...... :UNIVERSrrY of ORTHERN BRITISH COLUMBIA LI BRARY Prince George, B.C. FOOD INSECURITY IN ABORIGINAL WOMEN LIVING WITH HIV/AIDS: EVIDENCE-INFORMED HEALTH PROMOTION INTERVENTIONS FOR FAMILY NURSE PRACTITIONER PRACTICE by Shannon M. Martens BSN, University ofSaskatchewan/SIAST, 2001 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRISTISH COLUMBIA APRIL 2014 © Shannon M. Martens, 2014 ABSTRACT Food insecurity negatively affects HIV/AIDS populations. The purpose of this integrated literature review is to identify evidence-informed health promotion interventions to prevent and treat food insecurity amongst Aboriginal women living with HIVI AIDS in rural and remote British Columbia, Canada. A comprehensive literature search identified 31 pieces of literature for data analysis. The highest priority identified for family nurse practitioner practice was advocacy for healthy public policy: increase social assistance and the Family Bonus, expand the monthly nutritional supplement to include all with HIV/AIDS, and include remote Aboriginal communities in the Nutrition North Canada Program. The next identified priority was community action initiatives including: community hunter, gardening, and kitchen programs, as well as food banks. Finally, on the individual level, interventions included food insecurity assessment, nutritional counselling, micronutrient supplementation, and addressing depression and addictions. Through utilization of these interventions, family nurse practitioners will be enabled to effectively address food insecurity. ii TABLE OF CONTENTS Abstract 11 Table of Contents lll List of Tables v List of Figures Vl Acknowledgements Vll Chapter One Introduction 1 Chapter Two Background and Context HIV/AIDS Food Insecurity Factors Associated with Food Insecurity in HIV/AIDS Consequences of Food Insecurity in HIV/AIDS Setting and Population Nurse Practitioner Practice Research Question 6 6 15 20 22 Chapter Three The Theoretical Framework 23 Chapter Four Approach to the Project 27 Chapter Five Findings Food Insecurity Assessment and Knowledge in FNP Practice Food Assistance: A Food Insecurity Intervention in HIV/AIDS Community Interventions for Food Insecurity Policy Interventions for Food Insecurity Food Insecurity Interventions in Rural and Remote Aboriginal Communities Personal Interventions for Food Insecurity 32 34 47 Chapter Six Discussion Policy Interventions to Address Food Insecurity Community Interventions to Address Food Insecurity Personal Interventions to Address Food Insecurity Evaluation 53 54 57 63 69 Chapter Seven Summary and Conclusion 72 iii 8 9 13 35 38 41 45 74 References Appendices A B C D E F Literature Search Record Summary of Literature Retained for Data Analysis Household Food Security Survey Model (HFSSM) Scoring the HFSSM Resource Information Recommendations for Food Insecurity Interventions iv 89 94 98 102 103 104 LIST OF TABLES Table 1 Key Terms 31 Table 2 Short and Long-Term Objectives for Outcome Evaluation 70 Table D1 Food Security Status based on HFSSM 102 v LIST OF FIGURES Figure 1 29 Literature Search Strategy vi ACKNOWLEDGEMENTS All praise be to God the Father, Jesus, and the Holy Spirit, for giving me grace to finish this project. Without Your presence and wisdom, I would never have made it through. Thank you to my friends, family, and children. You sacrificed your needs to allow me the time to complete this task. Thank you for your patience, prayers, and listening ears. Thank you to my supervisors, Khaldoun, Erin, and Lela. You have provided a pathway for the completion ofthis project. Your insight is the foundation and structure of all that lies within this paper. vii 1 CHAPTER ONE Introduction Food security is emerging as a significant topic within the health community. The definition of food security is "access by all people at all times to enough food for an active, healthy life and includes at a minimum: a) the ready availability of nutritionally adequate and safe foods, and b) the assured ability to acquire acceptable foods in socially acceptable ways" (Anderson, 1990, p . 1575). Food insecurity, then, occurs when, "the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain" (Anderson, 1990, p. 1575). Food security is a basic human right and an important social determinant ofhealth (Mikkonen & Raphael, 2010). The social determinants of health are the living conditions and sociocultural circumstances that affect health such as food security, income, early childhood development, and housing: these factors can affect health measures such as life expectancy and chronic disease (Mikkonen & Raphael, 201 0). Thus, food insecurity can negatively influence health, especially in marginalized populations. As such, food security is increasingly discussed within the context of care of those with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) (Anema, Vogenthaler, Frongillo, Kadiyala, & Weiser, 2009). HIV is a retrovirus that damages the body's immune system (Centre for Disease Control and Prevention [CDC], 2014). Infection with HIV can lead to AIDS; this is characterized by the presence of a weakened immune system as measured by lowered CD4 counts or the occurrence of opportunistic infections (CDC, 2014) . Untreated, HIV may progress to AIDS in several years to one decade (CDC, 2014). However, with medications known as highly active 2 antiretroviral therapy (HAART), HIV -infected individuals can live decades before developing AIDS (CDC, 2014). HAART refers to a combination of at least three antiretroviral medications designed to suppress the replication of the HN virus within the body (HN Infosource, 2009). The advent ofHAART has led to declining rates ofHN infection globally (British Columbia Centre for Excellence in HNIAIDS [BC-CfE], 2011; Joint United Nations Programme on HNIAIDS [UNAIDS], 2012). Nevertheless, HNIAIDS remains a significant problem for many. Worldwide, 34 million individuals were living with HNIAIDS in 2011 (UNAIDS, 2012). Sub-Saharan Africa has the highest rates ofHN infection; 4.9% of the population are affected by HNIAIDS (UNAIDS, 2012). In the United States of America (USA), an estimated 1, 148, 200 people were infected with HNIAIDS at the end of2009 (CDC, 2012). In Canada, 71, 300 people were estimated to be living with HNIAIDS, with 3, 175 new cases at the end of2011 (Public Health Agency of Canada [PHAC], 2012). From this data, it can be concluded that HNIAIDS is a problem within resource-rich countries as well as resource-poor countries. In fact, HNI AIDS is a pandemic that is disproportionally associated with poverty even in resource-rich settings (Kalichman et al. 2010). Poverty contributes to inadequacies in the social determinants of health creating stigma, marginalization, and inability to meet basic needs: this increases vulnerability to HN infection through increased risky behaviours such as exchange of sex for money, substance use, and decreased access to health care (Canadian AIDS Society, 2004; Kalichman et al. , 2010). Poverty and HN often coexist; thus, food insecurity has emerged as a significant topic in HNIAIDS care. Food insecurity is a social determinant of health that has the potential to negatively affect the health of HNI AIDS 3 individuals. In HIV/AIDS populations, food insecurity has been linked with nonadherence to HAART, depression, worsening immunological status, weight loss and wasting, and overall mortality (Anema et al., 2011; Campa et al., 2005; McMahon, Wanke, Elliott, Skinner & Tang, 2011; Weiser et al., 2008; Weiser et al., 2009b). Therefore, food insecurity is an important variable to consider in the care of HIVI AIDS populations affected by poverty. The health of Aboriginal people (First Nations, Inuit, and Metis people) in Canada is negatively affected by disparities in the social determinants ofhealth (Adelson, 2005). These socioeconomic disparities have increased the vulnerability of Aboriginal populations to higher rates ofHIV/AIDS and food insecurity (Health Canada, 2007; PHAC, 2010b; Willows, Veugelers, Raine, & Kuhle, 2009). In particular, rural and remote Aboriginal communities experience high rates of food insecurity, ranging from 48-7 5% (Mercille, Receveur, & Potvin, 2012; Thompson et al., 2011). In addition to Aboriginal populations, women are more vulnerable to food insecurity due to their unpaid role as caregivers, lower wages, and domestic violence (Mikonnen & Raphael, 201 0; Power, 2008). It is due to the breadth of these disparities that the population of interest for this project will be Aboriginal women living with HIV/AIDS and food insecurity in rural/remote BC communities. Nurse practitioners are well situated to address food insecurity in Aboriginal populations affected by HIV/AIDS. In British Columbia (BC), family nurse practitioners (FNPs) autonomously provide primary care to all ages (College of Registered Nurses of British Columbia [CRNBC], 2010a). Tarlier and Browne (2011) contend that FNP practice is well equipped to address the health inequalities experienced by remote Aboriginal communities due to geographical location and social marginalization. FNP practice is guided by core competencies including professional role, responsibility, and accountability, health 4 assessment and diagnosis, therapeutic management, and health promotion and prevention of illness/injury (CRNBC, 2010a). The competency ofhealth promotion will be prioritized in this project; although, all areas of FNP competency are necessary and will be utilized. The essence of promoting health is enabling individuals and populations to increase their ability to control and improve their health (World Health Organization [WHO] , Health and Welfare Canada, & Canadian Public Health Association, 1986). Therefore, enabling Aboriginal women living with the health disparities of HIVI AIDS and food insecurity to improve their health through increasing food access and personal control over food supply is health promotion. For this reason, this project will use the Ottawa Charter for Health Promotion by the WHO et al. (1986) to apply a health promotion lens to the identification of foodinsecurity interventions. In order to identify effective initiatives and apply best practices, FNPs also utilize an evidence-informed practice approach. Evidence-informed practice utilizes research and practice knowledge of the best available quality to guide health practice, including health programming (U.S . Department ofHealth & Human Services [USDHHS], 20llb). Information in evidence-informed practice is applied with consideration of the culture and values of individuals and communities (USDHHS, 2011 b). Thus, an integrative literature review will be conducted utilizing an evidence-informed approach. The purpose of this integrated literature review is to identify evidence-informed health promotion interventions to prevent and treat food insecurity amongst Aboriginal women living with HIV/AIDS in rural and remote BC communities. As a prerequisite to identify effective interventions, it is necessary to examine the causes and consequences of food insecurity amongst Aboriginal women living with HIV/AIDS. Literature will be 5 selected and analyzed based on current interventions for food insecurity in HN/AIDS, Aboriginal, women, and general populations, and interventions addressing the potential causes of food insecurity in HNI AIDS. These food insecurity interventions will be primarily of use in FNP practice; however, other health professionals such as registered nurses, physicians, social workers, addictions and mental health counsellors, registered dietitians and other health care providers, and patient advocacy groups may also be able to utilize these interventions. 6 CHAPTER TWO Background and Context HIVIAIDS is a complex disease process which is influenced by many factors. In particular, food insecurity has negative health consequences in HIVI AIDS populations (Weiser et al., 2009b). As such, it is necessary to explore the background ofHIVIAIDS and food insecurity to understand each concept. The potential causes of food insecurity in HIVI AIDS populations will be researched and discussed, as well as the resulting negative consequences of food insecurity. The research question utilized to guide this integrated literature review is: "What are the best evidence-informed health promotion interventions that FNPs may employ to prevent and treat food insecurity among Aboriginal women living with HIVI AIDS in rural and remote settings?" The rationale for choosing this specific population, setting, and audience of this project will be discussed. Finally, the significance of this topic to FNP practice will be clarified and the research question will be presented. HIV/AIDS HIVI AIDS is a retroviral infection that damages the immune system; specifically Thelper cells called CD4lymphocytes are affected (Bennett, 2013). AIDS occurs when the immune system is impaired to the extent that opportunistic infections occur (Bennett, 2013). HIVI AIDS is monitored with CD4 counts and HIV-1 viral load to indicate disease progression and response to therapy (U.S. Department of Health & Human Services (USDHHS, 2011a). Mortality with HIV/AIDS has been dramatically decreased by the advent ofHAART (BC-CfE, 2011; UNAIDS, 2012). However, a 95% adherence rate to HAART is necessary in order to achieve a high likelihood of viral suppression (Paterson et al., 2000). Even relatively high rates ofHAART adherence (70 to 90%) are less likely to suppress the 7 HIV virus (Kitahata et al., 2004). Thus, HAART adherence is a critical factor in the care of HIVI AIDS populations. However, food intake is an important issue for individuals considering HAART therapy. HAART may increase appetite and metabolic demand causing food-insecure individuals to decline HAART due to fear of increased hunger (Frega, Duffy, Rawat, & Grede, 2010). Also, some forms ofHAART work better when taken with food. For example, darunavir, a protease inhibitor, increases 30% in bioavailability when taken with food (Busse & Penzak, 2007; Weiser et al., 2008). Side effects ofboth HIV infection and HAART, such as nausea and diarrhea, are lessened by adjusting food intake to frequent, appetizing meals: this may not be possible for those with food insecurity (de Pee & Semba, 2010). Hence, the lack of food may be a significant barrier to achieving viral suppression in a HIVI AIDS individual. Food insecurity also contributes to wasting and weight loss in HIVIAIDS. The CDC defines the HIV -associated wasting syndrome as an involuntary loss of 10% or more body weight with chronic diarrhea or chronic weakness and fever (USDHHS, 2011a). Causes of wasting and weight loss in HIVIAIDS are complex, including hormonal controls, malabsorbtion, and decreased dietary intake (Carbonnel et al., 1997; Dudgeon et al., 2006; Hsu, Pencharz, Macallan, & Tompkins, 2005). Even on HAART, wasting and weight loss may occur with serious outcomes such as disease progression and increased mortality (Grinspoon & Mulligan, 2003). Also, metabolic rates rise in HIVIAIDS. Resting energy expenditure (REE) is increased 10% in untreated HIVIAIDS adults; this rise in REE is likely similar in those on HAART and maybe even higher with opportunistic infections (Hsu et al., 2005; Kosmiski, 2011). The increase in REE actually compounds the need for an adequate 8 dietary intake; without the necessary intake, weight loss and wasting will occur (Kominski, 2011). Although, dietary intake may be decreased in HIV/AIDS due to dysphagia, anorexia, nausea, and depression/anxiety, food insecurity remains an important contributing factor (Fahey & Flemmig, 1997; Issac et al., 2008; Reynolds & Neidig, 2002). Given the increased risk of wasting and weight loss with subsequent mortality, food insecurity warrants special attention in the context of HIVIAIDS care. Food Insecurity It is important that FNPs are aware of the varying levels of food insecurity. One may be categorised as being food secure, moderately food insecure, or severely food insecure (Health Canada, 2007). Moderate food insecurity correlates with a compromise in the quality or quantity of food, without a large drop in food intake; whereas, severe food insecurity involves a reduction in the quantity of food consumption, a change in eating patterns, and the sensation of hunger (Health Canada, 2007). Additionally, members of the same household may have different levels of food security. Individual food security may vary within a household due to the relative division of food per each person (Food and Agriculture Organization of the United Nations [FAO], 2008). As such, a mother may experience severe food insecurity with hunger, whereas her child may be moderately food insecure with a lower quality diet. The causes of food insecurity are multifaceted. Health Canada (2007) found food insecurity was higher in households with low and low-middle incomes, single parent households led by women, and in less stable housing arrangements such as renting. Those on social assistance are particularly vulnerable to food insecurity. Social assistance is a safety net which provides funding for basic life necessities to those without an income; however, 9 60% of Canadian households on social assistance experienced food insecurity (Canadian Immigrant, 2011; Health Canada, 2007). Awareness of these risk factors can alert FNPs in practice to inquire regarding food insecurity. Awareness of food insecurity is increasingly relevant because food insecurity is on the rise in resource-rich countries. In the USA, 12.6% of the population were food insecure in 2003 to 2005 (Nord & Hopwood, 2008). In Canada, 7.7% of households were food insecure: 5.1% were moderately insecure and 2.7% were severely food insecure in 2007 to 2008 (Health Canada, 2012). However, since the recession in 2008, food bank usage in Canada has risen 31%, indicating that food insecurity may have increased (Food Banks Canada, 2012). Rates of food insecurity are even higher within HIV/AIDS populations. Norman et al. (2005) found that 52% of the HIV/AIDS population on HAART in BC were food insecure. More recently, Anema et al. (2011) reported that 71% of the HIV/AIDS population on HAART in BC reported food insecurity. Clearly, resource-rich countries are affected by food insecurity and HIVIAIDS populations within these countries are affected to a larger extent. Factors Associated with Food Insecurity in HIV/AIDS The potential causes of food insecurity in HIV/AIDS populations are similar in some respects to the general population. A review of five cross-sectional studies revealed four factors associated with food insecurity in HIV/AIDS : low income, unstable housing and homelessness, depression, and addictions (Anema et al., 2011 ; Normen et al. , 2005; Vogenthaler et al. , 2010; Vogenthaler et al. , 2011 ; Weiser et al., 2009a). Although the aim of cross-sectional research is not to explore causality, associations may be determined that suggest important areas of intervention to reduce food insecurity (Centre for Evidence Based 10 Medicine, 2013; Weiser et al., 2009a). Thus, although these associated factors may be the cause or the result of food insecurity, they will be explored as potential causes to identify areas of intervention for food insecurity. Income. Income is significantly connected with food insecurity in HIVIAIDS populations. Normen et al. (2005) reported that low income was associated with a 3.78 times greater likelihood of food insecurity. Similarly, Anema et al. (2011) found that low annual income was associated with a 3.15 times greater likelihood of being food insecure. These results are not surprising considering income has a significant association with food insecurity in the general population (Health Canada, 2007). Income is also associated with food insecurity in a stepwise fashion; in other words, food insecurity increases as income decreases (Health Canada, 2007; Norman et al. , 2005). However, even small increases in income were associated with lower food insecurity in low income HIVIAIDS populations (Vogenthaler et al., 2010). Therefore, FNP interventions that increase income for HIVIAIDS populations have the potential to decrease food insecurity, even in small amounts. As such, awareness of income sources for HIVI AIDS populations is necessary. People with HIVIAIDS may rely on different income forms such as employment insurance sickness benefit, long-term disability benefits, and Canadian and Quebec pension plan disability benefit (Canadian HIVI AIDS Legal Network [CHALN], 2005). However, social assistance is often the main source of income for marginalized populations including intravenous drug users (IVDU) and Aboriginal populations (CHALN, 2005). Social assistance benefits are under the poverty line in all provinces and territories in Canada (CHALN, 2005). For example, in BC, a single woman under the age of 65 years would receive $235 as a monthly support allowance and $375 as a monthly shelter allowance 11 (Ministry of Social Development [MSD], 2013). A woman with one child receives somewhat more: $375.58 as a monthly support allowance and $570 as a monthly shelter allowance (MSD, 2013). As well, the Family Bonus is allotted per child in BC: this is a combination of the Canada Child Tax Benefit, National Child Benefit Supplement, and a base amount (Government ofBC, n.d.). Overall, these amounts are still inadequate to meet basic needs. Thus, food insecurity interventions addressing income in this project will consider the adequacy of social assistance rates. Homelessness and unstable housing. Homelessness and unstable housing are also associated with food insecurity in HIVIAIDS. Homelessness was the strongest predictor of food insecurity in a study by Vogenthaler et al. (20 10). Likewise, Normen et al. (2005) found that unstable housing was associated with a 2.24 times greater likelihood of food insecurity in HIVI AIDS populations. Again, income is a factor because cost of housing contributes to homelessness. The Canada Mortgage and Housing Corporation (2012) notes core housing needs have increased from 2007 to 2009 due largely to lack of affordability. As cost of housing rises, low-income HIVIAIDS populations may use funding designated for food to pay for housing. Hanson (20 11) reported that women could not afford sufficient food due to high housing costs. This dichotomy between paying for housing versus paying for food may lead to eventual loss ofhousing in low income HIVIAIDS populations. However, as housing is lost or becomes less adequate (i.e. shelters, hotels), the availability of kitchens to store food and cook low-cost meals decreases; this also increases vulnerability to food insecurity. Given the increased incidence of inadequate and unstable housing in Aboriginal communities as well as HIVI AIDS populations, housing is a key area for FNP interventions for food insecurity in this project (Ontario HIV Treatment Network Rapid Response Service, 2011). 12 Depression. The literature on HIVIAIDS populations also reveals a strong association between depression and food insecurity. Vogenthaler et al. (2011) found that HIV/AIDS individuals with food insufficiency were 2. 73 times more likely to be depressed. Anema et al. (2011) found 67% of the HIV/AIDS population had depressive symptoms and were 2.34 times more likely to be food insecure. Similarly, Weiser et al. (2009a) found that food insecurity was linked to lowered mental health composite scores. Depression is also significant in Aboriginal communities: 30% of adults in on-reserve First Nations communities reported depressive moods and suicidal ideation (First Nations Information Governance Committee, 2005 as cited in Health Canada, 2009). FNP interventions targeting depression are relevant to Aboriginal HIV/AIDS populations with food insecurity. Addictions. Finally, an important area of intervention for FNP practice is addressing the various addictions associated with food insecurity in the HIV/AIDS literature. Anema et al. (20 11) found a 1. 85 times greater likelihood of food insecurity in those who utilize illicit drugs and a 2.30 times greater likelihood of food insecurity in those who smoked tobacco. Norman et al. (2005) reported a 2.31 times greater likelihood of food insecurity in those who utilized injection drugs in their lifetime. Weiser et al. (2009a) also observed that crack cocaine use was associated with a 2.06 times greater likelihood of food insecurity. These addictions may lead to food insecurity in several ways. Crack cocaine addicts may lead a chaotic life which may impair the ability to obtain basic needs; also, the cost of drugs and cigarettes may further limit funds available for food leading to increased risk of food insecurity (Weiser et al. , 2009a). Additionally, as a known anorectic, cocaine may contribute to wasting (Forester, Tucker, & Gorbach, 2005; Vicentic & Jones, 2007). This highlights the importance of addressing cocaine addictions, as well as general drug addictions and tobacco 13 use in food insecure HIVI AIDS populations. Additionally, the increased incidence of HIV transmission in Aboriginal populations attributable to IVDU suggests that addiction treatment within this project' s population will be beneficial (PHAC, 2010b). In summary, low income, unstable housing and homelessness, depression, and addictions were associated with food insecurity in HIVIAIDS populations. These factors also are relevant in Aboriginal populations. Although causality may not be determined, these associations provide important areas of entry point for the formation of food insecurity interventions in Aboriginal HIVIAIDS populations. As such, one area of project analysis will focus on interventions that address these potential causes of food insecurity in HIVI AIDS populations. Consequences of Food Insecurity in HIVIAIDS As previously mentioned, food insecurity can contribute to negative health consequences in HIVI AIDS populations. In particular, viral suppression and immune system recovery are reduced. McMahon et al. (20 11) found that CD4 counts did not recover as substantially in food insecure individuals on HAART: overall CD4 counts were lower by 99.52 cells. However, McMahon et al. did not consider HAART nonadherence as a factor; although, nonadherence has been linked with food insecurity in studies by Wang et al. (20 11) and Weiser et al. (2008). Wang et al. and Weiser et al. both found food insecurity was associated with lowered viral suppression; however, HAART nonadherence only partially explained this relationship. As further explanation, Wang et al. suggested that HAART decreased in bioavailability with lowered dietary intake. Overall, the previous studies indicate that food insecurity has a detrimental effect on the resilience of the immune system in HIVIAIDS; this is partially but not fully explained by HAART nonadherence. 14 Other serious outcomes of food insecurity in HIVI AIDS include wasting and mortality. Campa et al. (2005) reported an association between food insecurity and HIVrelated wasting. Likewise, Anema et al. (2013) and Weiser et al. (2009b) reported a link between food insecurity and increased mortality. Anema et al. found that food insecure IVDU living with HIVI AIDS were almost twice as likely to die compared to those who were food secure. Weiser et al. further explored the impact of food insecurity on non-accidental mortality with consideration oflow body mass index (BMI) as a modifying variable. Food insecurity combined with a low BMI was associated with a 1.9 times increased likelihood of mortality (Weiser et al. , 2009b). However, no increase in mortality was reported in food secure populations with a low BMI whereas the food insecure population without a low BMI still displayed a trend toward mortality approaching statistical significance (Weiser et al., 2009b ). This finding suggests that food security may lead to increased mortality through other mechanisms in addition to wasting. Possible linkages between food insecurity and negative health outcomes in HIVIAIDS populations include HAART nonadherence, depression, addictions, and a lowered bioavailability ofHAART (Weiser et al. , 2009b). As well, micronutrient deficiencies may be a pathway between food insecurity and a weaker immune system response (McMahon et al. , 2011). Food insecurity leads to malnutrition: this is a deficit, excess, or disproportional intake in either rnicronutrients or macronutrients (F AO, 2008). Macronutrients refer to fats , proteins, or carbohydrates and micronutrients refer to vitamins, minerals, antioxidants, and phytochemicals (Raiten, Mulligan, Papathakis, & Wanke, 2011 ; Tinnerello, 1999). Micronutrient deficiencies were found commonly amongst HIVIAIDS populations and the need for rnicronutrients seemed higher in this population (de Pee & 15 Semba, 2010). De Pee and Semba (2010) observed that deficiencies in micronutrients appeared to be associated with poor outcomes such as disease progression, increased transmission, and earlier mortality in HIVIAIDS populations. However, de Pee and Semba also discussed that it is difficult to isolate micronutrient deficiencies from other negative events occurring simultaneously such as opportunistic infections. The associations between food insecurity and negative health outcomes in HIVI AIDS are clear, although the explanations for these associations are multifactorial. The literature calls for longitudinal research to establish causality between food insecurity and negative health outcomes (Vogenthaler et al., 2010; Vogenthaler et al., 2011; Wang et al., 2011; Weiser et al., 2009a; Weiser et al., 2009b). More research is needed to understand the biologic and social linkages between food insecurity and other socioeconomic variables such as illicit drug use and depression (Anema et al., 2011). Nevertheless, the identified pathways ofHAART non-adherence, depression, addictions, decreased HAART bioavailability, and micronutrient deficiencies provide important points for intervention to prevent the negative outcomes associated with food insecurity. Setting and Population The recommendations of this project will be focused in order to be applicable to FNP practice in BC, Canada. BC was chosen as the setting because much of the available HIVI AIDS literature on the potential causes and consequences of food insecurity is set in BC with study populations recruited from the provincial HAART program (Anema et al., 2011; Anema et al., 2013; Normen et al., 2005; Weiser et al., 2009b). Canada is considered a resource-rich country, and the potential causes and consequences ofHIVIAIDS in the previous section were explored within resource-rich settings. Thus, the causes and 16 consequences of food insecurity can be applied to this project's population of Aboriginal women living with HIV/AIDS in rural and remote BC with consideration of the unique contextual factors and population health needs. Women populations. Women have a higher risk of food insecurity due to multiple factors. In general, women are more vulnerable to poverty due to their traditional roles of child rearing, housework, and caregiving which are largely unpaid in addition to lower workforce wages (Mikonnen & Raphael, 2010). In particular, women with children are more vulnerable to food insecurity, especially in single parent, female led households (Health Canada, 2007). Yet the presence of an intimate partner does not guarantee food security: women exposed to intimate partner violence and economic abuse are also at risk for food insecurity (Power, 2008). As well, women often skip meals and eat less preferred foods in order to ensure their children have enough to eat (Bove & Olsen, 2006; Hanson, 2011). Women often fulfill the roles of shopping and cooking for a household; therefore, improving food security by developing skills in women may improve the food security for an entire household. As such, women will be included in this project's population of interest. Aboriginal populations. Food insecurity is also higher amongst Aboriginal people: 21% of Aboriginal households were food insecure in 2007-2008 (Health Canada, 2012). As well, in a seminal Canadian survey representing 98% of the population in 2004, rates of food insecurity among Aboriginal populations were 3.6 times higher than the national rate (Health Canada, 2007). This is partially explained by the higher prevalence of socioeconomic risk factors including low income, not owning one's own home, having three or more children, and being in lone-parent households; however, a 2.6 times higher risk of food-insecurity remained even after adjustment for socioeconomic variables (Willow et al., 2009). As such, 17 socioeconomic disparities only partially explain the increased food insecurity in Aboriginal populations. Importantly, cultural food security, including the acquisition, consumption, and sharing of traditional foods, has declined, due in part to the relocation to urban centres, increased access to store bought food, changing migratory patterns of animals, and increased cost of hunting (Dietitians of Canada, 20 12; Powers, 2008). Lack of access to cultural foods may also explain the higher rates of Aboriginal food insecurity. In addition to food insecurity, Aboriginal people also experience a higher rate of HIV. In Canada in 2008, incidence ofHIV infection was 3.6 times higher in Aboriginal populations with IVDU as the primary mode of transmission (PHAC, 201 Ob ). Furthermore, the age of HIV infection is younger in Aboriginal populations and HIVI AIDS affects Aboriginal women disproportionally: 49% of new HIV infections were among Aboriginal women as compared to 21% in non-Aboriginal women from 1998 to 2008 (PHAC, 201 Oa). The increased incidence of HIVIAIDS in Aboriginal populations is again attributed to the inequities in the social determinants of health such as income, housing, early childhood development including abuse, exposure to prison, and racism (Adelson, 2005; PHAC, 201 Ob ). Aboriginal women, then, are more likely to contract HIV at a younger age and live with HIVIAIDS in a socioeconomically disadvantaged state. As such, they are the population of interest for this project. In order to comprehend the overrepresentation of food insecurity and HIVI AIDS in Aboriginal people, it is important to understand the generational trauma that Aboriginal people have experienced (Bombay, Matheson, & Anisman, 2009). Trauma experienced at the collective level in one generation may be passed on to subsequent generations (Bombay et al., 2009). Childhood trauma can lead to poor coping strategies and poor mental health which 18 may compromise parenting skills and contribute to subsequent trauma to the next generation (Bombay et al. , 2009). Important traumatic events that have occurred include loss of land, forced attendance in the residential school system, and the removal of many Aboriginal children into foster care (Bombay et al. , 2009). The history of colonialism and residential school trauma has formed the poor socioeconomic conditions that now increase the vulnerability of the Aboriginal population to HIVIAIDS (PHAC, 2010b). Adelson (2005) indicates that there are social, political, economic, and cultural disparities in Aboriginal populations which combine to cause health disparities such as disease, disability, and early death. Thus, inequalities in the social determinants of health, including food insecurity, are relevant to the discussion of HIVI AIDS in the Aboriginal population. Rural setting. Food insecurity is experienced differently in urban versus rural settings. To narrow the focus of this project, the setting will be rural and remote BC. HIVI AIDS is commonly assumed to be confined to urban populations (Varcoe & Dick, 2008). However, with the exception ofVancouver, parts ofNorthern Health, the Northwest and Northern Interior Health Service Delivery Areas, have the highest rates of new HIV infections in BC (BC Centre for Disease Control [BCCDC], 2012). This statistic does not distinguish between HIVIAIDS populations in northern urban centers such as Prince George, BC versus rural/remote communities. However, it is reasonable to presume there are Aboriginal HIVIAIDS populations also living in rural and remote areas of northern BC because Aboriginal populations often move between urban settings and their home communities (Northern Aboriginal HIVIAIDS Task Force, 2005). As such, a rural and remote Aboriginal HIVI AIDS population exists and will benefit from the interventions in this project. 19 Rural populations are defined by Statistics Canada (2011) as those who live outside of areas with populations of 1,000 or more: according to this defmition, 14% ofthe BC population lived in rural areas. However, rural may be defmed in multiple ways depending on the issue in question (duPlessis, Beshiri, Bollman, & Clemenson, 2001). This project seeks to address the needs of Aboriginal women that live in smaller centres in BC, even if the population is greater than 1,000. Thus, for this project, rural will be defmed as "towns or municipalities outside the commuting zone of larger urban centres (with 10,000 or more population)" (duPlessis et al. , 2001 , p. 6). Also, remote communities will be defmed as those more than 350 kilometers away from a service centre (or a city) with year-round road access (Skinner, Hanning, Desjardins, & Tsuji, 2013). Health in rural and remote areas is an area of concern. Romanow (2002) reported that rural and remote populations have a lower health status than those in urban centres. Rural populations experience higher mortality rates which is often related to a higher risk of circulatory disease, injuries, and suicide (Canadian Institute for Health Information, 2006). This may be partially explained by limited access to health care professionals and facilities, and increased expenses related to healthcare travel (Romanow, 2002). The unique health challenges in rural and remote communities will be considered within this project. As previously mentioned, food insecurity is prevalent in rural/remote communities (Thompson et al. , 2011). Added dimensions of food insecurity in remote Aboriginal communities include: high cost of store-bought food, limited choice in healthy food, and varying quality of fresh food (Dietitians of Canada, 2012). Aboriginal communities are often marginalized economically and may not have adequate infrastructure for food processing and production; and, transport networks may be less available (Fieldhouse & Thompson, 20 12). 20 Even in rural areas with road access, travelling to larger, cheaper supermarkets may be hindered by transportation barriers such as travel distance, lack of a vehicle, and cost of gasoline, vehicle repair, and vehicle registration (Bove & Olson, 2006; Mercille et al., 2012). The barriers of limited selection, high food prices, and limited transportation in rural and remote areas will be considered in the identification of food insecurity interventions. Additionally, barriers to health programing in ruraVremote communities must also be considered. These barriers were explored in women at risk for HIVI AIDS in rural BC by Varcoe and Dick (2008). Social programming may be unavailable or not appropriate to the needs of a rural population (Varcoe & Dick, 2008). Professional information may be leaked and assumptions are made about individuals who attend clinics, especially in regards to the stigmatized topics of mental health, HIV, and addictions (Varcoe & Dick, 2008). Lack of confidentiality and stigma may hinder efforts to form programs addressing food insecurity and HIVIAIDS : this will be considered in the formation of this project's interventions. Nurse Practitioner Practice The audience for this project will be FNPs working with Aboriginal women living with food insecurity and HIVI AIDS in ruraVremote communities. In addition, other health care professionals may also derive benefit from this project's fmdings . FNP practice will be defmed in order to exemplify to the various audiences how the interventions identified in this project fit within the scope ofFNP practice. Nurse practitioners (NPs) are advanced practice nurses that are educated at the graduate level to autonomously provide essential health services (Canadian Nurses Association [CNA] , 2010; CRNBC, 2010a). NP practice in BC is divided into three streams: family, adult, and pediatric (CRNBC, 2012). Family nurse practitioners (FNPs) deliver primary health care to all ages with a focus on the family as a 21 unit (CRNBC, 2012). As such, the family/household of Aboriginal women living with HIV/AIDS will be considered in this project's recommendations. Due to the renewed interest in the NP role over the last two decades, all provinces and territories in Canada now have legislation that provides definition and legal parameters for the NP role (Dicenso et al. , 2007; Tarlier & Browne, 2011). In BC, legislation of the NP role was passed in 2005; specifically, the Nurse (Registered) and Nurse Practitioner Regulation under the Health Professions Act governs NP practice (CRNBC, 2010b; Ministry of Health, n.d. ; Salyers et al., 2012). Additionally, the College of Registered Nurses of British Columbia (CRNBC) regulates NP education, examination, and licensure ofNP practice in BC (Salyers et al. , 2012). The core competencies as outlined by the CRNBC provide the requirements for NP registration (20 1Oa); thus, these competencies will also be utilized to identify food insecurity interventions appropriate to FNP practice. The NP core competencies will be further discussed in Chapter Three. FNPs are health care providers who are well positioned to address food insecurity in Aboriginal women living with HIVI AIDS in rural and remote areas. In fact, the NP role has grown out of the legacy of outpost nursing which provided necessary health care to rural and remote areas (Dicenso et al. , 2007; Tar1ier & Browne, 2011). The provision of primary health care to underserved and marginalized populations is central to the values ofNP practice (Tarlier & Browne, 2011). FNP education by the University ofNorthem British Columbia continues to support this value by focusing on educating graduate students to provide primary health care for rural and remote populations (Salyers et al. , 2012). Thus, FNPs graduate with knowledge and resources to address the health needs of rural and remote 22 populations. As such, marginalized populations in rural and remote BC will benefit from increasing FNP knowledge and ability to treat food insecurity. Research Question As mentioned before, the purpose of this project is to identify evidence-informed health promotion interventions to prevent and treat food insecurity amongst Aboriginal women living with HIVI AIDS in rural and remote BC settings. Therefore, the research question utilized to guide this integrated literature review is: "What are the best evidenceinformed health promotion interventions that FNPs may employ to prevent and treat food insecurity among Aboriginal women living with HIVI AIDS in rural and remote settings?" The rationale for addressing food insecurity in Aboriginal women with HIVIAIDS in rural and remote settings has already been discussed. The following Chapter will discuss the concept of health promotion, and the role of the Ottawa charter and NP competencies in identifying the most appropriate, applicable food-insecurity interventions for this project. 23 CHAPTER THREE The Theoretical Framework NP practice is grounded theoretically in the principles of primary health care: accessibility, public participation, health promotion, appropriate technology, and intersectoral collaboration (CNA, 201 0; CRNBC, 201 Oa). Within primary health care, health promotion is identified as a key competency in NP practice. Health promotion is defmed as, "the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and realize aspirations, to satisfy needs, and to change or cope with the environment" (WHO et a!., 1986, para 1). Health promotion is a process that enables people to better their own state of health, including the social determinants of health. Health promotion is one of four categories of the NP core competencies: professional role; responsibility; and accountability, health assessment and diagnosis, therapeutic management, and health promotion and prevention of illness and injury (CRNBC, 201 Oa). NP core competencies have been developed to ensure entry-level NPs possess appropriate and safe skills for practice, to review NP education programs, and to design NP testing (CRNBC, 201 Oa). A full discussion of the entry-level competencies for NP practice may be found in Competencies Required for Nurse Practitioners in British Columbia by the CRNBC (2010a). To ensure relevance to FNP practice, the CRNBC conducted a revision process in 2009-2010; this included obtaining perspectives from practicing FNPs. Thus, NP core competencies have been developed to reflect the practice of current FNPs. In order to address food insecurity, FNPs will need to utilize all four categories ofNP core competency. Patients must first be assessed for food insecurity and diagnosed. The 24 individual causes of food insecurity may require therapeutic management competencies such as pharmacotherapy for depression. Research and leadership competencies are required to generate knowledge and develop appropriate food insecurity resources. Finally, health promotion is a key NP competency applied in the identification of food insecurity interventions. As previously discussed, food is a resource for health, and assisting this project's population to increase food access is a form of health promotion. Therefore, in this project, a health promotion lens will be applied to the identification of food insecurity interventions for Aboriginal women living with HIVIAIDS in rural/remote BC. Specifically, The Ottawa Charter for Health Promotion by the WHO et al. (1986) will be used. Methods employed in health promotion include advocating, enabling, and mediating; these methods may be used to support equitable access to the social determinants of health (WHO et al., 1986). Advocacy for health is aimed at political, economic, social, environmental, and cultural factors which affect health (WHO et al., 1986). Enabling populations includes improving access to resources and education, as well as increasing control over health choices (WHO et al. , 1986). Mediating involves reconciling differences between competing aspects of society towards the goal of healthier policies, products, and environments (WHO et al. , 1986). Advocating, enabling, and mediating are employed in five health promotion strategies as indicated by The Ottawa Charter for Health Promotion (WHO et al., 1986). 1. Building healthy public policy addresses health, income, and social policy changes that promote greater equity. 2. Creating supportive environments promotes the development of safe and enjoyable technology, work environments, energy production, and urbanization. 25 3. Strengthening community action involves the empowerment of communities to take ownership, make decisions, and plan strategies to further their health. 4. Developing personal skills involves providing information, education, and supporting the development of life skills on a personal level. 5. Reorienting health services involves the redirection of the health sector towards the provision of health promotion services, in addition to clinical and curative services. These health promotion strategies provide the theoretical framework upon which the interventions for addressing food insecurity in this project will be founded. Health promotion principles will also support this project's interventions. The concept of empowerment will be utilized: this is, "enabling individuals and communities to assume more power over the personal, socioeconomic, and environmental factors that affect their health" (Rootman et al., 2001 , p. 4). Also, the health promotion principles of participation, equity, intersectoral collaboration, and sustainability will be considered in the identification of food insecurity interventions (Rootman et al. , 2001). Finally, health promotion strategies utilize a multi-strategy approach (Rootman et al. , 2001). For example, health promotion strategies are delivered at different levels of society, including the personal level, the social or community level, and the structural level (Jackson et al. , 2006). Similarly, FNP practice takes place at the individual level, but also at a community and population level (CRNBC, 201 Oa). Employing multiple health promotion strategies at all three levels is more effective (Jackson et al. , 2006). Therefore, this project will identify food-insecurity interventions on all three levels. This project will utilize the five health promotion strategies of building healthy public policy, strengthening community action, creating supportive environments, developing 26 personal skills, and reorienting health services to provide the framework for proposed food insecurity interventions in Aboriginal women living with HIV/AIDS . Underlying principles of health promotion will be incorporated including empowerment, participation, equity, intersectoral collaboration, a multi-strategy approach, and sustainability (Rootman et al., 2001). Most importantly, the interventions will fit within the NP core competencies, so as to ensure the relevance of the proposed food insecurity interventions to the scope of FNP practice. Interventions will be evidence-informed; this aspect is applied through appraisal of the evidence in the literature analysis in Chapter Five and application of this evidence with consideration of the values and culture of Aboriginal women living with HIVI AIDS in rural/remote BC. The next Chapter describes the approach to the literature search and analysis. 27 CHAPTER FOUR Approach to the Project A systematic approach to the literature search was applied in order to address the research question, "What are the best evidence-informed health promotion interventions that FNPs may employ to prevent and treat food insecurity among Aboriginal women living with HIVI AIDS in rural and remote settings?" Key terms selected at the beginning of the research process included: human immunodeficiency virus, HIV, acquired immunodeficiency syndrome, AIDS , food security, and food insecurity. As the research question was refined, more key terms were added. See Table 1 on p. 31 for a summary of key terms utilized. Electronic databases were selected according to the hierarchy of pre-processed information (Fyfe, 2013). The following databases were searched with key terms: National Guidelines Clearinghouse, Clinical Practice Guidelines and Protocols in BC, Cochrane Reviews, Evidenced Based Nursing, MEDLINE (OVID), MEDLINE with full text, and CINAHL with full text. A series of internet searches were conducted and grey literature websites were reviewed and/or literature was retrieved from: the Saskatchewan Ministry of Health, Health Canada, the Public Health Agency of Canada, the World Health Organization, Food and Agriculture Organization of the United Nations, Food Secure Canada, Food Secure Saskatchewan, BC Food Security Gateway, Saskatchewan Ministry of Social Services, British Columbia Centre for Excellence in HIVIAIDS, BC Ministry of Social Development and Social Innovation, Ministry of Health: BC Guidelines, Canadian HIVI AIDS Legal Network, Canada Mortgage and Housing Corporation, Dietitians of Canada, the Positive Living Society of British Columbia, and AIDS Saskatoon. Please refer to Appendix A on p. 89 for the literature search review, numbers of hits, and articles retained. 28 The literature search for this project occurred in three installments. The initial literature search retrieved literature on food insecurity interventions in resource-poor HIVIAIDS populations, and literature on the causes and consequences of food insecurity in resource-rich HIVI AIDS populations. Literature on food insecurity interventions in resourcerich HIVIAIDS populations was not found. Next, a second literature search retrieved literature on food insecurity interventions in women and Aboriginal populations, as well as NP and health promotion literature. A preliminary search for intervention literature on the potential causes of HIVI AIDS food insecurity was performed. After further consideration, a third literature review was completed, focusing on food insecurity interventions in the general population and interventions addressing the potential causes of food insecurity in HIVIAIDS . See Figure 1 on p. 29 for a search strategy summary. Inclusion and exclusion criteria were also applied. Inclusion criteria were as follows: individual studies, systematic reviews, clinical practice guidelines, and governmentaVagency publications on interventions pertaining to food insecurity in HIVIAIDS, Aboriginal, women, and general populations in a resource-rich Canadian and USA settings. However, literature on food insecurity interventions in resource-poor HIVI AIDS populations was also included, due to the lack of literature set in resource-rich settings. Finally, intervention literature was included on the potential causes of food insecurity in HIVIAIDS populations: low income, homelessness and unstable housing, depression, and addictions. Exclusion criteria left out the populations of HIV infected children and pregnant women and the subject ofHIV transmission. Literature set in resource-poor areas was largely excluded except as previously described. Literature in non-English languages and over 10 years old was also excluded. Editorial and opinion papers were largely excluded as lower 29 forms of evidence; however, exceptions were made for key expert opinions on food insecurity and addictions. Food insecurity literature that did not discuss interventions was excluded from the literature analysis, though utilized in the introduction and background. Literature solely focused on healthy eating was excluded; because, no specific information was provided on the treatment of food insecurity. Figure 1 Literature Search Strategy Initial Literature Search: 97 pieces of literature Second Literature Search: 32 pieces of literature 1 190 pieces of literature plus 8 articles suggested by supervisor = 198 pieces of literature Initial overview: Reviewed for relevance and inclusion/exclusion criteria. 51 pieces of literature l Reviewed in-depth utilizing methods as described below \II 31 pieces of literature See Appendix B on p. 94 for a summary. Third Literature Search: 61 pieces of literature 30 As outlined in Cronin, Ryan, and Coughlan (2008), an initial overview of the literature was performed, applying inclusion and exclusion criteria. Fifty-one pieces of literature were selected for in-depth analysis, and were grouped according to themes. Critical appraisal of the quantitative and qualitative data was guided by the process outlined by Bums and Grove (2009) . Comprehension, comparison, analysis, and evaluation of quantitative literature were performed, including consideration of statistical conclusion validity, internal validity, and external validity (Bums & Grove, 2009). Qualitative literature was analysed for descriptive vividness, methodological congruence, analytical preciseness, theoretical connectedness, and heuristic relevance (Bums & Grove, 2009). Systematic reviews were analyzed utilizing the appraisal tool set forth by the Public Health Resource Unit (2006) . Clinical practical guidelines (CPGs) were examined utilizing a rapid evaluation tool that was developed from information by Slutsky (2005). Non-research literature including governmental reports, agency reports, and two review articles was analyzed for purpose, credibility, quality, content, coherence, recommendations, key thoughts, and strength and weaknesses as outlined by Cronin et al. (2008). The level of evidence was considered according to the level of evidence pyramid by Evidence-Based Nursing (2006) . Thirteen pieces of literature were subsequently found to fit with the exclusion criteria, due to date of publication greater than ten years old, lack of food insecurity interventions, and as lower forms of evidence (editorial). One descriptive review was excluded for lack of relevance to the rural/remote setting. Six quantitative studies were excluded due to major threats to internal, external, and statistical conclusion validity, as well as failure to obtain ethical approval combined with fmancial coercion in one study. Thirty one pieces of literature were retained in which the strengths outweighed weaknesses: these will be 31 analyzed in Chapter Five. See Appendix B on p. 94 for a summary of literature included in this integrative literature review. Tabl e 1 IGey T,erms Disease Food Nurse Insecurity Practitioners/ Population HIV[MeSH], AIDS , Acquired Immunodeficiency Syndrome [MeSH], Human Immunodeficiency Virus. Food Insecurity, Food Security, Food Supply [MeSH]. Nurse Practitioners, Aboriginal, First Nation, First Nations People, Indians, (North American), Native Americans, Women, Rural Population [MeSH]. Framework Interventions Ottawa Charter, Evidenced Based Practice, Health Promotion Theory. Nutritional Support, Supplementary Feeding, Food Assistance, Dietary Supplements, Food Supplementation, Initiative, Strategy, Strategies, Counselling, Nutritional Counselling, Depression, Employment, Unemployment, Social Support, Livelihood Programs, Intervention, Intervention Studies[MeSH], Treatment, Therapy, Cocaine-Related Disorders [MeSH]. 32 CHAPTER FIVE Findings The purpose of this integrated literature review is to identify evidence-informed health promotion interventions to prevent and treat food insecurity in Aboriginal women living with HIVIAIDS in rural and remote BC settings. Thirty-one pieces of literature were included in the fmalliterature analysis including 18 studies, six government/agency reports, three systematic reviews, two CPGs, and two review articles: see Appendix B on p. 94. The literature was appraised utilizing methods as outlined in Chapter Four. Pertinent strengths and major weaknesses of the literature are discussed. However, strengths and weaknesses that did not affect the inclusion or relative importance of the literature are not discussed. Themes were developed based on levels of personal, community, and structural interventions in accordance with a health promotion approach. Other themes that emerged included: NP assessment and knowledge of food insecurity, food assistance in resource-poor HIVI AIDS populations, and food insecurity interventions in rural/remote Aboriginal communities. Also, literature was reviewed on interventions addressing the potential cause of food insecurity in HIV/AIDS : depression and addictions were reviewed in the personal interventions and income and housing were analyzed within the structural interventions. The literature was analyzed for applicability to Aboriginal women living with HIV/AIDS and food insecurity in rural/remote BC. The literature on food assistance was set in resource-poor settings such as Haiti, where poverty, natural disasters, and political instability increase vulnerability to food insecurity (Ivers, Chang, Jerome, & Freedberg, 2010). In comparison, rural/remote BC Aboriginal communities may have a different social environment and relatively more resources. However, rural/remote Aboriginal communities 33 can be economically marginalized with high rates of food insecurity: this is similar to some extent to resource-poor settings (Fieldhouse & Thompson, 2012; Thompson et al. , 2011). Thus, the results may be applied to this project's population with caution. Also, much of the literature has researched food insecurity in the urban setting. Interventions employed in urban settings can be adapted to the rural settings with consideration of the additional food security barriers such as transportation and availability of social programs. Application of food insecurity to this project's population will be discussed in depth in Chapter Six. Studies were analyzed for methods of food insecurity assessment. Many studies used food security surveys such as the Radimer/Comell survey and the Household Food Insecurity Access Scale (HFIAS). These have been validated in the literature through comparison of survey results to other measures of food insecurity (Coates, Swindale, & Balinsky 2007; Kendall, Olson, & Frongillo, 1995). The HFSSM was tested per a Rasch model to ensure that this survey actually measured food security (Health Canada, 2007). The Radimer/Comell survey, HFIAS, and HFSSM used the following four characteristics to defme food insecurity: decreased food quality and quantity, anxiety regarding food access, and shame in methods of food acquisition (Coates et al. , 2007; Health Canada, 2007; Radimer, 1990 as cited in Kendall et al. , 1995). Several studies did not utilize a food security survey; but, these characteristics were used to identify and discuss food insecurity. For example, EnglerStringer and Berenbaurn (2007) discussed food quality, quantity, anxiety, and dignity regarding food access in their qualitative study. Carney et al. (2012) failed to identify the food security survey that was used which is a weakness; however, they did discuss recognized aspects of foo d security such as anxiety regarding food supply. Literature that utilized these four characteristics to assess food insecurity was considered valid. 34 Food Insecurity Assessment and Knowledge in FNP Practice As discussed, an important first step is assessment of food insecurity in Aboriginal women living with HN/AIDS . Specifically, food security surveys may be utilized. One food security survey considered was the HFSSM developed by Health Canada (2007) for the Canadian Community Health Survey. Strengths of the HFSSM include development and testing in Aboriginal populations; however, this survey has only been utilized in a research setting. Also, the HFSSM is composed of 18 questions; as such, the HFSSM has the potential to increase time burden. Time burden is an important factor in the clinical setting. A crosssectional study by Hoisington, Braverman, Hargunani, Adams, and Alto (2012) explored assessment offood security amongNPs and physicians: only 12% frequently asked about household food sufficiency. Monitoring for nutritional food quality was hindered by lack of time (p<0.01); however, Hoisington et al. found that 88% of the study population were willing to utilize a single question food security screen. To decrease time burden, Young, Jeganathan, Houtzager, Di Guilmi, and Pumomo (2009) conducted a cross-sectional study to validate the use of a two question food security survey in the clinical setting among HN/AIDS populations. The two questions were selected from a six question clinical food security survey by Blumberg, Bialostosky, Hamilton, and Briefel (1999). The two questions survey is as follows : 1. The food I/we bought just didn ' t last, and Ilwe didn ' t have money to get more (Never/Sometimes/Often True). 2. Ilwe couldn ' t afford to eat balanced meals (Never/Sometimes/Often True). A positive answer to either question indicates food insecurity. Young et al applied both surveys simultaneously and found a strong correlation (0.895) between the two surveys 35 (p<0.0001). This two question food security survey had a sensitivity of 100% (95% CI: 75100), a specificity of 78% (95% CI: 61-90), and a negative predictive value of 100% (95% CI: 88 -1 00) (Young et al., 2009). Thus, Young et al. concluded that the two item survey was a valid and reliable tool for screening for food security among HIV populations in the clinical setting; although, the survey does require further validation in a larger population and false positives are possible. The use of the two question survey in FNP practice is preferable as it would decrease time demand compared to an 18-item survey. Another barrier to food security assessment was lack of food security knowledge (p<0.01) amongst physicians and NPs in Portland, Oregon in a cross-sectional study by Hoisington et al. (2012). Similarly, only 33% ofNPs agreed or strongly agreed to have food security knowledge in a cross-sectional survey by Tscholl and Holben amongst NPs in rural and urban Ohio, USA (2006). Overall, the low level of food security knowledge displays a significant gap in NP knowledge; although, information on FNP practice in rural/remote BC would be more applicable to this project. Tscholl and Holben suggest food security education for NPs could be incorporated in academic settings. As well, Tscholl and Holben suggest NPs could create a list of local food assistance programs to aid food insecure individuals encountered in the office (Tscholl & Holben, 2006). Although, Tscholl and Holben did assess NP practices such as referral to dietitians and social work, they did not specify if these practices were exclusively for food insecurity. Exploration of the NP perspective on food insecurity interventions would have strengthened the results of this study. Food Assistance: A Food Insecurity Intervention in HIVIAIDS To begin the discussion on food insecurity interventions, interventions employed within HIVIAIDS populations will be explored. The following studies are chosen to evaluate 36 the impact of food assistance in reducing food insecurity and resulting negative consequences in HIVIAIDS populations. Due to the lack of research on food insecurity interventions in HIV/AIDS populations in resource-rich settings, literature in resource-poor settings was included. Food assistance may refer to the use of food banks, food hampers, feeding programs, and emergency food assistance which are generally short-term measures to relieve hunger (Dietitians of Canada, 2007 as cited in the Public Health Nutritionists of Saskatchewan Working Group, 201 0). The principles of empowerment and collective involvement are not inherent in the food assistance process. Additionally, food assistance cannot fully eliminate food insecurity as food assistance may not be regarded as socially acceptable manner of obtaining food (Anderson, 1990). Benefits with food assistance in food insecure HIV/AIDS populations were evident. A prospective observational cohort study by Ivers et al. (2010) in adults with HIV/AIDS in Haiti found food assistance was associated with improved food security at six and twelve months (p