An extremely high prevalence of food insecurity was identified among the American Indian households included in this study, and the proportion of households self-reporting food insecurity was significantly different between rural and urban households. These findings are significant as this is the first study of food insecurity to include both urban and rural American Indian families and to examine adults and children concurrently. Our analysis suggested identification as American Indian, urban households, lower educational levels, single adult households, and participation in WIC as factors that are associated with the increased odds for food insecurity. Moreover, differences in dietary intake patterns of both adults and children were identified between food insecure and secure households, suggesting the food insecurity negatively impacts dietary quality for these families. Different coping strategies were reported by rural and urban families that provide context to the quantitative findings.
The prevalence of food insecurity was significantly higher among urban households compared to their rural counterparts, which is of particular importance, as the majority of people who identify as American Indian report living outside of tribal-designated areas . Two previous studies included urban American Indians in their sample, and neither found differences in food security between urban and rural participants. Gundersen examined a national sample of American Indian households (n = 1143) included in the 2001–2004 Core Food Security Module of the Current Population Survey and reported no interaction between food insecurity and geographic designation (i.e., rural or urban) for households with children . The author did suggest these results were counterintuitive, as protective factors are known to exist within rural or reservation-based communities, including increased social capital  and food sharing practices [10, 25]. However, the extent to which these conditions may have contributed to the lower food insecurity in the rural communities in our study is unclear. Jernigan et al. examined food insecurity in a sample of low-income American Indians in California . Of note, their study population was approximately half male and half Hispanic. In comparison, our sample included a full range of incomes, almost all females (~95%), and less than 10% Hispanic participants, and these demographic differences may have contributed to the differences in our findings.
Our analyses did suggest differences between rural and urban households with regard to factors associated with a higher risk of food insecurity. Namely, single adult households, lower educational attainment, and working outside of the home were associated with a high prevalence of food insecurity in rural households, while only the distance traveled to purchase food and the number of children in the household were associated factors in urban households. Our findings align with previous reports suggesting that identification as American Indian , not being employed outside of the home [8, 10], low education  and number of children in the household  are associated with a high prevalence of food insecurity in American Indian communities; findings related to the relationship between food security and participation in food assistance programs for American Indian have been conflicting . As for distance traveled to purchase food, Mullany et al. demonstrated that households with transportation barriers were more likely to be food insecure , which may partially explain why increasing distance traveled to purchase food was associated with lower odds of food insecurity among urban households. In other words, these households may have more resources to travel greater distances to access food at lower cost, such as at Wal-Mart®, rather than relying on convenience stores and small markets where prices are typically much greater and the availability of fresh foods is limited.
Our findings demonstrated significant differences in dietary intake between food secure and insecure households for both American Indian adults and children. Bauer et al. found American Indian children (ages 5–6 years) from a rural reservation who were food insecure consumed more hot or ready-made food from convenience stores, including higher intake of pizza and fried chicken . Adult diet was not considered, and no other studies have examined the relationship between food security status and dietary intake patterns in American Indian families. Moreover, we demonstrated differences among dietary intake for food insecure children compared to food secure children in very young children (2–5 years), which have not been previously demonstrated. These findings may be of clinical significance, as the food groups in which we identified differences in dietary intake patterns are known to contribute to obesity, such as high intake of fruit juice, soda, other SSBs, fried potatoes, and lower intake of vegetables. The finding of significantly increased salad intake among insecure children was unexpected, and we are seeking to better understand how adults are defining salad intake for their children.
Strengths and limitations
This study was strengthened by the inclusion of both urban and rural American Indian households, as the majority of food security studies in American Indian populations to date have included only rural communities or single reservations [8,9,10, 27]. This factor also represents a potential limitation as our data were pooled from multiple, diverse communities. As another strength, our data are contextualized by findings from focus group sessions. For this study, we used only two items of the USDA 18-item Household Food Security Survey, which may have prevented us from capturing more nuanced dimensions of food security and may contribute to differences between our study and existing reports that used different measures . However, these two particular survey items have been validated specifically in households with young children. The time of year when the food insecurity screener is administered may impact the responses, but this potential limitation likely was mitigated in our study as responses were collected over a 2-year period due to staggered enrollment at study sites. All of the survey measures used in the study were self-report, which may be associated with under- or over-reporting.
Many of the communities who participated in this study are currently drawing on traditional culture, strengths, and community resiliency to overcome existing barriers to food security, and we feel it is in alignment with community-based participatory research approaches to address their efforts here. For example, one participating community recently initiated a survey where 73% of respondents viewed hunger as an issue on the reservation . Respondents suggested approaches to address food insecurity, namely, better coordination among programs, greater outreach to children and Elders, more jobs, adoption of a food sovereignty policy by the tribal legislature, and provision of classes (e.g., gardening, harvesting, wild game preparation, canning) and identified existing resources, including community-supported orchards/gardens, food distribution programs, and school-based feeding programs. Another participating rural community supports a strong land reclamation program emphasizing production of traditional foods (e.g., wild rice) in addition to food distribution programs and efforts focused on child and Elder nutrition. For families in the urban community in our study, several resources are provided through the health clinic, such as access to a community garden and food pantry, transportation passes to increase mobility to supermarkets with a broader range of options and prices, and a comprehensive community resource guide (updated monthly). The clinic also provides patient navigation services, including assistance meeting eligibility requirements for food assistance and services specific to American Indian families, such as obtaining a Certificate of Indian Blood and other tribal identification. This identification is needed for access to services like emergency funds provided by some tribes for their citizens living in urban settings, discounts at various Indian-owned businesses, and school-based American Indian-specific programs.