Final Project Milestone Two: Literature Review

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Public Health Nutrition: 17(1), 73–82 doi:10.1017/S1368980013000281

Very low food security in the USA is linked with exposure to violence

Mariana M Chilton1,*, Jenny R Rabinowich1 and Nicholas H Woolf 2 1Drexel University School of Public Health, Department of Health Management and Policy, 1505 Race Street, Mail Stop 1035, Philadelphia, PA 19102-1192, USA: 2Woolf Consulting Inc., Carpinteria, CA, USA

Submitted 14 March 2012: Final revision received 13 December 2012: Accepted 13 January 2013: First published online 22 February 2013

Abstract

Objective: To investigate characteristics of exposure to violence in relation to food security status among female-headed households. Design: Ongoing mixed-method participatory action study. Questions addressed food insecurity, public assistance, and maternal and child health. Grounded theory analysis of qualitative themes related to violence was performed. These themes were then categorized by food security status. Setting: Homes of low-income families in Philadelphia, PA, USA. Subjects: Forty-four mothers of children under 3 years of age participating in public assistance programmes. Results: Forty women described exposure to violence ranging from fear of violence to personal experiences with rape. Exposure to violence affected mental health, ability to continue school and obtain work with living wages, and subsequently the ability to afford food. Exposure to violence during childhood and being a perpetrator of violence were both linked to very low food security status and depressive symptoms. Ten of seventeen (59 %) participants reporting very low food security described life-changing violence, compared with three of fifteen (20 %) participants reporting low food security and four of twelve (33 %) reporting food security. Examples of violent experiences among the very low food secure group included exposure to child abuse, neglect and rape that suggest exposure to violence is an important factor in the experience of very low food security. Conclusions: Descriptions of childhood trauma and life-changing violence are linked with severe food security. Policy makers and clinicians should incorporate violence prevention efforts when addressing hunger.

Keywords Food insecurity

Women Violence Poverty Hunger

Food insecurity is the lack of access to enough food for an

active and healthy life due to economic circumstances,

and is regularly monitored through the Current Popula-

tion Survey by the Economic Research Service of the US

Department of Agriculture(1). Food insecurity rates for

female-headed households have remained extremely

high compared with all other households in the USA.

In 2010, 35?1 % of female-headed households with children

reported household food insecurity v. 14?5 % of all

households(1). Very low food security at the household

level is defined as the episodic reduction in food intake

and disruption of normal eating patterns due to lack of

money and resources. Female-headed households with

children have the highest rate of very low food security

compared with all other households (10?8 % v. 5?4 %) (1)

Quantitative research studies demonstrate an association

between maternal depressive symptoms, household food

security and poor child development(2–4); far fewer have

investigated associations between food insecurity and

experiences that may be related to depression such as

exposure to domestic violence and adverse childhood

experiences(3,5,6).

The present study on exposure to violence and its

relationship to food security status utilizes qualitative,

demographic and household food security data collected

in the ongoing Witnesses to Hunger study. The Witnesses

to Hunger study incorporated the photovoice technique (7)

and semi-structured in-home interviews with forty-four

mothers of young children under 3 years of age who

received public assistance. The present study elucidates

themes related to violence exposure and investigates

the potential relationship between the type and quality of

the reported exposures to violence and the severity of

household food insecurity. Qualitative reports regarding

experiences with rape and sexual assault, child abuse,

attempted suicide and perpetration of violence by parti-

cipants illuminate potential pathways that may link food

insecurity and violence.

*Corresponding author: Email [email protected] r The Authors 2013

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Background and significance

Quantitative research demonstrates that maternal

depression, anxiety and social isolation are correlated

with food insecurity and with poor child development

and behaviour(8–13). In addition, household food insecurity

is associated with suicidal ideation among adolescents(14)

and poor physical, mental and psychosocial health

among children(15–19). These studies leave many ques-

tions unanswered about the origins and nature of poor

mental health reported by food-insecure caregivers.

Clues regarding the relationship between depression and

hunger are found in mixed-methods research. For instance,

Tarasuk found that odds of social isolation among women

reporting household food insecurity with hunger (now

called ‘very low food security’) were significantly higher

than the odds of social isolation among women reporting

food security(20). It is already well established that social

isolation is intertwined with depression, stress and anxiety,

and relates to exposure to violence, abuse and neglect (21–23)

Hamelin et al. reported the presence of stress and anxiety

among food-insecure families(24), and our previous research

reported anxiety, depression and exposure to violence

among food-insecure women in Philadelphia(25). Wehler

et al. found that homeless and low-income mothers who

experienced sexual assault in childhood were over four

times more likely to have household-level food insecurity

than women who had not been assaulted (6)

. Others

demonstrated that child hunger was more prevalent in

households in which mothers reported higher odds of

post-traumatic stress disorder and substance abuse(5).

Melchior et al.’s longitudinal study found that mothers in

persistently food-insecure homes had significantly higher

rates of depression and/or a psychotic spectrum disorder,

or had experienced domestic violence(3).

Recent advancements in neuroscience research have shed

light on the importance of a child’s earliest years for later adult

health and well-being, as well as later economic activity(26,27).

Thus, a child’s exposure to ‘toxic stress’ – the kind of emo-

tional, psychological and physical stress associated with

neglect, abuse and deprivation – has been shown to harm the

child’s current and future physical and mental health(27–30). In

addition, recent research has identified how adversity that

occurs in critical moments during childhood and adoles-

cence has a decisive impact on behaviours, choices and

social relationships that extend into adulthood(31).

Methods

The present study received approval from the Drexel

University Institutional Review Board in 2008. Written

informed consent was obtained from all participants. The

study utilized qualitative investigation paired with quan-

titative measures to investigate women’s experiences with

food security and public assistance programmes such as

SNAP (Supplemental Nutrition Assistance Program), WIC

(Special Supplemental Nutrition Program for Women,

Infants, and Children) and TANF (Temporary Assistance

for Needy Families). Participants were recruited through

a mailed flier sent to 150 caregivers of young children

under 3 years of age who had requested outreach

through the ongoing Children’s Health Watch research

study. Sixteen participants responded to the flier by

calling our offices and twenty-six participants were

recruited through snowball sampling with the original

sixteen between June and September 2008; two partici-

pants were recruited in December 2010. In addition to

utilizing quantitative measures of household food security

and public assistance programme participation, the pre-

sent study utilized the photovoice methodology coupled

with ethnographic and semi-structured interviews. At

the first interview conducted in the participant’s home,

participants completed an informed consent form and

responded to a brief survey that inquired about public

assistance programme participation, household food

security, maternal depressive symptoms, self-rated health

and caregiver-rated child health. At this meeting, partici-

pants received a digital camera and were trained in basic

digital photography. After two to three weeks, researchers

returned to download the photographs of participants

and conducted semi-structured, qualitative interviews

utilizing the photovoice interview technique. Finally,

participants were invited to participate in one of four

focus groups so the researchers could double check on

major themes and for participants to identify which

themes and photographs they deemed most representa-

tive and significant. More details about these methods are

outlined in previous publications(32,33).

Data collection and analysis

Quantitative data collected and reported herein include

basic demographics, public assistance programme parti-

cipation and the eighteen-question US Household Food

Security Survey Module. We follow methods of household

food security categorization as outlined by the US

Department of Agriculture for households with children,

where zero to two affirmative responses indicate food

security, between three and seven responses indicate low

food security, and eight or more affirmative responses

indicate very low food security(34). We used the Kemper

three-item screen to measure maternal depressive symp-

toms(35). Mothers and caregivers were categorized as having

maternal depressive symptoms if they responded affirma-

tively to two of the three depression questions. We also

measured mothers’ self-rated health and caregiver-rated

child health with the validated questions from the Third

National Health and Nutrition Examination Survey(36).

Violence-related results from the qualitative investigation

are the primary focus of the present paper. Photographs

taken by each participant served as the basis for discussion

within the context of one-on-one, open-ended interviews.

Two of the three authors conducted these interviews

74 MM Chilton et al.

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utilizing the photovoice technique, as developed by Wang

and colleagues(7,37). The interview technique included

follow-up questions to the narrative core of the story to elicit

greater details. Thus, most research questions were unique

to the narratives provided during each interview. Each

interview lasted between 1?5 and 3 h, and approximately

half the women completed follow-up interviews. A total of

sixty-eight interviews were conducted between June 2008

and December 2010. Additionally, twenty-eight of the forty-

four participants participated in one of four focus groups, in

which women identified representative themes and selected

photographs for the exhibit and website.

All interviews and focus groups were audio-recorded,

transcribed verbatim and entered into ATLAS.ti, a qualita-

tive software program that supports management and

analysis of qualitative data. The qualitative data were wide-

ranging in topic, and we therefore began by reorganizing

the data using a phenomenological approach similar to

that described by Wertz(38). This involved each author

separately coding eight to ten transcribed interviews for

major themes, developing a master code list through

consensus discussion of the three authors, and reorganizing

the narratives by these agreed-upon themes.

Information on violence surfaced primarily when we

asked questions about the relationship between food inse-

curity and mental health, as many of these questions were

answered with stories of exposure to violence and multiple

hardships. We defined violence broadly to include descrip-

tions of all traumatic experiences from fear of violence to

actual violence, either to oneself or others. The third author

then used a grounded theory approach(39), a commonly

used method in qualitative research on food insecurity(40–43),

to investigate these themes further. Through constant com-

parison analysis of over 200 cases of violence, three primary

dimensions of violence emerged as most salient to the

participants, namely severity, locus and life stage, with three

to five dimensional points for each. We then summed the

number of participants reporting at least one case of violence

at each level of severity, locus or life stage, and also cate-

gorized each participant by household food security status,

maternal depressive symptoms, and child and self-reported

health status. We then summed the number of participants

who described at least one case in each category of violence,

and summed the number of participants in each category of

food security, depression and child and self-rated health, in

order to identify patterns of relationship among the dimen-

sions of violence described by participants and the food

security and health status measures (see Table 3).

Results

Dimensions of violence in relation to food security

status and depressive symptoms

Demographic results displayed in Table 1 show that most

caregivers were participating in the major public assistance

programmes – SNAP, WIC and TANF – at the time

of the interview. Twelve of forty-four women reported

food security, fifteen of forty-four women reported low

food security, and seventeen of forty-four women

reported very low food security. Twenty-one of forty-four

reported depressive symptoms. Compared with the food

secure and low food secure groups, a higher proportion

of very low food secure participants reported that their

own health was fair/or poor and reported depressive

symptoms. Over a quarter of the participants (12/44)

never completed high school, fourteen had graduated from

high school and nearly half (18/44) had attended a tech-

nical school or taken some college courses. Paradoxically,

a higher proportion of those who had attended some

college/technical school reported very low food security

compared with those who had only a high school

education or less. Based on information gleaned in the

qualitative interviews, this is likely due to a mix of factors,

including struggles to balance income between hours

working v. attending school, the high cost of college

tuition and college loans which drain income that could

otherwise be put towards basic necessities such as food,

and the fact that education received by most participants

was through job training programmes required by the

TANF (cash assistance) programme. These trainings

received mixed reviews from the participants and rarely

resulted in greater earnings. In addition, these results are

affected also by exposure to violence.

In the qualitative interviews participants described

childhood experiences that included witnessing the inti-

mate partner abuse of their parents/guardians, exposure

to substance abuse and domestic abuse/neglect. Theme

analysis demonstrated five dimensional points of severity

of violence, ranging from ‘casually recalled’ violence to

violence with ‘life-changing impact’ (see Table 2). We also

categorized violence in terms of locus, referring to closeness

of violence to the caregiver: ‘being a victim’, ‘being a per-

petrator’, ‘participants’ children’s experience’, ‘close others’

and ‘distant others’. We distinguished three life stages:

‘childhood’, ‘past adolescent/adulthood’ and ‘currently’.

We categorized each dimension of exposure to vio-

lence by participants’ food security status and depressive

symptoms to investigate resulting patterns (see Table 3).

Each dimension of violence exposure revealed at least

one category in which the group of very low food secure

women differed from the low food secure and the food

secure groups. In the life stage dimension, eighteen

women reported exposure to violence as a child, twenty-

seven reported violence in the recent past, and thirty-four

women reported experiencing violence currently. For

violence occurring during childhood, large differences

appeared between the very low food secure and low food

secure and food secure (9/17 v. 5/15 and 4/12). When

locus of violence was considered, there were qualitative

differences between all three groups in the case of per-

petration of violence. A strikingly higher proportion of

Very low food security linked with violence 75

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participants (10/17) described themselves as perpetrators

of violence among the very low food secure group

compared with the low food secure group (2/15) and the

food secure group (2/12). In terms of violence severity,

more than half of the participants reporting very low food

security reported violence that had life-changing impact,

as opposed to a fifth and a third of the participants in the

low food secure and food secure groups, respectively.

When level, locus and life stage were investigated in

relation to the quantitative measure of maternal depres-

sive symptoms, a greater proportion of high levels of

violence exposure were described among those who

reported maternal depressive symptoms. For instance,

women who reported depression also reported levels of

violence that had longer-lasting and life-changing impact

compared with women who did not have depressive

symptoms. Also, similar to the group of very low food

secure participants, those with depressive symptoms

were more likely to have been a perpetrator of violence

or had violence affect close others such as family members

and friends. When the data were categorized by self-rated

health and caregiver-rated child health, there were few

recognizable differences in proportion among each

category (results not shown).

Table 1 Characteristics of the Witnesses to Hunger sample by food security status (n 44)

Household food security status

Overall sample (n 44)

Food secure (n 12)

Low food security (n 15)

Very low food security (n 17)

Characteristic Mean SD Mean SD Mean SD Mean SD

Mother’s age (years) 26?7 6?6 25?4 6?3 25?2 5?3 29?1 7?5 Child age (months) 17?7 9?6 13?2 7?5 18?2 11?2 20?5 8?8

n n % n % n %

Race/ethnicity Black 31 9 75 10 67 12 71 Hispanic 10 1 8 5 33 4 23 White 3 2 17 0 0 1 6

Mother’s place of birth US born 43 12 100 14 93 17 100 Immigrant 1 0 0 1 7 0 0

Marital status Not married 39 10 83 14 93 15 88 Married 5 2 17 1 7 2 12

Education ,12th grade 12 3 25 4 27 5 29 High-school graduate/GED 14 6 50 5 33 3 18 Technical school/some college 18 3 25 6 40 9 53

Employment Unemployed 32 9 75 11 73 12 71 Employed 12 3 25 4 27 5 29

TANF* No TANF 21 5 42 7 47 9 53 TANF 23 7 58 8 53 8 47

SNAP- No SNAP 1 0 0 0 0 1 6 SNAP 43 12 100 15 100 16 94

WIC-

No WIC 7 0 0 1 7 6 32 WIC 37 12 100 14 93 11 68

Child health Fair/poor 12 1 8 5 33 6 35 Excellent/good 32 11 92 10 67 11 65

Maternal health Fair/poor 17 4 33 5 33 8 47 Excellent/good 27 8 67 10 67 9 53

Depressive symptoms Maternal depressive symptoms 21 2 17 7 53 12 71 None 23 10 83 8 47 5 29

GED, General Educational Development. All percentages have been rounded to the nearest whole number. *Temporary Assistance for Needy Families: programme providing cash welfare benefit to families with children with extremely limited or no additional income (http://www.hhs.gov/recovery/programs/tanf/index.html). -Supplemental Nutrition Assistance Program (formerly the Food Stamp Program): programme providing income-eligible families with electronic benefits that can be used for the purchase of food products (http://www.fns.usda.gov/snap/). -

Special Supplemental Nutrition Program for Women, Infants, and Children: provides supplemental foods, health-care referrals and nutrition education for low- income pregnant and breast-feeding women and children up to 5 years of age (http://www.fns.usda.gov/wic/).

76 MM Chilton et al.

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Examples of exposure to violence described by

very low food secure participants

Descriptions of severe violence congregated among the

seventeen participants who reported very low food

security. These experiences included exposure to rape

and sexual assault, child abuse and neglect, becoming

a perpetrator of violence, and attempted suicide and

suicidal ideation. Again, these themes emerged in dialogues

related to issues that the women identified as significant

to their experiences with poverty and hardship. Most

often, questions that elicited these experiences with vio-

lence and fear were non-directive, open-ended follow-up

questions to references of depression, having a difficult

childhood, complex emotions about parents and other

helpers, and difficulty securing and maintaining employ-

ment. We describe below examples of the most severe

violence that had a major impact on the lives of the women

reporting very low food security. We report from their

transcribed narratives. The ellipses [y] signify elimination

of transition words such as ‘like’ and ‘um’ and repetitive

phrases that do not alter the meaning or word proximity.

Rape and sexual assault

The women who described sexual assault did so primarily

to explain how they came to be in their current financial

situation where they cannot afford enough food, which in

many cases was linked to low self-esteem and minimal

positive adult influences during childhood. For instance,

Participant #23, a 40-year-old married caregiver of a

toddler, described how her stepfather had repeatedly

raped her since the time she was aged nine. She also

described how she never told her mother because she

worried her mother would blame her and ‘beat’ her in

response. From the participant’s perspective, her mother

was in a state of denial despite Participant #23’s serious

resulting medical conditions such as a ruptured bladder

and vaginal bleeding. Worry about telling a trusted adult

was found among several other participants. An unmarried

mother of a two-and-half-year-old, Participant #43,

described that when she was age 17 she finally reported

to the police and to her family that her adopted father had

been raping her for years. As a result, her stepmother

kicked her out of the house. Both women identified here

described episodes of living in abandoned homes without

running water and electricity. One turned to prostitution

and crack cocaine, the other to a homeless shelter. These

episodes are not the only rape experiences resulting in

severe poverty in this sample. Six women reported having

been raped by family members and each participant

coped by escaping to the streets before age 18, in most

cases dropping out of high school. Participant #17, a

single caregiver of a toddler, reported she was so scared

that men would rape her that she was very promiscuous

(she slept with any man who ‘wanted’ her) for fear that

she would be raped again if she refused their sexual

advances. This violence-related high-risk behaviour was

also described as linked to hunger she experienced in

early childhood because her mother was exposed to

violence and suffered from alcoholism:

‘Sometimes we didn’t have food to eat for two days.

My mother was an alcoholic. So her drink came

first. She was a victim of abuse. She was being

abused, physically abused by her boyfriend. She

was bein’ abused so her thing was drink. I guess it

comforted her and took all that away from her. So

her drink came before anything else. We needed

clothes. We went without a whole lot.’

There were very few reported instances in which the

family was supportive of the woman who reported rape

or sexual assault as a child or adolescent. In addition to

experiencing rape by a family member, Participant #26,

an unmarried mother living with her two children, age

two and three, was beaten and molested by other adults.

She described the connection between the molestation

and the physical abuse she experienced as a child:

‘I really want you to understand and hear how it is

on my side; how I feel. I got molested by a mentally

retarded uncle. Nobody believed me that I got

molested [y] I can’t sleep anymore at night. As a

child, I used to get hit. I don’t wanna go into details,

but things I used to have happen to me at home,

what my mom was goin’ through and how I was

Table 2 Categorization of violence severity

Severity level Name Definition Example(s)

1 Casually recalled Little or no impact apparent, regardless of severity of event

Assault or murder of a neighbour or distant friend

2 Fear of violence Participant expresses fear in relation to the event

Fear of children being out in the street or in day care and at risk of abuse/molestation by others

3 Short-lived impact Consequences of event are described as short-lived

Abuse or neglect experienced by participant as a child

4 Longer-lasting impact Consequences of event are described as long-term, but there is resolution or the consequences were not life-changing

Attempted murder or threats to close family members, experiences of intimate partner violence (as a child or in current relationships)

5 Life-changing impact Event described as permanently life- changing

Murder or suicide of family/close friends, rape experienced by participant

Very low food security linked with violence 77

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bein’ treated – the ‘‘shut-up’’, the ‘‘stop’’, [y] the

‘‘pop you in the head’’ – whatever the case, I would

get it.’

Overall, experiences with rape and sexual assault were

described as linked to past and current physical and

mental health problems, inability to sleep, to eat, to feel

safe and to develop lasting, trusting relationships. These

physical and mental health problems were often provided

as the reasons behind an inability to maintain a steady job,

to complete their educations and to enter into nurturing

relationships.

Exposure to child abuse and intergenerational violence

In addition to Participant #26, several other women

described their experiences with having been abused as

children. These experiences sometimes included the

withholding of food or abusive activities around food.

Participant #21 described her experience of being in

foster care:

‘The lady that we was with for a year, she used to

beat us when we were bad. That’s what my mom

did, so it didn’t bother me. But when I went to the

next foster home, she used to make us eat cat food

for breakfast. I’d throw up. [y] She’d say I’m not

goin’ to school until I eat that. I wet the bed when

I was a little girl. She made me sit on the toilet all

night long because I wet the bed. Her grandson, the

whole time we were there for the six years [between

age 4 and 12 years], he raped us.’

Participant #6, a single, 20-year-old mother of a two-year-old

and a one-year-old, described that she not only suffered

abuse by her mother, but also by her older brother

who punched her so hard in the chest when she was

nine that she was hospitalized. Abuse by her mother

continued into adulthood. When asked by the researchers

how the current abuse by her mother affected her ability

to stay at her job, she described how she would hide

the abuse:

‘I’ll always hide it. I mean I’ve been through worse,

a lot worse. So, that’s really nothing too new.

I thought it would be important for me to take a

picture of it because I’m twenty years old. I’m an

adult. There’s no reason why my mom should be

putting her hands on me. But this is nothing com-

pared to the way she used to beat me with belts,

with extension cords, with shoes, with broomsticks,

with phone cords, anything.’

Noting her mother’s depression, history of violent rela-

tionships and history of abuse she suffered as a child, this

participant recognized that she herself is a part of a

generations-long pattern.

Violence perpetuated throughout generations was a

common thread in descriptions of exposure to violence asT a b

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78 MM Chilton et al.

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a child. The women described how they are working to

break this cycle, or how they get caught up in the cycle of

violence. Participant #44, a soon-to-be-married mother of

a three-year-old, described her relationship with her

mother as ‘nonexistent’ because she blames her mother

(who had severe drinking problems) for her childhood

deprivation and mistreatment:

‘I blamed my mother for all of it because there’s no

other person to blame. It goes back to how she was

raised, and I think that’s the cycle in our Black

families. Like, they take it from when they were

raised and bring it to now. Well, you have to break

the cycle. My mom was a miserable Black woman,

period. But why should I be a miserable Black

woman because she’s a miserable Black woman?’

This participant insisted that she does not want the

violence to define who she is today. This desire to break

the cycle was echoed by Participant #10, a single mother

of three children, aged 11, eight and two, who described

her upbringing as saturated with violence that she is

trying to stop as an adult:

‘We grew up with our parents cussin’ and hollerin’

and beatin’ us all the time. You gotta break the

chain somewhere, you gotta break it. I guess that’s

what our parents did, so that’s what we do. I guess

because their parents fussed, cussed, and hollered

and drank and whatever, it was appropriate. They

didn’t see anything wrong with it. You just so

accustomed to what’s around you. That’s why I try

to be careful of what I bring around.’

Wanting to break the cycle of violence was described as

almost impossible, demanding total vigilance. This was

often difficult, because the family members of the parti-

cipants, and their surrounding neighborhoods, were

described as steeped in violence and dysfunction.

Perpetrators of violence

From several women’s perspectives, violence emerges

out of frustration with those around them and from

deprivation. In response to a question about how the

welfare system helps low-income families (the original

intent of the present study), Participant #37, a mother

of two young children, aged one and two, described

how the system lets her down and how frustration with

poverty might lead her to crime:

‘[The system] should be to help the poor. They

wonder why there’s so much crime. I never did a

crime in my life. Here I’m gettin’ thoughts where I

wanna bust somebody upside the head to get some

money. I’m just keepin’ it real and tellin’ you the

truth. I’d never, ever in my life, ‘cause I go and have

thoughts like that. But, I be, I’m strugglin’ so hard to

[make it], it makes my mind go down. [y] I shouldn’t

even be havin’ thoughts like that. I’m strugglin’

so hard.’

This narrative outlines how frustration with the system

and with deprivation leads to violent thoughts, and

sometimes to violent actions, turning victims into perpe-

trators. Participant #5, who had run away from home at

age 14 because she was raped by her father and physi-

cally abused by her mother, described how she would

turn to violence as a relief from her suffering and from her

lack of control:

‘From the first fight, when the girl used to beat me

up every day, it felt good to have control again. If

I beat her up, she will leave me alone. If I just really

slam her head into this concrete like this, it felt like

a sign of relief. In a sick way, it felt good. Like,

‘‘if I just beat this girl down enough, or this man

down enough, they would leave me alone and I will

get the respect I deserve.’’ And that’s how I looked

at life, like I had to fight my way.’

This description is a recognition that turning to violence to

cope with frustration is an indication of lack of control over

her life situation, and being a perpetrator of violence

became an important coping mechanism.

Attempted suicide and suicidal ideation

Aside from occasionally victimizing others, participants

explained they sometimes turned the violence against

themselves. A mother of five children described her

attempted suicide as a teenager. She explained:

‘I got so depressed that I tried to hang myself and

the belt broke. [y] I guess I got so depressed of

being by myself.’

She described that her loneliness was related to having no

who cared for or supported her. Participant #44 reported

trying to commit suicide by swallowing bleach. Partici-

pant #41, a 20-year-old mother of a one-year-old,

described how, during her teenage years, she often

thought of committing suicide because her mother

encouraged her to do so, as it would be ‘one less mouth

to feed’. More recently, Participant #14 contacted the

interviewers for assistance while she was considering

shooting herself with a gun that was in her home. Suicide

attempts were described as responses to inability to cope

with previous experiences of violence and to frustrations

associated with economic deprivation.

Discussion

Direct questions about violence exposure were not initi-

ally included in the semi-structured interview protocol,

yet the methods in the present study facilitated the

emergence of exposure to violence as an important

theme that the low-income mothers chose to describe.

Very low food security linked with violence 79

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The nature of photovoice allows for research participants

to frame the issues most important to them. While the

photographs are not discussed herein, the method of

utilizing photographs to elicit the issues most important to

the women (instead of the issues most important to the

researchers) made for insightful breakthroughs that

would not have been made otherwise.

Forty participants described at least one scenario of

violence and fear. The most severe forms of violence –

those with longer-lasting and life-changing impacts –

were described by proportionately more women who

reported very low food security. This is an indication that

traumatic experiences may be a factor that characterizes

very low food secure households.

Although a majority of women reported exposure to

violence currently, and reported that they were a victim of

violence, those who reported exposure to the severest

levels of violence explained how these experiences led

them down a path towards deprivation typified by not

having enough money for food or other basic needs. The

long-lasting, transformative impact of violence exposure

on health and development are well documented in

research that investigates children’s exposure to adverse

childhood experiences. Exposure to violence and ‘toxic

stress’ has severe life-long consequences on social,

emotional and cognitive development. This, in turn,

affects one’s ability to succeed in school and thus affects

earnings(44). This understanding of the long-term effects

of adverse experiences in childhood, especially, helps

explain the potential link that we found in this sample

between exposure to violence in childhood and very low

food security in adulthood.

According to trauma theory, acting violently towards

others and/or having suicidal ideation are normal reac-

tions to very stressful circumstances. Trauma theory refers

to the complex effects of trauma on physical and mental

health and behaviour (45)

. Research based in psychology,

sociology and psychobiology describes how exposure to

abuse and neglect or traumatic events such as war or

interpersonal violence has lasting effects on adult beha-

viour and psychopathology(46). These adult behaviours

include re-enactment of violence, disassociation, sleep-

lessness, addiction to trauma and becoming a perpetrator

of violence(45). Participants in the present study reflected

these experiences and behaviours, and described quali-

tatively how their perpetration of violence is linked to

exposure to traumatic events earlier in life and their

experiences with food insecurity. Our results are similar

to those found among women in Uganda where food

insecurity was related to higher sexual risk-taking, trading

sex for money and staying in violent relationships(47).

The narratives describing exposure to violence also

showed proportional differences among those who

reported depressive symptoms, especially related to

severity and quality of violence. In addition, qualitative

descriptions of violence often followed from descriptions

of feeling sad, depressed, anxious, stressed and fru-

strated. Each of these experiences relates to feeling

depressed even though not picked up by the quantitative

depressive screen, and it was therefore clear from the

women’s descriptions that depression and exposure to

violence went hand in hand.

Limitations

A strength of the present study is its ability to elicit issues

important to participants themselves, rather than the

researchers. This may also be a weakness. It is possible

that self-selection into this type of study – in which

women were encouraged to participate if they had ideas

for change – may have biased participation by those who

had experiences with violence and who were eager to

express ideas for breaking the cycle of violence.

Recruitment through an ongoing study of participants

who utilized a hospital emergency room introduces

selection bias for those who may have a higher exposure

to violence overall. Interviews took place in participants’

homes and may have resulted in greater comfort in

answering the food security survey that may bias results

towards those who identify themselves as severely

deprived. In addition, drawing out the relationship

between food insecurity and violence in explicit, linear

terms was difficult within the open-ended interview, as

the entire interview was spent on describing issues rela-

ted to public assistance, poverty and breaking cycles of

hunger and economic deprivation. Further research on

the explicit pathways, beyond low educational attainment

and inability to maintain a living-wage job, will help make

the relationship between violence and food insecurity

more explicit. The lack of inclusion of a validated,

quantitative measure of exposure to violence leaves open

questions regarding the reliability of results, because the

violence stories emerged naturally in conversation.

Finally, we did not track for differences in exposure to

drug and alcohol addiction, which may relate to exposure

to violence and ability to pay for food.

Implications for research and practice

Just as studies have found exposure to violence to be an

important factor that leads to homelessness(48), violence

exposure may be a significant factor in experiences of

hunger. Few quantitative studies have suggested that

exposure to violence may be associated with very low

food security. While some food insecurity research has

captured strong associations between depression, dys-

thymia and social isolation, those data suggest a need for

investigation into the prevalence of exposure to violence.

The present results suggest an urgent need for quantita-

tive measures in population-based surveys to test the

hypothesis that food security status is linked with exposure

to violence.

Low-income mothers of young children may need

intensive wrap-around services that can help them during

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experiences of trauma in addition to ensuring women and

their children have adequate access to federal nutrition

assistance programmes. Our results also suggest that

young children of very low food secure women are

exposed to violence and its physical, mental and beha-

vioural sequelae. This exposure could have disastrous

effects on children’s social, emotional and cognitive

development.

There are three steps to move forward with food

security research. First, population research should

incorporate questions about exposure to violence to

assess relationships between food security status and

trauma. Second, health-care providers should screen for

both food security and violence and refer as needed to

domestic violence resources; additionally, those assisting

women with exposure to domestic and intimate partner

violence should refer to food assistance programmes.

Finally, community-wide interventions to address com-

munity violence, domestic violence, child abuse and

intimate partner violence could readily incorporate a

community food security approach that seeks to improve

access to food and ensures families can readily access

federal nutrition assistance programmes.

Acknowledgements

Source of funding: The study was supported by Claneil

Foundation, Inc. and Merck & Co, Inc. Conflicts of

interest: The authors have no conflict of interest. Authors’

contributions: M.M.C. conceived of and directed the

study, and authored and edited the manuscript. J.R.R.

assisted with carrying out the research interviews, ana-

lysing the data and authoring the manuscript. N.H.W.

assisted with data analysis and authoring the manuscript.

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