Food insecurity among nursing students: A mixed methods study

Abstract

Background:

College students are among 48.1 table million Americans who experience food insecurity, affecting aspects of daily living, health, and academic performance. This study sought to assess food security in nursing students to determine the prevalence and significance of this issue.

Methods:

A mixed-methods descriptive design was utilized to collect and analyze data through an online survey of junior and senior undergraduate nursing students. Both qualitative and quantitative questions were related to personal experience with food insecurity.

Results:

Approximately 40% of students responded that they were Sometimes/Often worried that food would run out before the next income arrived. In addition, 52% of the participants Sometimes/Often could not afford an adequate amount of food, and 35% reported having a shortage of food.

Conclusion:

University leadership, College of Nursing administrators, and nursing faculty should be aware of food insecurity among their students and identify strategies to assess and decrease this issue.

Nursing students represent future nurses who will be taking care of patients in hospitals and clinical settings across the world. It is important to understand the difficulties that are faced while in nursing school, not only academically but financially, physically, and mentally.¹ The purpose of this mixed-methods, descriptive study was to investigate a population of junior and senior nursing students at a university in the Southern United States to determine the prevalence and significance of food insecurity.

1 ∣. BACKGROUND

Food security is characterized by having full access to food without limitations. The opposite of food security is called food insecurity and is characterized by household eating patterns being disrupted and food intake quantity and/or quality being reduced due to insufficient monetary funds or other resources.² Food insecurity affects nearly 48.1 million American households. Gundersen and Ziliak³ acknowledge that at any point in a lifetime, food insecurity is associated with negative health outcomes and quality of life. Food insecurity may lead to depressive symptomatology,⁴ reduced quality of sleep,⁵ and increased occurrence of type II diabetes and obesity.⁶

National investigations have recently uncovered alarming rates of hunger on college campuses with rates as high as 32%.⁷ Although most universities are beginning to recognize and create programs to assist students with food insecurity on college campuses,⁸ very little, if anything has been published on the prevalence of this problem in the nursing student population. This lack of information related to food insecurity in nursing students is a current gap in knowledge and in the scientific literature. It is important that faculty, administrators, and other nurses acknowledge that our future nurses currently in universities across the world may also struggle with this filling this basic human need of having regular nutritious meals.⁹

Students participating in higher education are especially at risk for food insecurity as they attend to their academic requirements—often sacrificing employment opportunities and facing greater financial instability.¹⁰ A large study that included 42 public universities in Wisconsin found that students who have food insecurity often come from homes where there was a lack of food.¹¹ Further, these students often identify as racial or ethnic minority, live off-campus, and attend college in an urban area.

The rate of food insecurity amongst college students ranges from 14% to 59%, which is higher than the national rate across the general population.¹² Assessment of food security within colleges should include periodic surveying as students often sway between levels of food security and insecurity (eg, high food security, marginal food security, low food security, and very low food security).¹³ Knol et al¹⁴ used the Adult Food Security Survey Module to investigate food security and self-rated health and obesity in a college sample (N = 351). That study revealed that 37.6% had high food security, 25.1% had marginal food security, 15.4% had low food security, and 22.2% had very low food security. Moreover, students with food insecurity were more likely to report fair and poor health outcomes compared to students with food security.¹⁴

The current study was inspired by a group of nursing faculty and an undergraduate nursing honors student with a desire to explore food security within the College of Nursing. Nursing students are part of a rigorous and fast-paced curriculum, often leaving little to no time for employment. The presence of food insecurity places the future health care providers of our nation at risk for poor health outcomes, while the immediate effects are poor mental health and an inability to concentrate during class and examinations.^15-18 For example, college students with reported food insecurity report lower grade point averages compared to students with food security.¹⁴

2 ∣. METHODS

A mixed-methods descriptive design was utilized to collect and analyze data. The project was conducted at a Southern university along the Gulf Coast after receiving approval from the Institutional Review Board. The survey was disseminated through university email to professional component nursing students (junior and senior) who were enrolled in the university's college of nursing undergraduate Bachelor of Science (BSN) program (N = 427). There were 100 nursing students from the sample that participated in the quantitative and qualitative survey questionnaire. Inclusion criteria included being a junior or senior professional component BSN nursing student. Exclusion criteria included any pre-nursing or graduate-level nursing students. Both quantitative and qualitative feedback were collected through the Qualtrics online survey system, and descriptive statistical analyses were conducted through IBM SPSS version 25.

The survey asked participants to self-disclose standard demographic information and self-reported food security. Food security was measured with a modified version of the US Household Food Security Survey Module (HFSSM).¹⁹ The HFSSM is a screener used by the US Department of Agriculture to calculate household food security scores and food security status. The version of the HFSSM used included eight questions and asked participants to reflect on the past 9 months about their experience with food insecurity. Questions related to children from the Family version of the HFSSM were not included. For the current study, students were asked to only report for the last 9 months because that was the period the nursing students had been enrolled in the professional nursing curriculum. Response options for questions 1 to 3 were on a 3-point response scale. The remaining five questions were Yes or No response type. This instrument is both valid and reliable in previous community samples (α = 0.76-0.91),^20,21 and it allows a distinction to be made between moderate and severe levels of food insecurity.²²

Utilization of food pantries and awareness of local food pantry options (eg, churches, and social service organizations) at the students' disposal were also explored. Students responded to this question: “Do you have any recommendations or solutions to decrease student hunger?” A content analysis of the responses was conducted with three of the researchers to identify themes. Notably, after the survey was closed, all nursing students, regardless of participation in the study, received educational materials via email on the topic of food insecurity and availability of resources including the location of food banks within a 10-mile radius of the university. Within the email, there was a voiceover PowerPoint presentation providing detail on the Feeding the Gulf Coast website (www.feedingthegulfcoast.org). In addition, similar information on food insecurity was distributed by way of flyers, electronic social media postings, information kiosks, poster boards, and oral presentations to nursing students at the beginning of select courses.

3 ∣. RESULTS

A total of 100 nursing students out of N = 427 responded to the invitation to participate in the food security assessment (23.4% response rate). Most respondents were aged 18 to 24 (79%), identified as female (91%), and identified as Caucasian/White (83%). The sample was split almost evenly with students who reported working while in school (47%) and students not working (53%). Most students (92%) reported living off-campus. Most students also self-reported receiving financial assistance from their family members or significant others (68%) with 19% self-reporting no financial assistance. When self-reporting height and weight, there were 48% of students in the normal weight category, 22% in the overweight category, 25% in the obese category and 4% not reporting height or weight (see Table 1 for demographic data). Of the students whose body mass index (BMI) was calculated, 56% of students within the normal weight range said that sometimes their food did not last for the period needed. And for those who were in the obese category of BMI, 23.8% said that they rarely had a problem with food not lasting with their current funds. One further question was asked, “How important is it to you to eat healthy each day?” Approximately 34% reported that eating healthy was Very Important/Extremely Important, a little more than half (54%) of the students reported that eating healthy was Moderately Important to them, and 12% reported that eating healthy was Slightly Important/Not at all Important.

TABLE 1.

Demographics

Variables	Percentages
Gender
Male	7%
Female	91%
Age
18-24	79%
25-34	16%
35-44	4%
45-54	1%
Ethnicity
Caucasian	83%
African American	12%
Asian/Pacific Islander	3%
Other	2%
Living Location
On-campus	8%
Off-campus	92%
Employed
Yes	47%
No	53%
Is family assistance available?
Yes	68%
No	19%
Maybe	13%
BMI
Underweight (<18.5)	1%
Healthy weight (18.5-24.9)	48%
Overweight (25-29.9)	22%
Obese (>30)	25%

Abbreviation: BMI, body mass index.

Table 2 provides the HFSSM data. Approximately 40% of students responded that Sometimes/Often they were worried that food would run out before the next income arrived. It appeared that nursing students Sometimes/Often (52%) could not afford an adequate amount of food, which led to food shortages (35%). A little more than half (52%) of the nursing students reported that their income Sometimes/Often impacted the ability to consume a balanced meal, and 12% reported that eating healthy was Slightly Important/Not at all Important.

TABLE 2.

Household Food Security Survey Module questions and responses

	Number of responses (N = 100)
In the past nine months …	Rarely	Sometimes	Often
I worried whether my food would run out before I got the money to buy more.	60	24	16
The food that I bought just did not last, and I did not have money to get more.	65	26	9
I could not afford to eat balanced meals.	48	25	27
In the past nine months….	Number of responses (N = 100)
	Yes
Did you or other adults in the household ever cut the size of your meals because there was not enough money for food?	25
Did you ever eat less than you felt you should because there was not enough money for food?	27
Were you ever hungry but did not eat because there was not enough food?	25
Did you lose weight because there was not enough food?	13
Did other adults in your household ever not eat for a whole day because there was not enough money for food?	6

Note: U.S. Adult Food Security Survey Module: three stage design with screeners, 2012.

The lower half of Table 2 emphasizes the impact and effects of food insecurity on nursing students over the past 9 months. A quarter of the sample (25%) responded Yes to cutting down meal sizes to conserve food, eating less food because she did not have enough money for the appropriate meal size (27%), and going hungry because purchasing food was not possible (25%). Approximately 13% of nursing students reported losing weight because of food shortages. Finally, 6% of students reported that the issue of food insecurity impacted other adults in the household, perhaps causing members to skip eating for a whole day. This study did not ask if adolescents or children in the household were impacted.

Lastly, students were encouraged to provide written feedback on possible solutions to food insecurity in the college of nursing and on a college campus in general. Regarding the college of nursing, students suggested amending the nursing program's structure and curriculum. Responses included:

• “Stop giving us unreasonable working hours and work which cuts into our ability to have jobs and even go grocery shopping. I have to run through a drive-thru and chow down on the way to class or risk starving for the day because I do not have the time to go to a grocery store.”

• “Include campus meals with [nursing] tuition.”

• “Allow us to get paid for clinical hours or allow for students off-campus to have meal plans. “Make meal plans more affordable.”

Students also responded with creative ideas to reduce food insecurity on campus. Overall, the students wished the campus encouraged healthy eating and provided healthy alternatives. Responses included:

• “Make healthier food options, organic and conventional types, more affordable to all people, and it will transcend this campus.”

• “Include more food options on campus.”

• “Put fresh fruit and vegetables in the cafeteria instead of everything coming from a can. Make the meal plans less expensive. Extend summer hours at the cafeteria, so students have somewhere to eat instead of being limited to 1, maybe 2, meals per day on the weekends.”

• “Make food pantries more readily available on campus.”

• “Does [university name] have an agriculture department? It would be great if students could buy produce at reduced costs and all the money raised would go back to the department.”

• “Coupons for food discounts.”

• “Increasing campus “Awareness! Lots of students do not know that they have access to these [food] resources.”

4 ∣. DISCUSSION

When comparing the current study findings to another study with a group of young adult college students in the Appalachian area, Wattick et al²³ found that when students have self-reported food insecurity (36%), they have higher stress and mental health symptoms such as depression or anxiety. Although food insecurity is a risk factor for obesity, especially for women,²⁴ of the current study did not show a significant relationship between food insecurity and obesity. Research has found that food insecurity is often characterized by cyclical environments of food availability and food scarcity which compromise diet quality, often leading to maladaptive eating styles and weight gain.²⁵ Specifically, Mirabitur et al²⁶ found that students who lived on campus and received food provision as part of a meal plan were more food secure as compared to those who lived off-campus or lived on campus where food provision was not a part of the package. In the current study, 92% of the nursing students lived off-campus, so this may explain part of the issue. Freshman and sophomore students are more likely to live in on-campus housing.²⁷ However, during the junior and senior years, living in the dorm is not as common as living in an apartment or other living situation that may be less expensive than dorm living and does not require payment for food provision.²⁷

In the current study, we found that food insecurity among nursing students (52%) was higher than the national rate of food insecurity among the general population. Another study with college students from a midsize rural university in Oregon had 59% of their sample report food insecurity.²⁸ Similar results were found in a study of four public universities in Illinois when there was self-report of 35% of college students having food insecurity.¹² Soladavini et al²⁹ found that international students had greater odds of experiencing food insecurity as well as finding students that had more part-time jobs and those receiving financial aid had higher odds of food insecurity. Another study related to college students found that African American or multi-ethnic students were more likely to experience food insecurity.³⁰ Lastly, a study in Hawaii also found 21% of their students were food insecure and an additional 21% were at risk for food insecurity.³¹ Further, these researchers found that students who lived on campus and those living off-campus with a roommate as well as students who are Native Americans (Hawaiians), Pacific Islanders, and Filipinos were also at higher risk of food insecurity. The current study had a very small population of multi-ethnic and African American students. We found no significant differences when compared to Caucasian American nursing students.

Since the time of the survey, the university has started a food pantry on campus at a central location, and the College of Nursing has also established a food pantry in two different campus locations. In addition, faculty members in the College of Nursing have begun providing food support and encouragement during final examination week. To extend services to students even further, the university now has an overall support network available to any student on campus who has a financial need, emotional support, housing assistance, and food support among other social service needs. Students can access the support network online and work with university personnel in a professional manner. Hopefully, if students attending a university know that faculty and administrations are concerned about the welfare of their students while they are in school, students will be more comfortable reaching out for help and sharing information with other fellow students who may be suffering from the same issues.

This study provided an opportunity for students to identify potential strategies to decrease food insecurity on campus. This study also identified that nursing students in this location were impacted by food insecurity. It is crucial that students in a college of the nursing settings are assessed for food security as part of their orientation process. One should not assume that because a student is attending a university that they have enough money for food. This study found that students had many suggestions and strategies to help decrease food insecurity.

5 ∣. LIMITATIONS

Several limitations should be noted. This study was limited to one geographical location and only captured about one-fifth of the nursing student population. Therefore, we cannot generalize these findings to other colleges of nursing. The study was based on self-report with no outside confirmation of financial status. It is difficult to know if food insecurity only occurs while in school and not on holiday or summer breaks. Further, this was a cross-sectional descriptive design study providing the opportunity for researchers to understand the prevalence of food insecurity in the current nursing student population. Food insecurity could change depending on the time of the year, the current economy, and the community where the school is located. Examining food insecurity in nursing students from other schools across the nation would be an area to compare the severity of food insecurity based on different geographic locations in the United States. It is possible that with only 100 undergraduate participants taking the survey, the students who had more food insecurity may have participated as compared to those who were food secure and possibly had no interest in completing the survey. More research is needed now that there are several places on campus with interventions such as food pantries to help with food insecurity.

6 ∣. IMPLICATIONS

Access to healthy food is an important part of meeting basic human needs and is required for overall health. Therefore, providing resources is crucial to promoting student success academically, mentally, and physically.²³ To effectively change the current state of food insecurity at the college level, faculty are well-positioned to bring awareness of food resources to their students while advocating for low cost, readily available, fresh, and nutritious foods on campus. Providing opportunities for acquiring healthy foods through university food services, on-campus food pantries, and faculty-led food drives is an essential first step in fostering students' academic achievement. Forming partnerships within the local community to expand access to food is a necessary next step. Ensuring food security among college students should be a focus of health policy initiatives for postsecondary institutions to promote student success. The faculty who have participated in this study and manuscript hope to continue bringing awareness to nursing school administrators, faculty, and other nurses who are working with student nurses in the hospital settings about the possibility of food insecurity in the upcoming generation of new nurses.

7 ∣. CONCLUSION

This study identifies the need for nursing faculty and colleges of nursing administrators to be aware of food insecurities among their students who will be the future nurses of tomorrow. Notably, many students may feel helpless during periods of food scarcity as indicated by their inability to receive assistance from family or significant others. Finally, nursing students advocated for a more flexible curriculum and for the campus dining facility to include more affordable and healthier food options and easier access to such foods. The findings of this study also support the need for continued efforts of other community agencies such as churches and social service groups to help meet nursing students' basic food needs when the issue comes to light. It is important that nursing students are also aware of dialing “211” in most states in the United States, as this is a resource for many social services agencies that can be of assistance to people at a time of critical need. Conducting assessments of food security and providing nursing students with resources related to food banks and community groups that provide meals on a regular basis will help nursing students to not only help themselves when needed but to also help others in the future.