The Cost of a Nutritious Diet for Households Including People Living with HIV/AIDS in Nova Scotia: Findings and Lessons Learned by FoodNOW 2020 to 2022

The province of Nova Scotia has historically reported the highest rates of household food insecurity of all Canadian provinces [1]. Food security as defined by the United Nations’ World Food Summit is “when all people, at all times, have physical and economic access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life” [2], whereas household food insecurity is understood as the “inadequate or insecure access to food because of financial constraints” (p. 3) [1], as reflected in how it is measured in Canada. In 2019, it was reported that the prevalence of households experiencing food insecurity in Nova Scotia was 18.8%, the highest rate of all provinces [3]. Researchers have reported a strong correlation between household food insecurity and negative health outcomes [4], such as poor mental health [5], chronic pain [6], diabetes [7], and premature death from infections and other health complications [4].

Given the high rates of household food insecurity in Nova Scotia [1, 3], the impact of the current cost of living for households receiving Income Assistance, minimum wage, or with precarious employment and including a person living with HIV/AIDS (PLWHA) should be assessed. Evidence within health literature supports that the health and well-being of a PLWHA is directly impacted by household food insecurity [8] and poverty [9]. In 2018, the Government of Canada established the costs of the Market Basket Measure (MBM) as Canada’s poverty line. The MBM is defined as a basket of the goods and services, such as food, clothing, and transportation, that reflects a modest and basic standard of living for a four-person household [10]. In fact, food insecurity and its most important determinant, poverty, are among the numerous systemic barriers to nutritional needs that a PLWHA experiences [9]. Optimal nutrition in congruence with medication therapies is critical to the overall health and well-being of a PLWHA in maintaining their immune system and preventing disease progression [9, 11]. Food costing methodology allows researchers to create economic simulations that replicate possible individual and household scenarios, an approach to surveying commonly used by several disciplines (e.g., forecasting climate change outcomes, profiling consumer behaviours) [12].

The first wave of the COVID-19 pandemic started in Canada in early 2020. During this time, provincial public health measures across Canada were implemented. Between February and April 2020, the Canadian workforce experienced a 15% decline in employment [13]. Nearly half of these job losses occurred primarily in the bottom earnings quartile and affected over 1 million Canadians [13, 14]. By May 2020, one in seven Canadian households were estimated to be experiencing food insecurity, a statistic reported to be underestimated [15]. Prior to the COVID-19 pandemic, the majority of those in food insecure households, but not all, were employed. Approximately 35% of food insecure households reported that their main source of income was from employment insurance, social assistance, or seniors’ income, rather than salary/wages [1]. In April 2021, the third wave of the COVID-19 pandemic occurred in Nova Scotia, which led to a government-mandated lockdown across the province, forcing all essential services, including grocery stores and food services, to operate at as low as 25% capacity [16]. As of June 2021, the unemployment rate in Nova Scotia was approximately 1.2% higher than the national average [17]. During the mandated lockdowns, grocery store visits lessened due to the perceived health risks of shopping in-store, store operating hours were reduced, wait times increased for entering the store, and public transportation operations were reduced [15]. As a result, 43% of Canadians have shopped less in-store for groceries during the pandemic [18].

Various stakeholders, including community members and HIV service organizations, were consulted in the development of this project as part of an integrated knowledge translation approach [19]. These stakeholders indicated that food insecurity and poverty were major concerns for a PLWHA. This project is part of the second phase of a four-phase, provincially funded research study called FoodNOW (Food to eNhance Our Wellness), which is centred on nutritional assessment of people, families, and communities living with HIV/AIDS in Nova Scotia. As such, FoodNOW recognizes that infectious disease wellness translates to everyone’s wellness. The purpose of this research was to assess the affordability of the National Nutritious Food Basket (NNFB) in relation to other basic expenses for households with a PLWHA in Nova Scotia. The NNFB represents a basic nutritious diet, which consists of a variety of foods that best reflect Canada’s Food Guide recommendations while also considering food items that are commonly consumed by Canadians [20].

Over the past two decades, food costing in Nova Scotia has been undertaken using participatory food costing (PFC) methods, developed by the Food Action Research Centre (FoodARC) and partners [21], which includes community involvement at all stages. With a participatory approach, trained community members would collect food costing data themselves. PFC is used for monitoring the cost of a basic nutritious diet, examining social and economic policies impacting food security, and advocating for and informing policy change [21]. PFC was last conducted in Nova Scotia in 2015 using the NNFB tool [20] to calculate the cost of a basic nutritious diet for different age and gender groups, including pregnancy and lactation with the last economic simulations [21] published prior to the COVID-19 pandemic. Since the onset of the pandemic in March 2020, households in Canada have been experiencing increased rates of unemployment and food insecurity [13, 14, 22], indicating that now is an important time to engage in food costing to better understand the current food security climate and how related policies may be addressed with these data in mind.

Virtual food costing (VFC) was developed as an alternative food costing method (Figure 1) during the COVID-19 pandemic in response to restrictions to in-person grocery shopping/food costing, as it was considered a safer option for both researchers and immunocompromised community members. Unlike in-person PFC, VFC was conducted exclusively online, and given that VFC is a novel method, the research team decided to conduct the data collection themselves. This means our study was not participatory as initially intended but, rather, community-based, as stakeholders and community members asked for this project and offered consultation throughout the study but did not take part in data collection. As part of VFC as a novel method, face/content validation was conducted as a pre-test towards preliminary assessment of the effectiveness of VFC. In efforts to assess both user experience and the potential for VFC to become participatory in the future, the researchers conducted face/content validation while navigating each website platform (n = 4). Over a two-week period in June 2021, two researchers (AC, JM) collected food prices from the websites of four major retailers in Nova Scotia. The NNFB tool (NNFB Excel spreadsheet [20]) was used to calculate the cost of the NNFB for the 22 age, sex, and life stage groups. Using the weight (per kg) of each item, the researchers (AC, JM) recorded the least expensive option offered for each of the 61 NNFB grocery items [20]. For price validation (Table 1), the data collected using VFC was compared to 2015 PFC data [23], which was adjusted for 2021 inflation using a consumer price index (CPI) calculator [24] based in Canadian data.

Using the above outlined methodology, we calculated six different household scenarios for Nova Scotia (Table 2), with one individual living with HIV/AIDS in each household. Monthly household income was estimated based on employment status and eligibility for federal and provincial Income Assistance and benefits [25–31]. To calculate estimated household expenses, four components of the MBM [32] were used for clothing, transportation, shelter, and miscellaneous expenses. The MBM expense estimates represented Nova Scotians across the province, including both rural and urban centre populations [32]. Food expenses were determined using the results of VFC. The 2019 NNFB for one week, plus 5% for miscellaneous costs, was calculated for the 22 age, sex, and life stage groups [20]. We then calculated the monthly cost of the NNFB by multiplying the weekly total by a factor of 4.33 [23]. For the household scenarios (Table 2), the monthly cost of the NNFB for each household member was added, and the total was multiplied by the appropriate household size adjustment factor [23]. Households with a PLWHA must also consider the cost of antiretroviral medications [33], dispensing fees [33, 34], a daily multivitamin [35], and an additional 10% of energy (food) intake [36, 37]. A 10% increase in food intake may be recommended, since a PLWHA can have up to a 10% increase in total energy expenditure [36, 37]. To best represent the cost of the 10% increase in energy intake for a PLWHA, 10% of the cost of the monthly NNFB was added for one person in the household. This method could be adapted for costing other special diets that require additional dietary expenses. In Nova Scotia, dispensing fees are paid for each 90-day supply of antiretrovirals, totalling $45 (CAD) annually [33]. Persons who are registered for Income Assistance can be reimbursed for dispensing fees but may be charged up to $5 (CAD) for each prescription filled [34]. The dispensing fees were represented in the household scenarios ($45 divided by 12 for monthly total) for those who would be responsible for paying dispensing fee costs. To determine the remaining income of each household, the cost of shelter, clothes, transportation, NNFB, daily multivitamin, medication dispensing fees (if applicable), and miscellaneous expenses were deducted from the total monthly income (Table 2).