The Relationship of Food Security, Cervical Health, and Produce Intake in Rural Appalachia A ...

230 Pages·2014·2.68 MB·English

by  Gunawardena, Warnaka

The Relationship of Food Security, Cervical Health, and Produce Intake in Rural
Appalachia

A thesis presented to
the faculty of
the College of Health Sciences and Professions of Ohio University

In partial fulfillment
of the requirements for the degree
Master of Science

Sumali S. Hewage
May 2014
© 2014 Sumali S. Hewage. All Rights Reserved.
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This thesis titled
The Relationship of Food Security, Cervical Health, and Produce Intake in Rural
Appalachia

by
SUMALI S. HEWAGE

has been approved for
the School of Applied Health Sciences and Wellness
and the College of Health Sciences and Professions by

David H. Holben
Professor of Food and Nutrition Sciences

Randy Leite

Dean, College of Health Sciences and Professions
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Abstract
HEWAGE, SUMALI S., M.S., May 2014, Food and Nutrition Sciences
The Relationship of Food Security, Cervical Health, and Produce Intake in Rural
Appalachia
Director of Thesis: David H. Holben
Food insecurity is associated with lower produce intake. Consumption of produce
(vegetables and fruit) high in antioxidants may reduce risk of human papillomavirus
(HPV) and cervical dysplasia. This study was designed to examine the differences in
HPV status by food security status; differences in risky sexual behaviors by food security
status; differences in produce intake/behaviors by food security status; differences in
produce intake/behaviors by HPV status; and the association of produce intake/behaviors
and food security, adjusted for demographic confounders including the HPV status
among women in rural Appalachia who were attending a clinic for gynecological care.
Females who were English speaking and writing, 21 years and older, and
attending a health clinic for cervical screening/testing (includes Papanicolaou [Pap] test,
HPV test, and/or colposcopy) were recruited. A survey including questions from the U.S.
Department of Agriculture household adult food security module, validated produce
intake and behavior-related questions, and Community Awareness Resources and
Education (CARE) Risky Sexual Behavior Index was used. HPV results were obtained
from the clinic.
Participants (n = 153) (HPV negative, n = 139 [91.4%]; HPV positive, n = 13
[8.6%]) were 29 ± 8 years and primarily White/Non-Hispanic (n = 144, 94.1%). For
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household adult food security, 113 (75.3%) were fully food secure, while 37 (24.7%)
women were not fully food secure. According to the CARE Risky Sexual Behavior
Index categorization, there were 49 (35.5%) women at a low-risk level, 28 (20.3%) at a
medium-risk level, and 61 (44.2%) who were at a high-risk level. Most (66%) of the
study participants met the U.S. recommendations for daily fruit and vegetable intake.
There were no significance differences in food security status, produce intake or produce
intake behaviors by HPV status. Women who were not fully food secure showed
significantly higher Risky Sexual Behavior scores, compared to their fully food secure
counterparts (p < 0.001). Although produce intake did not differ between food security
status groups, perceived diet quality scores were significantly higher in fully food secure
women, compared to not fully food secure women (p = 0.014), with median scores of
78.68 and 59.57, respectively. After adjusting for demographic confounders, Univariate
General Linear Model analysis results showed that perceived diet quality score was a
predictor for the household adult food security scale score (p = 0.019). Additionally,
insurance (p < 0.001), education (p = 0.004), smoking status (p = 0.006) significantly
predicted the household adult food security scale score.
Overall, food insecurity appears to lead to or result in higher risky sexual
behaviors and poorer perceived diet quality. Further studies with larger samples are
required to examine produce intake and related behaviors among women with increased
risk for cervical cancer development in rural Appalachian Ohio.
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Dedication

I would like to dedicate my work to my ever loving husband who is always with me giving
me endless guidance, encouragement, support, patience, and appreciation to stand strong
during hard times.
You are my pillar of strength of life.
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Acknowledgments
I would like to pay my sincere gratitude to everyone who helped me in many
ways to excel in my studies at Ohio University.
I am greatly thankful to Dr. David Holben, my academic advisor and research
director, for the continuous support, guidance, and encouragement he gave to me during
my studies at Ohio University. Under his guidance, I was able to open up to new fields
that I believe directed me to my future career path. Also, I wish to convey my hearty
appreciation to Dr. Alexander Sergeev who provided me with theoretical academic
explanations to carry out a proper research work. I would like to thank Ms. Jennifer
Yoder for the time, direction, and suggestions she gave to help me to produce a quality
research project. Without their support, this task would have been a distant reality.
Finally, I wish to thank Dr. Jody Gerome for the immense support she gave during data
collection and for providing other professional recommendations.
I am giving my appreciation to Ms. Angela Hamilton, for the support she
provided in data collection and data input. My heartiest gratefulness goes to the School
of Applied Health Sciences and Wellness for the assistance given. Additionally, I would
like to give my deepest gratitude to each person who helped me at some point in my
studies at Ohio University.
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Table of Contents
Page
Abstract ........................................................................................................................... 3
Dedication ....................................................................................................................... 5
Acknowledgments ........................................................................................................... 6
List of Tables................................................................................................................. 11
List of Figures ............................................................................................................... 13
Chapter 1: Introduction .................................................................................................. 14
Study Purposes and Research Questions ............................................................. 20
Chapter 2: Literature Review ......................................................................................... 22
Food Security ..................................................................................................... 22
Related Definitions ............................................................................................ 23
History of the Food Security Measurement Project ............................................. 26
The Current Population Survey Food Security Supplement ................................ 28
Household Food Security Survey Module .......................................................... 31
Food Security in the United States...................................................................... 37
Geographic Characteristics ................................................................................. 43
Adult and Women’s Food Security..................................................................... 46
Correlation Between Food Insecurity and Poverty .............................................. 49
Consequences of Food Insecurity ....................................................................... 50
Chronic Disease ................................................................................................. 52
Chronic Disease Risk and Poverty ...................................................................... 54
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Appalachia ......................................................................................................... 55
Chronic Disease Risk in Appalachia ................................................................... 61
Cancer ............................................................................................................... 63
Cervical Cancer.................................................................................................. 65
Cervical Dysplasia ............................................................................................. 74
Human Papilloma Virus ..................................................................................... 76
The Mechanism of the HPV Infection and Host Control of HPV Infection ......... 78
Low-Risk and High-Risk HPV Types ................................................................ 80
Risk Factors ....................................................................................................... 82
Cervical Cancer Preventive Measures ................................................................ 84
Barriers to Prevent Cervical Cancer.................................................................... 88
Cervical Cancer, Poverty, and Produce Intake .................................................... 89
Cervical Cancer in Rural Appalachia .................................................................. 92
Antioxidants and Cervical Cancer ...................................................................... 94
Produce Intake in the United States .................................................................... 98
Produce Intake in Appalachia ........................................................................... 102
Produce Intake and Food Security .................................................................... 103
Summary ......................................................................................................... 108
Chapter 3: Methodology .............................................................................................. 109
Research Design .............................................................................................. 109
Study Population .............................................................................................. 109
Sampling Procedure ......................................................................................... 110
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Research Instrument and Scoring ..................................................................... 111
Research Questions and Statistical Analysis ..................................................... 113
Chapter 4: Results........................................................................................................ 116
Characteristics of the Participant ...................................................................... 116
Household Adult Food Security Status ............................................................. 117
HPV Clinical Data ........................................................................................... 118
Risky Sexual Behavior ..................................................................................... 119
Produce Intake ................................................................................................. 119
Produce Intake Related Behaviors .................................................................... 122
Difference in HPV Prevalence by Household Adult Food Security Status ........ 125
Difference in Risky Behavior Score by Household Adult Food Security Status 125
Difference in Produce Intake by Household Adult Food Security ..................... 125
Differences in Produce Intake Related Behaviors by Household Adult
Food Security ................................................................................................... 126
Difference Difference in Produce Intake by HPV Status ................................... 127
Difference in Produce Intake Related Behaviors by HPV Status ....................... 128
Relationship of Household Adult Food Security Scale Score and Adjusted
Results of General Linear Model ...................................................................... 129
Chapter 5: Discussion, Conclusion, and Recommendations ......................................... 131
Characteristics of Participants .......................................................................... 131
Demographic characteristics ................................................................. 131
Food security ........................................................................................ 132
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HPV status ........................................................................................... 134
Risky sexual behaviors ......................................................................... 135
Produce intake and produce intake related behaviors ............................ 137
Household Adult Food Security and HPV Prevalence ...................................... 138
Household Adult Food Security and Risky Sexual Behavior ............................ 138
Household Adult Food Security and Produce Intake and Related Behaviors ..... 138
HPV Status and Produce Intake and Related Behaviors .................................... 142
Predictors of Household Adult Food Security Scale Score ................................ 145
Conclusion and Recommendations ................................................................... 146
References ................................................................................................................... 149
Appendix A: U.S. Household Food Security Survey Module ....................................... 202
Appendix B: U.S. Measurement of Household Food Security Status ............................ 205
Appendix C: Institutional Review Board (IRB) Approval Letter .................................. 206
Appendix D: Flyer Used for Participant Recruitment ................................................... 207
Appendix E: Consent Form for Participant Recruitment .............................................. 208
Appendix F: Survey ..................................................................................................... 211
Appendix G: Food Security Scale Values and Status Levels Corresponding to
Number of Affirmative Responses ................................................................... 224
Appendix H: CARE Risky Sexual Behavior Index, 2009 Scale Scoring ....................... 225
Appendix I: 13-Item Tool to Assess Psychosocial Indicators of Produce Intake ........... 226
Appendix J: 7-Item Fruit and Vegetable Scale ............................................................. 229