Nutritional Epidemiology

Development of a Spanish-Language Version of the U.S. Household Food

Security Survey Module1,2
Gail G. Harrison,*†3 Ame Stormer,* Dena R. Herman* and Donna M. Winham**
*School of Public Health; †Center for Human Nutrition and Center for Health Policy Research,
University of California, Los Angeles, CA and **Arizona State University East, Mesa, AZ

ABSTRACT A survey module used to monitor the prevalence of household food insecurity and hunger in the
United States was developed by a broadly based collaborative project with leadership from the USDA and the
National Center for Health Statistics (NCHS). It has been administered annually since 1995 as a supplement to the
Census Bureau’s Current Population Survey (CPS) and is part of the National Health and Nutrition Examination
Survey (NHANES) and other national surveys. Spanish is the second most common language in the United States,
yet no standardized Spanish-language version of this instrument has yet been sanctioned by the relevant federal
agencies. In the CPS, interviewers free-translate the questions while interviewing respondents who prefer to have
the interview conducted in Spanish. National prevalence data indicate relatively high rates of food insecurity for
Hispanic households, raising the question whether methodological artifacts may contribute to these rates. We
analyzed eight Spanish-language versions of the instrument that have been used in published work for variability
in wording and phrasing. We then conducted focus groups of low-income Spanish-speaking participants from
Mexico, Central America, Puerto Rico and Cuba to refine a single Spanish-language instrument. We also employed
professional translators to render the English instrument into “standard” Spanish; both instruments were then
back-translated. The focus group– derived instrument uses simpler language and grammar; its back-translation
integrity to the English version was slightly better than the professionally translated version. We provide the
instrument for use and further testing by other investigators. J. Nutr. 133: 1192–1197, 2003.

KEY WORDS: ● food security ● Hispanics ● Spanish ● surveys

Hunger in the social sense, i.e., that brought about by
inadequate economic resources, has long been a relevant con-
cern to nutrition policy in the United States, but only in the
last decade has there been a major effort to measure hunger
and its context and antecedents in large surveys. The only
consistent nationally representative information before this
time comes from a single question incorporated into all of the
national Household Food Consumption Surveys since 1977–
78.4 During the period from the late 1970s through the early
1990s, the complexity and details of the concept of food
insecurity were developed and explored in a variety of settings
and situations. Most notable were the series of state-level
studies known as the Community Childhood Hunger Identi-
fication Project (CCHIP)5 organized by advocacy and philan-
1
Presented at Experimental Biology 2002, April 2002, New Orleans, LA
[Winham, D. M., Herman, D. R. & Harrison, G. (2002) Spanish-language
versions of the USDA/DHHS Core Food Security Module. FASEB J. 16: A750.].
2
Supported by agreement #43–3AEM9 – 80106 from the Economic Research
Service, U.S. Department of Agriculture.
3
To whom correspondence should be addressed. E-mail: gailh@ucla.edu.
4
“Which of the following best describes the food eaten in your household in
the last 12 months: We have enough and the kinds of food we want; we have
enough but not always the kinds of food we want; we sometimes do not have
enough to eat; we often don’t have enough to eat.”
5
Abbreviations used: CCHIP, Community Childhood Hunger Identification
Project; CPS, Current Population Survey; FNS, Food and Nutrition Service (of the
USDA); LSRO, Life Sciences Research Office (of the Federation of American
thropic groups (1), theoretical work begun at Cornell Univer-
sity with Radimer’s dissertation on the concept (2) and
subsequent studies among various groups in the northeastern
United States (3,4). These investigators demonstrated that
consistent answers could be obtained to questions designed to
measure food insecurity, and that household-level manage-
ment or coping strategies could be identified and utilized as the
basis for evaluation. In 1990, a Life Sciences Research Office
(LSRO) panel agreed upon an operational definition for food
security and its inverse, food insecurity (5), defining food
security as “access by all people at all times to enough food for
an active, healthy life. Food security includes at a minimum:
1) the ready availability of nutritionally adequate and safe
foods, and 2) an assured ability to acquire acceptable foods in
socially acceptable ways . . ..” Food insecurity was defined as
“Limited or uncertain availability of nutritionally adequate
and safe foods or limited or uncertain ability to acquire ac-
ceptable foods in socially acceptable ways.” At about the same
time, Congress passed the National Nutrition Monitoring and
Related Research Act of 1990, and a subsequent long-range
plan clarified the government’s responsibility to develop a
sound national measure of food insecurity and hunger appro-
Societies for Experimental Biology); NHANES, National Health and Nutrition Ex-
amination Survey; WIC, Women, Infants and Children.

0022-3166/03 $3.00 © 2003 American Society for Nutritional Sciences.

Manuscript received 14 August 2002. Initial review completed 10 September 2002. Revision accepted 2 January 2003.

1192

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 SPANISH-LANGUAGE FOOD SECURITY MODULE
priate for use throughout the national nutrition monitoring
system and at state and local levels (6).
In the early 1990s, the USDA’s Food and Nutrition Service
(FNS) began the process of systematically developing, testing
and implementing an instrument to measure food insecurity
and hunger at the household level. More than 50 items,
derived from previous work by various investigators, were
eventually incorporated into the supplement to the April 1995
CPS, querying various aspects of food access, food sufficiency
and food security during the previous 30 d and 12 mo. After
this first large-scale measurement on a representative sample of
the population, and subsequent further application in the
September 1996 and April 1997 CPS, the results were ana-
lyzed extensively and a unidimensional scale developed utiliz-
ing a one-parameter logistic item response theory (Rasch)
model (7). This scale was divided into four ranges to classify
households as food secure, food insecure without hunger, food
insecure with moderate hunger and food insecure with severe
hunger, enabling analysis of the prevalence of food insecurity
at several levels of severity. A report on food security levels in
the United States was published in 1997 (8) utilizing the data
from the 1995 CPS, and the data have since been updated
regularly (9,10). During this period, several other major sur-
veys have included the food security module, including the
Census Bureau’s Panel Study of Program Dynamics and Survey
of Income and Program Participation, the National Center for
Health Statistics’ National Health and Nutrition Examination
Survey (NHANES), the Department of Education’s Early
Childhood Longitudinal Study (ECLS), the University of
Michigan’s Panel Study of Income Dynamics, as well as state
and local or targeted studies. An abbreviated six-item version
of the survey module (11) has been developed, which identi-
fies household food insecurity and hunger among adult house-
hold members but not among children. The six-item module
was included in the first round of the large California Health
Interview Survey and in several state-level studies of families
that left cash welfare programs.
In all of the work that has gone into developing and testing
the food security instrument, none has systematically consid-
ered the need for a standardized Spanish-language version.
Spanish is the second most commonly spoken language in the
United States. Census data in 1990 reported that Spanish was
the primary language spoken at home for 17.3 million people,
of whom almost 3.5 million spoke only Spanish (12). The
proportion is much higher in several states including Califor-
nia, Texas and Florida. National surveys and smaller studies in
areas with large Spanish-speaking populations routinely pro-
vide interviewers able to conduct interviews in Spanish and
English, but attention to the development and quality of
Spanish-language instruments is at best inconsistent. In ad-
ministering the food security supplement to Spanish-speaking
households in the CPS, interviewers have either free-trans-
lated the questions into Spanish during the interview or in-
terviewed a bilingual household member in English. Other
surveys, including NHANES, have used written Spanish trans-
lations but these have never been examined systematically or
tested for integrity to the original instrument or interpretation
by various groups of native speakers. The USDA’s Guide to
Measuring Household Food Security (13) makes no mention
of translation issues.
Household food insecurity has been estimated in the CPS
consistently to be somewhat higher for Hispanic households
than for others including other ethnic minority groups even
when household income, region of residence and household
composition have been controlled (14). There is also some
suggestion from Frongillo’s examination of the performance of
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1193
the instrument in different surveys that Hispanics in a Con-
necticut survey answered affirmatively to the least severe food
insecurity items more frequently than comparable respondents
in other surveys (15). Survey instruments utilized across lan-
guages and cultures encounter numerous problems of validity,
and semantic equivalence is only one among several issues
(16). Thus the question arises whether there may be artifactual
influences from translation and interpretation of the questions
in the instrument that affect prevalence estimates. The
present study is a first step in addressing that question. Our
objective was to evaluate the existing Spanish-language ver-
sions of the CPS food security supplement instrument and to
determine whether any of them is adequate for use as a
standard. If no version was found to be adequate, we would
then undertake the development of a suitable version that
could then be applied and subsequently tested for its scaling
performance and other characteristics
MATERIALS AND METHODS
We started by assembling the existing Spanish-language versions
of the instrument, through identification of published sources and
informal queries to colleagues. We identified eight versions that have
been utilized in published studies or national surveys or are currently
being used by researchers. They were from the Survey of Program
Dynamics (U.S. Census Bureau), NHANES (National Center for
Health Statistics), the ECLS (U.S. Department of Education), the
Alameda County (California) Calworks Program, Physicians for Hu-
man Rights (17) and a version that was created by California Food
Policy Advocates (18) and modified by Herman (19). We then
proceeded to do a word-by-word and question-by-question compara-
tive analysis. Although there was some similar phrasing common to
all or most versions, variation existed in choices of vocabulary, verb
tenses or phrases in every one of the 18 questions. The most obvious
differences with potential for variable interpretation included choice
of verb tense and active vs. passive voice in Spanish, choice of words
for which more than one possible choice exists, and wording for
several English phrases for which direct translations are not mean-
ingful (e.g., “cut the size of meals”), phrases for which the English
phrase does carry the same connotation in Spanish (e.g., “balanced
meals”), and items for which there are a number of ways of rendering
the translation (e.g., “not eat for a whole day” was translated with
slightly different nuances as no comer por un dı́a entero or estar sin
comer todo un dı́a or dejar de comer por un dı́a completo or no comer
alguna vez en todo el dı́a in the different instruments).
Items of concern included the variability in the choice of words to
represent food (alimentos vs. comidas vs. comestibles), the fact that the
most common word for “food” and “meals” is the same (comidas), the
choice of terms for portion size (porcion vs. cantidad vs. tamaño), and
responses concerning frequency that could affect the metric proper-
ties of derived data (e.g., “often true” was variably rendered as a
menudo or casi siempre or frecuentemente.)
We then proceeded to recruit focus groups of low-income, Span-
ish-speaking adults who were willing to serve as “experts” on the
wording of the questions. The sampling can be best described as an
ethnically stratified opportunistic sample because we first focused
within a low-income population and then recruited individuals who
were the primary food-responsible person in their household, whose
preferred or only language was Spanish, who were literate in Spanish
and who were born in Mexico, Central America, Puerto Rico or
Cuba. Working with the Public Health Foundation Enterprises
Women, Infants, and Children (WIC) Program in Los Angeles, we
identified key informants (knowledgeable paraprofessionals, clients
and staff) who were informed in detail about the study’s purposes and
requirements, and who then recruited Mexican and Central Ameri-
can participants. There were insufficient numbers of Cuban and Puerto
Rican individuals within WIC program participants, but the same key
informants were able to put us in touch with suitable Cuban and Puerto
Rican individuals whom we invited to additional focus groups. On the
whole, the participants were low income (77% had household incomes
below $20,000/y) and fairly young (the mean age was 30 y).
 1194 HARRISON ET AL.
Focus groups were held over a period of 5 mo in the fall and winter
of 2001–2002, and ranged in size from 4 to 15 participants. Each
group was facilitated by a professional translator and one or more of
the authors; verbatim notes were recorded on a laptop computer by a
single note-taker (both the facilitator and the note-taker are profes-
sionals whose first language is Spanish; although they themselves
were not food security researchers, they had received substantial
orientation by the authors concerning the rationale and content of
the domain). Four Cuban men and one Puerto Rican man partici-
pated; all other participants were women. Among Central American
participants, countries of origin included Guatemala, El Salvador and
Honduras. Introductory comments by the facilitator made it clear
that participants were being selected as native-speaking “experts” to
determine the best way for surveys to ask certain questions in Spanish
about food, having enough food and problems in having enough food.
In addition to specific input on the wording of the questions in the
instrument, we devoted part of the focus group time to exploring
participants’ experience with and perceptions of hunger and food
insecurity; that information will be presented elsewhere. Focus groups
lasted ⬃90 min and were terminated when saturation was reached
(material elicited began to be redundant). Light refreshments were
served and participants were compensated for their time and effort
with a gift of a $50 prepaid telephone card.
An initial focus group consisted of women of Central American
and Mexican origin; that group was presented with all eight existing
instruments with each question compared in detail, and asked to
select the best two or three options for each. Subsequent focus groups
were homogeneous for country or region of origin. They were pre-
sented with the two or three options/question derived from the first,
larger group and asked to choose or modify to reach an optimal way
of asking the question. After these groups, we constructed an instru-
ment incorporating the most agreed-upon refinements and choices
(“focus group instrument”); at the same time, the professional trans-
lator/facilitator worked with three other certified translators to pro-
duce an independent version in “standard” Spanish (“professional
instrument”). Finally, 14 WIC participants from Mexico and Central
America who had not been previous focus group participants were
administered both instruments, in random order, and asked to indi-
cate which version they preferred and why, and to suggest any
changes. Finally, both versions of the instrument were back-trans-
lated by independent translators into English and the back-transla-
tions compared with the original English-language instrument.
Focus group data were analyzed by systematic mapping of verbatim
recorded comments to questionnaire items, tallying of opinions, ad-
justment for repeat comments by the same person, and notation of
the strength of consensus or disagreement among individuals within
groups and across groups. Two of the researchers (A.S. and D.H.)
were the primary qualitative analysts. The variable size of the focus
groups (4 –15 members) creates the possibility of some bias because
smaller groups allow more thorough exposition of individuals’ opin-
ions; we attempted to compensate for this somewhat by adjusting for
repetitive material from the same respondent.
All procedures involving human subjects were approved by
UCLA’s Committee on Protection of Human Subjects in Research.
RESULTS
There was general agreement among groups that 1) all of
the existing versions could be improved; 2) there were several
glaring errors that could be easily corrected; 3) although there
was some minor variation among the various country-of-origin
groups in a few colloquial terms (such as estufa vs. cocina for
stove), there was no hesitation in agreeing on a commonly
understood and clear choice; and 4) among the various
choices, simpler was almost always judged better as long as
clarity was maintained. Specific recommendations that are of
note include the following:
Some existing instruments used the term almacén for
“store,” which all groups agreed represented department rather
than grocery stores (tienda was preferred).
The verb reducir, used in some versions for the question
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about cutting the size of portions served, was uniformly inter-
preted to mean loss of body weight or size rather than reduc-
tion in size of food portions; the phrase dió menos cantidad was
preferred.
The word barato for “low cost” food implied cheap food in
the sense of low quality; the phrase bajo costo was preferred.
The choice of the word for food received widespread dis-
cussion and debate. The general agreement was that alimentos
carries a connotation of nutritive food, whereas comida is the
more general term and thus preferred for this context. Comestibles
was understood to imply only packaged and purchased food.
There was repeated discussion of the optimal translation for
“statement” (as in “which of the following statements best
describes . . .” with general consensus that oraciones (sentenc-
es) was preferable to declaraciones (literally statements or dec-
larations), which sounds more legalistic.
The use of more words than necessary to transmit a concept
clearly was generally rejected in favor of simpler language.
Examples are the recommendations to use por un dı́a or por todo
un dı́a rather than por un dı́a entero for “a whole day”; and
recommendations to use the simplest of the alternatives to
describe frequency (frecuentemente, a veces and nunca for often,
sometimes and never).
The concept of a “balanced meal” (questions 4 and 6)
raised a number of questions of conceptual validity. There was
general agreement that the terminology comida balanceada was
preferable to dieta balanceada (both have been used in various
versions of the instrument) and that the latter has a different
meaning; however, the meaning of the whole concept re-
mained somewhat unclear. Although the idea of a “balanced”
diet or meal seems to be basic to European-American culture,
it does not elicit the same recognition as implying nutritional
adequacy or variety among these Hispanic groups. The Puerto
Rican group (only) suggested comida nutritiva (nutritious food
or nutritious meal). Not having the option of removing this
question entirely, in the end we adapted our Spanish-language
version to recognize the ambiguity of the phrase and provide
alternative wording.
Of the final group of 14 respondents who were administered
our focus group– derived instruments and the “professional”
instrument, in random order, nine preferred the focus group
version, two said they were equally good and three preferred
the professionally translated version. The reasons given by the
majority for preferring the focus group– derived instrument
were simplicity, clarity, lack of redundancy and lack of formal-
ity. Those who preferred the more formal instrument said it
made them feel that the interview was more “official” when
this version was used. Back-translations of both instruments
reinforced respondents’ opinion of the slight advantage of the
simpler instrument, which demonstrated greater integrity to
the original version in several minor specifics. No individual
was classified differently by the two instruments.
The focus group– derived instrument is presented as the
Appendix to this paper; the formal “professional” instrument
and back-translations of both are available on request to the
authors.
DISCUSSION
Adequate translation of an instrument to be widely used is
intuitively important, but seldom given the kind of systematic
attention it deserves. Behling and Law recently published a
brief guide to the subject (16), and they mention that their
work was inspired by the lack of guidelines available to help
researchers in this essential task. They point out that there are
three underlying problems that plague efforts to create mean-
 SPANISH-LANGUAGE FOOD SECURITY MODULE
ingful target language equivalents from source language instru-
ments: lack of semantic equivalence across languages; lack of
conceptual equivalence across cultures; and lack of normative
equivalence across societies. Semantic equivalence is the rel-
atively straightforward identification of optimal words and
phrases in the target language that have meanings that match
those in the source document. Although straightforward, this
task requires a systematic and detailed attention to heteroge-
neity in the target language group that is seldom undertaken.
It is this task of improving semantic equivalence that we have
attempted to address in the present work.
Conceptual equivalence across cultures (the degree to
which the constructs or concepts operationalized in the source
instrument exist in the same form in the thoughts of members
of the target culture) and normative equivalence across soci-
eties (the degree to which people are willing to and comfort-
able with discussing specific topics, or the degree to which they
are willing to do so with strangers) are more difficult to
address. Formal cognitive testing has been conducted with the
items in the English version of this instrument (20), and would
be a logical next step in validating the instrument presented
here. We identified one clear problem of conceptual equiva-
lence, namely, the idea of a “balanced meal.” This particular
item has also been noted to be problematic in the adaptation
of an instrument in Indonesia (21) and also in Hawaii (22).
The term “balance” with regard to meals seems to derive from
English roots, and appears to have different meanings in dif-
ferent cultural contexts. As a result of the ambiguity created by
translation of this phrase, we have on the accompanying
instrument identified two alternative phrasings (comida bal-
anceada and comida nutritiva).
We cannot at this point comment on normative variation
in the ease with which the experience of hunger and food
insecurity (a relatively private or sensitive topic to some in-
dividuals) is discussed because we did not explore the issue
with non-Hispanics in the same way. These groups of first-
generation Hispanic adults did not hesitate to offer their
opinions, suggestions and experiences to us and to each other
after becoming familiar and comfortable with the individuals
and the concepts, but comparative data are not available.
Further research, on a larger and more quantitative scale,
will be required to more fully explore the validity of a Spanish-
language food security instrument for the United States, in-
cluding formal cognitive testing, exploration of appropriate-
ness with still other Hispanic groups residing in different parts
of the country, and determination of scaling characteristics
and other properties of the instrument.
ACKNOWLEDGMENTS
The authors thank Evelyn Cederbaum for facilitating all of the
focus groups and leading the group of certified translators in produc-
ing the “professional” version of the Spanish instrument; the staff of
the Public Health Foundation Enterprises WIC program in Los An-
geles for help in recruitment of focus group participants and facilita-
tion of the logistics for the focus groups; Mark Nord of USDA/ERS
for ongoing support and flexibility; and the focus group participants
for their willing contributions of expertise and experience.
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 1196 HARRISON ET AL.

APPENDIX: U.S. HOUSEHOLD FOOD SECURITY INSTRUMENT, SPANISH VERSION

1*. ¿ Cuál de las siguentes oraciones describe mejor la 4. (Yo/Nosotros) no tenı́amos lo suficiente para comer una
situación de comida en su casa en los últimos doce comida balanceada (nutritiva). Para (Usted./su casa), ¿
meses ? (CHOOSE ONLY ONE OPTION) Esto fue frecuentemente, a veces, o nunca en los últimos
[ ] Siempre como (comemos) lo suficiente y los tipos de 12 meses?
alimentos que deseo (deseamos) (SKIP TO 2) [ ] Frecuentemente
[ ] Como (comemos) lo suficiente pero no siempre lo que [ ] A veces
deseo (deseamos) (CONTINUE TO 1B) [ ] Nunca
[ ] A veces no como (comemos) lo suficiente o (CON- [ ] Don’t Know or Refused
TINUE TO 1A)
[ ] Frecuentemente no como (comemos) lo suficiente 5. Dependı́a (Dependı́amos) de unos pocos alimentos de
(CONTINUE TO 1A) bajo costo para dar comida a los niños por que se nos
[ ] Don’t Know or Refused terminó el dinero disponible para comprar alimentos.
Para (Usted./su casa), ¿ Esto fue frecuentemente, a veces,
1a. Aquı́ hay algunas razones por cual las personas no o nunca en los últimos 12 meses?
comen lo suficiente. Para cada una, dı́game si es una [ ] Frecuentemente
razón por la cual usted no come lo suficiente (MARK [ ] A veces
ALL THAT APPLY) [ ] Nunca
SI NO DON⬘T KNOW [ ] Don’t Know or Refused
[ ] [ ] [ ] No tengo suficiente dinero para comida
[ ] [ ] [ ] Se me hace difı́cil ir a la tienda 6. No tenı́a (tenı́amos) suficiente dinero para ofrecer una
[ ] [ ] [ ] Estoy a dieta comida balanceada (nutritiva) a los niños. Para
[ ] [ ] [ ] No tengo una estufa que funcione (Usted./su casa), ¿ Esto fue frecuentemente, a veces, o
[ ] [ ] [ ] No puedo cocinar o comer debido a problemas nunca en los últimos 12 meses?
de salud
(CONTINUE TO 2) [ ] Frecuentemente
[ ] A veces
1b. Aquı́ hay algunas razones por que las personas no [ ] Nunca
siempre tienen las clases de comida que quieren o [ ] Don’t Know or Refused
necesitan. Para cada una, por favor dı́game si esa es una
razón por que no tiene las clases de comida que usted 7. Mi (s)/nuestros hijo(s) no comı́a(n) lo suficiente por que
quiere o necesita. (MARK ALL THAT APPLY). no tenı́a(mos) dinero para comprar suficiente comida.
SI NO DON⬘T KNOW Para (Usted./su casa), ¿ Esto fue frecuentemente, a veces,
[ ] [ ] [ ] No hay suficiente dinero para comida o nunca en los últimos 12 meses?
[ ] [ ] [ ] Muy difı́cil ir a la tienda [ ] Frecuentemente
[ ] [ ] [ ] Estoy a dieta [ ] A veces
[ ] [ ] [ ] No hay la clase de comida que quiero [ ] Nunca
[ ] [ ] [ ] No hay buena calidad de comida [ ] Don’t Know or Refused
Ahora le voy a leer algunas respuestas de la gente sobre
su situación de comida. Para cada repuesta, favor de 8. En los últimos 12 meses, desde el último (nombre del
indicarme si ocurre en su casa frecuentemente, a veces, mes presente). ¿ Usted o algún miembro de su familia
o nunca en los últimos 12 meses, es decir desde el comió menos o dejó de comer por que no habı́a sufici-
ultimo (display current month). ente dinero para la comida?
[ ] Sı́ (GO TO 8A)
2. La primera oración es “Me (nos) preocupó que la comida [ ] No (SKIP TO 9)
se podı́a acabar antes de tener dinero para comprar mas.” [ ] Don’t Know (SKIP TO 9)
Para (Usted./su casa), ¿ Esto fue frecuentemente, a veces,
o nunca en los últimos 12 meses?
8a. ¿Con qué frecuencia sucedió esto— casi cada mes, al-
[ ] Frecuentemente gunos meses, o solo en uno o dos meses?
[ ] A veces
[ ] Nunca [ ] Casi cada mes
[ ] Don’t Know or Refused [ ] Algunos meses
[ ] Solo en uno o dos meses
3. La comida que compré (compramos) no duró mucho y [ ] Don’t Know
no habı́a dinero para comprar más.
Para (Usted./su casa), ¿ Esto fue frecuentemente, a veces, 9. En los últimos 12 meses, ¿ Comió usted menos de lo que
o nunca en los últimos 12 meses? pensaba que debı́a por que no hubo suficiente dinero
[ ] Frecuentemente para comida?
[ ] A veces [ ] Sı́
[ ] Nunca [ ] No
[ ] Don’t Know or Refused [ ] Don’t Know
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 SPANISH-LANGUAGE FOOD SECURITY MODULE 1197

10. En los últimos 12 meses, ¿ Alguna vez tuvo hambre 14. En los últimos 12 meses, ¿ Alguna vez su hijo o cual-
pero no comió por que no tuvo suficiente dinero para quiera de sus hijos no comió por que no hubo suficiente
comida? dinero para comida?
[ ] Sı́ [ ] Sı́ (GO TO 12A)
[ ] No [ ] No (SKIP TO 13)
[ ] Don’t Know [ ] Don’t Know (SKIP TO 13)
11. En los últimos 12 meses, ¿ Perdió usted peso por que no
tuvo suficiente dinero para comprar comida? 14a. ¿Con qué frecuencia sucedió esto— casi cada mes,
algunos meses, o solo en uno o dos meses?
[ ] Sı́
[ ] No [ ] Casi cada mes
[ ] Don’t Know [ ] Algunos meses
[ ] Solo en uno o dos meses
12. En los últimos 12 meses, ¿ Usted o algún otro adulto de [ ] Don’t Know
su familia no comió por todo el dı́a por que no hubo
suficiente dinero para comida
15. En los últimos 12 meses, ¿ Alguna vez su hijo o cual-
[ ] Sı́ (GO TO 12A) quiera de sus hijos tuvo hambre pero no tuvo suficiente
[ ] No (SKIP TO 13) dinero para comprar mas comida?
[ ] Don’t Know (SKIP TO 13)
[ ] Sı́
12a. ¿Con qué frecuencia sucedió esto— casi cada mes, [ ] No
algunos meses, o solo en uno o dos meses? [ ] Don’t Know
[ ] Casi cada mes
[ ] Algunos meses 16. En los últimos 12 meses, ¿ Alguna vez sus hijos no comieron
[ ] Solo en uno o dos meses por todo el dı́a por que no hubo suficiente dinero para
[ ] Don’t Know comida?
13. En los últimos 12 meses, ¿ Alguna vez le dió menos [ ] Sı́
cantidad de comida a su(s) hijo(s) por que no hubo [ ] No
suficiente dinero para comida? [ ] Don’t Know
[ ] Sı́ *Items 1, 1a and 1b are optional and not required to
[ ] No calculate the scale or to classify households. These may be
[ ] Don’t Know omitted if not needed for analytical purposes or screening.

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