This paper reports a study to assess the prevalence and degree of food insecurity among food aid recipients in urban and rural areas of Catalonia. As it happens in many high-income countries (24, 25), Spain is a country where food insecurity has not traditionally been monitored by national institutions, yet the role of the food aid such as food banks and charity organizations has been considerably acknowledged (26–28). In that sense, the percentage of food insecure people identified by the FAO reports or other studies who are recipients of food aid is not known. After the covid-19 lockdown, a dramatic increase in food aid demand was reported by almost every institution, reinforcing the need to track food security in our context, and to substantiate the best methods to obtain reliable and complete data that allows adequate action to tackle food insecurity (29–31).
Our results show that 80.2% food aid recipients suffered moderate or severe food insecurity, and that more than 75% were anxious about having enough food and had to eat a limited variety of foods and/or foods that would not be of their preference. The share of food insecurity and of worry about food was higher in new users. An additional 58% reported having to eat less than desired due to budgetary constraints, with 17.7% finding themselves in this situation more than ten times in the past four weeks. These are alarming figures, since respondents in our study are already receiving food aid, meaning that while food aid is critical to many people’s lives, it is not adequately addressing food insecurity.
The COVID pandemic has threatened the accessibility of food through effects on food costs and infrastructure, including changes in food assistance distribution, public transit access and shortages of certain products (32). In fact, research is suggesting that prior to the COVID crisis, food aid devices were not having an acute function, but rather it was a staple for many families who relied on it on a regular and continued basis due to their longstanding financial constraints (33, 34). In our study, the mean duration of food assistance for non-covid users was 19 months (SD 17). As many others have argued, food aid alone does not suffice to address food insecurity, and structural actions directed to its social determinants are required (24, 35). In this regard, additional research is needed to understand the barriers to using food assistance programs, especially among those that may be newly food insecure since COVID-19.When comparing our data with other countries’ studies on food aid users, it was found that the prevalence of food insecure participants and the length of food aid use in our study is higher than what has been reported in Australia (36), Germany (19) or the UK (37). These studies use different measures of food insecurity; therefore, differences may be partly due to data collection methods. Moreover, the social welfare system and the articulation of food aid in each country also can impact these figures. However, the magnitude of the difference in the rate of food insecure respondents (67.5% in McKay et al, over 70% in Depa et al, and over 50% in Barker et al vs 92.7% in our study) and the mean length of food aid use (4 months in McKay, while 10 months in our research), emphasizes the impact of the COVID crisis for food security, even for those receiving food aid. On the other hand, data such as the obtained by Holmes et al in Greater Vancouver in 2018 (33), where over 90% of the food bank members were food insecure and had been using this resource for a mean period of 5 months, also signals towards a very institutionalized issue. Evidence demonstrates that both the supplemental food assistance and improvements in food resources management are needed to reduce food insecurity in participants as improvements in food resource management alone did not statistically improve food security.
Our research also shows how the subjective dimension of food insecurity is a significant component of this phenomenon. The punctuation of the domain of anxiety and uncertainty is significantly higher in new users due to the covid pandemic, influencing the overall score of the HFIAS questionnaire. The mental burden and personal impact of the experience of not being able to access enough food or having to significantly modify one’s dietary habits due to financial constraints has been extensively documented (38, 39)and we could argue that it is more intense the newer the situation is, and/or the greater the differences with the immediate context (40). All in all, these findings stress the contextual nature of food insecurity, and reinforces the adequacy of the progressive broadening that the concept of food insecurity has suffered across time (41). Likewise, these observations invite a more thorough consideration of the psychological aspects of food insecurity and their effect on mental health and overall wellbeing.
Noteworthy, about one third of the food aid users report someone in their household to suffer a diet-related illness, including diabetes, hypertension, celiac disease or food allergies and intolerances. Overweight and obesity were also present, although probably underreported (42). An important reason for this is that less healthy, highly processed foods, often laden with sodium, added sugar, and saturated fat, can be cheaper on a per calorie basis than healthier foods such as fruits and vegetables, whole grains, and lean protein (43). The concomitance of food insecurity and diet-related illnesses has been widely documented, to the extent that reducing food insecurity has been purported to have the capacity to reduce health disparities (44, 45)
In this regard, the data retrieved through the HDDS questionnaire offers additional information on the quality of food intake in terms of the number of food groups that is being consumed, but it is admittedly limited, in at least three ways. First, questions were raised that the respondents had correctly interpreted the 24h timeframe in which this questionnaire should be responded. The reason is that it was administered following the HFIAS, which uses a 30-day recall period. Upon consideration of the results, if these two measures are to be administered consecutively it might be advisable to do it in the opposite order - as the change of time frame from 24h to 30days may be easier for the respondent. Second, it does not allow to discern the quality nor the adequacy of nutritional intake. In light of the current food environments being overabundant in ultra-processed foods (46) - especially in low-income settings (47) and their link to health (48–50) a greater level of detail in terms of the specific products consumed would be necessary. In this regard, it may be advisable to complement or substitute the application of the HDDS by other tools that allow to collect this information, like dietary recalls and food questionnaires, to specific measures designed to assess dietary quality. Third, its internal validity could be threatened in view of the diversification of the dietary patterns of the population and the recognition that there are multiple possibilities to achieve nutritional adequacy from a myriad of food groups combinations.
In our sample, almost two thirds (64.58%) had adequate food diversity according to the HDDS. Differences among covid and non-covid users were not significant, but they were among rural and urban respondents. These differences could be due to differences in the overall food environment (i.e.: rural respondents have more access to a greater variety of foods in their local acquisition points), in the food that is provisioned by the food aid organizations (i.e.: sometimes rural food aid organizations receive food not only from food banks, but also from small producers and cooperatives), in the food literacy of the household (i.e. their ability and competence of the household to actually acquire, conserve, prepare and eat a varied diet). For example, (51) found that the behaviours and food literacy related to planning and management, shopping, preparation, and cooking were all statistically independently associated with food insecurity. In this regard, future research should take into consideration and measure these aspects, especially if the food insecurity study is to lead to actions to address it.
Findings suggest that the population accessing food aid in rural or urban areas have a direct impact on dietary diversity but not in food insecurity. This could be attributed to food pantries limitation, closures due to illness, social distancing or lack of volunteers. Populations living outside major metropolitan areas may be more likely to use friends and family for support and to see government assistance programs as a last resort. However, with social distancing, nets may be eroded, and these households may be particularly vulnerable. In rural areas where food assistance programs such as food pantries are limited, closures due to illness, social distancing, or lack of volunteers may be particularly challenging.
The present study also observed that food insecurity data at the household level is linked with gender inequality. In that sense, we observed higher food recipients who were women (75%) than men (25%). There has been extensive research on the role women play in ensuring food and nutrition security of other household members. Nevertheless, relatively little attention has been paid to their own food security situation. Probably, gender inequality would be related with employment opportunities and educational attainment. Although improvements in women’s education have been affirmed to contribute to 43% of the reduction in child malnutrition in countries from the European Union, gender inequality in mild and moderate food insecurity is still exhibited (52).
We must also consider that the fact that most respondents in our sample are female might also influence the results on the high prevalence of food insecurity, as previous research shows that women are more prone to suffer from it than men, even within the same household (52, 53). Gender disparities in income and education, and other axes of inequalities such as race would explain these differences at an external level. Within the household, aspects like the number of members, number of children and also internal feeding dynamics (i.e.: women are more prone to skip meals or have a smaller portion in favor of other household members) contribute to the gender gap.
Also, food literacy programs are supported as a strategy to reduce food insecurity by policy makers as they focus on the utilization aspect of food security (54). This reflects an individual responsibility approach by policy makers to target low income and vulnerable populations with the assumption that these groups are most in need of food literacy development.
Despite the clear findings in the present study, there are few limitations that must be taken into consideration when interpreting the results. The intention to gather specific information in urban and rural areas is notorious in our research, nevertheless there has been a difficulty to collect data from rural food aid institutions. This fact was added to the laborious task to gather vulnerable collective such as families in food insecurity situations. Probably, those are the targets to address for further research. Also, some of the most vulnerable groups and at the greatest risk of food insecurity, such as people living in remote areas and linguistically diverse groups were not always able to complete the written evaluation.
This paper provides evidence that much of the gap in food insecurity is due to dietary diversity and children in households. Social networks can serve as informal insurance or provide women with more bargaining power within the household. Programs that target marginalized groups may also have substantial impacts on addressing food insecurity. The way we measure food insecurity relationships needs further research. Novel models that include variables as: minimum salary, family incomes, social networks nearby, educational attainment or toxic habits in household will give a broad answer around how, for whom and under what circumstances a change in food access, food insecurity and dietary diversity are likely to also assist in different contexts. Additional analysis is needed to better understand the existing characteristics leading to food insecurity in urban or rural areas. In- depth studies which collect detailed information involved in food insecurity and dietary diversity, are likely to deepen understanding of the food aid system and give a framework to food policies in vulnerable contexts.