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Sample questions for staff at food insecurity screening partnering agencies 1. Please describe the current food insecurity screening and referral process at your organization? 2. Does the current screening instrument meet your agency’s needs or the needs of the population you serve? 3. To what resources do you refer patients who have been identified as food insecure? 4. What have been some of the barriers to that have arisen since the screening and referral process started? 5. How did you or your agency try to address some of these barriers? 6. What do you think most contributes to the success of the screening so far? 7. What are the primary outcomes that have resulted from your food insecurity screening and referral process? 8. How has implementation of a food insecurity screening changed your care provision for food insecure patients at your organization? Characteristic Number (Percentage or Mean) Male 234 (23.9%) Female 745 (76.1%) Average age 42.8 (Range 18 to 95) English language survey 549 (54.2%) Spanish language survey 464 (45.8%) Race/ethnicitya Latino 759 (74.9%) African American 151 (14.9%) White 53 (5.2%) Asian 41 (4.1%) American Indian 10 (1.0%) Other 25 (2.5%) Education <High school 338 (35.0%) High school degree 279 (28.9%) Some college 177 (18.3%) Associate of art or technical degree 76 (7.9%) Bachelor’s degree 65 (6.7%) Some graduate school or degree 32 (3.3%) Average number of children <18 at home 1.5 (Range 0 to 11) Has at least 1 child at home 69.3% Participate in CalFresh (food stamps, EBT, SNAP) 264 (26.4%) Participate in (all that apply) WIC 219 (21.6%) CFAP 82 (8.1%) CalWORKS 95 (9.4%) General relief 35 (3.5%) CACFP 2 (0.2%) Head Start 14 (1.4%) Medi-Cal 633 (62.5%) HFP-CHIP 23 (2.3%) Reduced price school meal 54 (5.3%) Section 8 housing 54 (5.3%) Summer food program 8 (0.8%) SSI 65 (6.4%) None of the above 208 (20.5%) In past 12 months, frequency to worry that food would run out Often 162 (16.0%) Sometimes 453 (44.7%) Never 398 (39.4%) In past 12 months, food did not last and did not have money to get more Often 118 (11.6%) Sometimes 417 (41.2%) Never 478 (47.2%) ↵a Question allowed participant to make all that apply; total may sum to more than 100%.
Abbreviations: CFAP, California Food Assistance Program; CACFP, Child and Adult Care Food Program; CalWORKS, California Work Opportunity and Responsibility for Kids program; EBT, Electronic Benefit Transfer; HFP-CHIP, Healthy Families Program-Children’s Health Insurance Program; SNAP, Supplemental Nutrition Assistance Program; SSI, Supplemental Security Income; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
- Table 3.
Survey Responses by Food Insecurity Status, Intercept Survey at Four Public and Nonprofit Clinics in Los Angeles County, Fall 2018 (n = 1,013)
All Not food insecure Food insecure Odds ratio (95% CI)* P (n = 1013) (n = 362) (n = 626) Clinics should help me find food (strongly agree or agree) 84.6% 79.4% 87.3% 1.78 (1.26, 2.53) <0.0001 With whom most comfortable sharing personal information about not having enough to eat: Doctor 45.3% 35.6% 51.0% 1.88 (1.44, 2.45) <0.0001 Nurse 15.6% 11.6% 17.9% 1.66 (1.13, 2.43) 0.009 Front desk staff 4.5% 2.5% 5.6% 2.32 (1.10, 4.89) 0.026 On paper 21.2% 15.2% 24.6% 1.82 (1.30, 2.56) <0.0001 On a computer or tablet 10.3% 7.7% 11.8% 1.60 (1.01, 2.52) 0.040 Currently participate in SNAP 26.7% 19.3% 31.0% 1.88 (1.38, 2.58) <0.0001 If not currently enrolled in SNAP, why: Don’t know how to apply 18.7% 12.8% 22.7% 2.00 (1.33, 3.02) <0.0001 Am not eligible 37.4% 40.1% 35.6% 0.82 (0.61, 1.12) 0.218 Don’t want to be dependent on government 25.3% 30.8% 21.6% 0.62 (0.44, 0.87) 0.005 Application too difficult 2.8% 2.6% 2.7% 0.93 (0.37, 2.34) 0.875 Concerned what others will think 1.7% 2.1% 1.4% 0.67 (0.21, 2.11) 0.495 Worried about citizenship 6.4% 3.5% 8.4% 2.57 (1.25, 5.26) 0.010 Applied and waiting 2.1% 2.1% 2.1% 1.02 (0.36, 2.88) 0.920 Other reason 10.5% 10.7% 10.3% 0.96 (0.59, 1.55) 0.880 Staff ever asked if client has enough to eat (yes) 33.8% 38.4% 31.0% 0.72 (0.55, 0.95) 0.020 Staff recommended SNAP 28.8% 28.6% 28.9% 1.01 (0.76, 1.35) 0.937 Enrolled in SNAP due to staff referral 20.0% 14.0% 23.6% 1.89 (1.33, 2.69) <0.0001 ↵* Food insecure compared to not food insecure (reference).
Note: For the Hunger Vital Sign 2-item screener, 25 (2.5%) participants did not answer both questions.
Abbreviations: CI, Confidence Interval; SNAP, Supplemental Nutrition Assistance Program.
- Table 4.
Summary Descriptions of the Main Themes From Interviews With Food Insecurity Screening Partnering Agencies
Theme/Summary Description Screening process Refers to the process of screening patients in primary care settings to identify those who are food insecure and refer them to food programs (eg, SNAP) and other food resources, such as food banks. Sub-themes include screening tools and perceived tool utility, data tracking, identification of referral resources, referral protocol, warm hand-off protocol, and follow-up. Workforce Refers to the profile of individuals who work for the participating agencies, such as status (full-time, part-time, or volunteer status), expertise, prior experience with food-insecure populations, type of training received under SNAP-Ed grant, and perceived training quality. Barriers Refers to perceived obstacles in the food insecurity screening process. Sub-themes include perceived population-level barriers (eg, literacy, fear of immigration raids), organization-level barriers (eg, competing goals within each clinic), and system-level barriers (eg, lack of formal arrangements with other county agencies). Facilitators Refers to factors that are perceived to make the screening processes easier, including collaborations and regional coalitions, local knowledge, community trust, and having food resources (eg, farmers’ markets) at clinic sites. Impact Refers to the perceived outcome of agency efforts in low-income communities. Subthemes include outcomes measurement and anecdotal evidence. Sustainability Refers to discussions of resources needed to ensure that current efforts are sustainable and scalable in the long-term. - Table 5.
Salient Quotes for Themes That Emerged From Interviews With Food Insecurity Screening Partnering Agencies
Theme/Quote Screening process I think the two questions are a great tool to open discussion and to stimulate the thought with the parents, and to kind of de-mystify or destigmatize the idea of food insecurity, because a lot of our parents, you know, obviously don’t want to admit being food insecure, but when you bring it up in the form of a question, it gives validity to the issue, and lack of judgment, so I think it’s a perfect way to kind of set the table. (Agency 3, Participant 1)
We were identifying all the determinants especially for food, and then we never knew what was happening. That’s when we realized we really needed to connect someone here with us, track it, follow up, see did they get food recourses, did they go, was that helpful to them—that’s how we discovered some of the food banks weren’t so helpful, others were too far. We’re looking to see what else we could do. (Agency 5)Workforce A [nutritionist or social worker] can be self-sustained through the billing process because they no longer have to see the provider for this…and the service would be a billable service. The clinic has such high needs for all kinds of things, but [food access and insecurity counseling] is not a billable service, so it is not sustainable. (Agency 1, Participant 1)
There hasn’t been a whole lot of training. The staff that are actually involved in the food insecurity screening right now…haven’t done much training. It was more, “This is what we’re doing now. This is what we need you to do. Here are the questions.” And we gave them the information on food insecurity and really briefly sort of talked about why it’s important. (Agency 4)Population-level barriers I remember this one patient told me that, right now they’re gonna start getting housing, and once they get housing, they’ll be able to focus more on the food. (Agency 2, Participant 1)
We’ll give the resource, we’ll give the people, we’ll do this, and then families are coming back and saying it’s not enough or they weren’t able to access, they forgot to call, or they lost the paper. (Agency 3, Participant 2)”Organizational barriers Taking patients from the PEDS clinic to the medical office, I don’t encourage that at all because not every patient will receive the same-day service. Because sometimes health education staff are busy in the classroom or clinic doing their presentation. What I will recommend is that the clinic staff keep a log of all of them, pass it to the social worker, and they make appointments or follow-up calls to them to make sure that they receive services that they need. (Agency 4)
I think what’s needed now is the actual follow-through part, making sure we have enough social workers and staff in our family support programs and case management built up to be able to handle when those screens are positive. That’s the real crux of the sustainability. (Agency 3, Participant 2)System-level barriers Focus groups around CalFresh [SNAP] enrollment actually got a little ugly, because [patients] had poor experiences unfortunately. Our team had to contact a few attorneys just to figure out, okay, what is the language, what does this mean? Because some of the information is a little confusing to participants or there’s a lot of different information out there. (Agency 2, Participant 3) Facilitators The mission and the heart of the people that are running the program. And I would say that’s pretty much core to everything that we do. Everything we do is very mission driven for us. I think that part is probably the number one factor that has aided us in the success. It’s that willingness to do it because you recognize it’s important, you see it in the data, and you see your population suffering, and it’s the right thing to do. (Agency 3, Participant 2) We had a presentation showing why we do this work and why it’s important to screen patients for food insecurity, and we’ve shared stories from our patients in the community and how we’ve helped them out. I think them hearing this coming from our own patients has really motivated them to see the big picture. Really, the support from the clinic administrators who are there with their staff and have really pushed them to be empathetic and make sure we’re screening the patients. A lot of staff and providers didn’t know what food insecurity was. Having a patient come in and share their story really impacted our staff and made them want to work with us. (Agency 2, Participant 3) Impact It’s an entirely different way of approaching primary care. It’s about a whole new model of forming relationships, really getting to know what’s going on in the lives of your patients and what are the true barriers to their health, and forming that pyramid of needs, and addressing them in the order of the highest priority. I’m not saying we’re there by the way, that sounds wonderful, it’s a vision. […] I don’t think that screening for food insecurity in isolation is how we’ve been successful. It’s the entire approach we’ve taken, and food insecurity is one domain in 7 or 8 that we look at for our patients. (Agency 5)
We have families that have come in and thank us for caring and asking those questions because there’s embarrassment, there’s pride, and parents will not think first to come to a healthcare institution to report things like, “I’m hungry.” And it’s been a really neat thing that, for me, at least as a provider and a pediatrician, that families will come to me and talk to me about things that people may not ordinarily put in the healthcare bucket. And it’s a neat place that people are recognizing that it very much can be in the healthcare bucket because it very much impacts your health, your growth, and everything. So, that’s been, I think, a very big win for us. (Agency 3, Participant 2)Sustainability I think we’re constantly working on it and trying to see what points in the workflow need to be improved. So, I think sort of trying to figure out how to implement this, has been a really good example of how our departments can work together. And even though [another county agency] was in the building, we never really worked with them or knew what they do, or they didn’t know what we did, we didn’t know how they worked, they didn’t know how we worked. And, so, I think that sort of collaboration is helpful both for this and potentially for more projects in the future. (Agency 4)
