residents (n=815)
Food Secure Moderately Food Severely Food (Raw scores 0-1) Insecure Insecure
(Raw scores 2-4) (Raw scores 5-6)
TABLE 1 Characteristics of participants in the Tyre Resident and Palestinian Refugee Surveys1
Tyre Resident Survey Palestinian Refugee Survey
Responders Value Responders Value
n n
Household members, n
Monthly income, U.S. dollars/household member
Head of household educational level, %
Completed 9th grade
Completed primary level
813
800
734
4.95 (4.68, 5.21)
218 (170, 265)
35.8
69.8
2501
2312
2501
4.45 (4.30, 4.60)
120 (103, 136)
27.4
54.2
1 Values are means (95% CIs) or percentages.
Internal validity. The internal validity of the food security tools was assessed for each survey separately by using statistical methods based on the single-parameter logistic Item-Response-Theory (Rasch) model. These methods assess the psychometric characteristics of the items and the extent to which they measure the same underlying latent trait—in this case, the severity of food insecurity. The Rasch model is essentially a nonlinear factor analysis, and model outputs include estimates of severity parameters for each item and each household on the same underlying logit continuum as well as fit statistics for each item and residual correlations between items (16). After fitting the model separately for the 2 surveys, the item severity parameters for the 5 items that appeared in both surveys were compared to assess the comparability of the food security scales in the 2 surveys.
The 6 food security scale items in each of the surveys, dichoto- mized to indicate any/no occurrence of the condition or behavior, were fit to the Rasch model by using conditional maximum likelihood methods. The scales were equated on the basis of the 5 common items, and it was determined that the following classifications based on raw score ranges were of approximately equal severity in the 2 surveys: food secure (0–1), moderately food insecure (2–4), and severely food insecure (5,6). Households that did not respond to any of the food security questions (0.32% of respondents in the Palestinian Refugee Survey and none in the Tyre Resident Survey) were omitted from the analyses.
Construct validity. Household food security categories aggregated for analysis as defined below were examined in association with determinants and consequences of food security status. Determinants used in this study were household size, gender and educational attainment of head of household, and household income. Reduction in food quality and quantity is a behavior that is measured within the food security structure; therefore, inquiring about the consumption of specific food groups is a way of validating the module. Another consequence of food insecurity is the coping strategy or strategies that households undertake to ensure that they get enough food in times of need.
The construct validation of the tools was conducted by using pooled data from the 2 surveys (n = 3308) to increase statistical power to detect variations in severity of food insecurity. Pooling the data was possible because the severity ranges of the food security classifications were similar and many of the same data elements were collected by using the same methods in the 2 surveys. In addition, the data in both surveys were collected from generally poor populations using face-to-face interviews. The sample design was the same in the 2 surveys and was a stratified 2-stage, clustered sample design with villages, neighborhoods, or camps as the primary sampling units and households as secondary sampling units.
Development of the AFFSS and its validation. Given the similarity in severities of the 5 items common to the 2 surveys, the results from the 2 scales were combined so that the additional question from each survey could be included in a single scale. This results in a scale with better reliability and with items more evenly distributed across the severity continuum than either scale by itself. This 7-item scale, the AFFSS, is described in Supplemental Table 1. The scale was not used in this study, but it is proposed for further use in Arab-speaking populations.
Statistical analysis All data were imported into Stata 11.1 and into SAS (version 9.13) for statistical analysis. The demographic and socioeconomic characteristics as well as the classification of food security status of each subpopulation were examined first. The analyses were then conducted on the pooled data. By using logistic regression models, we examined the association between food security and demographic and socioeconomic character- istics. The outcome variable, food security, was coded as food secure (0– 1) versus food insecure (2–6) in 1 model and as food secure/moderately food insecure (0–4) versus severely food insecure (5–6) in another model.
Food security as a categorical independent variable was examined in association with each coping strategy by using logistic regression analysis and in association with each food group by using linear regression modeling. All models included a dummy variable identifying the survey to control for any differences in measurement of food security and for any other unobserved differences between the populations.
Results
Sample characteristics. Southern Lebanese participants tended to have larger households, higher monthly household incomes, and higher educational attainment than Palestinian refugees (Table 1). Also, a higher percentage of southern Lebanese house- holds were food secure (58%) compared with Palestinian refugees (38%). An estimated 20% of Palestinian refugee households were severely food insecure compared with 10% of the southern Lebanese households (Fig. 1).
FIGURE 1 Prevalence of household food insecurity among Palestinian refugees from the Palestinian Refugee Survey (n = 2493) and among southern Lebanese residents from the Tyre Resident Survey (n = 815).
Validation of an Arab Family Food Security Scale 753
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s:: 11 12 0
~ + Item 11 Raw=7 Raw=6 Raw=6 I 10
Did not eat ,,
+ Did not eat 0 o 10 whole day C. - Equal severity + whole day .c: Raw=6 Raw=5 Raw=5 ~ 9 Q)
"' 9 > :,
:i + Skipped 0 Skipped meal + Raw=5 Raw=4 Raw=4 .c: ., 8 meal 0 8 Cut size of + e
Cut size of E meal Raw=4 Raw=3 Q) 7 Raw=3 ,,
7 meal -~ Not enough ·.; Food did not + some foods Raw=3 Q) ::, 6 + Raw=2 Raw=2 It: last Q) 6
Did not get -~ Inadequate + Raw=2
>, enough of > 5 Raw=1 Q) quality Concerned Raw=1 I- en some foods food would Raw=1 f 5 + Inadequate 4 run out w quality > 3 Q)
4 ., E 4 5 6 7 8 9 10 11
Item parameter -+-AFFSS ~ Item severity. Palestinian Refugee survey population --Palestine subscale --T re subscale
FIGURE 2 Comparison of item severity parameters of equivalent items used in the food security questionnaires in the Palestinian Refugee and Tyre Resident Surveys.
Validation of food security scales. Results from the focus groups indicated that in all 7 regions of Lebanon the food security questions were well understood and were not per- ceived to be offensive nor were the questions posed too sensitive. The question that stated that ‘‘food bought did not last’’ was only administered to Palestinian refugees but tested in all regions of Lebanon. Participants found the question to be confusing. In the Arabic translation, the term was understood as referring to food spoilage rather than insuffi- cient food quantity for the household. Focus group partici- pants suggested replacement of ‘‘food we bought did not last’’ with ‘‘food bought was not enough.’’
After adjusting for a modest difference in item dispersion, the severity parameters of the items common to the 2 surveys were very similar (Fig. 2). Analysis (not shown) suggests that the difference in discrimination corresponding to the difference in item dispersion had relatively little impact on reliability. Resid- ual correlations among items in each survey were small, indi- cating no serious violation of the conditional independence assumed by the Rasch model (analysis not shown).
The similarity of the item parameters of the 5 items common to the 2 surveys justified estimation of the Rasch model for the data from the 2 surveys jointly. This model confirmed that the 7 items fit the model assumptions well enough to constitute a measure with good internal validity and reasonable reliability (Table 2). Item in-fits ranged from 0.73 to 1.16, whereas in-fits in the range of 0.7 to 1.3 are generally considered to adequately approximate the Rasch model assumption of equal discrimina- tion. Item out-fit statistics were somewhat elevated for the 2
FIGURE 3 Household or item severity parameters of items used in the AFFSS and subscales used in Palestinian Refugee and Tyre Resident Surveys. AFFSS, Arab Family Food Security Scale.
least-severe items, ‘‘inadequate quality’’ and ‘‘concerned food would run out,’’ and for ‘‘not enough of some foods,’’ indicating a small proportion of erratic responses to these items. However, given the good in-fit statistics for these items, the moderately elevated out-fit statistics do not indicate any serious violations of model assumptions. The relative severity of items was essentially unaffected by the difference in time reference in the 2 surveys (6 mo vs. 12 mo) and by the difference in wording of the question on ‘‘not enough of some foods.’’
The joint psychometric analysis of data from the 2 surveys supports direct comparison of the household severity parameters for the 2 scales implemented in this study as well as comparisons to the household and item severity parameters for the proposed 7-item AFFSS (Fig. 3). These show a range of severity and indicate that the thresholds defining severity categories for the 2 subscales used in the construct validation analysis (i.e., between raw scores 1 and 2 and between raw scores 4 and 5) are, in fact, nearly of equal severity in the 2 surveys. Corresponding thresholds on the combined scale that is proposed for future use are $2 for food insecurity (moderate or severe) and $6 for severe food insecurity.
The item severity parameters of items in the AFFSS were also plotted against equivalent items from the U.S. Food Security Survey Module collected in the nationally representative U.S. Current Population Survey (CPS-FSS) (Fig. 4). The similarity of relative severity of the items suggests that the scales measure essentially the same latent trait in Lebanon and the United States. Thus, the household measures of severity and prevalence
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TABLE 2 Item severity parameters and item-fit statistics for the Arab Family Food Security Scale
Severity parameter Error Item n1 (logits) (logits) In-fit Out-fit
Concerned food would run out2 431 5.15 0.127 1.02 1.57
Inadequate quality food 1981 5.29 0.063 1.16 2.17
Food bought did not last3 1550 6.01 0.067 0.96 1.22
Not enough of some foods 1981 6.41 0.058 1.13 1.77
Cut size of meal 1981 7.71 0.063 0.73 0.66
Skipped meal 1981 8.39 0.069 0.79 0.56
Did not eat whole day or went to bed hungry 1981 10.03 0.100 0.96 0.77
1 The analysis sample for psychometric assessment included only households with nonextreme responses on the 6 questions in the respective survey (i.e., omitting those with raw scores of 0 or 6) and with no missing responses. 2 This item was administered only in the Tyre Resident Survey. 3 This item was administered only in the Palestinian Refugee Survey.
754 Sahyoun et al.
11 + Item
Did not eat 10 - Equal severity whole day ,,, ,,,
~ 9 ,,, IL + Skipped meal 0
ui 8 ::i + Cut size of ~ 7 meal :. Balanced > .. Food did not meal/not C/1 6 last E enough of .. some foods :I:: Worried/
5 concerned
4 4 5 6 7 8 9 10 11
Item severity, AFFSS
FIGURE 4 Comparison of item severity parameters of equivalent items in the 7-item AFFSS and the U.S. CPS-FSS. AFFSS, Arab Family Food Security Scale; CPS-FSS, Current Population Survey Food Security Supplement.
rates can be made comparable. No attempt has been made at this time, however, to compare the proposed ranges of severity of food insecurity based on the AFFSS with those used in the U.S. scale.
Food insecurity and its predictors. Results from bivariate analysis (not shown) show that the larger the family size, the higher the risk of being moderately and severely food insecure [ORs (95% CIs): 1.1 (1.07, 1.14) (P < 0.001) and 1.07 (1.02, 1.11) (P = 0.003), respectively]. In multivariate logistic regres- sion, the higher the mean monthly household income per household member and the higher the educational attainment of the head of household, the lower the risk of food insecurity, as expected (Table 3).
Food insecurity, food group intake, and coping strategies. There was a strong significant association between food insecu- rity, at both levels of severity, and lower consumption of all food categories except for legumes, which showed higher consump- tion among food-insecure households. The associations were stronger with the more severe range of food insecurity (Table 4). These findings were also reflected in food expenditure per capita, which was significantly lower among moderate and severely food-insecure households (Table 4).
Additionally, the odds of borrowing money and accepting gifts/donations were significantly higher among moderately food-insecure households [ORs (95% CIs): 1.51 (1.01, 2.25) and 1.90 (1.09, 3.30), respectively] and among severely food- insecure households especially [ORs (95% CIs): 2.20 (1.48, 3.28) and 3.90 (1.95, 7.94), respectively] (Table 5).
Discussion
The intent of this research was to validate 2 similar but not identical food security tools used to collect data from southern Lebanese and Palestinian refugee populations in Lebanon and to develop and validate a 7-item food security tool, the AFFSS, for potential use among Arabic-speaking populations.
Food insecurity is quite prevalent among the 2 populations surveyed, the southern Lebanese and Palestinian refugees. Approx- imately 60% of southern Lebanese are involved in growing tobacco on their own land or on land rented from others. However, tobacco is not a lucrative livelihood, it is seasonal, and its price is government-controlled. Families resort to having several different jobs and may experience periodic food insecurity due to uneven incomes (17). Similarly, Palestinian families are restricted from holding many jobs, especially those that are better paid (14).
The food security questions tested by focus groups were understood and accepted in all areas of Lebanon. The recom- mendation to replace ‘‘food bought did not last’’ with ‘‘food was not enough’’ has now been integrated into the AFFSS (Supple- mental Table 1). Additionally, the food security subscales had acceptable levels of internal consistency and construct validity and the AFFSS also had acceptable levels of internal consistency. The AFFSS scores cover a wide range of severity, with scores most likely to be thresholds for overall food insecurity around 2 or 3 and severe food insecurity around 5 or 6. Given this wide range of item severity, the scale may be usable in a general population or in a severe food insecure population. However, thresholds for classification of families by food security status should be made with input from stakeholders in the region.
The difference in time reference between the 2 subscales in our study did not seem to have an impact on the results. Psychometric analysis showed that the relative severity of items was not affected by this difference. Therefore, either time reference could be used for future surveys. Other studies have reliably used 3 mo (6) or even 30 d (18) as the reference periods, and so the time frame is dependent on the purpose of the survey and the context of its administration.
On the basis of the scores and the corresponding questions, a score of $3 on the 7-item scale is approximately equivalent to the threshold for food insecurity used in the United States (5). Several of the food security items in the AFFSS are equivalent to items in the CPS-FSS. The similarity in the severity parameters of the 2 scales is quite strong and is evidence of the stability of this measurement construct across languages and cultures. This similarity suggests that the 2 scales measure essentially the same latent trait in both populations and also indicate that the 2 measures may be meaningfully compared. This similarity was also reported between the validated food security scale used in Iran and the CPS-FSS (19), further demonstrating the similarity in experiencing food insecurity across cultures.
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TABLE 3 Logistic regression of food insecurity on household demographic and socioeconomic factors1
Model 1: food insecurity
(score 2–6 vs. 0–1) Model 2: severe food insecurity
(score 5–6 vs. 0–4)
Demographic and socioeconomic factors OR (95% CI) P value OR (95% CI) P value
Women head of household (referent: men head of household)
Monthly household income per capita (U.S. dollars)
Head of household completed 9th grade (referent: did not complete 9th grade)
1.51 (1.17, 1.94)
0.99 (0.98, 0.99)
0.66 (0.54, 0.80)
0.002
,0.0001
,0.0001
1.37 (1.05, 1.79)
0.99 (0.98, 0.99)
0.62 (0.47, 0.81)
0.020
,0.0001
0.001
1 n = 2936. P values were derived from multiple regression analysis adjusted for displayed variables and study effect.
Validation of an Arab Family Food Security Scale 755
N THE JOURNAL OF NUTRITION
T A B L E
4
F re q u e n c y o
f h o u s e h o ld fo
o d g
ro u p c
o n s u m p tio
n a n d
fo o d e
x p e n d itu
re b y fo
o d s
e c u rity s
ta tu s 1
M oderately
Severely Food secure
food insecure food insecure
(score 0–1; (score 2–4;
(score 5–6; n = 1451)
n = 1292) n = 565)
Food groups, tim es/w
k
M ilk and dairy
7.1 (6.7, 7.5) 5.9 (5.7, 6.1)*
4.3 (4.0, 4.6)*
M eat and poultry
3.0 (2.9, 3.1) 1.8 (1.7, 1.9)*
1.1 (1.1, 1.2)*
Legum es
1.7 (1.6, 1.8) 1.9 (1.8, 2.0)*
2.2 (2.0, 2.4)*
Vegetables 7.4 (7.2, 7.7)
6.0 (5.6, 6.4)* 4.8 (4.5, 5.2)*
Fruit 6.4 (6.1, 6.7)
3.4 (3.2, 3.7)* 2.0 (1.8, 2.2)*
Sw eets
3.4 (3.1, 3.7) 2.9 (2.5, 3.4)*
2.3 (1.9, 2.6)*
Sodas 3.9 (3.3, 4.3)
2.9 (2.1, 3.3)* 2.4 (1.6, 2.7)*
Food expenditure per 90.9 (83.1, 98.6)
70.3* (67.4, 73.2) 49.6* (43.9, 55.4)
capita, U.S. dollars
1 V a lu e s
a re
m e a n s
(9 5 %
C Is ) a d ju s te d
fo r s tu d y
e ffe
c t;
n =
3 3 0 8 . P
v a lu e s
w e re d
e riv
e d fro
m in
d e p e n d e n t t te
s ts . *
D iffe
re n t fro
m c o n tro
l (fo o d -s e c u re c
a te g o ry ),
P ,
0 .0 1 .
H o w ever,
ex p erien
ces u sin
g th e H o u seh
o ld
F o o d
In secu
rity A ccess
Scale sh o w
th at
alth o u gh
th e scale
h as
b een
in tern
ally valid
ated in vario u s lo
w - an
d m id d le-in
co m e co
u n tries, m
an y o
f its q u estio
n s m
ay n o t b
e ex tern
ally valid an d h
en ce can
n o t b
e co m -
p ared acro
ss cu ltu
res (2 0 ). T
o in fo rm
targeted in terven
tio n s an
d im
p ro ve p
lan n in g, it h
as b een reco
m m en d ed th
at co u n tries d
evelo p
th eir o
w n d
irect m easu
res o n th
e b asis o
f p ercep
tio n s an
d ex -
p erien
ces o f h
o u seh
o ld fo
o d in
secu rity at th
e co u n try level (2
1 ). W
e th erefo
re d evelo
p ed fro
m th
e gro u n d u
p th is d
irect to o l to m
easu re
fo o d in
secu rity in L
eb an
o n an
d in terview
ed k ey in
fo rm
an ts as w
ell as co
n d u cted fo
cu s gro
u p s to ascertain co
m p reh
en sio
n an d rel-
evan ce. T
h e stren
gth o f th
is ap p ro ach is th
at it is b ased o
n an in -d ep th u
n d erstan
d in g o
f ex p erien
ces o f fo
o d in
secu rity am
o n g
vu ln erab
le L eb an
ese co m m u n ities. H
o w ever, p
o ten
tial lim itatio
n s
in clu
d e issu
es su ch as resp
o n d en t b
ias, esp ecially am
o n g refu
gees w h o m
ay b e ex
p ectin
g to receive assistan ce o
r b en efi ts (2
0 ). Sim
ilar to o
th er fo
o d secu
rity m o d u les, th
is to o l can
n o t give in
fo rm
atio n
ab o u t th
e cau ses o
f h o u seh
o ld fo
o d in
secu rity. W
e reco m m en d , th
ere- fo re, th
at m ix ed m
eth o d s th
at in clu
d e b
o th q
u alitative an
d q u an ti-
tative research b e u
sed in fu tu re su
rveys w h ere it is feasib
le to d o so
. R esu
lts o f h
o u seh
o ld fo
o d co
n su m p tio
n can su p p o rt th
e valid ity
o f to o ls
in assessin
g th e statu
s o f fo o d
secu rity.
In th is
stu d y,
T A B L E
5
O d d s o
f e n g a g in g in c
o p in g s
tra te g ie s b
y fo o d -
in s e c u re h
o u s e h o ld s c
o m p a re d w
ith fo o d -s e c u re h
o u s e h o ld s 1
M oderately food insecure
Severely food insecure (score 2–4)
(score 5–6)
Coping strategies 2
O R (95%
CI) P value
O R (95%
CI) P value
Borrow ed m
oney 1.51 (1.01, 2.25)
0.04 2.20 (1.48, 3.28)
, 0.0001
W orked m
ore 1.54 (0.62, 3.79)
0.35 0.84 (0.25, 2.70)
0.75
Accepted gifts/donations 1.90 (1.09, 3.3)
0.02 3.90 (1.95, 7.94)
, 0.0001
Borrow ed food
1.40 (0.70, 2.8) 0.34
2.20 (1.09, 4.40) 0.028
Could not do anything 0.33 (0.11, 1.03)
0.06 1.36 (0.48, 3.85)
0.56
1 n =
1 7 3 6 . P
v a lu e s w
e re d
e te rm
in e d fro
m lo
g is tic re
g re s s io n m
o d e ls w
ith e a c h
c o p in g
s tra
te g y
a s
th e
o u tc o m e
v a ria
b le
a n d
fo o d
s e c u rity
a n d
s tu d y
e ffe
c t a s
in d e p e n d e n t v
a ria
b le s .
2 Q
u e s tio
n s
o n
c o p in g
s tra
te g ie s
w e re
a d m in is te re d
o n ly
to p a rtic
ip a n ts
w h o
re s p o n d e d p
o s itiv
e ly to th
e q u e s tio
n ‘‘W a s th
e re a tim
e w h e n y
o u w
e re c
o n c e rn e d
th a t y
o u w
o u ld ru
n o u t o
f fo o d fo
r y o u r h
o u s e h o ld fo
r th e n
e x t m
o n th ? ’’ (T
y re R
e s id e n t
S u rv e y ) o
r ‘‘T h e fo
o d th
a t I b
o u g h t ju
s t d
id n o t la
s t a
n d w
e d id n
o t h
a v e m
o n e y to g
e t
m o re ’’ (P
a le s tin
ia n R
e fu g e e S
u rv e y ).
7 5 6
S a h y o u n e
t a l.
h o u seh
o ld s th
at w ere fo
o d in
secu re h
ad lo w er fo
o d ex
p en d itu
re, an d alth
o u gh d
ietary in tak
e d ata co
llectio n w
as lim ited in sco
p e, th
e d ata in
d icate th
at, o n average, fo
o d -in
secu re h
o u seh
o ld s co
n su m ed
an im
al p ro d u cts as w
ell as fru it an
d vegetab les sign
ifi can
tly few er
tim es p
er w eek
. L egu
m es (e.g., len
tils an d ch
ick p eas), w
h ich are an
in tegral p
art o f th
e d iet in L
eb an
o n an
d are less ex p en sive, w
ere co n su m ed m
o re. T
h ese resu
lts h ave b
een rep o rted b
y o th ers (2
2 ,2 3 ).
T h e co
p in g stra
teg ies a
d o p ted b
y fo o d -in
secu re h
o u seh
o ld s
also su p p o rt th
e valid ity o
f th e m
o d u les u
sed in th e su
rveys. F o o d -
in secu
re h o u seh
o ld s, esp
ecially th o se in th
e severe catego ry, d
e- crease th
e q u ality an
d q u an
tities o f fo
o d co
n su m ed b
u t also reso
rt to o
th er sh
o rt-term
co p in g strategies, su
ch as b o rro
w in g m
o n ey
an d fo
o d an
d /o r accep
tin g gifts/d
o n atio
n s. T
h ere w
ere n o asso
ci- atio
n s b
etw een fo
o d in
secu rity an
d w o rk in g m
o re in th
is p o p u la-
tio n o
r w ith th
e resp
o n se
th at
th ey
co u ld n
o t d o
an yth
in g to
im p ro ve th
eir situ atio
n . T
h ese q
u estio
n s are d
iffi cu lt to in
terp ret
co n sid
erin g th
e co m p lex
ity o f th
e w o rk situ
atio n in L
eb an
o n fo
r P alestin
ian s an
d th e lim
ited w o rk availab
ility in so u th ern L
eb an
o n
villages. T h e co
p in g strategies w
ere ask ed o
n ly o
f th o se fam
ilies w h o w
ere co n cern
ed th at fo
o d w
o u ld ru
n o u t o
r w h o se fo
o d d
id n o t last o
ver a given p erio
d . It is p
o ssib
le th at fo
o d -secu
re fam ilies
d evelo
p ed o
th er co
p in g strategies th
at led to fo o d secu
rity. T h e p
sy ch o m etric a
n a ly sis rep
o rted in th
is a rticle su
p p o rts
th e in
tern a l v
a lid
ity o f th
e A F F S S a
n d th
e su b sca
les. T h e d
eter- m in a n ts a
n d co
n seq
u en ce o
f fo o d secu
rity m ea su red in th
is stu d y
p ro v id e a
d d itio
n a l su
p p o rt fo
r th e v
a lid
ity o f th
e m o d u les. T
h e
A F F S S is v
a lid
a ted a
n d is a
v a ila
b le in cla
ssica l a
n d L
eb a n ese
A ra b ic la
n g u a g es. It a
lso co v ers a w
id e ra
n g e o
f sev erity m
ea -
su res o
f fo o d in
secu rity. T
h e sca
le co u ld b
e u sa b le, th
erefo re, in a
g en era
l p o p u la tio
n o r in
a sev
ere fo o d -in
secu re
p o p u la tio
n .
T h u s, h
a v in g a v
a lid
a ted sta
n d a rd ized to
o l fo
r m ea su rin
g fo o d
secu rity sta
tu s in A
ra b ic-sp
ea k in g co
u n tries is v
ery u sefu
l to a ssess a
n d m
o n ito
r fo o d secu
rity in th e reg
io n .
A c k n o w le d g m e n ts
T h e a
u th o rs th
a n k C
h irin
e H a rb fo
r q u a lita
tiv e d
a ta co
llectio n
a n d a
n a ly sis a
n d A
id a E
l A ily fo
r d a ta en
try a n d q
u a lity co
n tro
l. N .R .S ., H
.G ., a
n d N
.H . co
n ceiv
ed th e stu
d y ; N
.R .S . a
n d H
.G .
d esig
n ed th
e resea rch
; N .R .S ., H
.G ., a
n d K
.S . co
n d u cted th
e resea
rch ; N
.R .S ., M
.N ., A
.J.S ., K
.S ., a
n d H
.G . a
n a ly zed th
e d ata; N
.R .S ., A
.J.S., an d H
.G . w
ro te th
e m an
u scrip
t; an d N
.R .S.
h ad p
rim ary resp
o n sib
ility fo r th
e fi n al co
n ten
t. A ll au
th o rs rea
d an
d ap p ro v ed th
e fi n a l m
an u scrip
t.
L ite
ra tu
re C
ite d
1 .
F ro n g illo E
A . V
a lid
a tio
n o f m
ea su res o
f fo o d in
secu rity a
n d h
u n g er.
J N u tr. 1
9 9 9 ;1 2 9 S
u p p l:5
0 6 S – 9 S .
2 .
W o rld
H ea lth
O rg a n iza
tio n . T ra d e,
fo reig
n p o licy,
d ip lo m a cy,
a n d
h ea lth
: g lo ssa
ry o f g lo b a liza
tio n , tra
d e
a n d
h ea lth
term s.
G en ev a :
W H O ; 2
0 1 2 [cited 2
0 1 4 F
eb 1 8 ]. A
v a ila
b le fro
m : h
ttp ://w
w w .w
h o .in
t/ tra
d e/g
lo ssa
ry /sto
ry 0 2 8 /en
/.
3 .
N a ja F, N
a sred
d in e L
, Ita n i L
, C h a m ieh M
C , A
d ra N
, S ib a i A
M , H
w a lla
N . D
ieta ry p
a ttern
s a n d th
eir a sso
cia tio
n w ith o
b esity a
n d so
cio d em
o -
g ra p h ic fa
cto rs in a n
a tio
n a l sa
m p le o
f L eb a n ese a
d u lts. P
u b lic H
ea lth
N u tr. 2
0 1 1 ;1 4 :1 5 7 0 – 8 .
4 .
P érez-E
sca m illa
R , S eg a ll-C
o rrêa
A M . F o o d
in secu
rity m ea su rem
en t
a n d in
d ica
to rs. R
ev ista d
e N u triça
o . 2
0 0 8 ;2 1 :1 5 s– 2 6 s.
5 .
B ick
el G , N
o rd M
, P rice C
, H a m ilto
n W , C
o o k J. G
u id e to m
ea su rin
g h o u seh
o ld fo
o d secu
rity. R ev ised 2
0 0 0 . A
lex a n d ria (V
A ): U
S D A , F
o o d
a n d N
u tritio
n S erv
ice; 2 0 0 0 .
6 .
P érez-E
sca m illa R
, S eg a ll-C
o rrea A
M , K
u rd ia n M
a ra n h a L
, S a m p a io
M d M
d e F, M
arin -L eo n L
, P an igassi G
. A n ad
ap ted versio
n o f th
e U .S.
D ep artm
en t o f A gricu
ltu re
fo o d
in secu
rity m o d u le
is a
valid to o l fo r
assessin g
h o u seh
o ld
fo o d
in secu
rity in
C am
p in as,
B razil.
J N u tr.
2 0 0 4 ;1 3 4 :1 9 2 3 –8 .
Downloaded from jn.nutrition.org by guest on March 15, 2016
THE JOURNAL OF NUTRITION
7 .
M elg
a r-Q
u iñ o
n ez
H , Z u b ieta
A C , V a ld ez
E , W h itela
w B , K a iser
L .
V a lid
a tio
n o f a
n in stru
m en t to m
o n ito
r fo o d in
secu rity in S
ierra d e
M a n a n tla
n , Ja
lisco . S
a lu d P
u b lica M
ex . 2
0 0 5 ;4 7 :4 1 3 – 2 2 .
´ 8 .
A lv a rez M
C , E
stra d a A
, M o n to y a E
C , M
elg a r-Q
u in o n ez H
. V a lid
a cio
n ˜ ´
´ d e
esca la
d e
la seg
u rid
a d
a lim
en ta ria
d o m éstica
en A n tio
q u ia ,
C o lo m b ia . S
a lu d P
u b lica M
ex . 2
0 0 6 ;4 8 :4 7 4 – 8 1 .
9 .
K a b b a n i N
, W eh elie Y
. M ea su rin
g h u n g er a
n d fo
o d in
secu rity in Y
em en .
W o rk in g P
a p er 4
1 9 . E
co n o m ic R
esea rch F
o ru m ; 2
0 0 4 [cited 2
0 1 4 F
eb 1 8 ].
A v a ila
b le
fro m : h ttp
://w w w .erf.o
rg .eg
/C M
S /u p lo a d s/p
d f/0
4 1 9 _ fi -
n a l.p
d f.
1 0 . G o rd o n N
H , H
a lileh S
. A n a
n a ly sis o
f cro ss sectio
n a l su
rv ey d
a ta o
f stu
n tin
g a m o n g P
a lestin
ia n ch
ild ren less th
a n fi
v e y
ea rs o
f a g e. M
a tern
C h ild H
ea lth J. 2
0 1 3 ;1 7 :1 2 8 8 – 9 6 .
1 1 . B a w a d i H
A , T
a y y em
R F, D
w a iry A
N , A
l-A k o u r N
. P rev
a len
ce o f fo
o d
in secu
rity a m o n g
w o m en
in n o rth
ern Jo rd a n . J H ea lth
P o p u l N u tr.
2 0 1 2 ;3 0 :4 9 – 5 5 .
1 2 . D o o cy
S , S iro
is A , A n d erso
n J,
T ilev
a M , B ierm
a n n
E , S to rey
JD ,
B u rn h am
G . F
o o d secu
rity a n d h
u m an
ita ria
n a ssista
n ce a
m o n g d
isp la ced
Ira q i p
o p u la tio
n s in Jo
rd a n a
n d S
yria. S o c S
ci M ed . 2
0 1 1 ;7 2 :2 7 3 – 8 2 .
1 3 . FA
O . R
ep o rt o
f th e fo
o d secu
rity a ssessm
en t, W
est B a n k a
n d G
a za
S trip
. R o m e: F
A O ; 2
0 0 3 .
1 4 . C h a a b a n J, G
h a tta
s H , H
a b ib R
, H a n a fi S
, S a h y o u n N
, S a lti N
, S ey fert
K , N a a m a n i N . S o cio
-eco n o m ic
su rv ey
o f P a lestin
ia n
refu g ees
in L eb a n o n . B eiru
t (L eb a n o n ):
A m erica
n U n iv ersity
o f B eiru
t, U n ited
N a tio
n s R
elief a n d W
o rk s A
g en cy fo
r P a lestin
e R efu
g ees in th
e N ea r
E a st; 2
0 1 0 .
1 5 . M a x w ell D
, W a tk in s B
, W h eeler R
, C o llin
s G . C
o p in g stra
teg ies in
d ex a
to o l fo
r ra p id ly m
ea su rin
g fo o d secu
rity a n d th
e im p a ct o
f fo o d a
id
p ro g ra m m es in em
erg en cies: F
ield M eth
o d s M
a n u a l. N
a iro
b i: C
A R E
a n d W
F P ; 2
0 0 3 [cited 2
0 1 4 F
eb 1 8 ]. A
v a ila
b le fro
m : h
ttp ://w
w w .fa
o .
o rg /crisisa
n d h u n g er/ro
o t/p
d f/co
p _ stra
t.p d f.
1 6 . C a rlso
n S J, A
n d rew
s M S , B
ick el G
W . M
ea su rin
g fo o d in
secu rity a
n d
h u n g er
in th e U n ited
S ta tes:
d ev elo
p m en
t o f a
n a tio
n a l b en ch m a rk
m ea su re a
n d p
rev a len
ce estim a tes. J N
u tr. 1
9 9 9 ;1 2 9 :5 1 0 S – 6 S .
1 7 . S a v e th
e C h ild
ren . R
a p id a
ssessm en
t in so u th ern L
eb a n o n . 2
0 0 6 [cited
2 0 1 3 M
a y 2
7 ]. A
v a ila
b le fro
m : h
ttp ://reliefw
eb .in
t/sites/reliefw eb .in
t/ fi les/reso
u rces/1
E 5 0 5 4 9 6 0 2 1 7 3 FA
C C 1 2 5 7 1 D F 0 0 3 6 A 5 B D -sc-lb
n -2 9 au g.p
d f.
1 8 . C o a tes J, S
w in d a le A
, B ilin
sk y P. H
o u seh
o ld fo
o d in
secu rity a
ccess sca le
(H F IA
S ) fo
r m ea su rem
en t o
f h o u seh
o ld fo
o d a
ccess: in d ica
to r g
u id e
(v. 3 ). W
a sh in g to n : F
o o d a
n d N
u tritio
n T ech
n ica
l A ssista
n ce P
ro ject,
A ca d em
y fo r E
d u ca tio
n a l D
ev elo
p m en t; 2
0 0 7 .
1 9 . R a fi ei
M , N o rd
M , S a d eg h iza
d eh
A , E n teza
ri M H . A ssessin
g th e
in tern
a l v a lid
ity o f a
h o u seh
o ld
su rv ey -b a sed
fo o d
secu rity
m ea su re
a d a p ted fo
r u se in Ira
n . N
u tr J. 2
0 0 9 ;8 :2 8 .
2 0 . D eitch
ler M , B
a lla
rd T , S
w in d a le A
, C o a tes J. V
a lid
a tio
n o f a m
ea su re o
f h o u seh
o ld
h u n g er
fo r
cro ss-cu
ltu ra l
u se.
W a sh in g to n :
F o o d
a n d
N u tritio
n T ech
n ica
l A ssista
n ce II P
ro ject (F
A N T A -2 ), A
E D ; 2
0 1 0 .
2 1 . W o lfe W
S , F
ro n g illo E
A . B
u ild
in g h
o u seh
o ld fo
o d -secu
rity m ea su re-
m en t to
o l fro
m th
e g ro u n d u
p . F
o o d N
u tr B
u ll. 2
0 0 1 ;2 2 :5 – 1 2 .
2 2 . M elg
a r-Q
u in o n ez H
R , N
o rd N
, P erez-E
sca m illa R
, S eg a ll-C
o rrea A
M .
P sy ch o m etric
p ro p erties
o f a
m o d ifi ed
U S -h o u seh
o ld
fo o d
secu rity
su rv ey m
o d u le in C
a m p in a s, B
ra zil. E
u r J C
lin N u tr. 2
0 0 8 ;6 2 :6 6 5 – 7 3 .
2 3 . M elg
a r-Q
u in o n ez
H R , Z u b ieta
A C , M k N elly
B , N teziy
a rem
y e
A ,
G era
rd o M
F, D u n fo rd C
. H o u seh
o ld fo
o d in
secu rity a
n d fo
o d ex
p en -
d itu
re in B o liv
ia , B
u rk in a F
a so , a
n d th
e P h ilip
p in es. J N
u tr. 2
0 0 6 ;1 3 6
S u p p l:1
4 3 1 S – 7 S .
V a lid a tio
n o f a
n A ra b F
a m ily F
o o d S
e c u rity S
c a le
7 5 7
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