Article Figures & Data
Figures
- Figure 1.
Steps and data flow for screening and referral. Abbreviations: WIC, Women, Infants, and Children; SNAP, Supplemental Nutrition Assistance Program.
- Figure 2.
Survey responses across stakeholder groups. Abbreviations: HCWs, health care workers; FAO, food assistance organizations.
Tables
Patients HCWs* FAO Staff Interview Participants Total 20 10 12 Gender Male 3 1 1 Female 17 9 11 Age 20 to 39 13 3 5 40 to 59 3 6 5 60 to 79 4 1 2 Race/ethnicity White/Caucasian 13 9 10 Latinx/Hispanic 5 0 1 Multiple races/ethnicities 2 1 1 Language Interview conducted in English 17 10 12 Interview conducted in Spanish 3 0 0 Survey Participants Total 50 39 37 Gender Male 22 (44.0%) 14 (35.9%) 3 (8.1%) Female 28 (56.0%) 25 (64.1%) 34 (91.9%) Age 20 to 39 14 (28.0%) 15 (38.5%) 13 (35.1%) 40 to 59 26 (52.0%) 19 (48.7%) 14 (37.8%) 60 to 89 10 (20.0%) 5 (12.8%) 10 (27.0%) Race/ethnicity† White 38 (76.0%) 32 (82.1%) 29 (78.4%) Latinx/Hispanic 9 (18.0%) 3 (7.7%) 7 (18.9%) American Indian or Native American 4 (8.0%) 0 (0.0%) 1 (2.7%) Asian or Asian American 0 (0.0%) 2 (5.1%) 0 (0.0%) Other race or ethnicity 2 (4.0%) 2 (5.2%) 1 (2.7%) Prefer not to say 0 (0.0%) 1 (2.6%) 1 (2.7%) Language Survey administered in English 45 (90.0%) 39 (100.0%) 37 (100.0%) Survey administered in Spanish 5 (10.0%) 0 (0.0%) 0 (0.0%) Food insecurity status‡ Never food insecure 1 (2.0%) 28 (71.8%) 14 (37.8%) Previously food insecure 12 (24.0%) 9 (23.1%) 13 (35.1%) Currently food insecure 37 (74.0%) 2 (5.1%) 10 (27.0%) HCWs, health care workers, FAO, food assistance organizations.
↵* Interview respondents included both medical providers and other medical practice staff whereas survey respondents included only medical providers.
↵† Sums to more than 100%; respondents selected all race/ethnicity categories with which they identified.
↵‡ Assessed using the Hunger Vital Sign screening tool.
- Table 2.
Themes, Perspectives across Stakeholder Groups, and Illustrative Quotations for Qualitative Findings on Screening, Referral, and Closing the Loop to Address Food Insecurity (FI) in Primary Care Practice
Themes Stakeholder Perspectives* Illustrative Quotations Findings on Screening Recognition that FI affects health Patients: Sometimes surprised to be asked the screening questions, but understand the health connection
HCWs: Believe it's important to understand social situation and needs
FAO staff: Believe that FI affects health and understand the connection[Screening] is more of a health check than a food check. —patient, #1†
If [patients] can't access meals in a way that corresponds with their health care needs, we have to figure something out. It's…an integral part of what primary care physicians should do. —HCW, #25
Housing and food are basics. [Our organization] I believe helps families be healthy and to make good decisions. —FAO staff, #32Comfort with screening and its implementation in primary care Patients: Generally comfortable discussing FI but some concerns about potential consequences of screening
HCWs: Unsure how to fit screening approaches that patients are comfortable with into busy clinic workflow
FAO staff: Concern that patients will not feel comfortable discussing FI[The questions] made me feel kinda uncomfortable because I have had past experience with, like CPS…I just don't want…a reason for them to take my daughter away. —patient, #4
There's a lot of other things to talk about during the visit, and [there's] just not the time to identify social determinants. —HCW, #23
People believe that they should rely on each other, their family, versus coming in and asking for help. We sometimes call it the Western mentality and pride comes into play when it comes to food insecurity, too. —FAO staff, #34Importance of using screening information to help people Patients: Want to know that the purpose of data collection is to suggest resources
HCWs: Concern that data collected may not be usedI [would feel comfortable with the screening] if it were related to the services that we were getting that day. But if it was just kind of off the fly, I would kind of question their motives. —patient, #13
There's lots of good intentions, but putting something in a database in a computer I don't think actually helps people. —HCW, #28Findings on Referral Recognition of value if confidentiality is ensured Patients: Generally recognize benefits but request for permission and confidentiality are necessities
HCWs: Concern about the Health Insurance Portability and Accountability Act (HIPAA), although some data sharing already happeningFAO staff: Generally recognize benefitsI think I'd feel fairly comfortable as long as they keep their confidentiality. —patient, #4
I think the main issue is that there isn't some type of a patient privacy or HIPAA violation with sharing that information to try and connect them with the resources —HCW, #26Concerns about workload and capacity HCWs: Concerns about lack of staff time and lack of compensation for referral work
FAO staff: Concerns about time and capacity to respond to referralsPhysicians are overloaded with information right now…so that care coordination piece for physicians is taking a lot of time and energy. —HCW, #26
We're definitely looking at caps and what we can reasonably do. Once we hit those caps it would just be wait-lists, and I mean it's all we can do. —FAO staff, #33Barriers to accessing resources Patients: Encounter challenges accessing resources even if they are referred
FAO staff: Many factors can deter access, even when people are referredUsually I have to take my kids with me ‘cause it takes all of their hands, plus mine [to get the food home from the food bank without a car]. But then it's bus fare for all of them, too.” —patient, #2
I think a challenge for people getting in here is transportation. Or when we've tried to call the numbers they give us, they're disconnected or no longer in service.” —FAO staff, #35
[Many people] are just scared that they will affect applying for their citizenship or residence. FAO staff, #31Findings on Closing the Loop Differing perspectives on value and acceptability Patients: Generally recognize benefits but request for permission a necessity and strong privacy concerns among a minority of respondents
HCWs: Strong positive view of benefits
FAO staff: Recognize potential benefits but concern for client privacyI don't guess it would bother me…but you know, I think that we need to know that they're doing that…sign a paper or something. —patient, #14
I really don't want anybody to know that I'm on [SNAP]. It's really nobody's business…I'm not proud of it. —patient, #7
I think that closing the referral is great. Then you know what you're saying is helping or not. —HCW, #21
I think it would be helpful, but I don't know if [our clients] would. I feel like some people might be judged if they shared that information. By the providers. —FAO staff, #35Logistics and implementation Patients: Concern about data security
HCWs: Importance of integration into existing data systems and workflows
FAO staff: Concerns about time, cost, and regulationsI think the only thing I get nervous about is just the fact that everything's being hacked lately. —patient, #2
We need to put it into our EMR, or just think about where [the information] would go, and how would that be done. —HCW, #24
We're overstretched as it is, and adding like another piece of data entry onto it, would be something that we'd have to really look at to make sure that it was worthwhile for us to kind of do that extra work. —FAO staff, #32
There could be the confirmation…that the referral's been received. We just can't confirm if [the person is] eligible for the program or not due to federal privacy regulations. —FAO staff, #36HCWs, health care workers; FAO, food assistance organizations; EMR, electronic medical record; CPS, child protective services.
↵* If a stakeholder group is not included for a theme, it indicates that particular theme did not emerge among that stakeholder group.
↵† Numbers indicate specific interview participant (patients numbered 1-20, HCW numbered 21-30, FAO staff numbered 31-42).
