Food for Thought: An Evaluation of Food Insecurity Screening Methods and Location
Statement of Problem
When kids go hungry, it takes a toll on nearly every aspect of their health. From increased risk of asthma and anxiety to cognitive delay and hospitalization, food insecurity is a strong predictor of poor health outcomes. In Philadelphia, nearly 1 in 4 children was food insecure in 2019, a number that continued to climb during the COVID-19 pandemic.
For these reasons, medical providers have been increasingly interested in screening for food insecurity and other social determinants of health. However, little is known about how to screen families for a social need like food insecurity in a way that is comfortable and elicits an accurate report of the challenges they face. Furthermore, few studies have examined why rates of engagement with resources are low even after a referral is provided.
We conducted a three-part study to learn more about these issues:
- First, we randomized caregivers arriving with patients to Children’s Hospital of Philadelphia’s (CHOP) Emergency Department (ED) to either a written, tablet-based screen for food insecurity, or the identical screening tool asked verbally.
- Second, we conducted surveys and telephone interviews to explore caregivers’ experiences with food insecurity screening and resource referral
- Third, we partnered with a community food resource agency to provide a “warm handoff” through which caregivers were contacted directly within two weeks of the ED visit for resource navigation.
Our findings highlighted caregiver preferences and perceptions related to screening and social resource referral, addressing three main questions:
1) How should we screen for social risk?
Our randomized controlled trial found a significantly higher rate of reported food insecurity among caregivers screened by tablet (24%) compared to those screened verbally (18%). Caregivers shared during phone interviews that the tablet provided a level of anonymity that helped them feel less “judged,” as food insecurity can be a stigmatizing condition and disclosure of this sensitive information can raise fears of negative repercussions such as the involvement of Child Protective Services.
Furthermore, while there was a high level of comfort with screening regardless of the clinical setting, more participants reported comfort completing the screen in the ED compared to their child's doctor's office (86% vs. 80%). Caregivers described a close relationship with a physician as both a facilitator and a barrier to relaying social need. It is also important to note that experience of food insecurity was associated with lower levels of screening comfort.
2) What gets in the way of caregivers engaging with social resources?
Caregivers often refused resources because they did not see their situation as “bad enough” to require additional help. Many reported discomfort taking resources that other families might need more. Others reported negative past experiences with social resources and expectations that their income or employment status would disqualify them from receiving additional support. Caregivers also explained that competing life priorities are often a barrier to resource engagement.
3) How do caregivers think the referral process could be improved?
Several caregivers suggested that keeping track of a physical list of resources was difficult for them and that electronic platforms provided an additional sense of privacy. Caregivers also stressed the importance of providing geographically appropriate resources and ensuring that instructions for accessing them are widely available.
These findings have influenced social risk screening protocols at CHOP and throughout southeast Pennsylvania via the COACH collaborative, with implementation of social risk screening tools using a tablet. While we found overall high levels of comfort with screening, it is notable that comfort levels were lower among those reporting food insecurity, with caregivers expressing fear of stigma or negative repercussions as a consequence of reporting social risk.
This and other emerging literature emphasize the potential for unintended consequences with social risk screening and have led to a growing interest in a model of universally offered social assistance, rather than one of screening and intervention. Our team will be launching a new study to further elevate the caregiver perspective, systematically exploring how screening affects families’ acceptance, perception and engagement with social resources.
This project page was last updated in March 2022.
Children's Hospital of Philadelphia, PolicyLab. Food for Thought: An Evaluation of Food Insecurity Screening Methods and Location [Online]. Available at: http://www.policylab.chop.edu. [Accessed: plug in date accessed here].