Food Insecurity and Psychological Distress Amongst Parenting Women in Treatment for Opioid Use: Identifying Barriers to Nutritional Equity and Implications for Future Intervention Research

Abstract

Purpose

To describe the prevalence of food insecurity among pregnant and parenting women with opioid use disorder (OUD), its association with psychosocial health, and their experience with the Special Supplemental Nutrition Program for Women Infant Child (WIC) program.

Design

This cross-sectional study collected survey data through REDCAP.

Setting

The study was conducted at a single, urban, opioid treatment program.

Subjects

A total of 91 female participants (≥18 years of age and receiving OUD treatment services) were approached about the study and all consented.

Measures

Measures included: US Household Short Form Food Security Survey, Patient Health Questionnaire 4(PHQ4), Perceived Stress Scale (PSS), and a demographics and food behavior survey.

Analysis

Descriptive analyses (frequency, means) described data and Chi-Square, Fischer’s exact, t-tests were used to compare data between food security groups.

Results

Participants were on average 34 years old, Caucasian (68%), and non-Hispanic (87%). Most reported low (32%) to very low (33%) food security. Pearson correlation analyses indicate a strong positive linear relationship between Food Security Score and PHQ4 Total (P = .0002), PHQ4 Depression (P = .0003), PHQ4 Anxiety (P = .0009), and PSS Total (P < .0001). Only 38% felt the foods available in WIC supported their breastfeeding. Limitations include a single site and recall bias.

Conclusions

Significant nutritional inequity in families affected by maternal substance use exists, with potential for adverse maternal and child development related implications.

Keywords

opioid food insecurity nutrition

Purpose

In the United States, the rates of perinatal opioid use disorder (OUD) has more than doubled between 2010 and 2017.¹ Pregnant and parenting women in treatment for OUD suffer severe disadvantages, as this population is largely affected by poverty, leading to adverse public health risk for both mother and child.² Social determinants effect this population, yet little is known about how food insecurity impacts pregnant and parenting women in recovery.

Food insecurity is a major risk and probable outcome for low-income populations; and is more complicated in populations who are affected by substance use. Research among adults with substance use histories has demonstrated an association between food insecurity and marijuana, methamphetamines, and several classes of prescription drugs.^3,4 Still, gaps in knowledge and practice persist around improving the nutritional status of pregnant and parenting women with substance use histories. Research has examined prenatal opioid use and biological markers of nutrition⁵ and food hardship and depressive symptoms among pregnant women with OUD.⁶ Yet, there is little data on food security status of pregnant and parenting women with OUD and their self-reported barriers to food access and nutrition.

In addition, within the context of nutritional equity, it is vital to understand how public assistance programs such as the Women, Infant, and Children (WIC) Program influences nutritional health and decision making around infant feeding. Understanding the decision making around WIC food package choice and the perspective on how it does/does not support breastfeeding is critical to addressing the nutritional needs of women and their young families. Therefore, the primary aim of this study was to describe the prevalence of food insecurity in the population of pregnant and parenting women in OUD treatment. The secondary aims were to examine women’s experience with the current WIC food package selection and whether selection influences decisions to breastfeed, to determine if food insecurity is associated with depression, anxiety, and stress; and to identify self-reported barriers to nutritional health among women in recovery.

Methods

Study Design

This cross-sectional study collected data from women in treatment through electronic survey administration in REDCAP from February to March 2022 (see Table 1 for survey items).

Table 1.

Demographics and Food Security Survey Questions.

Domain	Question
Demographic characteristics	What is your age (in years)?_______
	Which of these groups would you say best represents your race? Check all that apply.
	• White
	• Black or African American
	• Hispanic or Latino
	• Asian or Pacific Islander
	• American Indian
	• Other. Please tell us: __________________
	What is your ethnicity?
	• Hispanic
	• Not hispanic
	What is your current household size? (Number of people living in your home.)
	______ adult (18 years and older)
	______ children (younger than 18 years old)
	Do you have utensils needed for cooking/preparing meals?
	• Yes
	• No
	Do you have consistent access to gas/electricity for refrigeration and stove?
	• Yes
	• No
	Do you live in a communal living environment (for example a shelter, recovery house, or residential program)?
	• Yes
	• No
	Would you be interested in a group here at your opioid use treatment program on nutrition, cooking and budgeting for meals?
	• Yes
	• No
	Have you ever breastfed your child?
	• Yes
	• No
Barriers healthy eating	What barriers prevent you from eating healthy? (Please select all that apply.)
	• Cost
	• Transportation
	• Child care
	• Location of food store
	• Knowledge of healthy foods to purchase
	• Cooking skills
	• Utensils/appliances to cook
WIC program	Do you receive public benefits for food through the WIC program?
	• Yes
	• No
	If you use WIC food packages, please complete the following questions:
	Is it easy to understand what is included in the current WIC food packages?
	• Yes
	• No
	Were you concerned over your ability (if needed) to change your WIC food package after delivery of your child (for example, going from fully breastfeeding to formula feeding)?
	□ Yes
	□ No
	Did the current WIC food packages influence your decision on how to feed your child?
	□ Yes, the current WIC food packages influenced my decision to breastfeed my child.
	□ Yes, the current WIC food packages influenced my decision to bottle feed my child.
	□ No, the current WIC food packages did not influence my decision on how to feed my child.
	If you answered YES that the WIC food packages influence your decision to breastfeed your child:
	Did you feel the foods available in the current WIC food packages helped support you to breastfeed your child?
	□ Yes
	□ No

Sample

Convenience sampling was used to recruit pregnant and parenting women who were receiving treatment for OUD at a single, university-affiliated, opioid treatment program located in an urban setting. Participants were eligible if they were women 18 years of age and older and receiving services at the OUD treatment site. This study was approved by an Institutional Review Board and written consent was obtained for all participants who enrolled. Of 189 women receiving outpatient services at the opioid treatment program at the time when participants were recruited, 90 (48% of the clinic population) women were approached about the study and completed the surveys.

Measures

Demographics and Food Behavior Survey

The demographics and food behavior survey was investigator developed to measure sociodemographic characteristics (ie, age, race, ethnicity, household size) and food related behaviors (ie, breastfeeding, barriers to healthy eating/food access, access to utensils, gas/electricity, experience with the WIC program).

US Household Short Form Food Security Survey

The US Household Short Form Food Security Survey is a measure of the severity of household food access problems and was used to identify food-insecure households and households with very low food security for this sample.⁷ Respondents were asked about the size of meals, skipped meals, having enough to eat, ability to eat balanced meals, and hunger due to lack of money for food over the last 12 months. A sum of affirmative responses was calculated and organized into very low (raw score of 5-6), low (raw score 2-4), marginal and high (raw score 0-1) food security.

Patient Health Questionnaire 4

The PHQ4 is a validated 4 item screener for depression and anxiety, 2 questions detecting risk for anxiety and 2 for depressive disorders.⁸ Scores are summed for each subscale (anxiety and depression). Increasing PHQ4 scores are strongly associated with multiple domains of functional impairment and psychological distress.

Perceived Stress Scale

General stress was measured using the Perceived Stress Scale, a 10-item survey measuring the degree to which individuals perceive situations in the past month as being stressful (ie, unpredictable, uncontrollable, and overloaded).⁹ It uses a 5-point Likert scale response, with higher scores representing higher perceived stress.

Statistical Analyses

Frequency counts and percentages and means and standard deviations were used to describe data overall and by level of food security. Food security was defined as High (raw U.S. Food Security score 0-1), Low (raw U.S. Food Security score 2-4), or Very Low (raw U.S. Food Security score 5-6). Chi-square, Fischer’s Exact, and t-tests were used to compare data between food security groups. A Pearson correlation was conducted to evaluate the association between the food security score and the PSS Total Sore and the PHQ4 Total, Depression and Anxiety Scores. Separate linear regression models assessed the association between PSS total score, PHQ4 total score, PHQ4 anxiety score, and PHQ4 depression score, and the Food Security score. Multiple linear regression analyses included age and race. These variables were selected [provide rationale for adjusting for age and race]. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA) and data were regarded as statistically significant at P < .05.

Results

The majority of participants were white (68%) and non-Hispanic (87%) (Table 2). The mean age was 34 years. Overall, respondents indicated low food security (32% indicating low food security, 33% indicating very low food security).

Table 2.

Participant Characteristics.

	N = 90 n (%)
Age in years, median (range)	34 (23-63)
Household size
Number of adults living in household (mean, std dev)	1.7 (1.2)
Number of children living in household (mean, std dev)	1.5 (1.3)
Race
White	61 (68%)
Black/African American	19 (21%)
Latino/Hispanic	8 (9%)
American Indian	1 (1%)
Other	1 (1%)
Ethnicity
Hispanic	12 (13%)
Non-hispanic	78 (87%)
Ever breastfed?
Yes	45 (50%)
No	45 (50%)
Easy understand WIC?
Yes	58 (64%)
No	32 (36%)
WIC support breastfeeding?
Yes	34 (38%)
No	56 (62%)
WIC influence feeding?
Yes	23 (26%)
No	67 (74%)
Food security
High	31 (34%)
Low	29 (32%)
Very low	30 (33%)

More than half (64%) of participants reported WIC food packages were easy to understand. Yet only 38% felt that the WIC package supported their breastfeeding and 29% felt the WIC food packages influenced how they fed their child. Almost a quarter (23%) reported feeling concerned about their ability to change their WIC food package in the postpartum period.

Reported barriers to healthy eating and food access included (Table 3): cost (64%), knowledge of healthy foods (37%), cooking skills (28%), location of food store (20%), transportation (19%), utensils/appliances (16%), and childcare (7%). Most participants (80%) reported having utensils at home and 97% reported having consistent access to gas and electricity. About a third (32%) reported living in a communal environment and most (63%) reported having an interest in a nutrition group at their OUD treatment program.

Table 3.

Barriers to Healthy Eating.

	N = 90 n (%)
Live in communal environment
Yes	(29) 32.20%
No	(61) 67.80%
Cost
Yes	(58) 64.40%
No	(32) 35.60%
Transportation
Yes	(17) 18.90%
No	(73) 81.10%
Child care
Yes	(6) 6.70%
No	(84) 93.30%
Location of food store
Yes	(18) 20.00%
No	(72) 80.00%
Knowledge of healthy foods
Yes	(33) 36.70%
No	(57) 63.30%
Cooking skills
Yes	(25) 27.80%
No	(65) 72.20%
Utensils/Appliances
Yes	(14) 15.60%
No	(76) 84.40%

Correlation analyses (Table 4) indicate a strong positive linear relationship between Food Security Score and PHQ4 Total Score (P = .0002), PHQ4 Depression Score (P = .0003), PHQ4 Anxiety Score (P = .0009), and PSS Total Score (P < .0001). As Food Security Score increased, these 4 scores increased. There were no significant associations between Food Security Score and age, race, ethnicity, breastfeeding history, or the WIC-related items. Results from the linear regression analyses are presented in Table 5. PSS total score, PHQ4 total score, PHQ4 anxiety score, and PHQ4 depression score were associated with Food Security score in both adjusted and unadjusted models.

Table 4.

Correlation Between Food Security and Psychosocial Measures.

	Pearson Correlation Coefficient
	P-value
	Food security score	PSS	PHQ4	PHQ4	PHQ4
	Food security score	Total score	Total score	Anxiety score	Depression score
Food security score	1.00	.46	.38	.34	.36
Food security score		<.0001	.0002	.0009	.0003
PSS total score	.46	1.00	.73	.64	.74
PSS total score	<.0001		<.0001	<.0001	<.0001
PHQ4 total score	.38	.73	1.00	.93	.93
PHQ4 total score	.0002	<.0001		<.0001	<.0001
PHQ4 anxiety score	.34	.64	.93	1.00	.74
PHQ4 anxiety score	.0009	<.0001	<.0001		<.0001
PHQ4 depression score	.36	.74	.93	.74	1.00
PHQ4 depression score	.0003	<.0001	<.0001	<.0001

Abbreviations: PHQ4, Patient Health Questionnaire 4; PSS, Perceived Stress Score.

Table 5.

Associations Between PSS and PHQ4 and Food Security Score (Adjusting for Age and Race).

	Unadjusted Model		Adjusted Model
	B (se)	P-value	B (SE)	P-value
PSS total score	.16 (.03)	<.001	.16 (.034)	<.001
PHQ4 total score	.26 (.07)	.0002	.25 (.07)	.0003
PHQ4 anxiety score	.43 (.12)	.0009	.42 (.12)	.001
PHQ4 depression score	.47 (.12)	.0003	.46 (.12)	.0005

Note: SE represents standard error.

Discussion

The major finding of this study is that two-thirds of pregnant or parenting women with OUD surveyed reported having low to very low food security. This is striking, given the participants’ households included multiple children and other adults, suggesting food insecurity affects a wider familial network. Given our understanding of adverse childhood experiences, the potential for intergenerational transmission of food insecurity is a public health concern.¹⁰ Additionally, a third of participants lived in a communal setting beckoning the need for programming to support unsheltered individuals and those in residential treatment programs. Communal settings may not offer the variety of dietary preferences reflected in multi-cultural populations and rules associated with kitchen access outside of communal mealtimes may present a challenge to individuals with young children.

Study data indicate statistically significant correlation between food security and psychological distress measures, including anxiety, depression, and stress. This corroborates other work in similar populations,^10–12 however, this study also found an association of food insecurity with anxiety in pregnant and parenting women with OUD. In addition, we found a dose response between levels of food insecurity and PHQ4 and PSS scores, indicating more psychological distress in those with the most food insecurity.

Multiple barriers to food security were identified. Partnerships between substance use treatment facilities and local departments of public health may be 1 solution to collaboratively address food insecurity by creating policy and directing funding towards integrating emergency food pantries onsite where individuals receive treatment and recovery support. Utilizing community needs assessments may also help determine site specific needs and produce personalized nutrition programming.

Several gaps were identified in knowledge and experience with the WIC food program. These findings identify several barriers related to the education and public health messaging of the current WIC food packages as well as the resources available within the food packages. Substance use treatment programs may serve as a resource for WIC recipients in helping them to better understand their options and assist them to improve health literacy to ensure they fully understand program benefits as well as how to navigate necessary changes in their WIC food package. Further research is needed to identify factors associated with how WIC food packages influenced participant decisions of how to feed their child.

Several limitations exist for this study. First, this was conducted at a single site limiting generalizability. Additionally given the self-report nature of the surveys, there is the possibility of recall bias. Last, McLinden et al (2018) found an association between lower likelihood of experiencing severe food insecurity in those receiving methadone treatment compared to those not receiving treatment, which may indicate that our findings may reflect under-reporting of food insecurity amongst those with an opioid use history.¹³ A strength of this study was the use of several validated survey instruments as well as the novel questions developed for this study that capture the context of food insecurity barriers in this population of pregnant and parenting women in treatment for opioid use.

So What?

What is already known on this topic?

Nutrition should be an addressable social determinant of health for women in recovery.

What did this study add?

Our study found food insecurity was prevalent among pregnant and parenting women with OUD and was associated with stress, depression, and anxiety. The WIC food packages were not easily understood by many participants and influenced women’s decision to breastfeed and switch between food packages, suggesting room for policy work and advocacy.

What are implications for health hromotion practice and research?

Future funding, policy development and research is critical to ensuring the perinatal nutrition of the pregnant woman and her developing fetus, and the subsequent nutrition of the dyad after birth are adequate to support healthy child development and maternal health.

Footnotes

Author Contribution

All authors contributed to the study conception and design. Data collection and analyses were performed by Dr Gannon, Dr Short, and Ms. Wu. Material preparation was performed by all authors. The first draft of the manuscript was written by Dr Gannon and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethical Approval

The authors declare there are no conflicts of interest with this study. This research does involve human subject research and as such as approved by Thomas Jefferson University Institutional Review Board and the City of Philadelphia Institutional Review Board. All subjects included in the study provided informed consent, and considerable measures were taken to ensure subjects understood the study using the talk back method. This research received funding from the W.W. Smith Charitable Trust.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the WW Smith Charitable Trust.

ORCID iD

Meghan Gannon

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