“You’re not having any trouble getting food, right?” I was asked as I waited for the doctor to see me. “Uh, no,” I replied. The medical assistant was clearly uncomfortable, not wanting to ask the question. I was uncomfortable, even as someone who has never worried about where my next meal would come from; even as a researcher who thinks daily about food insecurity screening.
Although there is a growing interest in the health care system’s ability to address social determinants of health (SDOH), little is known about how to screen for determinants in a way that is comfortable for patients and increases the likelihood that they will disclose any challenges they’re facing. Getting to the root of this is particularly important when it comes to the care of children. Children are disproportionately affected by the rise in poverty rates in the United States. Economic hardships can compromise their development, negatively affect their overall health and adversely affect their ability to succeed in school and in life. Furthermore, food insecurity—the limited or uncertain availability of nutritionally adequate or safe foods—while strongly associated with poverty, is an independent predictor of poor health outcomes for children.
The American Academy of Pediatrics and the American Pediatric Association recommend screening for SDOH—in particular food insecurity—in all pediatric settings. But how should clinicians ask these questions to ensure caregivers are comfortable enough to provide accurate information? Verbal screening can lead to a meaningful conversation with a trusted provider, but it can sometimes be uncomfortable for patients to discuss social stressors that may carry stigma. On the other hand, with written screenings patients might misinterpret questions or experience literacy barriers.
Testing Caregiver Experiences
At PolicyLab, we strive to meet families where they are and connect them to resources and services that address the unmet needs of both caregivers and their children. But that can be challenging if we don’t have accurate information. Our team wanted to explore the best way to ask patient-families about food insecurity, so we conducted a randomized study with more than 1,800 caregivers visiting Children’s Hospital of Philadelphia’s (CHOP) emergency department (ED). We compared a verbal, face-to-face interview to an electronic tablet-based screener with questions on food insecurity. After completing the screening, caregivers shared whether they thought the screening questions were important, their comfort level with the screening location and their preference for screening in person versus on the tablet.
For patients screened by tablet, there was a significantly higher rate of reported food insecurity (24%) compared to those screened verbally (18%). Of those who had a preference for how the screener was delivered, the vast majority preferred the tablet-based screen over the verbal interview. While there was a high level of comfort with screening regardless of the clinical setting in which it was delivered, more participants reported comfort completing the screen in the ED compared to in their child's doctor's office (86% vs. 80%). It is possible that, together with a tablet-based screen, the added level of anonymity inherent to being a patient in the ED enhanced participants' comfort levels.
How Does This Data Inform Future Research and Practice?
What if we could eliminate bias and discomfort, while maximizing the utility of our screening for SDOH in the clinical setting? The results of this study suggest that written, tablet-based screening is a feasible and effective tool that may allow us to streamline routine inquiry into food insecurity and possibly other SDOH while improving detection and enhancing patient and provider comfort. This puts us one step closer to ensuring we’re helping families connect with the appropriate resources to address social and environmental challenges.
Next up, our team will be taking an even closer look at the screening and referral process in the second phase of this research project. We’ll be talking directly to patients through a series of phone interviews to look into factors affecting caregiver comfort with food insecurity screening both in terms of how and where the screener is delivered, as well as the factors that affect their ultimate engagement with food resources that are referred to them. It is our hope that these findings will help us build and inform programs that successfully connect families with desired resources in order to reduce family-level food insecurity and improve health outcomes for children.