Impact of a school-based food assistance program on household food insecurity in Greece, 2012-2019: a multi-year evaluation of the DIATROFI program

Abstract

Background: Childhood food insecurity can persist among low socioeconomic areas in high-income countries. Universal Free School Meal (UFSM) programs are designed to respond to this pressing issue. This study aimed to conduct a multi-year evaluation of the DIATROFI Program's impact on household food insecurity in Greece.

Methods: This study utilized data from 18,716 students (618 kindergarten to high schools), from low socioeconomic areas participating in the school-level UFSM Program DIATROFI between 2012 and 2019. Parents of students completed annual baseline and follow-up paper-based self-completed questionnaires. The primary outcome was household food insecurity, measured using the Food Security Survey Module (FSSM) at both questionnaires, and evaluated through mixed linear and logistic regression models with repeated measurements.

Findings: Students' median age was 9 years old (Interquartile range (IQR): 6.5, 12.0), 51.6% (n = 9658) were girls, and 82.2% (n = 15,382) lived in low/medium socioeconomic affluence households. Households with food insecurity reduced from 51.5% (n = 9630) to 47.6% (n = 8901) after one school year. Food insecurity score declined steadily for four years of consecutive participation, compared to baseline score (one-year b:-0.26; 95% Confidence Interval (CI):-0.30, -0.22, and four-year -1.28; -1.53, -1.03). The likelihood of retaining food insecure status reduced from 17% after one-year participation (Odds Ratio (OR): 0.83; 95% CI: 0.79, 0.87) to 36% after four-year participation (0.64; 0.49, 0.82). The Program's impact on household food insecurity alleviation was greater among households with low parental education and low socioeconomic affluence.

Interpretation: The DIATROFI Program effectively improved household food security during and after the Greek socioeconomic crisis. School-level UFSM programs targeting underprivileged students can improve household food insecurity, with a more pronounced effect with increased years of participation, and among economically disadvantaged households.

Funding: The DIATROFI Program was funded through various national and private organizations, including national prefecture authorities, Greek payment authorities, philanthropic/charitable organizations, and private companies.

Keywords: Food accessibility; Food assistance; Food security; Pediatric.

Fig. 1

Flow chart of sample inclusion in the DIATROFI Program.

Fig. 2

Mixed effect linear and logistic regression models with repeated measures evaluating the improvement in household food insecurity (decrease in score) and likelihood of reporting household food insecurity status in children participating in the DIATROFI program for the first time at different follow-up periods in the total sample 2012–2019. Top Right: Mixed effect linear regression model with repeated measures. For each time point, the square indicates the beta coefficient and their corresponding bar, the 95% Confidence Intervals. Top Left: Mixed effect logistic regression model with repeated measures. For each time point, the square indicates the Odds Ratio and their corresponding bar, the 95% Confidence Intervals. Bottom Right: Mixed effect linear regression model with repeated measures stratified by Family Affluence level. For each time point, the square indicates the beta coefficient and their corresponding bar, the 95% Confidence Intervals. (∗) denotes a p-value for interaction <0.05 at different time points, with high affluence level as the reference group. Bottom Left: Mixed effect linear regression model with repeated measures stratified by Parental educational level. For each time point, the square indicates the beta coefficient and their corresponding bar, the 95% Confidence Intervals. (∗) denotes a p-value for interaction <0.05 at different time points, with low parental educational level as the reference group. All models were adjusted for child sex, age, parental highest educational level, and household affluence level. Household food insecurity score was imputed based on a previously published imputation methodology. Random intercepts for area and school year of initial participation were included. All but one child from each family was randomly selected to be included in this sample. All children included are distinct. Parental educational level corresponds to the highest educational attainment achieved by one parent in the family. All interaction terms were included in separate models. The exact numerical results are presented in the Supplementary Table S7. b: Beta coefficient, 95% CI: 95% Confidence Interval.