Community and International Nutrition

An Assessment of Various Household Food Security Measures in Hawaiı̀

Has Implications for National Food Security Research and Monitoring1,2
Joda P. Derrickson,*3 Anne G. Fisher,† Jennifer E. L. Anderson** and Amy Christine Brown‡
*Kaneohe, Hawaiı̀ 96744; Departments of †Occupational Therapy and **Food Science and Human Nutrition,
Colorado State University, Fort Collins, Colorado 80523 and ‡Department of Human Nutrition, Food and
Animal Sciences, University of Hawaiı̀ at Manoa, 1955 East West Road, Honolulu, Hawaiı̀ 96822

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ABSTRACT The Core Food Security Module (CFSM), the national food security monitoring tool, requires three
affirmative responses to categorize households as food insecure. If this tool is unreliable or inaccurate, vulnerable
segments of our population may be adversely affected. The objectives of the present study were to assess the
credibility of applying the CFSM categorical measure to a population sample from Hawaiı̀ and to assess the
concurrent validity of the CFSM, the new face-valid measure and measures adapted from the Radimer/Cornell (RC)
measure and Community Childhood Hunger Identification Project. The sample included 1469 respondents gath-
ered through a statewide telephone sample and 144 food pantry recipients. Responses to the 18 CFSM questions
were used to create all four measures. The credibility of the CFSM categorical measure was also assessed via
comparisons with individual items and with the 1995 national modal CFSM response pattern. Categorical mea-
sures were compared across food security prevalence estimates and indices of income and vegetable intake and
with the CFSM scale measure. Differences in the modal response pattern between samples affected CFSM
categorization. Only 36% of households followed the Hawaiı̀ modal response pattern, and categorization was not
consistent with the content of key items. Although 85% of the households were classified as food secure by the
CFSM, only 78% were classified as food secure with each of the other food security measures. Concurrent validity
of all measures was confirmed. A reassessment of the national CFSM categorical measure appears warranted. J.
Nutr. 131: 749 –757, 2001.

KEY WORDS: ● hunger ● household food security ● food insecurity ● Hawaiı̀

Food insecurity occurs “whenever the availability of nutri-
tionally adequate and safe foods or the ability to acquire
acceptable foods in socially-acceptable ways is limited or un-
certain” (Life Sciences Research Office 1990). Previous re-
searchers have defined food insecurity as an experience of
severe economizing of food resources (Bickel et al. 1996,
Radimer 1990, Wehler et al. 1992). To effectively ameliorate
hunger and related health problems, policymakers depend on
surveillance or monitoring measures for valid and reliable
information (Nord et al. 1990). If the Core Food Security
Module (CFSM)4 monitoring tool for food insecurity is unre-
liable or inaccurate, vulnerable segments of the population
may be adversely affected.
The national food security measure called the CFSM was
created by a team of experts to measure the extent and severity
of household food insecurity during a 12-mo period (Carlson et
1
Findings were reported as an oral presentation at the 2000 ASNS Annual
Meeting.
2
Supported in part by a grant from the Institute for Research on Poverty,
University of Wisconsin, Madison.
3
To whom correspondence should be addressed.
E-mail: laniwai4@pixi.com
4
Abbreviations used: CCHIP, Community Childhood Hunger Identification
Project, CFSM, Core Food Security Module, CPS, Current Population Survey,
HHS, Hawaiı̀ Health Survey, Q, Question, RC, Radimer/Cornell, RAI, Resource
Augmentation Index.
al. 1999, Hamilton et al. 1997a). It was based on earlier
research completed by the Radimer/Cornell (RC) research
team and by leaders of the Community Childhood Hunger
Identification Project (CCHIP) (Radimer 1990, Radimer et al.
1992, Wehler et al. 1992). The original data set used to
develop the CFSM was the April 1995 food security supple-
ment of the Current Population Survey (CPS). As indicated
in Table 1, the CFSM contains 18 items, of which 8 pertain
only to households with children. The order of the items
represents the “CFSM modal response pattern” of respondents
who completed the 1995 food security supplement. As indi-
cated in the first column of the table, categorization of house-
holds is based on the sum of affirmative responses. For exam-
ple, responses to at least three items were required for
classification as “food insecure.” As explained by Carlson
(1999), “Determination of the initial threshold of each desig-
nated severity range was done by identifying the second or
third items in the modal response pattern sequence that con-
ceptually indicates the continuous characterizing of the cate-
gory.” According to Bickel (1999), face validity of categoriza-
tion was not a priority.
Previous work by the author confirmed the overall face
validity (Derrickson and Anderson 2000) and “goodness-of-
fit” of the CFSM items with Asians and Pacific Islanders in
Hawaiı̀ (Derrickson et al. 2000a). Limited resource audiences

0022-3166/01 $3.00 © 2001 American Society for Nutritional Sciences.

Manuscript received 17 December 1999. Initial review completed 22 February 2000. Revision accepted 28 November 2000.

749
750 DERRICKSON ET AL.
TABLE 1
Operationalized framework of the Core Food Security Module (CFSM) for households with children1
Sequence of 18 items answered affirmatively
Category in modal households2
Food secure 2. Worried food would run out
Sum: ⬍34 3. Food bought didn’t last
Food insecure 4. Family couldn’t afford balanced meals3
Sum: 3–7 5. Relied on a few low cost foods
8. Cut size of meals/skip meals: adults
6. Could not afford balanced meal: child
9. Adult ate less than felt they should
Moderate hunger 8a. Adult cut size or skip meals for three or
Sum: 8–12 months in the last year
7. Child not eating enough
10. Adult hungry but didn’t eat
11. Adult lost weight
13. Cut size of child’s meals
Severe hunger 12. Adult didn’t eat for whole day
Sum: 13–18 14. Child hungry
12a. Adult didn’t eat for whole day: ⱖ3/12 mo
15. Child skip meals: short term
15b. Child skip meals: ⱖ3/12 mo
16. Child didn’t eat for a whole day
1 Adapted from Bickel et al., 1996.
2 “Modal” households are those whose responses to the 18 items exactly fit the common pattern determined by the Rasch measurement model
to the 1995 national survey data (Hamilton et al. 1997b). For each item, respondents were asked “in the last 12 months . . . item . . . because of not
enough money for food.”
3 Sum refers to the total number of affirmative responses of the CFSM for households with children.
4 Items in italics represent threshold scale items.
in Hawaiı̀ (Caucasians, Hawaiians and part Hawaiians, Filipi-
nos and Samoans) consistently reported that their experience
of “hunger” meant a cyclical pattern of inadequate intake (i.e.,
“When you don’t know when your next meal is coming, or
where it’s coming from and/or how”). Similar to Radimer
(1990), the Face Valid Food Security Measure (FVFSM) cre-
ated by the author was developed to be true to the “grounded
experience” reported by low-income Hawaiı̀ residents (Der-
rickson 1999, Glaser and Strauss 1967). As indicated in Table
2, similar to the RC and CCHIP measures, in the FVFSM a
household with any affirmative response is categorized as “at
risk of hunger.” However, unlike all three other categorical
measures, hunger categorization in the CFSM requires specific
affirmation of hunger items. Adult hunger is determined by an
affirmative response to either question (Q)10, “Respondent
hunger,” or Q12, “Any adult did not eat for a whole day.”
Child hunger is determined by an affirmative response to Q14,
“Child hunger.” In summary, the FVFSM accepts the respon-
dent’s declaration of their experience as an adequate threshold
indicator of three food insecurity categories (at risk of hunger,
adult hunger and child hunger). In contrast, the CFSM mea-
sure categorizes various levels of severity of household food
insecurity through a pattern of multiple indicators, regardless
of the content of the items.
This study represents one part of a larger effort to determine
the most effective food security monitoring tool to use in
Hawaiı̀. The study objectives were to assess the credibility of
applying the CFSM in Hawaiı̀ and to compare the concurrent
validity of the CFSM with three alternative food security
measures: an adapted RC measure, an adapted CCHIP mea-
Expected behaviors
Diminished household food resources force economizing in food
spending: running short of money, substituting cheaper, dietary
monotony
Food insecurity short of actual hunger: extreme food acquisition and
management coping strategies, use of socially non-normative
food resources, nutritional quality of diets and health affected
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Managing insufficient resources; adult hunger in household, for at
least some members, sometimes
Severe hunger in household and hunger among children
sure and the FVFSM. The measures evaluated are all measures
that defined food security status categories, not to be confused
with the CFSM scale measure (Hamilton et al. 1997a). It was
hypothesized that one of the alternative food security measures
would be more credible to use in Hawaiı̀ than the CFSM.
Until this time, no research team has independently evaluated
the CFSM measure or compared the CFSM measure with
other food security measures (Radimer et al. 1992, Wehler et
al. 1992).
Credibility assessment was operationalized to include an
assessment of reliability and validity. “Reliability refers to the
consistency or reproducibility of an operational definition;
validity refers to the goodness of fit between an operational
definition and the concept it is purported to measure” (Sin-
gleton et al. 1993). Concurrent validity was also defined by
Singleton et al. (1993) as “the ability of a measure to indicate
an individual’s present standing on the criterion variable.”
MATERIALS AND METHODS
Samples. Three samples were surveyed for a total sample size of
1664, which were derived from the following:
1. A convenience sample of 144 food pantry recipients
2. Sixty-one of the 144 respondents who completed the survey a
second time; a mean of 11 d apart
3. A statewide sample of 1469 respondents who completed the
Hawaiı̀ Health Survey (HHS) in 1998
Before data collection, all participants confirmed verbal consent as
required by a university human subjects review committee. This is the
same data set we used to assess the validity and reliability of the
CFSM scale measure (Derrickson et al. 2000a). The population
 HOUSEHOLD FOOD SECURITY MEASURES IN HAWAIÌ 751

TABLE 2
Comparison of four household food security measures by food security category

Adapted Community
Childhood Hunger
Category Core Food Security Module Face Valid Food Security Measure Adapted Radimer/Cornell Identification Project

Food secure ⬍3 affirmative responses 0 affirmative responses 0 affirmative responses 0 affirmative responses
“Only worried” Affirmative to Q2 “Worried
food would run out”

Food insecure/at Adults only: 3–6 affirmative Any affirmative response to food Any affirmative response to Any affirmative response to
risk of hunger responses; with 1⫹ child: insecurity indicators food insecurity indicators food insecurity indicators
3–7 affirmative responses except Q2

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Moderate Adults only: 7–8 affirmative Affirmative response to Q10 or 12 Affirmative response to Q8, Affirmative response to
hunger/adult responses; with 1⫹ child: 8a or 9–12a without Q10, 11, 12 or 12a
hunger 8–12 affirmative affirmative response
responses child indicators: Q7 or
13–16

Severe/child Adults only: 9–10
hunger affirmative responses;
with 1⫹ children: 13⫹
affirmative responses
Summary Categorization based on
sum of responses
Hunger categories may
include both adult and
child hunger
Conservative, particularly in
classifying food
insecurity
Affirmative response to Q14 only
Based on responses to specific
indicators
Separate hunger categories for
adults and children
More liberal food insecurity
classification but most strict
hunger classification
Affirmative response to any
one of the following: Q7
or 13–16
Based on responses to
specific indicators
Separate hunger categories
for adults and children
More liberal classification
of all categories
Affirmative response to any
one of the following: Q7
or 13–16
Based on responses to
specific indicators
Separate hunger categories
for adults and children
More liberal food insecurity
and child hunger: more
strict adult classification

sampled was representative of the ethnicity of Hawaiı̀ residents: 909
(54.6%) indicated they most identified with an Asian or a Pacific
Islander ethnic group (Department of Business, Economic Develop-
ment and Tourism 1997).
Data collection. All data were collected in Hawaiı̀ between June
and November 1998. Data collection began with a pilot study of food
pantry respondents who completed the survey once and 61 (80%)
who also completed the survey a second time at an average of 11 d
later. Data were gathered by interviewers who were experienced in
calling limited resource households (Derrickson et al. 1995, SMS
Research and Marketing Service, Inc. 1992) using standard telephone
survey methods to enhance response rates and minimize interviewer
bias (Lavarakas 1988, SMS Research and Marketing Service, Inc.
1998). Preliminary findings indicated that the CFSM was likely to be
reliable and valid to use in Hawaiı̀ (Derrickson 1999).
The final data set came from food security questions that were
included in the HHS between September and November 1998. HHS
is a telephone interview survey of at least 3500 households each year.
The survey is modeled after the National Household Interview Sur-
vey conducted by the National Center for Health Statistics (SMS
Research and Marketing Service, Inc. 1998). Households were ran-
domly chosen from local telephone books. Once a household was
chosen, the household was sent a letter from the director of the
Department of Health encouraging survey participation. Data collec-
tion was administered through telephone interview using a computer-
assisted telephone interviewing system (SMS Research and Market-
ing Service, Inc. 1998). A complete description of the data collection
methods used in the HHS is given elsewhere (SMS Research and
Marketing Service, Inc. 1998).
Survey instrument. The survey instrument included the follow-
ing:
● Basic demographic questions (age, household composition and
ethnicity): “With what ethnic group do you identify most?”
● The 18 CFSM questions preceded by the four-part food insuf-
ficiency question (Rose et al. 1995)
● Eight resource augmentation questions
● Two diet-quality indicators
Specifically, the four resource augmentation questions queried
whether the following coping behaviors were used to enhance either
the household food supply or money for food: 1)using charitable food
assistance, 2) delaying bill payments, 3) borrowing money for food,
and 4) sending children over to someone else’s house (only for
households with children). These questions were used by the CFSM
research team (Hamilton et al. 1997a). In addition, four follow-up
questions (“How often did you [resource augmentation behavior]”)
were asked if the initial response was affirmative. Follow-up questions
were asked to determine how reliant a household was on each
particular coping behavior. Response format to the follow-up ques-
tions was consistent with that asked of the follow-up questions in the
CFSM (almost every month, some months but not every month or
only 1 or 2 mo). Thus, a maximum of eight resource augmentation
questions were asked of households with children, and six were asked
of households without children. Affirmative responses were summed
to create the Resource Augmentation Index (RAI).
Previous research indicated that in Hawaiı̀, food insecurity often
led to compromised vegetable intake and increased reliance on an
inexpensive high-fat dried noodle product, locally called Saimin or
Ramen, to stretch food resources (Derrickson and Anderson 2000).
Survey respondents were specifically asked the following questions:
1. “Not counting salad or potatoes, how many servings of veg-
etables do you usually eat a day? Count 1/2 cup (120 mL), like
the size of a pudding cup, as one serving.”
2. “How many times last month did you or the child/children
(whoever ate more) eat Saimin that was purchased dried, not
frozen?”
Analysis of responses to the vegetable frequency question was
based on the serving sizes of the Food Guide Pyramid (U.S. Depart-
ment of Agriculture 1999). The vegetable frequency question was
validated with a 24-h vegetable recall (Derrickson 1999). Values of
the two vegetable indices were highly correlated (r ⫽ 0.81, P
⬍ 0.001). Mean values were not significantly different between
measures (1.61 ⫾ 1.15 for recall and 1.54 ⫾ 1.21 for vegetable
frequency; t ⫽ ⫺0.7, P ⫽ 0.40). Responses to the Saimin question
752 DERRICKSON ET AL.

TABLE 3
Comparison of the household food security sum vs. item response for Hawaiı̀ data (n ⫽ 1664)

Food Sum of affirmative responses by Modal response Responses to items by household

security household type2 patterns type Hawaiı̀ modal order
sum of
CFSM1 affirmative Total Adults only Family National Hawaiı̀ Total Adults only Family
categories responses n n n Item3 Item3 n n n

Food secure 0 1300 843 457 — — — — —

1 63 28 35 Q2 Q2 291 77 214
2 48 23 25 Q3 Q3 258 83 175
Food insecure 3 51 18 33 Q4 Q4 238 71 166
4 41 10 31 Q5 Q5 159 — 159

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5 29 7 22 Q8 Q6 120 — 120
Moderate hunger 6 34 12 22 Q6 Q9 144 48 96
7 22 8 14 Q9 Q8 127 40 87
8 16 3 13 Q8a Q8a 103 31 72
Severe hunger 9 14 4 10 Q7 Q7 60 — 60
10 1 4 10 Q10 Q10 74 21 53
11 7 — 7 Q11 Q11 60 22 38
12 7 — 7 Q13 Q14 33 — 33
13 7 — 7 Q12 Q13 28 — 28
14 7 — 7 Q14 Q12 40 8 32
15 4 — 4 Q12a Q15 23 — 23
16 6 — 6 Q15 Q15a 19 — 19
17 3 — 3 Q15a Q12a 26 4 22
18 — Q16 Q16 5 — 5

1 CFSM, Core Food Security Module.

2 CFSM categorical algorithm applied for households with and without children (Price et al. 1997).
3 Findings are ordered according to the original CFSM modal item response patter (Hamilton et al. 1997a).

were all converted to a monthly frequency by multiplying weekly
responses by 4.
Food security measures. The food security data were collected
and analyzed according to the “Guidelines for Using the Core Food
Security Module” (Price et al. 1997). The CFSM scale measures and
item calibration values were created using the Rasch FACETS soft-
ware program (Derrickson et al. 2000a, Linacre 1986, Rasch 1966,
Wright and Masters 1982, Wright and Stone 1979). As indicated in
Table 1, an “item calibration value” represents the position of the
item along the constructed food insecurity scale. For example, Q16,
with a high positive item calibration value of 4.82, indicates a very
high degree of insecurity and hunger, whereas an item with a low
negative calibration, such as Q2 (⫺4.99), is indicative of mild food
insecurity (Hamilton et al. 1997). Similarly, household “scale mea-
sures” indicate the severity of household food insecurity reported by
the respondent. A higher number of affirmative responses result in a
higher positive placement on the food insecurity scale. Scale mea-
sures ranged from a low of ⫺4.5, which is indicative of less severe
food insecurity, to a high of ⫹4.5, which is indicative of severe
hunger (Derrickson et al. 2000a).
The total number of affirmative responses was called the “re-
spondent food security sum.” The algorithms outlined in Table 2
were applied to create the four food security categorical variables.
Because both the CCHIP and RC measures do not contain all of
the CFSM items, these measures were “adapted” to the CFSM
items. They are referred to as the adapted RC and the adapted
CCHIP measures. Most important, because the adapted CCHIP
measure does not include Q2, “Worried food would run out,” a
new category of food insecurity was created. The “Only worried
about food insecurity” category was created within the adapted
CCHIP measure to study the responses of those who responded
affirmatively to Q2 but not to any other items. Creation of the
“Only worried about food insecurity” category is an applied re-
search artifact, not in anyway meant to discredit or alter the
original CCHIP measure designed to measure hunger among chil-
dren (Wehler et al. 1992).
Data analysis. Data analysis can be broken into two parts
corresponding to our objectives:
1. An evaluation of the validity and reliability of applying the
CFSM categorical measure in Hawaiı̀
2. A concurrent validity comparisons of the four food security
categorical measures, which included the following:
a. Comparisons of food security status prevalence estimates
b. Comparison of dietary measures, the RAI and the CFSM
scale measure
The evaluation of the reliability and validity of the CFSM
measure was initiated by an assessment of modal response patterns.
Specifically, the Hawaiı̀ modal response pattern was compared
with the original CFSM modal response pattern (Hamilton et al.
1997a) to assess impact on categorization. To clarify, as outlined
in Table 1, the CFSM modal response pattern is the sequence of
items ranging from Q2 to Q16. It is expected that if a respondent
responded in the affirmative to an item (i.e., Q10, “Respondent
hungry”), then she or he also responded in the affirmative to all of
the preceding items (Q2 to Q9) (Hamilton et al. 1997a). If there
were notable differences in the item hierarchy between samples,
then the CFSM categorical algorithm, which is based on a set sum
of affirmative responses, would not be expected to consistently
categorize households.
To study the effect of modal pattern response rates on the CFSM
categorical measure, a “Hawaiı̀ modal pattern” variable was created.
Specifically, those who followed the Hawaiı̀ modal response pattern
outlined in Table 3 were given a score of 1, and those who did not
follow this modal pattern were given a score of 0. Adherence to the
Hawaiı̀ modal response pattern was explored across the four CFSM
food security categories. Finally, an investigation of content validity
of the CFSM was completed by comparing affirmative responses with
key food security items (Q2, Q3, Q4, Q8, Q9, Q10, Q12 and Q14)
across the four CFSM food security categories.
To assess concurrent validity, the four food security measures were
compared across indices of resource augmentation and vegetable
 HOUSEHOLD FOOD SECURITY MEASURES IN HAWAIÌ 753

TABLE 4
Affirmative responses to CFSM items by the CFSM household categorical measure1

Food Food Moderate Severe

Item Total secure insecure hunger hunger

n 1664 1411 158 64 31

n n (%)2

Q2. “Worried food would run out” 291 61 (4.3) 137 (86.7) 62 (96.9) 31 (100)
Q3. “Food bought didn’t last” 258 40 (2.8) 126 (79.7) 61 (95.3) 31 (100)
Q4. “Unable to eat balanced meals” 237 30 (2.1) 119 (75.3) 59 (93.7) 29 (96.7)
Q7. “Child/ren not eating enough” 60 1 (1.7) 15 (12.5) 20 (50.0) 24 (88.9)
Q8. “Adult/s cut size or skip meals” 127 1 (0.9) 40 (25.8) 56 (87.5) 30 (96.8)

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Q9. “Respondent ate less than felt he/she should” 144 7 (5.9) 54 (34.6) 52 (82.5) 31 (100)
Q10. “Respondent hungry” 74 — 17 (10.9) 32 (50.0) 25 (80.6)
Q11. “Respondent lost weight” 60 2 (1.7) 9 (5.8) 25 (39.7) 24 (77.4)
Q12. “Adult/s didn’t eat for a whole day” 40 — 5 (3.2) 14 (21.9) 21 (67.7)
Q14. “Child/ren hungry” 33 — 4 (2.5) 8 (12.5) 21 (67.7)

1 CFSM, Core Food Security Module.

2 Percentages indicate the percent of respondents in that food security category who were asked and responded affirmatively to the respective
question.

intake and with mean values of the household scale measures (Der-
rickson et al. 2000a). To assess the relationship of the four categorical
measures to the CFSM household scale measure, mean household
scale measures were compared across each category of the four mea-
sures. Specifically, the mean household scale measures were compared
with the closest corresponding item calibration values (Derrickson et
al. 2000a). Next, the item with the closest corresponding item cali-
bration value was compared with categorical algorithms outlined in
Table 2. Statistical analysis was completed with SPSS (Version 6.2;
SPSS, Chicago, IL). One-way ANOVA and Tukey’s post hoc tests
were also used to assess differences in the mean vegetable intake, scale
measures and the resource augmentation index between measures.
The ␣ value was set at P ⫽ 0.05 for all ANOVA tests.
RESULTS
Assessment of the credibility of the CFSM measure.
Findings outlined in Table 3 indicated that the modal response
patterns or item hierarchy differed between the national 1995
CPS sample and the Hawaiı̀ sample. When differences in
modal response pattern sequencing involves a threshold item,
the reproducibility of the CFSM categorical algorithm is af-
fected. For instance, the fifth through eighth items in both
modal response patterns (Q6, Q8 and Q9) and the 15th
through 17th (Q12a through Q15a) items were not in the
same sequence. However, because no “threshold items” (Q4,
Q8a and Q12) were affected, there was no apparent effect on
CFSM categorization. Q14, “Child hungry,” is 14th in the
CFSM modal response pattern but 12th in the Hawaiı̀ modal
response pattern (Hamilton et al. 1997a). Findings imply that
households with children in Hawaiı̀ who followed the Hawaiı̀
modal response up to Q14 were classified as experiencing
“moderate hunger” rather than “severe hunger.” As indicated
in Table 1, “Severe hunger” is the category that is supposed to
capture hunger among children. This issue would be more
troublesome if hungry households did not follow the Hawaiı̀
modal response pattern.
Response rates to the Hawaiı̀ modal response pattern were
next explored to further clarify the effect on food security
categorization. Overall, only 129 (36%) of the 364 respon-
dents with one or more affirmative responses followed the
Hawaiı̀ modal response pattern: 100 (77%) of the 129 had five
or fewer affirmative responses. Also, 32 (52%) of the 62
respondents with only one affirmative response constituted
25% of the respondents who followed the Hawaiı̀ modal re-
sponse pattern. Twenty-four (39%) of these 62 respondents
affirmatively answered either Q3 (12), “Food bought didn’t
last,” or Q4 (12), “Could not afford to eat balanced meals,” not
Q2, “Worried about food.” Only eight (10.5%) of the 76
households with eight or more affirmative responses followed
the Hawaiı̀ modal response pattern. Four of the 31 (12.9%)
households classified as experiencing severe hunger by the
CFSM measure followed the Hawaiı̀ modal response pattern.
There were no statistically significant differences in modal
pattern response by household family status (Pearson ␹2 ⫽
0.83, P ⫽ 0.36). Because of high measurement variability,
these findings question the reliability of using a modal response
pattern as the basis of food security categorization.
The potential issue of “misclassification” of the CFSM, or
validity of applying the CFSM categorical measure to Hawaiı̀
data, was further elucidated through comparisons of affirma-
tive response rates to selected items across the four CFSM
categories (Table 4). Although many findings are noteworthy,
the most important findings disputing the face validity of the
CFSM categories with Hawaiı̀ data are listed below:
Food secure. Given that 1300 of the 1411 households
categorized as food secure had no affirmative responses, a
relatively high percentage of the remaining 111 had an unex-
pected response pattern: 30 (27%) responded affirmatively to
Q4, “Unable to afford balanced meals,” and 7 (6.3%) re-
sponded affirmatively to Q9, “Adult not eating enough.”
Food insecure. Seventeen of the 158 (10.9%) households
classified as food insecure responded affirmatively to Q10,
“Respondent hungry,” 5 (3.2%) to Q12, “Adults did not eat
for a whole day” and 4 (2.5%) to Q14, “Child hungry.”
Moderate hunger. Thirty-two of 64 (50%) households clas-
sified as experiencing moderate hunger responded affirmatively
to Q10, “Respondent hungry,” and 14 (22%) responded affir-
matively to Q12, “Adults not eat for a whole day,” a key
indicator of severe hunger (Hamilton et al. 1997a).
Severe hunger. Twenty-one of the 31 (67%) households
classified as experiencing severe hunger responded affirma-
tively to Q12. Twelve of the 33 (36%) households admitting
to experiencing hunger among children (Q14) were classified
754 DERRICKSON ET AL.

TABLE 5
Household food security status prevalence rates by the CFSM categorical measure1

Family status Site

Food security measures Overall Adults only ⱖ1 Child HHS1 Food pantry Retest

n 1664 957 (57.5%)2 707 (42.5%)2 1459 (87.7%)2 144 (8.7%)2 61 (3.7%)2

n (%)3

CFSM1
Secure 1411 (84.8) 894 (93.3) 517 (73.2) 1360 (93.2) 36 (25.0) 15 (24.6)
Insecure 158 (9.5) 36 (3.8) 122 (17.3) 72 (4.9) 60 (41.7) 26 (42.6)
Moderate 64 (3.8) 24 (2.5) 40 (5.7) 20 (1.4) 30 (20.8) 14 (23.0)

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Severe 31 (1.9) 4 (0.4) 27 (1.6) 7 (0.5) 18 (12.5) 6 (19.4)
Face valid
Food secure 1300 (78.1) 843 (88.0) 457 (64.6) 1278 (87.6) 18 (12.5) 4 (6.6)
At risk 259 (15.6) 92 (9.6) 167 (23.6) 147 (10.1) 73 (50.7) 39 (63.9)
Adult 72 (4.3) 23 (2.4) 50 (7.1) 30 (2.1) 32 (22.2) 10 (16.4)
Child 33 (2.0) 0 33 (4.7) 4 (0.3) 21 (14.6) 8 (13.1)
Adapted Radimer/Cornell
Secure 1300 (78.1) 843 (88.0) 457 (64.6) 1278 (87.6) 18 (12.5) 4 (6.6)
Insecure 172 (10.3) 56 (5.9) 116 (16.4) 108 (7.4) 44 (30.6) 20 (32.8)
Adult 119 (7.2) 58 (6.1) 61 (8.6) 53 (3.6) 46 (31.9) 20 (32.8)
Child 73 (4.4) 0 73 (10.3) 20 (1.4) 36 (25.0) 17 (27.9)
Adapted CCHIP1
Not hungry 1300 (78.1) 843 (88.0) 457 (64.7) 1278 (87.6) 18 (12.5) 4 (6.6)
Worried 31 (1.9) 9 (0.9) 23 (3.3) 28 (1.9) 4 (2.8) 0
At risk 197 (11.8) 75 (7.8) 122 (17.3) 108 (7.4) 57 (39.6) 32 (52.5)
Adult 62 (3.7) 30 (3.1) 32 (4.5) 25 (1.7) 29 (20.1) 8 (13.1)
Child 73 (4.4) 0 73 (10.3) 20 (1.4) 36 (25.0) 17 (27.9)

1 CFSM, Core Food Security Module; CCHIP, Community Childhood Hunger Identification Project; HHS, Hawaiı̀ Health Survey.
2 Percentages indicate row totals.
3 Percentages indicate column totals.

as experiencing food insecurity without hunger (n ⫽ 4) or food
insecurity with moderate hunger (n ⫽ 8).
Comparison of various four categorical measures. Com-
parisons of prevalence estimates between samples are pre-
sented in Table 5. Although not unexpected, the 6.7% dif-
ference in the overall rate or percentage classified as food
secure between the CFSM categorical measure and other mea-
sures in the total sample is perhaps most important. Also, both
the adapted CCHIP and adapted RC measures classified 73
(4.4%) of the sample as experiencing hunger among children.
This is more than double the 31 (1.9%) categorized as “se-
verely hungry” by the CFSM or the 33 (2.0%) categorized as
experiencing child hunger with FVFSM. The food security
measure reporting the highest prevalence of hunger was the
adapted RC method; 119 (7.2%) were categorized as experi-
encing adult hunger.
Table 6 depicts comparisons of the mean values of the
RAI, respondent daily vegetable intake, monthly Saimin
intake and the CFSM scale measures for each categorical
measure. All four categorical measures supported the fol-
lowing findings: as the severity of food insecurity worsened,
there was an increased utilization of resource augmentation
behaviors, a general decrease in vegetable intake and an
increased dependence on Saimin. The mean resource aug-
mentation index values for all measures were significantly
different between food security categories. The range gen-
erally extended from 0.25 for food secure respondents to 4.1
for respondents classified as experiencing hunger among
children. The categorical distinction in reduced vegetable
intake was most pronounced with the FVFSM in which
food secure respondents reported a mean daily vegetable
intake of 2.0 servings of vegetables, whereas respondents in
households with hungry children averaged only a single
serving. The “Only worried about food insecurity” respon-
dents (with only an affirmative response to Q2) reported
significantly higher use of resource augmentation behaviors
(mean of 1.2 versus 0.2), lower mean vegetable intake (1.4
versus 2.0 servings) and significantly greater reliance on
Saimin (10.4 versus 3.7 times a month) than respondents
who were responded affirmatively to no CFSM items.
The results of the previous “concurrent validity assess-
ments” were similar between measures. However, the compar-
isons of mean CFSM scale measures were quite different be-
tween measures. Notably, the household scale measure could
be calculated for only 362 respondents who responded affir-
matively to one or more items (Derrickson et al. 2000a,
Wright and Stone 1980). Therefore, only the CFSM had
household scale measures for respondents categorized as food
secure. The mean household scale measure was consistent with
the item calibration of Q2, “Worried food would run out.”
Household scale measures of the other CFSM categories cor-
responded well to their categorical algorithms outlined in
Table 2 (Hamilton et al. 1997a). However, in the adult hunger
category of both the adapted RC and adapted CCHIP mea-
sures, mean household scale measures were equivalent to Q9,
“Respondent did not eat enough.” Q9 is much less severe than
Q10, in which the respondent indicated she or he had per-
sonally experienced hunger (Hamilton et al. 1997a, Derrick-
son et al. 2001). Similarly, the mean household scale measures
for those classified as experiencing hunger among children in
 HOUSEHOLD FOOD SECURITY MEASURES IN HAWAIÌ 755

TABLE 6
One-way ANOVA of selected variables by household food security categorical measures (n ⫽ 1603)1

Daily
Measures and vegetable Monthly Scale Item with item calibration value
categories RAI2 intake3 saimin4 measure5 closest to mean scale measure5

CFSM6
Food secure 0.2a 2.00a 3.9a ⫺4.05a Q2. Worried food would run out
Food insecure 2.3b 1.72a 9.5b ⫺1.96b Q5. Reliance on low-cost foods
Moderate hunger 3.7c 1.18b 7.7b 0.53c Q8a. Adults skip/cut size often
Severe hunger 5.2d 1.29a 14.2c 2.52d Q12a. Adults not eat 1⫻ day often
Face valid
Food secure 0.2a 2.02a 3.7a — —
⫺2.84a

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At risk of hunger 1.8b 1.67b 8.4b Q4/5. Unable to eat balanced meals
Adult hunger 3.8c 1.45b 7.9b 0.10b Q8a/Q10. Respondent hungry
Child hunger 5.0d 1.00b 13.5c 1.61c Q13/14. Children hungry
Adapted Radimer
Cornell
Food secure 0.2a 2.02a 3.7a — —
Food insecure 1.4b 1.75a 6.8b ⫺3.39a Q3. Food didn’t last
Adult hunger 3.0c 1.40b 8.4b ⫺1.01b Q8/9. Adult not eating enough
Child hunger 4.1d 1.36b 12.9c 0.67c Q7. Children ate less than should
Adapted CCHIP6
No hunger 0.2a 2.02a 3.7a — —
Only worried 1.2b 1.44a 10.4b ⫺4.54a Q2. Worried food would run out
At risk of hunger 1.8c 1.67a 8.1c ⫺2.72b Q4. Unable to eat balanced meals
Adult hunger 3.4c 1.52a 5.5b ⫺0.34c Q8a. Adult often cut size/skip
Child hunger 4.2d 1.36b 12.9c 0.67d Q7. Children ate less than should

1 The sample size of 1603 includes all respondents from the Hawaiı̀ Health Survey and all food pantry respondents but not those who completed
the survey a second time (n ⫽ 61). All tests were conducted with Tukey’s post hoc test after significant F tests. Subscript letters indicate that mean
values in a column were not statistically significantly different from mean values with the same letter.
2 The range of resource augmentation index (RAI) values are from 0 to 8 for households with children and a maximum of 6 for households without
children.
3 Represents average daily vegetable intake of respondent.
4 Indicates the maximum saimin intake of anyone in the household in the last month.
5 Sample size ⫽ 362.
6 CFSM, Core Food Security Module; CCHIP, Community Child Hunger Identification Project.

both adapted measures were consistent with Q7, “Children
not eating enough.” Again, Q7 is less severe item than Q14,
“Child hunger” (Derrickson et al. 2001, Hamilton et al.
1997a). The FVFSM did yield mean scale measures for each
food security category that were consistent with the concep-
tual basis of the CFSM measure as outlined in Table 1. It was
the only measure with hunger categories that consistently
corresponded with a respondent’s report of experiencing “hun-
ger” (Q10 and Q14).
DISCUSSION
This study marks the first independent evaluation of the
CFSM categorical food security measure.
Findings confirm our hypothesis that in Hawaiı̀, the CFSM
categorical measure does not reliably or accurately categorize
food insecure households based on the face validity of affir-
mative responses. The CFSM modal response pattern was not
reproducible. Most households did not follow a modal response
pattern. These results may be due to differences in ethnic and
geographical composition between samples (Hamilton et al.
1997b, State of Hawaiı̀, Department of Business, Economic
Development and Tourism 1997). Thus, caution should be
used in extrapolating these findings. However, like the CFSM
scale measure (Derrickson and Anderson 2000a), the identi-
fied weaknesses found with the CFSM categorical measure in
Hawaiı̀ are likely to exist across many samples. For instance:
1. The questionable reliability of the modal response pat-
tern (the basis for the CFSM categorical measure) was
also reported in the original CFSM work (Hamilton et
al. 1997a). In the 1995 CPS study, the authors report
that 82% of households without children followed the
CFSM modal response pattern. However, 65% of these
households responded “no” to all items. Of the house-
holds responding to at least one item affirmatively, only
49% followed the modal pattern (Hamilton et al.
1997a). Moreover, a majority of these respondents affir-
matively answered less than four items. No data were
reported on the reliability of the modal response pattern
for households with children.
2. Radimer (1999) questioned the credibility of requiring
three or more affirmative responses. Her field experience
with food insecure households was similar to our own
(Derrickson and Anderson 2000, Radimer 1990). Her
conceptual work contributed immensely to the CFSM
operationalized framework outlined in Table 1 (Bickel
et al. 1996).
3. The questionable credibility of categorization arises
when a comparison of the content of affirmative re-
sponses confirms the observations of Bavier (1999). He
inquired why the content of responses (i.e., Q10, “Re-
spondent hungry”) in national data sets do not more
consistently align with the CFSM categorization (Mod-
erate hungry).
756 DERRICKSON ET AL.
Some probable causes of the uncertain aspects of the CFSM
categorical measure are as follows:
1. High measurement variability affects categorization.
The experience of household food insecurity reported by
respondents varies. Households do not uniformly reply
to food insecurity indicators in the same manner because
their experience of household food insecurity varies.
2. The dependence on a modal response pattern for cate-
gorization is a fundamental problem. Because food inse-
curity is not reported in a highly consistent manner, the
content of questions to which a household responds
affirmatively to varies across households. Thus, face or
content validity of the CFSM will always be an issue
unless a high percentage of food insecure households
follow the modal response pattern.
3. Summing ordinal scales is not a valid means of making
quantitative comparisons. The same “respondent food
security sum” can result for different reasons (Fisher
1993).
4. Food insecurity is a multifaceted phenomenon. Psycho-
logical (Q2) and qualitative (Q4 and Q6) items are
incorporated into a measure that is primarily focused on
quantitative aspects of food insecurity.
5. There are multiple “targets” of the questions. To clarify,
there are three questions pertaining to the entire house-
hold (Q2, Q3 and Q4), four questions that pertain only
to adults in the household (Q8, Q8a, Q12 and Q12),
three questions that pertain only to the respondent (Q9,
Q10 and Q11) and eight questions that pertain to all
children in the household (Q5, Q6, Q7 and Q13–16).
If the face or content validity of responses to specific items
is valued, then the CFSM appears to underreport the severity
of food insecurity across all food security categories. Perhaps a
categorical measure fundamentally based on a modal response
pattern can be highly reliable only if response variance is low,
the measure is narrowly focused and the survey instrument
contains questions that affirm food security (Derrickson et al.
2000a). Alternately, if a pattern of responses is valued, regard-
less of the face validity of categorization, the CFSM appears to
accurately measure increasing severity of food insecurity.
Implications for food security monitoring. One practical
application of any food security measure is to separate food
secure households from food insecure households. Notably, all
three alternative food security measures require only one af-
firmative response, whereas the CFSM requires three affirma-
tive responses. Furthermore, respondents with only one affir-
mative response to Q2 (Only worried about food insecurity)
exhibited behaviors consistent with food insecurity (decreased
vegetable intake, greater reliance on alternative food resources
and low cost foods). This finding suggests that households with
only one affirmative response to the least severe item appear to
be food insecure, not food secure. If only one affirmative
response was required to classify food insecure households,
then the CFSM measure would underestimate the prevalence
of household food insecurity across the nation. Table 5 illus-
trates that in food secure populations, this difference may
appear to be relatively small (3–5%). However, in food inse-
cure populations, the difference in prevalence estimates may
be large (10 –15%). A reassessment of the CFSM categorical
measure appears warranted for the following reasons:
1. These estimates pertain to a percentage of households,
not the number of people in households.
2. Food security is an important item of the well-being of
any population.
3. In addition, the federal government, which oversees
food security monitoring, also oversees funding and ad-
ministration of food and nutrition assistance programs
designed to enhance food and nutrition security.
If an unreliable or inaccurate food security categorical mea-
sure is used as a risk criterion for assistance, as a screening tool
or even in comparative surveillance efforts, vulnerable seg-
ments of our population may be adversely affected.
Previously, Derrickson (1999) reported that for reasons of
respondent fatigue and lower cost of administration and to
minimize the loss of dignity of the respondent over sensitive
questions, a smaller set of food security questions should be
used). Embretson (1996) has argued that “shorter tests can be
more reliable than longer tests.” One hesitation over using a
shorter set of questions, or requiring only one affirmative
response to categorize households, may be the fear of increased
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false-positive responses (when persons respond affirmatively to
having experienced a certain degree of food insecurity when
they really have not). However, self-reporting of hunger-re-
lated items is a sensitive domain, one more likely to be
underreported than overreported (Derrickson 1999 and 2001,
George Chee, ‘Ohana Community Food Service, personal
communication, Honolulu, Hawaiı̀, November 5, 1999).
Thus, false-negative responses will likely counter false-positive
responses.
Based on the work of Blumberg and colleagues (1999), the
federal government now offers a “standard 6-item indicators
set” as an alternative to the 18 items. In previous work, we
support the concept of a shorter measure, particularly because
it reduces respondent burden and is less expensive to admin-
ister (Derrickson et al. 1999). However, the recommended set
of six items (Q3, Q4, Q8, Q8a, Q9 and Q10) did not ade-
quately meet Rasch fit statistics in Hawaiı̀ (Derrickson et al.
1999 and 2000a). Furthermore, this set of six questions does
not capture the important element of anxiety measured by Q2
(“Worried food would run out”), nor does it capture hunger
among children. Alternatively, the FVFSM may be more ef-
fective as a simple food security monitoring tool. For instance,
the FVFSM relies on four CFSM items to distinguish house-
hold food security from household food insecurity (Q2, Q3, Q4
and Q9 or Q8), two items to classify adult hunger (Q10 and
Q12) and one item (Q14) to identify hunger among children.
Thus, only seven items would be required to implement the
FVFSM. If an administration protocol is similar to that of the
CFSM (Bickel et al. 2000), then all food secure households
(80 – 85%) would be screened out before Q10 (“Respondent
hungry”). Further verification of the criterion-mediated valid-
ity of the FVFSM has been reported by Derrickson et al.
(2000b).
Future work. In summary, findings indicate acceptable
concurrent validity of all four measures assessed. Results are
consistent with previous work (Hamilton et al. 1997b, Rad-
imer 1999) and are grounded in qualitative work and research
with the CFSM scale measure (Derrickson and Anderson
2000, Derrickson et al. 2000a). Notably, findings also raise
questions regarding the credibility and reproducibility of the
CFSM, which indicate that further assessment of the CFSM
categorical measure is warranted. Because the CFSM has pro-
vided benchmark food security prevalence estimates (Hamil-
ton et al. 1997b, Nord et al. 1999), changes in the national
food security categorical measure may be problematic. Never-
theless, our findings indicate that households with only one
affirmative response shown signs of food insecurity. The first
step then in reassessing the CFSM may be reclassifying house-
holds with one or two affirmative response as some mild form
of “Food insecurity without hunger.”
 HOUSEHOLD FOOD SECURITY MEASURES IN HAWAIÌ
ACKNOWLEDGMENTS
We are indebted to Gary Bickel, the Hawaiı̀ State Department of
Health, Office of Health Status Monitoring, SMS Research and
Marketing Service, Inc. staff, George Chee, Dwayne Makalena, var-
ious Salvation Army staff members on O’ahu and Scott Derrickson
for their constructive suggestions and editorial assistance.
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