Abstract
Introduction: Food insecurity is a major public health problem in the United States which was exacerbated by the COVID-19 pandemic. We used a multi-method approach to understand barriers and facilitators to implementing food insecurity screening and referrals at safety net health care clinics in Los Angeles County before the pandemic.
Methods: In 2018, we surveyed 1013 adult patients across eleven safety-net clinic waiting rooms in Los Angeles County. Descriptive statistics were generated to characterize food insecurity status, attitudes toward receiving food assistance, and use of public assistance programs. Twelve interviews with clinic staff explored effective and sustainable approaches to food insecurity screening and referral.
Results: Patients welcomed the opportunity to access food assistance in the clinic setting; 45% preferred discussing food issues directly with the doctor. Missed opportunities to screen for food insecurity and refer patients to food assistance were identified at the clinic level. Barriers to these opportunities included: competing demands on staff and clinic resources, difficulty establishing referral pathways, and doubts surrounding data.
Discussion: Integrating food insecurity assessment in clinical settings requires infrastructure support, staff training, clinic buy-in, and more coordination and oversight from local government, health center entities, and public health agencies.
- Food Assistance
- Food Insecurity
- Primary Health Care
- Public Health
- Qualitative Research
- Safety-net Providers
- Social Determinants of Health
Introduction
In 2019, some 13.7 million households in the United States had difficulty procuring food on a regular basis.1 The US Department of Agriculture defines food insecurity as a “household-level economic and social condition of limited or uncertain access to adequate food.”2 Food insecurity is associated with type 2 diabetes and overall poor health.3–7 During the coronavirus disease 2019 (COVID-19) pandemic, this condition was accentuated by a dramatic rise in unemployment, with analyses suggesting that in 2020 about a third of all households with children, regardless of income level had difficulty securing food, some of whom were experiencing the phenomenon for the first time.8 While upstream factors to this condition such as employment status, housing stability, and poverty9 frequently require macro-level investments and political will, local actions and institutional policies can work to address the immediate hunger and nutritional needs of communities.
Primary care clinics are among those areas of practice where such actions can take place. Given that clinics are often the usual and trusted sources of care and health related knowledge for patients, they are particularly well suited to address some of the social determinants of health,10–12 in particular those health system as well as other upstream, underlying factors that causes food insecurity.13 Success in administration of screening tools and referrals to local food resources and government assistance have been documented across various patient populations and different types of health settings; for example safety net clinics,14–16 and pediatric settings.17 Health care providers can play a vital role in identifying and referring patients who are food insecure. However, while an increasing number of health care providers express willingness to screen for food insecurity, practical day-to-day challenges remain; for instance, not knowing what to do when a patient screens positive.18 Limited research exists on the barriers to the screening processes including how best to measure this social risk and need with limited time, practical implications for integrating the data in patient electronic health records, and, once measured, how the condition is addressed efficiently and effectively through referral pathways.13 Additional barriers not well understood are the amount of additional time and workforce costs that are required to collect these individual-level data if screening and referral protocols were being followed in the clinic setting.13 As such, it is important to understand the full range of barriers and facilitators associated with the stepwise process of screening for food insecurity in safety net clinics. Helpful lessons derived from this work can offer guidance for how local counties and municipalities can potentially address this public health problem.
From 2016 to 2020, the Los Angeles County Department of Public Health (LACDPH) partnered with 5 health care systems and nonprofit organizations to address food insecurity as part of its Supplemental Nutrition Assistance Program–Education (SNAP-Ed) efforts. One aspect of these local SNAP-Ed efforts was the goal to increase capacity and improve processes of local clinics so that food insecurity screening and referrals to nutrition education classes, food pantries, and nutrition assistance programs can occur for patients who are SNAP eligible.19 In addition, a separate 2017 County of Los Angeles Board of Supervisors’ Motion on food insecurity led to efforts to pilot a screening tool and referral pathway for this social condition in 2 county clinic sites.
In this study we used a convergent parallel multi-method design20 to achieve the following: (a) characterize the profile of patients who experience food insecurity (survey data) in the safety net clinic setting and (b) to contextualize these patients’ experiences with screening for this condition at health center clinics serving low-income communities (qualitative, in-depth interview data). Of particular interest to this study was clarifying the mechanisms that connect system and organizational infrastructure with individual-level factors, which when identified can be leveraged to inform policy and programmatic changes in the field.21
Methods
Survey Sample
Patients were eligible to participate in the survey if they were over the age of 18 years and resided in the county of Los Angeles. Participant recruitment occurred during Fall 2018 across 11 patient waiting rooms at 4 large public and nonprofit clinics that serve adults who are low-income and Medicaid-eligible. Clinic settings included primary care, pediatrics, women’s health, and family medicine, and were located throughout the county. Each clinic was visited on 1 or 2 days. The survey instrument was designed to be self-administered, in English and Spanish, and all participants received a $5.00 gift card. A total of 1013 questionnaires were collected. The overall response rate was 81.1%.
Survey Instrument
The intercept survey was developed to assess patient experiences with food insecurity and their perceived access to support services. The validated Hunger Vital Sign items were used to measure food insecurity status.22 This 2-question screening tool asked, “Within the past 12 months we worried whether our food would run out before we got money to buy more” and “Within the past 12 months the food we bought just did not last and we did not have money to get more”. The answer options were often true, sometimes true, and never true. If a participant answered that either or both of these statements were often true or sometimes true, they were classified as “food insecure.”
Several questions probed participants on their attitudes related to receiving food insecurity assistance including whether they agree that clinics should help with finding food for them, with whom the participant would be most comfortable sharing their information about lack of food with and for those participants who were not enrolled in SNAP, and reasons why they were not enrolled. Other questions touched on whether staff ever asked participants if they have enough to eat, ever recommended SNAP to them, and based on the referral, did they ever enroll in SNAP.
Demographic questions in the survey instrument included sex, age, race/ethnicity, education, number of children in the household, and whether they participated in a range of social service programs, including SNAP and Medi-Cal (California’s Medicaid program).
Qualitative Sample and Protocol
To better understand how the food insecurity screening process and referral pathways worked in practice, 12 interviews were conducted in Fall of 2018 with staff from the 5 LACDPH partnering agencies who were engaged in food insecurity screening and referral. Of the 5 partnering agencies that were initiating or implementing a screening, 4 were health care systems and 1 a nonprofit organization. Agencies were selected to participate in the study because they had preexisting partnerships with LACDPH; either they were implementing SNAP-Ed and food insecurity screenings or had been instructed by the County Board of Supervisors to implement food insecurity screening and referral pathways to food resources. The patient surveys were conducted at these same 4 clinical sites.
Half of the interviews were with staff in clinical leadership positions. The other half were with staff in health education roles. All interviewees were familiar with day-to-day implementation of screening and referral tasks. Interviewees were not offered remuneration for their participation. Table 1 provides a sample of questions that were asked.
Condensed Sample of Interview Questions, Excluding Probes and Follow-Up
Eight of these in-depth interviews were conducted via telephone. Each interview lasted about an hour. Four interviews from 1 of the 2 county clinic sites were conducted by LACDPH before the commencement of this study. Transcripts from these interviews were provided by the department and were included in the overall pool of qualitative data.
All study protocols and materials were approved (Certified Exempt) by the Human Subjects Protection Committee (Institutional Review Board) at the RAND Corporation. Verbal consent was obtained from all participants and interviewees before the start of data collection.
Quantitative Analysis
To assess the specific patient profiles for those at risk of food insecurity, we conducted descriptive analyses and compared responses by food insecurity status using chi-square tests. Analyses were conducted using Stata 16 (StataCorp LLC, College Station, TX).23
Qualitative Analysis
During each interview session, a study team member conducted the interview, while another took notes. Each interview was recorded and transcribed by these 2 team members to ensure accuracy of information. All relevant transcripts were uploaded to Dedoose, an online collaborative coding platform, for sorting and analysis purposes.24 The analysis combined a directed content approach25 of codes that were built in the interview protocol with an exploration of new themes unbounded by the protocol domains.26 Examples of predetermined codes included “referral pathway,” “measured outcomes,” and “barriers.” Examples of grounded themes included “linkage challenges,” “competing clinic programs,” and “warm hand-off protocol.” This pragmatic combination of postpositivist and interpretivist approaches helped us address different aspects of our research questions that neither approach could address alone: what the clinic screening processes were, and how dimensions of the screening varied within and across participants.27 Each interview was coded by the 2 team members to ensure acceptable reliability. The kappa metric for this part of the analysis indicated a reliability of 0.82, based on 20% of the transcripts.25,26 Any discrepancies (if any) were resolved by consensus. We followed the American Psychological Association guidelines for qualitative research on this analysis.30
Quantitative Results
Participant Demographics
A majority of survey participants were female (76.1%) and the average age was 42.8 (Table 2). Slightly over half completed the survey in English. Three of 4 participants were Latino and 14.9% reported being African American. A little over a quarter of the participants, 26.4%, were enrolled in SNAP/CalFresh and 62.5% in Medi-Cal. A majority of participants experienced food insecurity in the past year, with 60.7% often or sometimes worrying about running out of food and 52.8% reporting that food did not last, and they often or sometimes did not have money to get more.
Survey Population Characteristics, Fall 2018, Los Angeles County (n = 1,013)
Attitudes on Receiving Food Insecurity Assistance
Approximately 84.6% of all survey participants agreed or strongly agreed with the statement that clinics should help them find food (Table 3). Those who were food insecure had higher odds of expecting clinics to help them find food than those who were not food insecure (odds ratio [OR], 1.78, 95% confidence interval [CI] 1.26, 2.53). Participants were most comfortable sharing personal information about not having enough to eat “with my doctor.” The second most common preference was on printed paper to respond to written questions asking about their food insecurity status, followed by speaking with a nurse. The survey asked whether the participant was on SNAP/CalFresh. Among those who said they were not on SNAP/CalFresh and were identified as food insecure, 22.7% reported they did not know how to apply for SNAP/CalFresh, 35.6% reported not being eligible, and 21.6% reported they did not want to be dependent on the government.
Survey Responses by Food Insecurity Status, Intercept Survey at Four Public and Nonprofit Clinics in Los Angeles County, Fall 2018 (n = 1,013)
Perceived Experience at the Clinic
One-third of the survey participants reported being asked by staff if they have enough to eat. Nearly 30% of the entire sample reported that staff recommended SNAP/CalFresh, but only 20.0% reported they enrolled due to a staff referral. Participants who were food insecure reported lower odds of having been asked by staff if they have enough to eat (OR 0.72, 95% CI 0.55, 0.95), but higher odds of enrolling in SNAP/CalFresh due to the staff referral (OR 1.89, 95% CI 1.33, 2.69).
Qualitative Results
Emergent themes and subthemes for food insecurity screening agencies are summarized in Table 4. Table 5 contains salient quotes for each of the key themes related to food insecurity screening.
Summary Descriptions of the Main Themes From Interviews With Food Insecurity Screening Partnering Agencies
Salient Quotes for Themes That Emerged From Interviews With Food Insecurity Screening Partnering Agencies
Food Insecurity Screening Process
Before participating in the SNAP-Ed program for 3 of the agencies, the screening process was not systematic, and clinical staff at most agencies inquired about patients’ food on an ad hoc basis. Most of them reported using the Hunger Vital Sign 2-item tool.22 Interviewees generally perceived the Hunger Vital Sign to be a useful tool, but some clinics adapted it or merged it into 1 question. Clinics that integrated the screening tool into their Electronic Health Record were most enthusiastic about the process.
Although the process was not standardized across the health clinics, a typical pathway might involve the following 3 stages once a patient screens positive. First, the patient is given a packet of information describing food insecurity, the impact it has on health, and what local resources are available. Second, the patient is provided with a referral to the clinic’s Registered Dietitian (RD) or health educator for further support. Last, the RD conducts an assessment on their eligibility for SNAP, and then refers the patients to other resources, such as social workers and food pantries.
Warm hand-offs occur when 1 provider introduces, in person, the patient to the provider to whom they are referred to address their problems. At the participating clinics, warm hand-offs to other county departments and follow-up did not seem to be the norm. Factors that can undermine the feasibility of the screening process include insufficient staff to cover all stages of the screening and referral pathways.
Workforce
Interviewees talked about the need to have a sufficiently large workforce to support activities at each point in the screening process and referral pathways. As clinics learn to screen consistently and to identify food insecure patients, they need to have enough employees to implement steps including transferring the patients in person from 1 care team member to another.
Barriers
Barriers to implementation of the food insecurity screener occurred at 3 levels: patient, organization, and system. These levels were not embedded in the interview protocol but emerged from the data. Perceived patient-specific challenges included stigma of poverty, low literacy, difficulty filling out forms, difficulty navigating systems of care, and multiple competing problems, such as housing instability, job insecurity, and transportation issues. Organizational barriers included staff turnover, challenges with staff role definition, challenges establishing the screening and referral workflows, competing programs, and insufficient training on screening tools. At the system level, some interviewees reported delays in getting other County departments to co-locate staff at clinics and providing confusing information on SNAP eligibility.
Facilitators
All interviewees discussed factors that contributed to the success of their efforts. They included capacity building opportunities such as empathy training, a motivated workforce, team-based workflows, colocation of other agencies’ enrollment workers, leadership support, and on-site resources such as wellness centers and farmers’ markets. The latter factor emerged as a distinctly strong facilitator, with most interviewees noting that it allows clinic staff to offer food insecure patients something tangible on the day of the visit.
Impact
Some interviewees discussed how introducing a food insecurity screening in the clinic has had an impact on staff awareness about the issue, as well the ways they provide care to their patients. Interviewees commented on a shift to a holistic approach to care, whereby providers try to understand the context of life for their patients and their families. Many interviewees also saw value in data monitoring. Data that was being tracked included population needs, screening rates, the percentage of patients for whom the provider has documented an intervention, patient satisfaction, successful linkage to food services, and other clinical outcomes (body mass index and labs).
Sustainability
All interviewees discussed the resources they needed to ensure their screening and referral pathways could be sustained in the long-term. They raised the issue of insufficient institutional capacity to follow up on patients who are food insecure, who needed case management, warm hand-offs, postreferral follow ups, and referrals to other resources.
Discussion
This study draws on a multi-method analysis to examine food insecurity at individual, organizational, and system levels. Findings suggest that health clinics and health systems can and should address food insecurity in the United States (US).10⇓⇓–13 Prior studies found that screening patients for food insecurity and referrals to relevant support resources can help ameliorate this public health problem.14⇓⇓–17 However, practical aspects of the design and implementation of screening and referral pathways at the organizational, county or municipal level can either undermine or boost the success of these screening programs. Our findings add to the knowledge base on barriers and facilitators to food insecurity screening for public program administrators and clinical leaders of programs aimed at reducing food insecurity. Given the financial consequences of the COVID-19 pandemic, screening programs will continue to play an important role in helping households access healthy food.
The survey and interview findings revealed missed opportunities in the clinic setting to help patients enroll in food assistance services or even to provide food on site. First, as other research has shown, many patients would like to seek assistance in the clinic setting,31 but many surveyed had not been prompted to discuss their concerns about food security in the clinic. The clinics included in the study had worked on implementing food insecurity screening for at least 1 year, which may indicate the difficulty with scaling a screening program and referral pathway. Suggestions from the in-depth interviews also noted that medical assistants occasionally forgot to administer the screening, indicating that workflows may not have been clearly established or did not account for the time it takes to administer the questions. While patients mostly said they would prefer to discuss food issues with their doctor, in the busy clinic setting, this issue may not be a priority during a doctor-patient encounter. Conveying concerns about insufficient food on printed paper (such as a pre-examination questionnaire) was the second most preferred method. A positive screen on printed paper allowed for nonmedical staff to identify the need and to initiate follow-up services during the clinic encounter.
Although some of the clinics were already engaged in clinic promotion of food resources, the efforts did not seem to be comprehensive or consistent. Clinics might consider distributing food vouchers that can be redeemed at local grocery stores or even conducting on-site food distributions. Moreover, clinics have other opportunities to share information about services, including using text messages or e-mails to alert patients to food distribution events and food pantries in their local area.
The qualitative themes identified key barriers that are consistent with the recent National Academies report that highlighted the importance of having a trained and appropriately staffed workforce and concerns surrounding data and standards,32 especially as they relate to social risk screening and addressing patients’ social needs. Specifically, findings from the current study revealed competing demands on clinic resources,33 the complexity of establishing referral pathways,34 and some residual doubts about the utility and effectiveness of the Hunger Vital Sign screener.35 While the 2-item Hunger Vital Sign screener reduces patient and clinic burden, this screener may be less reliable compared with the 6- or 18-item tools.36 Research highlights the need to allow health clinics sufficient flexibility to tailor existing instruments to local needs or even develop their own to ensure that the tool is integrated into existing electronic health record domains.13 However, such recommendations may contradict best practice from the field of survey development, which typically recommends rigorous psychometric testing and standardized implementation of surveys across institutions.37 Other research has also highlighted the lack of consensus on how and how often to screen patients for social needs, and by whom.38 Future research should examine these issues.
Our findings, as well as those of previous studies, suggest that routinely integrating food insecurity screening in clinical settings requires additional infrastructure, staff training, and a stronger evidence base to increase provider buy-in.13 Given the likely variation in staffing and resources across settings, prior research indicates that more flexibility is needed to adapt workflows to suit staffing levels and resources.15 Experience in the field also shows that stronger warm hand-off procedures may be needed to connect patients with the proper resources, as breakdowns after systematic screening likely occur quite often.
Limitations
The convenience survey sample may have omitted vulnerable persons who were not at the clinics on the day(s) scheduled for the intercept survey, limiting generalizability of the data. The relatively small sample size of the qualitative component hinders the broader interpretation of our findings. Our interviewees come from a large multicultural, multiracial, mostly urban county in southern California, so they may not be representative of experiences across the state or the US. Finally, self-selection bias represents another possible limitation since 1 of the originally eligible partnering agencies did not participate.
Conclusions
Addressing food insecurity in the US is a pressing public health need that was exacerbated by the COVID-19 pandemic. This study identified several challenges of screening and building referral systems for patients. Food pantries and food distribution events directly on-site may offer an immediate solution to meet the needs of food insecure patients. Local public health departments can work to initiate and strengthen county-level referral infrastructure which could be critical for ensuring that effective screening and referral systems are implemented in a standardized manner. Training support and capacity building opportunities such as empathy trainings, offered in partnership with public health departments, should be provided on an ongoing basis to keep clinic staff updated on best practices and as a strategy for addressing potential staff turnover, which frequently can lead to loss of institutional memory/knowledge. Training can also ensure that screening tools are being implemented as intended and that connectivity to federal and local resources, including SNAP, is established in a timely manner. Finally, county-level administrative and management support is crucial for capacity and coalition building. Health clinics and stakeholders should collaborate at a systems level and exchange best practices to help further address this need.
Notes
This article was externally peer reviewed.
Funding: This project was supported in part by a Contract 16-10148 from the California Department of Public Health to the Los Angeles County Department for work related to the US Department of Agriculture’s Supplemental Nutrition Assistance Program Education. The content of this article and any views expressed are those of the authors and do not represent the position(s) or viewpoint(s) of the affiliated agencies or the organizations mentioned in the text.
Conflicts of interest: None.
To see this article online, please go to: http://jabfm.org/content/36/2/240.full.
- Received for publication May 10, 2022.
- Revision received July 27, 2022.
- Revision received November 11, 2022.
- Accepted for publication November 28, 2022.
