Interventions Addressing Food Insecurity in Health Care Settings: A Systematic Review

Food insecurity and the risk of mortality among Hispanics with hypertension

BACKGROUND AND AIMS

Hypertension continues to be a major public health problem affecting almost half of the adults in the US. The intersection of hypertension with food insecurity has not been well-examined specifically among minority populations. We aimed to examine the influence of food insecurity on mortality among adult Hispanics.

METHODS AND RESULTS

Data on adult Hispanic (age≥ 20 years) respondents of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2010 were analyzed. Mortality was assessed by linking these data with the National Death Index through December 31, 2019. Using complex samples Cox regression analysis, the relationship between hypertension, food insecurity, and mortality was assessed. Sociodemographic (age, gender, poverty-income-ratio, marital status, and citizenship status) and health-related characteristics (COPD, diabetes, cardiovascular disease, chronic kidney disease) of the population were included as covariates in the regression analysis to assess mortality risk. The crude hazard ratio (HR) for overall mortality related to hypertension was 4.95 (95% confidence interval [CI] = 4.22-5.82, p < .001). The adjusted HR was elevated, 2.01 (95%CI = 1.50-2.70, p < .001), among individuals with both hypertension and food insecurity. However, among individuals with hypertension and no food insecurity, there was no statistically significant increase in the risk of mortality (HR = 1.09, 95%CI = 0.89-1.34, p > 0.05).

CONCLUSIONS

In adult Hispanics, food insecurity significantly increases the risk of mortality among those with hypertension compared to food-secure individuals. Clinicians should be sensitized to the need for food security among Hispanics with hypertension to effectively manage hypertension and reduce premature mortality.

Factors Associated With Uptake of an Open Access Health Center-Based Mobile Produce Market: A Case for Expanded Eligibility

BACKGROUND

Health care-based food assistance programs show promise but are underutilized. Strict eligibility requirements and program scheduling may dampen reach and outcomes.

OBJECTIVE

To explore factors associated with uptake of a health center-based mobile produce market with no eligibility requirements and few barriers to entry.

DESIGN

A cross-sectional analysis of medical record, sociodemographic, environmental, and market attendance data was used.

PARTICIPANTS/SETTING

The study sample consisted of 3071 adults (18+ years) who were patients of an urban health center in eastern Massachusetts and registered for the mobile market during the study period of August 2016 to February 2020.

MAIN OUTCOME MEASURES

The main outcome measure was monthly market attendance over the study period.

STATISTICAL ANALYSES

T-tests and χ2 tests were used to compare market users and never-users. Multiple logistic regression was used to analyze variables associated with market attendance each month.

RESULTS

In multiple variable analyses, Supplemental Nutrition Assistance Program enrollment was associated with slightly less frequent monthly market use (odds ratio [OR], 0.989; 95% CI, 0.984-0.994). Day-of, on-site market registration was associated with more frequent monthly use than self-registration on nonmarket days (OR, 1.08; 95% CI, 1.07-1.08). Having a psychiatric or substance use disorder diagnosis was associated with slightly less frequent market attendance (OR, 0.99; 95% CI, 0.98-0.99; and OR, 0.96; 95% CI, 0.95-0.97, respectively) compared with registrants without these diagnoses.

CONCLUSIONS

Individual, community-level, and organizational factors are associated with uptake of a free mobile produce market and should be considered when designing programs.

Food inequity and insecurity and MASLD: burden, challenges, and interventions

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an 'upstream' risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Focusing attention on the important association between food insecurity and psychological distress: a systematic review and meta-analysis

BACKGROUND

Food insecurity has involved more than 750 million individuals worldwide. The association of food insecurity with socio-economic factors is also undeniable demand more consideration. Food insecurity will become a global priority by 2030. This systematic review and meta-analysis examined current literature concerning the association between food insecurity and psychological distress.

METHODS

Relevant researches were identified by searching databases including PubMed, EMBASE, Scopus, and Web of Science, ProQuest, and Cochrane Library up to June 2024 without language limitation. Then a snowball search was conducted in the eligible studies. The quality assessment was made through Newcastle-Ottawa Scale.

RESULTS

Data were available from 44 cross-sectional articles for systematic review and 17 eligible articles for meta-analysis with 2,267,012 and 1,953,636 participants, respectively. Findings support the growing segment of literature on the association between food insecurity and psychological distress. The highly represented groups were households with low income. Psychological and diabetic distress was directly associated with food insecurity as it increased the odds of distress to 329% (OR: 3.29; 95% CI: 2.46-4.40). Sleep problems, anxiety, depression, lower life satisfaction, obesity, and a higher rate of smoking were among the secondary outcomes.

CONCLUSION

Food insecurity was a common stressor that can have a negative impact on psychological well-being and even physical health. The findings should be considered in the public health and making policy-making process.

Vida Sana y Completa: A randomized controlled trial to examine the effectiveness of diabetes prevention with and without medically supportive groceries among Latina women

Latina women have a high prevalence of obesity and obesity-related chronic diseases, such as diabetes. Approximately half of Latinas with obesity will also experience food insecurity, or a lack of access to enough food for an active and healthy life. Food insecurity is a barrier for effective prevention and management of obesity-related chronic diseases. The goal of this type 1 hybrid comparative effectiveness trial is to compare a culturally-tailored diabetes prevention intervention with and without medically supportive groceries. Adult Latina women (n = 412) with obesity (Body Mass Index (BMI) of >30 kg/m2) and food insecurity will be 1:1 randomized to the Vida Sana intervention (control), or to Vida Sana y Completa (intervention plus integrated treatment for food insecurity). Vida Sana is an evidence-based culturally tailored, 12-month diabetes prevention intervention that targets at least 5% weight loss and at least 150 min/week of moderate-to-vigorous physical activity. Participants enrolled in Vida Sana y Completa will also receive 12 weekly deliveries of medically supportive groceries. Those in Vida Sana alone will receive information on local food resources. Participants will be assessed at baseline and every 6 months for 24 months. The primary outcome is weight loss at 12 months. Secondary outcomes include weight loss maintenance, diet quality, and quality of life. Barriers and facilitators of implementation will be assessed using mixed methods according to the Consolidated Framework for Implementation Research. This study will provide critical evidence for addressing the combination of obesity and food insecurity in primary care for diabetes prevention. Trial Registration: NCT052111.

The Association Between Hospital-Based Food Pantry Use and Subsequent Emergency Department Utilization Among Medicaid Patients With Diabetes

We explored the association between the use of a hospital-based food pantry and subsequent emergency department (ED) utilization among Medicaid patients with diabetes in a large safety-net health system. Leveraging 2015-2019 electronic health record data, we used a staggered difference-in-differences approach to measure changes in ED use before vs after food pantry use. Food pantry use was associated with a 7.3 percentage point decrease per patient per quarter (95% confidence interval, -13.8 to -0.8) in the probability of subsequent ED utilization ( P = .03). Addressing food insecurity through hospital-based food pantries may be one mechanism for reducing ED use among low-income patients with diabetes.

Intensity and Variation of Health Navigator Support: Addressing Medical and Social Needs of Diabetes Patients in East Oakland

BACKGROUND

Healthcare systems are increasingly screening and referring patients for unmet social needs (e.g., food insecurity). Little is known about the intensity of support necessary to address unmet needs, how this support may vary by circumstance or time (duration), or the factors that may contribute to this variation.

OBJECTIVE

Describe health navigator services and the effort required to support patients with complex needs at a community health center in East Oakland, CA.

DESIGN

Retrospective analysis of de-identified patient contact notes (e.g., progress notes).

PARTICIPANTS

Convenience sample of patients (n = 27) enrolled in diabetes education and referred to health navigators.

INTERVENTIONS

Navigators provide education on managing conditions (e.g., diabetes), initiate and track medical and social needs referrals, and navigate patients to medical and social care organizations.

MAIN MEASURES

Descriptive statistics for prevalence, mean, median, and range values of patient contacts and navigation services. We described patterns and variation in navigation utilization (both contacts and navigation services) based on types of need.

KEY RESULTS

We identified 811 unmet social and medical needs that occurred over 710 contacts with health navigators; 722 navigation services were used to address these needs. Patients were supported by navigators for a median of 9 months; approximately 25% of patients received support for > 1 year. We categorized patients into 3 different levels of social risk, accounting for patient complexity and resource needs. The top tertile (n = 9; 33%) accounted for the majority of resource utilization, based on health navigator contacts (68%) and navigation services (75%).

CONCLUSIONS

The required intensity and support given to meet patients' medical and social needs is substantial and has significant variation. Meeting the needs of complex patients will require considerable investments in human capital, and a risk stratification system to help identify those most in need of services.

A Qualitative Study of A Health Center-Based Mobile Produce Market

Healthcare-based food assistance programs have the potential to improve patients' food security, but are underutilized. We conducted a qualitative study of user and staff perceptions of an on-site mobile market at a federally-qualified health center (FQHC). Five themes were identified: 1) financial need drives the decision to use the market, 2) people attend specifically to receive healthy food, 3) users feel a connection to the FQHC, which increases participation, 4) social networks increase usage of the program, and 5) long lines, inclement weather, inaccessibility, and inconsistent marketing and communication are attendance barriers. Findings should inform implementation of future healthcare-based food assistance programs.

Examining food insecurity in a regional New Zealand emergency department: A cross-sectional study

OBJECTIVE

To determine the prevalence of food insecurity (FI) among patients in a regional New Zealand ED, factors associated with FI and feasibility of an ED-based FI screening programme with voluntary social work (SW) follow up.

METHODS

Cross-sectional study of patients presenting to the Whangarei Hospital ED, using the validated two-item Hunger Vital Sign screening tool to assess for FI. Participants were offered SW follow up to discuss community food resources.

RESULTS

Of the 300 participants who completed the questionnaire, 111 (37.0%, 95% confidence interval [CI] 32.0-43.0) were food insecure. Factors associated with FI include Māori ethnicity (odds ratio [OR] 2.12 [95% CI 1.19-3.80], P = 0.011), household crowding (OR 1.19 [95% CI 1.02-1.39], P = 0.024) and lower socioeconomic status (OR 1.13 [95% CI 1.00-1.27], P = 0.048). There was no statistically significant association between FI and number of comorbidities or the primary reason for ED attendance. Of participants who were food insecure, only half reported being aware of (n = 56/111, 50.5%) or had used (n = 60/111, 54.1%) food resources. Participants who were food insecure were more likely to have utilised resources, either currently or in the past (OR 8.50 [95% CI 4.46-16.18], P < 0.001). Forty (13.3%) participants requested SW follow up and of those, most (n = 31/40, 77.5%) were successfully contacted. FI was associated with interest in SW follow up (OR 16.95 [95% CI 5.81-49.42], P < 0.001). At follow up, the majority (n = 24/31, 77.4%) of participants requested further information regarding food resources.

CONCLUSION

FI was prevalent among patients in a regional NZ ED. An ED-based FI screening programme with voluntary SW follow up was feasible and acceptable to ED patients.

Families Benefit After Utilization of a Clinic-Based Food Pantry Irrespective of Food Insecurity Experiences in a Pediatric Obesity Treatment Program

PURPOSE

To evaluate the congruence between food insecurity screening outcome and clinic-based food pantry utilization and to examine caregiver reported comfort, motivation, and benefits of utilization.

DESIGN

Mixed-methods study.

SETTING

Academic pediatric obesity treatment clinic.

SUBJECTS

Convenience sample of caregivers.

INTERVENTION

Clinic-based food pantry offered irrespective of food insecurity screening outcome.

MEASURES

Food insecurity screening (Hunger Vital Sign) and severity, self-rated caregiver health, willingness to disclose food insecurity and receive food, and food-related stress.

ANALYSIS

Chi-square and t-tests were utilized to examine associations and descriptive analysis explored benefits. Rapid qualitative analysis was utilized to identify themes.

RESULTS

Caregivers of 120 children were included (child mean age 11.8; 56.7% female, 67.6% Non-Hispanic Black), with 47 of 59 eligible completing follow-up surveys and 14 completing in-depth interviews. Approximately half (N = 30/59, 50.8%) of families utilizing the food pantry screened negative for food insecurity. Families utilizing the food pantry were more likely to report severe food insecurity (N = 23/59; 38.9%) compared to those declining (N = 3/61; 4.9%, P < .001). Caregivers accepting food were able to meet a child health goal (N = 30/47, 63.8%). Caregivers reported feeling comfortable receiving food (N = 13/14) and felt utilizing the food pantry led to consumption of healthier foods (N = 7/14).

CONCLUSIONS

Families who screened both positive and negative for food insecurity utilized and benefited from a clinic-based food pantry. Clinics should consider strategies offering food resources to all families irrespective of screening outcome.

Addressing food insecurity in rural primary care: a mixed-methods evaluation of barriers and facilitators

BACKGROUND

Food insecurity (FI) is associated with negative health outcomes and increased healthcare utilization. Rural populations face increased rates of FI and encounter additional barriers to achieving food security. We sought to identify barriers and facilitators to screening and interventions for FI in rural primary care practices.

METHODS

We conducted a mixed-methods study using surveys and semi-structured interviews of providers and staff members from rural primary care practices in northern New England. Survey data were analyzed descriptively, and thematic analysis was used to identify salient interview themes.

RESULTS

Participants from 24 rural practices completed the survey, and 13 subsequently completed an interview. Most survey respondents (54%) reported their practices systematically screen for FI and 71% reported food needs were "very important" for their patients and communities. Time and resource constraints were the most frequently cited barriers to screening for and addressing FI in practices based on survey results. Interview themes were categorized by screening and intervention procedures, community factors, patient factors, external factors, practice factors, process and implementation factors, and impact of FI screening and interventions. Time and resource constraints were a major theme in interviews, and factors attributed to rural practice settings included geographically large service areas, stigma from loss of privacy in small communities, and availability of food resources through farming.

CONCLUSIONS

Rural primary care practices placed a high value on addressing food needs but faced a variety of barriers to implementing and sustaining FI screening and interventions. Strategies that utilize practice strengths and address time and resource constraints, stigma, and large service areas could promote the adoption of novel interventions to address FI.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

Interventions addressing health-related social needs among patients with cancer

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

Food Insecurity and Social Policy: A Comparative Analysis of Welfare State Regimes in 19 Countries

We sought to determine whether a country's social policy configuration-its welfare state regime-is associated with food insecurity risk. We conducted a cross-sectional study of 2017 U.N. Food and Agriculture Organization individual-level food insecurity survey data from 19 countries (the most recent data available prior to COVID-19). Countries were categorized into three welfare state regimes: liberal (e.g., the United States), corporatist (e.g., Germany), or social democratic (e.g., Norway). Food insecurity probability, calibrated to an international reference standard, was calculated using a Rasch model. We used linear regression to compare food insecurity probability across regime types, adjusting for per-capita gross domestic product, age, gender, education, and household composition. There were 19,008 participants. The mean food insecurity probability was 0.067 (SD: 0.217). In adjusted analyses and compared with liberal regimes, food insecurity probability was lower in corporatist (risk difference: -0.039, 95% CI -0.066 to -0.011, p  =  .006) and social democratic regimes (risk difference: -0.037, 95% CI -0.062 to -0.012, p  =  .004). Social policy configuration is strongly associated with food insecurity risk. Social policy changes may help lower food insecurity risk in countries with high risk.

Perspective: Nutrition Health Disparities Framework: A Model to Advance Health Equity

Disparities in nutrition, such as poor diet quality and inadequate nutrient intake, arise from multiple factors and are related to adverse health outcomes such as obesity, diabetes, cardiovascular disease, and some cancers. The aim of the current perspective is to present a nutrition-centric socioecological framework that delineates determinants and factors that contribute to diet and nutrition-related disparities among disadvantaged populations. The Nutrition Health Disparities Framework (NHDF) describes the domains (biological, behavioral, physical/built environment, sociocultural environment, and healthcare system) that influence nutrition-related health disparities through the lens of each level of influence (that is, individual, interpersonal, community, and societal). On the basis of the scientific literature, the authors engaged in consensus decision making in selecting nutrition-related determinants of health within each domain and socioecological level when creating the NHDF. The framework identifies how neighborhood food availability and access (individual/built environment) intersect with cultural norms and practices (interpersonal/sociocultural environment) to influence dietary behaviors, exposures, and risk of diet-related diseases. In addition, the NHDF shows how factors such as genetic predisposition (individual/biology), family dietary practices (interpersonal/behavioral), and food marketing policies (societal) may impact the consumption of unhealthy foods and beverages and increase chronic disease risk. Family and peer norms (interpersonal/behavior) related to breastfeeding and early childhood nutrition interact with resource-poor environments such as lack of access to preventive healthcare settings (societal/healthcare system) and low usage of federal nutrition programs (societal/behavioral), which may increase risk of poor nutrition during childhood and food insecurity. The NHDF describes the synergistic interrelationships among factors at different levels of the socioecological model that influence nutrition-related outcomes and exacerbate health disparities. The framework is a useful resource for nutrition researchers, practitioners, food industry leaders, and policymakers interested in improving diet-related health outcomes and promoting health equity in diverse populations.

A Systematic Review of Interventions That Address Food Insecurity for Persons With Prediabetes or Diabetes Using the RE-AIM Framework

PURPOSE

The purpose of this study is to systematically review interventions that address food insecurity for persons with prediabetes or type 2 diabetes using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework.

METHODS

Six databases (OVIDMEDLINE, OVIDEMBASE, OVID APA PsycINFO, Web of Science, Cochrane Central Registry of Controlled Trials, and EBSCO CINAHL Complete) were searched through January 2023. Research team members independently performed screening of abstracts and full texts, data abstraction, and risk assessment.

RESULTS

In all, 3,139 unique citations were identified, and 20 studies met inclusion criteria. Interventions included medically tailored meals/groceries (n = 10) or produce prescriptions/vouchers (n = 10). Reach and effectiveness were the highest reported RE-AIM elements. Interventions reached a high-risk population via food banks, community-based outreach, and federally qualified health centers. A majority of participants identified as female, Black, or Hispanic/Latinx and were living below the federal poverty level. Most studies reported at least 1 diabetes outcome (ie, A1C, hypoglycemia, diabetes distress, diabetes self-management). Seventeen studies reported impact on A1C, with the majority reporting a decrease in A1C and 53% (9/17) of studies demonstrating a decrease over time. Self-management improved in 50% (3/6) of studies that evaluated this outcome. Self-efficacy improved in 40% (2/5) of studies, and improvements were seen in depressive symptoms/diabetes distress (4/7 studies) and quality of life (5/5 studies). Seven studies reported statistically significant improvements in food insecurity.

CONCLUSION

Food insecurity has been associated with higher risks and adverse clinical outcomes in adults with diabetes. Implementing interventions that address food insecurity among adults with or at risk for diabetes can enhance food security and clinically important diabetes-related outcomes. Additional research dedicated to the sustainability of interventions is needed.

Pediatric produce prescription initiatives in the U.S.: a scoping review

BACKGROUND

To describe pediatric Produce Prescription (PRx) interventions and their study designs, outcomes, and opportunities for future research.

METHODS

A scoping review framework was used to describe PRx interventions published between January 2000 and September 2023. Articles from online databases were uploaded into Covidence. Data on study characteristics, outcomes of interest (health, food insecurity (FI), nutritional and culinary efficacy, and fruit and vegetable (F/V) consumption), and feasibility were extracted. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment.

RESULTS

19 articles met inclusion criteria. Ten studies were quantitative, five were qualitative, and four used mixed-methods. Interventions included food vouchers (n = 14) or food box/pantries (n = 5). Four studies allowed food items in addition to F/Vs. Six studies measured changes in FI and five reported a statistically significant decrease. Seven studies measured changes in F/V consumption and five reported a statistically significant increase. One study reported a statistically significant reduction in child BMI z-score. Most studies reported high feasibility. Few studies used high-quality methods.

CONCLUSIONS

Pediatric PRx interventions show promising potential to reduce FI and improve diet quality and health-related outcomes. Future studies should utilize rigorous study designs and validated assessment tools to understand the impact of pediatric PRx on health.

IMPACT

This work offers a summary of programmatic outcomes including retention, redemption, incentives, nutrition education, study design and quality limitations to help inform future work. We found positive impacts of pediatric produce prescriptions (PRx) on FI, F/V consumption, and nutritional knowledge and culinary skills. More high-quality, rigorous studies are needed to understand the best delivery and design of PRx and their impact on child behavior and health outcomes. This work provides support for the need for rigorous studies and the potential for PRx to play a role in multi-pronged strategies that address pediatric FI and diet-related disease.

Food Insecurity Prevalence and Risk Factors at a Large Academic Medical Center in Michigan

Importance

Health care systems are increasingly adopting methods to screen for and integrate food insecurity and other social risk factors into electronic health records. However, there remain knowledge gaps regarding the cumulative burden of food insecurity in large clinical settings, which patients are most at risk, and the extent to which patients are interested in social assistance through their health care system.

Objective

To evaluate the 5-year prevalence and associated risk factors of food insecurity among adult primary care patients, and to examine factors associated with patients' interest in social assistance among those with food insecurity.

Design, Setting, and Participants

This cross-sectional analysis of a retrospective cohort study took place at a tertiary care academic medical center (encompassing 20 primary care clinics) in Michigan. Participants included adult patients who completed screening for social risk factors between August 1, 2017, and August 1, 2022. Data analysis was performed from November 2022 to June 2023.

Exposure

Food insecurity was assessed using the Hunger Vital Sign.

Main Outcomes and Measures

The primary outcome was patients' interest in social assistance, and associated factors were examined using multivariate logistic regression models, adjusting for patients' demographic and health characteristics.

Results

Over the 5-year period, 106 087 adult primary care patients (mean [SD] age, 52.9 [17.9] years; 61 343 women [57.8%]) completed the standardized social risk factors questionnaire and were included in the analysis. The overall prevalence of food insecurity was 4.2% (4498 patients), with monthly trends ranging from 1.5% (70 positive screens) in August 2018 to 5.0% (193 positive screens) in June 2022. Food insecurity was significantly higher among patients who were younger, female, non-Hispanic Black or Hispanic, unmarried or unpartnered, and with public health insurance. Food insecurity was significantly associated with a higher cumulative burden of social needs, including social isolation, medical care insecurity, medication nonadherence, housing instability, and lack of transportation. Only 20.6% of patients with food insecurity (927 patients) expressed interest in social assistance. Factors associated with interest in social assistance including being non-Hispanic Black, unmarried or unpartnered, a current smoker, and having a higher burden of other social needs.

Conclusions and Relevance

In this retrospective cohort study, the overall prevalence of food insecurity was 4.2%, of whom approximately 1 in 5 patients with food insecurity expressed interest in assistance. This study highlights ongoing challenges in ensuring all patients complete routine social determinants of health screening and gaps in patients' interest in assistance for food insecurity and other social needs through their health care system.

Understanding food insecurity risk in the United States: A longitudinal analysis

Background

Food insecurity, lack of consistent access to the food needed for an active, healthy life, harms population health. Although substantial biomedical evidence examines the connections between food insecurity and health, fewer studies examine why food insecurity occurs.

Methods

We propose a conceptual understanding of food insecurity risk based on institutions that distribute income-the factor payment system (income distribution stemming from paid labor and asset ownership), transfers within households, and the government tax-and-transfer system. A key feature of our understanding is 'roles' individuals inhabit in relation to the factor payment system: child, older adult, disabled working-age adult, student, unemployed individual, caregiver, or paid laborer. A second feature is that the roles of others in an individual's household also affect an individual's food insecurity risk. We tested hypotheses implied by this understanding, particularly hypotheses relating to role, household composition, and income support programs, using nationally-representative, longitudinal U.S. Current Population Survey data (2016-2019).

Results

There were 16,884 participants (year 1 food insecurity prevalence: 10.0%). Inhabiting roles of child (Relative Risk [RR] 1.79, 95% Confidence Interval [95%CI] 1.67 to 1.93), disabled working age-adult (RR 3.74, 95%CI 3.25 to 4.31), or unemployed individual (RR 3.29, 95%CI 2.51 to 4.33) were associated with a greater risk of food insecurity than being a paid laborer. Most food insecure households, 74.8%, had members inhabiting roles of child or disabled working age-adult, and/or contained individuals who experienced job loss. Similar associations held when examining those transitioning from food insecurity to food security in year 2.

Conclusions

The proposed understanding accords with the pattern of food insecurity risk observed in the U.S. An implication is that transfer income programs for individuals inhabiting roles, such as childhood and disability, that limit factor payment system participation may reduce food insecurity risk for both those individuals and those in their household.

Views and preferences of food-insecure pregnant women regarding food insecurity screening and support within routine antenatal care

BACKGROUND

Food insecurity is a public health concern that has profound impact on physical and mental health, and on social well-being. Pregnancy is a period in which food insecurity is likely to be particularly deleterious, due to the serious impact on both mother and child. Food insecurity is not routinely screened in antenatal healthcare settings, and the preferences of pregnant women regarding food insecurity screening and support are poorly understood. This study aimed to determine the views and preferences of food-insecure pregnant women regarding food insecurity screening and support within antenatal healthcare.

METHODS

This qualitative descriptive study used face-to-face semi-structured interviews, conducted in February and March 2023, to gain the views of purposively sampled food-insecure, pregnant women in Melbourne, Australia. Food insecurity was evidenced by an affirmative response to at least one of three assessment items in a screening questionnaire. Qualitative content analysis was conducted to summarise the views and preferences of women.

RESULTS

Nineteen food-insecure pregnant women were interviewed. Three themes were identified: (1) acceptability of being screened for food insecurity, (2) concerns about the consequences of disclosure and (3) preferences regarding food insecurity screening and supportive strategies that could be offered within an antenatal healthcare setting.

CONCLUSION

Women were accepting of food insecurity screening being conducted within routine healthcare. Women identified potential benefits of routine screening, such as feeling supported by their clinician to have a healthy pregnancy and less pressure to voluntarily ask for food assistance. Women gave suggestions for the implementation of food insecurity screening to optimise their healthcare experience, maintain their dignity and feel able to disclose within a safe and caring environment. These results indicate that food insecurity screening in the antenatal setting is likely to have support from pregnant women and is urgently needed in the interest of promoting optimal nutrition for women and children.

PATIENT CONTRIBUTION

Pregnant women with lived experience of food insecurity were purposively sampled to obtain their insights regarding screening and support within a pregnancy healthcare setting. Member-checking occurred following data collection, whereby all participants were offered the opportunity to review their interview transcript to ensure trustworthiness of the data.

Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use: A Randomized Clinical Trial

Importance

Food-as-medicine programs are becoming increasingly common, and rigorous evidence is needed regarding their effects on health.

Objective

To test whether an intensive food-as-medicine program for patients with diabetes and food insecurity improves glycemic control and affects health care use.

Design, Setting, and Participants

This stratified randomized clinical trial using a wait list design was conducted from April 19, 2019, to September 16, 2022, with patients followed up for 1 year. Patients were randomly assigned to either participate in the program immediately (treatment group) or 6 months later (control group). The trial took place at 2 sites, 1 rural and 1 urban, of a large, integrated health system in the mid-Atlantic region of the US. Eligibility required a diagnosis of type 2 diabetes, a hemoglobin A1c (HbA1c) level of 8% or higher, food insecurity, and residence within the service area of the participating clinics.

Intervention

The comprehensive program provided healthy groceries for 10 meals per week for an entire household, plus dietitian consultations, nurse evaluations, health coaching, and diabetes education. The program duration was typically 1 year.

Main Outcomes and Measures

The primary outcome was HbA1c level at 6 months. Secondary outcomes included other biometric measures, health care use, and self-reported diet and healthy behaviors, at both 6 months and 12 months.

Results

Of 3712 patients assessed for eligibility, 3168 were contacted, 1064 were deemed eligible, 500 consented to participate and were randomized, and 465 (mean [SD] age, 54.6 [11.8] years; 255 [54.8%] female) completed the study. Of those patients, 349 (mean [SD] age, 55.4 [11.2] years; 187 [53.6%] female) had laboratory test results at 6 months after enrollment. Both the treatment (n = 170) and control (n = 179) groups experienced a substantial decline in HbA1c levels at 6 months, resulting in a nonsignificant, between-group adjusted mean difference in HbA1c levels of -0.10 (95% CI, -0.46 to 0.25; P = .57). Access to the program increased preventive health care, including more mean (SD) dietitian visits (2.7 [1.8] vs 0.6 [1.3] visits in the treatment and control groups, respectively), patients with active prescription drug orders for metformin (134 [58.26] vs 119 [50.64]) and glucagon-like peptide 1 medications (114 [49.56] vs 83 [35.32]), and participants reporting an improved diet from 1 year earlier (153 of 164 [93.3%] vs 132 of 171 [77.2%]).

Conclusions and Relevance

In this randomized clinical trial, an intensive food-as-medicine program increased engagement with preventive health care but did not improve glycemic control compared with usual care among adult participants. Programs targeted to individuals with elevated biomarkers require a control group to demonstrate effectiveness to account for improvements that occur without the intervention. Additional research is needed to design food-as-medicine programs that improve health.

Trial Registration

ClinicalTrials.gov Identifier: NCT03718832.

The potential role of social care in reducing childhood obesity

PURPOSE OF REVIEW

This review evaluates the current evidence for relationships of social factors with childhood obesity and for a role of social care in reduction of childhood obesity.

RECENT FINDINGS

Most literature on the relationship between social factors and childhood obesity has examined food insecurity as a risk factor for obesity. Associations between food insecurity and excess weight in children are most consistent during infancy and among those with food insecurity at more than one time point. A few pilot food security interventions that link patients with produce or groceries show feasibility and potential promise for reducing childhood obesity risk factors. However, full-scale, randomized studies to examine interventions that reduce social needs and their effects on childhood obesity are lacking. Future research is needed to examine holistic social care approaches to effectively reduce childhood obesity risk factors.

SUMMARY

Food insecurity acts as a barrier to childhood obesity prevention and treatment. Patient-centered, validated measures of social needs and effective interventions to address social needs are needed to equitably prevent and treat childhood obesity.

Food Insecurity Predicts Magnitude of Early BMI Change in a Pediatric Weight Management Intervention

OBJECTIVE

The aim of this study was to estimate the prevalence of food insecurity among children with overweight/obesity presenting for weight management treatment and examine whether food insecurity predicts early change in body mass index (BMI), expressed as a percentage of the 95th percentile (%BMIp95).

METHOD

Children (N = 69; ages 3-18 years) presenting to a hospital-based pediatric weight management intervention and 1 parent/guardian per child (N = 69) were included. At the first appointment, parents/guardians completed the US Household Food Security Survey Module: Six-item Short Form and a demographics questionnaire. Height and weight of the children were measured at the first and third appointments to calculate %BMIp95.

RESULTS

Among participating families, 29.0% reported experiencing food insecurity. Controlling for the ratio of income to poverty, 11.4% of the variance in %BMIp95 change from the first to third appointments was accounted for by food insecurity, ▵F (1, 66) = 8.46, p = 0.01. Children with greater food insecurity demonstrated a smaller magnitude of %BMIp95 decrease, representing a small-to-medium effect size within the context of the regression model (f2 = 0.13).

CONCLUSION

A high proportion of families with children receiving weight management treatment reported experiencing food insecurity in comparison with US households with children. There may be unique characteristics of food insecurity, as opposed to household income alone, that explain the smaller magnitude of BMI decrease observed early in treatment. Future research should explore complex associations among food insecurity, income, BMI, and race over time.

Healthcare-based food assistance programmes in the United States: a scoping review and typology

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

A Systematic Review of Interventions for Obesity Among Adults With Food Insecurity

OBJECTIVE

Food insecurity is associated with reduced dietary quality and excess weight gain. However, interventions that are effective for obesity among individuals with food insecurity are unclear. The purpose of this systematic review was to synthesize studies in which authors examined interventions for obesity among adults with food insecurity.

METHODS

PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to October 2022. Studies were included if their authors reported on nonpharmacological and nonsurgical interventions that focused on adults with food insecurity and overweight/obesity and reported weight loss.

RESULTS

A total of 1360 titles were reviewed during the electronic search, and only 5 studies met inclusion criteria. There were 2 primary types of interventions that have been tested: first, behavioral weight loss counseling with or without tailoring for individuals with food insecurity and, second, subsidies for food. Findings of the benefits of one type of intervention over another are mixed.

CONCLUSIONS

This systematic review highlights that the current evidence for interventions that address food insecurity and obesity is mixed and limited in scope. There is a need for rigorous controlled trials to examine the effectiveness and cost-effectiveness of interventions for weight management among individuals with food insecurity and obesity while considering sustainability.

Behavior Problems in Low-Income Young Children Screened in Pediatric Primary Care

Importance

Screening of behavior problems in young children in pediatric primary care is essential to timely intervention and optimizing trajectories for social-emotional development. Identifying differential behavior problem trajectories provides guidance for tailoring prevention and treatment.

Objective

To identify trajectories of behavior problems in children 2 to 6 years of age screened in pediatric primary care.

Design, Setting, and Participants

This retrospective cohort study identified trajectories of behavior problems and demographic and clinical correlates. Data were collected as part of routine care in 3 pediatric primary care offices and 3 school-based health centers in Ohio serving a primarily low-income population. In total, 15 218 children aged 2 to 6 years with well-child visits between July 13, 2016, and January 31, 2022, were included.

Exposure

Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) at annual well-child visits.

Main Outcomes and Measures

Trajectory groups were identified using latent growth mixture modeling of SDQ total difficulties scores, and relative risk ratio (RRR) of various demographic (eg, race) and clinical (eg, depression in caregiver) variables were assessed by multinomial logistic regression analysis.

Results

Of 15 281 children (51.3% males), 10 410 (68.1%) were African American or Black, 299 (2.0%) were Asian, 13 (0.1%) were American Indian or Alaska Native, 876 (5.7%) were multiracial, 26 (0.2%) were Native Hawaiian and Other Pacific Islander, 2829 (18.5%) were White, and 39 (0.02%) were categorized as other. In addition, 944 (6.2%) identified as Hispanic and 14 246 (93.2%) as non-Hispanic. Four behavior problem trajectory groups reflecting severity were identified: low-stable (LS; 10 096 [66.1%]), moderate-decreasing (MD; 16.6%), low-increasing (LI; 13.1%), and high-increasing (HI; 4.3%). Relative to the LS group, patients in each elevated group were more likely to be male (HI RRR, 1.87 [95% CI, 1.55-2.26]; MD RRR, 1.55 [95% CI, 1.41-1.71]; and LI RRR, 1.94 [95% CI, 1.70-2.21]), White (HI RRR, 2.27 [95% CI, 1.83-2.81]; MD RRR, 1.28 [95% CI, 1.13-1.45]; and LI RRR, 1.54, [95% CI, 1.32-1.81]), publicly insured (HI RRR, 0.49 [95% CI, 0.28-0.84]; MD RRR, 0.56 [95% CI, 0.43-0.73]; and LI RRR, 0.50 [95% CI, 0.35-0.73]), have a social need (HI RRR, 3.07 [95% CI, 2.53-3.73]; MD RRR, 2.02 [95% CI, 1.82-2.25]; and LI RRR, 2.12 [95% CI, 1.84-2.44]), and have a caregiver with depression (HI RRR, 1.66 [95% CI, 1.38-2.00]; MD RRR, 1.44 [95% CI, 1.31-1.58]; and LI RRR, 1.39 [95% CI, 1.23-1.58]). Relative to the LI group, patients in the MD group were less likely to be male (RRR, 0.80; 95% CI, 0.68-0.93).

Conclusions

The substantial portion of young children with increased behavior problems observed in this cohort study underscores the need for screening in pediatric primary care. Caregivers with depression and family social needs warrant prioritization in early prevention and treatment to alter elevated trajectories.

A Systematic Review of Electronic Community Resource Referral Systems

INTRODUCTION

Community Resource Referral Systems delivered electronically through healthcare information technology systems (e.g., electronic medical records) have become more common in efforts to address patients' unmet health-related social needs. Community Resource Referral System connects patients with social supports such as food assistance, utility support, transportation, and housing. This systematic review identifies barriers and facilitators that influence the Community Resource Referral System's implementation in the U.S. by identifying and synthesizing peer-reviewed literature over a 15-year period.

METHODS

This systematic review was conducted following PRISMA guidelines. A search was conducted on five scientific databases to capture the literature published between January 2005 and December 2020. Data analysis was conducted from August 2021 to July 2022.

RESULTS

This review includes 41 articles of the 2,473 initial search results. Included literature revealed that Community Resource Referral Systems functioned to address a variety of health-related social needs and were delivered in different ways. Integrating the Community Resource Referral Systems into clinic workflows, maintenance of community-based organization inventories, and strong partnerships between clinics and community-based organizations facilitated implementation. The sensitivity of health-related social needs, technical challenges, and associated costs presented as barriers. Overall, electronic medical records-integration and automation of the referral process was reported as advantageous for the stakeholders.

DISCUSSION

This review provides information and guidance for healthcare administrators, clinicians, and researchers designing or implementing electronic Community Resource Referral Systems in the U.S. Future studies would benefit from stronger implementation science methodological approaches. Sustainable funding mechanisms for community-based organizations, clear stipulations regarding how healthcare funds can be spent on health-related social needs, and innovative governance structures that facilitate collaboration between clinics and community-based organizations are needed to promote the growth and sustainability of Community Resource Referral Systems in the U.S.

The Design and Impact of a Clinic-Based Community Program on Food Insecurity, Healthy Eating Behaviors, and Mood

Food insecurity is a national issue that disproportionately impacts Louisiana citizens, contributing to the state's poor health outcomes. We know that the Supplemental Nutrition Assistance Program (SNAP) and food pantries improve access to food, but we have limited data on what interventions improve food insecurity. The Geaux Get Healthy Clinical Program at Our Lady of the Lake (GGHOLOL) is a clinic-based community program that leverages community partnerships and a clinical setting to provide education and access to resources for individuals with food insecurity. This prospective study examines the impact of GGHOLOL on food insecurity as a pre-post survey evaluation over a two-year period. A total of 57 research participants with food insecurity completed the program. Mean food security scores improved at completion of GGHOLOL, and these scores further improved 6 months after enrollment. Furthermore, participants demonstrated sustainable improvements in healthy eating, cooking, and shopping behaviors. Lastly, participants improved their overall depression scores at the completion of the program with sustainable improvement at 6 months. With the improvement in GGHOLOL on food insecurity and nutrition behaviors, GGHOLOL may serve as a model for other programs addressing food insecurity in the future.

Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities

The Centers for Medicare and Medicaid Services recently adopted quality metrics that require hospitals to screen for health-related social risks. The hope is that these requirements will encourage health care organizations to refer patients with social needs to community resources and, as possible, offer navigation services. This approach-screening, referrals, and navigation-is based, in part, on the Accountable Health Communities (AHC) model. Twenty-two of 31 participants in the AHC model in 2019 were interviewed to generate guidance for health care organizations as they implement screening, referral, and navigation activities to improve patients' health-related social risks. From these interviews, the team identified 4 key program design elements that facilitated AHC implementation: (1) centralized management office, (2) accountability milestones, (3) prescriptive requirements, and (4) technology support. The structure and requirements of the AHC model spurred participating organizations to rapidly implement social care activities, but the model did not allow for the flexibility necessary to ensure sustained adoption of AHC activities. The AHC model required a designated centralized management office, which was instrumental in ensuring AHC activities were implemented effectively. The centralized management office was typically external from participating clinical sites that impacted the AHC model's integration within clinical workflows. The reliance on the centralized management office to implement AHC activities limited the sustainability of the model. As payers, policymakers, and delivery system leaders aim to develop sustainable and effective social care programs, insights from these interviews can help guide and shape policy and program design elements.

Addressing food insecurity: what is the role of healthcare?

Food insecurity - when individuals or households have difficulty accessing sufficient, safe, culturally appropriate and nutritious food due to lack of money or other resources - is a global public health concern. Levels of food insecurity have increased across the UK in recent years, due in part to a decade of austerity, widespread loss of income during the COVID-19 pandemic and the more recent cost-of-living crisis, leading to rising use of food banks. The stress of living with uncertain access to food and going periods without food is damaging to physical and mental health. Food insecurity is linked to both obesity and malnutrition, as often the most readily available foods are processed, high in fats, sugars and salt, but low in essential nutrients for health. While recognising that many of the drivers of food insecurity, and health inequalities more broadly (i.e. the social determinants of health) lie outside the health service, it is increasingly acknowledged that the National Health Service - and primary care in particular - has a key role to play in mitigating health inequalities. This review considers the potential role of healthcare in mitigating food insecurity, with a focus on primary care settings. Recent initiatives in Scotland, such as community links workers and general practitioner practice-attached financial advice workers, have shown promise as part of a more community-oriented approach to primary care, which can mitigate the effects of food insecurity. However, a more 'upstream' response is required, including 'cash first' interventions as part of broader national strategies to end the need for food banks.

Food Access Support Technology (FAST): a Centralized City-Wide Platform for Rapid Response to Food Insecurity

BACKGROUND

Food access for patients remains a critical need for health systems to address given varying resource availability and inefficient coordination among health and food services.

AIM

Develop and evaluate the Food Access Support Technology (FAST), a centralized digital platform for food access that pairs health systems with food and delivery community-based organizations (CBOs).

SETTING AND PARTICIPANTS

Two health systems, 12 food partners, and 2 delivery partners in Philadelphia, PA.

PROGRAM DESCRIPTION

Using FAST, referrers can post requests for food delivery on recipients' behalf, which are reviewed and claimed by eligible CBOs that can prepare food boxes for delivery to people's homes.

PROGRAM EVALUATION

Between March 2021 and July 2022, FAST received 364 requests, representing 207 food insecure households in 51 postal codes. The platform facilitated the completion of 258 (70.9%) requests, with a median completion time of 5 (IQR 0-7) days and a median of only 1.5 days (IQR 0-5) for requests marked "urgent." Qualitative interviews with FAST end-users endorsed the usability of the FAST platform and its effectiveness in facilitating resource-sharing between partners.

DISCUSSION

Our findings suggest that centralized platforms can address household food insecurity by (1) streamlining partnerships between health systems and CBOs for food delivery and (2) facilitating the real-time coordination of resources among CBOs.

Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States

BACKGROUND

Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations.

METHODS

This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2-17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4-10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI z-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program.

RESULTS

After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68-1.02) and 0.26 (95% CI, 0.06-0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52-0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30-2.02]) and children (odds ratio, 2.37 [1.70-3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by -0.29% age points (-0.42 to -0.16); among adults with hypertension, systolic and diastolic blood pressures declined by -8.38 mm Hg (-10.13 to -6.62) and -4.94 mm Hg (-5.96 to -3.92); and among adults with overweight or obesity, BMI decreased by -0.36 kg/m2 (-0.64 to -0.09). Child BMI z-score did not change -0.01 (-0.06 to 0.04).

CONCLUSIONS

In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health.

SNAP Participation and Medication Adherence Among Older Black Medicaid-Insured Individuals Living With Hypertension

BACKGROUND

Black people are more likely to be diagnosed with hypertension and to experience food insecurity and antihypertensive medication non-adherence compared to White people in the U.S. The Supplemental Nutrition Assistance Program (SNAP)-a means-tested program that targets food insecurity has been shown to affect health outcomes. This study analyzed the relationship between SNAP participation and antihypertensive medication adherence among older Black Medicaid-insured individuals.

METHODS

This is a retrospective cohort study using linked 2006-2014 state of Missouri Medicaid and SNAP administrative claims data. Analyses were restricted to older (≥60 years) Black individuals who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60 years with at least one pharmacy claim (n = 10,693). Our outcome measure is a dichotomous measure of antihypertensive medication adherence defined using the Proportion of Days Covered (≥80% PDC = 1). The exposure variables are four measures of SNAP participation.

RESULTS

A higher proportion of SNAP participants were adherent to their antihypertensive medications compared to non-SNAP participants (43.5% vs. 32.0%). On multivariable analyses, compared to non-SNAP participants there was an increased likelihood of antihypertensive medication adherence among SNAP participants (prevalence ratio [PR] = 1.25; 95% confidence interval [CI] = 1.16-1.35). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of antihypertensive medication adherence among those who were enrolled for 10-12 months (PR = 1.41; 95% CI = 1.08-1.85).

CONCLUSIONS

Medicaid-insured older Black adults who were SNAP participants had a higher likelihood of antihypertensive medication adherence compared to non-SNAP participants.

How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study

BACKGROUND

Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes.

METHODS

A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions.

SETTING

Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest.

DESIGN

2 × 2 factorial design.

INTERVENTIONS

Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce.

OUTCOMES

Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months.

DISCUSSION

Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity.

CLINICALTRIALS

gov: NCT05472441.

Diet and Food and Nutrition Insecurity and Cardiometabolic Disease

Poor nutrition is the leading cause of poor health, health care spending, and lost productivity in the United States and globally, which acts through cardiometabolic diseases as precursors to cardiovascular disease, cancer, and other conditions. There is great interest in how the social determinants of health (the conditions in which people are born, live, work, develop, and age) impact cardiometabolic disease. Food insecurity is an example of a powerful social determinant of health that impacts health outcomes. Nutrition insecurity, a distinct but related concept to food insecurity, is a direct determinant of health. In this article, we provide an overview of how diet in early life relates to cardiometabolic disease and then continue to focus on the concepts of food insecurity and nutrition insecurity. In the discussions herein we make important distinctions between the concepts of food insecurity and nutrition insecurity and provide a review of their concepts, histories, measurement and assessment devices, trends and prevalence, and links to health and health disparities. The discussions here set the stage for future research and practice to directly address the negative consequences of food and nutrition insecurity.

Profiles of Early Childhood Adversity in an Urban Pediatric Clinic: Implications for Pediatric Primary Care

Pediatricians are well-positioned to screen for early childhood adversities, but effective responses to positive screens require an understanding of which adversities typically co-occur, and to what extent they are associated with other risk or protective factors. Among children seen at an urban academic pediatric practice, this study aimed to (1) examine the prevalence of different types of early adversity and protective experiences reported by primary caregivers, and (2) define latent classes of co-occurring adversities. Of 1434 children whose parents completed the Safe Environment for Every Kid (SEEK) at well-child visits during November 2019-January 2021, three classes of adverse experiences emerged, including those reporting low adversity (L; 73%), caregiver stress (CS; 17%), and both caregiver stress and depression (CSD; 10%). Among those who also completed the Adverse Childhood Experiences Questionnaire (ACE-Q, n = 1373) and the Protective and Compensatory Experiences Scale (PACES, n = 1377), belonging to the L class was associated with lower ACE-Q and higher PACES scores. For parent-respondents only, ACE-Q scores were significantly greater for the CSD class compared to the CS and L classes. Pediatricians should attend to the needs of caregivers reporting both stress and depression, as these families may face especially high levels of adversity and low levels of protective factors.

Association of a primary care-based mobile food pantry with child body mass index: A propensity score matched cohort study

OBJECTIVE

To test the hypothesis that children in Food FARMacia-a six-month food insecurity intervention from May 2019 to January 2020-would have smaller age-adjusted, sex-specific body mass index (BMIz) gains than matched counterparts.

METHODS

In this proof-of-concept study, we performed a difference-in-differences (DiD) analysis of a propensity-score matched cohort among paediatric primary care patients aged <6 years with household food insecurity. Children with anthropometric measures prior to and after intervention started were included. The main outcome was child BMIz from standardized clinical anthropometric measurements. We examined differences in child BMIz change between Food FARMacia participants and matched non-participants.

RESULTS

Among 454 children with household food insecurity, 265 were included, 44 of whom were in Food FARMacia. Mean child age was 1.48 (SD 1.46) years and most reported Hispanic/Latino ethnicity (84.5%). After propensity score matching, children in Food FARMacia had smaller increases in BMIz (unadjusted DiD -0.28 [-0.52, -0.04]) compared to non-participants in the follow-up period. After adjusting for potential confounders, findings remained statistically significant [adjusted DiD, -0.31 units (95% CI: -0.54, -0.08)].

CONCLUSIONS

In this proof-of-concept cohort study of children in households with food insecurity, a paediatric primary care-based mobile food pantry program was associated with improvement in child BMIz over 6 months.

Supporting early childhood routines to promote cardiovascular health across the life course

Optimal cardiovascular health is an essential component of human health and well-being across the life course. Heart healthy practices around diet, physical activity, and sleep early in childhood have the potential to greatly improve lifespan and quality (Mehta et al., 2020). Early childhood routines, defined as functional practices that are predictable and repeatable, predict positive growth and development across the lifecourse (Fiese et al., 2002; Ferretti and Bub, 2017; Spagnola and Fiese, 2007). The American Heart Association has identified key heart healthy routines, such as daily regular activities including diet, physical activity, and sleep that promote cardiovascular health (Lloyd-Jones et al., 2022). Integrating the strength-based relational aspects of routines with the acquisition of cardiovascular health development capabilities allows children to establish their own optimal cardiovascular health trajectory early on. A systematic life course approach to supporting heart healthy routines in early childhood would inform clinical, research, and policy strategies to promote long-term cardiovascular health, and contribute to reducing inequalities in cardiovascular outcomes.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Healthcare-based interventions to address food insecurity during pregnancy: a systematic review

OBJECTIVE

This study was a systematic review aimed to assess published literature regarding healthcare-based interventions addressing food insecurity during pregnancy and their effects on patient-reported, pregnancy, or nutritional outcomes.

DATA SOURCES

A systematic search was performed in February 2022 (subsequently updated in August 2022) using Embase, Medline, Cochrane Library, and Scopus using terms related to food insecurity interventions during pregnancy.

STUDY ELIGIBILITY CRITERIA

Studies examining healthcare-based interventions addressing food insecurity during pregnancy with patient-reported outcomes (eg, program satisfaction), adverse pregnancy outcomes (eg, preterm birth), or nutritional outcomes (eg, dietary intake) were included. Studies using data before 1995, conducted outside the United States, or focused solely on dietary content or the Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program as the intervention of interest were excluded.

METHODS

Of note, 3 authors screened the abstracts and full articles for inclusion. The final cohort included 5 studies. Moreover, 3 authors independently extracted data from each article and assessed the study quality using the Grading of Recommendations, Assessment, Development, and Evaluations and the risk of bias using the National Institutes of Health Study Quality Assessment tools.

RESULTS

Overall, 5 studies describing the interventions addressing food insecurity during pregnancy were included. Study designs included prospective cohort (n=1) and retrospective cohort (n=4) studies. There was heterogeneity in the type of intervention, with 3 using food vouchers, 1 focusing on a group prenatal service with nutrition and food management education, and 1 using a food connection program. Most studies (4 [80%]) shared patient-reported outcomes (eg, food security levels and program utilization rates), with 2 studies examining pregnancy-related outcomes (ie, glucose level, blood pressure, and preterm birth) and 2 studies examining nutritional outcomes. The interventions were associated with improved levels of food insecurity, reduced odds of preterm birth, and improved blood pressure trends; the findings demonstrated a 56% to 81% program utilization rate. All studies exhibited moderate to low study quality, with fair to good internal validity.

CONCLUSION

Although data on healthcare-based interventions targeted at food insecurity during pregnancy are limited, the few studies identified suggest that such interventions may affect pregnancy outcomes. A better understanding of the local scope and context of food insecurity and community-based organizations' efforts not captured by the literature in this area can help inform the development of interventions targeting food access during pregnancy.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers

Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Interactive association of chronic illness and food insecurity with emergency department utilization among school-age children in the United States: A cross-sectional study

Background and Aims

Food insecurity combined with chronic disease conditions is a risk factor for Emergency Department (ED) utilization, an indicator of poor quality of care. However, such an association is not certain among school-age children with chronic conditions. Therefore, we aim to determine the association of food insecurity, chronic conditions, and ED utilization among school-age children in the United States.

Methods

We analyzed the data from the 2017 Medical expenditure panel survey (MEPS) among children aged 6-17 years (N = 5518). MEPS data was released electronically by the Agency for Healthcare Research and Quality (AHRQ). We identified four groups of school-age children based on the presence of food security and chronic conditions: 1) with food insecurity and chronic conditions; 2) no food insecurity and chronic conditions; 3) with food insecurity and no chronic conditions; and 4) no food insecurity and no chronic conditions. We compared ED utilization among these four groups using incidence rate ratios (IRR) after adjusting children's age, sex, race and ethnicity, household income, insurance coverage, obesity, and geographic region using count data model, specifically multivariable Poison regression. We used SAS 9.4 and STATA 14.2 for all the data analyses.

Results

There were unweighted 5518 school-age children who represented weighted 50,479,419 school-age children in the final analysis. Overall, 6.0% had food insecurity with chronic conditions. These children had higher ED utilization (19.7%) than the other three groups (13.3%, 8.8%, and 7.2%, p < 0.001). The adjusted IRR of ED utilization among school-age children with food insecurity and chronic conditions was 1.90 (95% confidence interval 1.20-3.01, p = 0.007) compared with those with food security and chronic conditions.

Conclusion

One in 16 school-age children has both food insecurity and chronic conditions. Food insecurity was positively associated with frequent ED visits in the presence of chronic conditions. Therefore, addressing food insecurity may reduce the risk of ED visits.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Food Insecurity Was Associated With Greater Family Health Care Expenditures In The US, 2016-17

Food insecurity has been associated with the health care expenditures of individuals, but it can affect the entire family. Evaluating the relationship between food insecurity and family expenditures provides a better understanding of the financial implications of food insecurity interventions. Our primary objective was to evaluate the association between food insecurity in one year (2016) and family health care expenditures-for all members, for children only, and for adults only-in the next year (2017). We also evaluated whether this association varied across types of insurance coverage within families: all private, all public, or mixed (including uninsured). Using nationally representative data, we found that food-insecure families had 20 percent greater total health care expenditures than food-secure families, for an annual difference of $2,456. Food insecurity was associated with greater expenditures across all family insurance patterns, including the 19.1 percent of families with mixed coverage. Our findings suggest that in families with mixed coverage, positive impacts of food insecurity interventions on health care use may accrue to family members other than the targeted beneficiaries and those who have different insurance, benefiting the entire family but potentially discouraging investments on the part of any one payer.

Social Needs Assessment and Linkage to Community Health Workers in a Large Urban Hospital System

OBJECTIVES

Identifying social needs is a growing priority in primary care, but there is significant variation in how patients access services to meet such needs. This study identifies predictors of successful linkage with a community health worker (CHW) among patients with social needs seen in an outpatient setting.

METHODS

This study uses a cross-sectional analysis of social needs assessments administered in an urban health system between April 2018 and December 2019. Social needs included: food insecurity, housing quality, housing instability, healthcare cost, healthcare related transportation, utilities, care for dependents, legal assistance, safety, and getting along with household members. Patients with at least 1 social need and accepting help were included in the analysis. On contact with a CHW, patients were entered into a separate database. The primary outcome was successful "linkage," defined by having a positive social needs assessment in the medical record and a corresponding record in the CHW database. Multivariate logistic regression was used to assess predictors of linkage.

RESULTS

Among patients with at least 1 social need accepting help, 25% (758/3064) were linked to a CHW. Positive predictors included female gender (OR 1.28 [95% CI 1.01-1.63]), Spanish language preference compared to English (1.51 [1.14-1.03]), and having a food related need (1.35 [1.03-1.79]). Negative predictors included age 18 to 65 (0.34 [0.17-0.71] for age 18-24) and 0 to 5 (0.45 [0.24-0.78]) compared to over 65, non-Hispanic White race compared to Hispanic race (0.39 [0.18-0.84]), and having needs of getting along with household members (0.52 [0.38-0.71]) and safety (0.64 [0.42-0.98]).

CONCLUSIONS

Twenty-five percent of patients who had at least 1 social need and were accepting help had a successful CHW linkage. Predictors of linkage suggest areas of further system-level improvements to screening and referral interventions to target at risk patients and communities.

Community-based participatory interventions to improve food security: A systematic review

Introduction

This systematic review aimed to evaluate community-based participatory (CBP) interventions to improve food security and/or its dimensions to highlight the scope and characteristics of interventions and extract the characteristics of effective interventions.

Methods

The electronic databases, including PubMed/MEDLINE, SCOPUS, EMBASE, Web of Science, and Google Scholar, were searched from 1980 to 30 August 2022 for relevant studies. We included randomized controlled trials (RCTs), cluster randomized controlled trials (cRCTs), controlled before and after studies (CBAs), non-randomized controlled trials (nRCT), and interrupted time series (ITS) studies to identify the community-based participatory interventions. The indicators of food and nutrition security into four dimensions, as well as food insecurity measured as score and/or prevalence of food insecurity based on validated perception-based measures were considered outcome. Two reviewers independently evaluated the studies for eligibility, extracted data, and evaluated the risk of bias in the included studies using the Effective Public Health Practice Project (EPHPP). The quality of included reports was categorized as strong (when there were no weak ratings), moderate (when one factor was rated as weak), or weak (when two or more factors were rated as weak). A descriptive analysis of the findings was performed.

Results

A total of twelve studies were included. The quality of all eligible studies (n = 12) was rated as moderate/weak. Most CBP interventions were guided by formative research (n = 9, 75%). Two main groups for utilized strategies were identified: agricultural and nutrition strategies. Agricultural strategies included agricultural education, preparing and improving soil and seeds, promoting and supporting gardening/harvesting utilizing traditional skills based on the local culture, and agroecological practices. Nutrition strategies included store and shopping programs, farmers' markets, fresh fruit and vegetable programs, nutrition education programs for mothers, and food vouchers. The main outcomes improved in the CBP interventions were food security (n = 2) and its dimensions, including availability (n = 3), access (n = 5), and utilization (n = 2). All agroecological practices achieved statistically significant outcomes in the intended food security target(s). However, nutritional interventions were not effective for some access components such as mean adequacy ratio, fruit and vegetable intake, and nutrition environment of the stores. No studies evaluated stability outcome components of food security.

Discussion

CBP interventions guided by formative research data and agroecological practices were promising strategies to improve food security and its dimensions. Insufficient data on the stability components of food security and weak design studies were the considerable gaps in the research evidence reviewed. More research employing randomized experimental designs with adequate sample size and high retention rates is required.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42020189477].

Exploring the consequences of food insecurity and harnessing the power of peer navigation and mHealth to reduce food insecurity and cardiometabolic comorbidities among persons with HIV: protocol for development and implementation trial of weCare/Secure

BACKGROUND

Food insecurity, or the lack of consistent access to nutritionally adequate and safe foods, effects up to 50% of people living with HIV (PWH) in the United States (US). PWH who are food insecure have lower antiretroviral adherence, are less likely to achieve viral suppression, and are at increased risk developing of serious illnesses, including cardiometabolic comorbidities. The objectives of this study are to better understand how food insecurity contributes to the development of cardiometabolic comorbidities among PWH and to test a novel bilingual peer navigation-mHealth intervention (weCare/Secure) designed to reduce these comorbidities in food-insecure PWH with prediabetes or Type 2 diabetes (T2DM).

METHODS

In Aim 1, we will recruit a longitudinal cohort of 1800 adult (≥18 years) PWH from our clinic-based population to determine the difference in the prevalence and incidence of cardiometabolic comorbidities between food-secure and food-insecure PWH. Food insecurity screening, indicators of cardiometabolic comorbidities, and other characteristics documented in the electronic health record (EHR) will be collected annually for up to 3 years from this cohort. In Aim 2, we will conduct a randomized controlled trial among a sample of food-insecure PWH who have prediabetes or T2DM to compare changes in insulin sensitivity over 6 months between participants in weCare/Secure and participants receiving usual care. In Aim 3, we will conduct semi-structured individual in-depth interviews to explore the effect of the intervention among intervention participants with varying insulin sensitivity outcomes.

TRIAL STATUS

Aim 1 (longitudinal cohort) recruitment began in May 2022 and is ongoing. Aim 2 (intervention) recruitment is planned for spring 2023 and is expected to be completed in spring 2024. Aim 3 (process evaluation) data collection will occur after sufficient completion of the 6-month assessment in Aim 2. Final results are anticipated in fall 2025.

CONCLUSIONS

This research seeks to advance our understanding of how food insecurity impacts the development of cardiometabolic comorbidities among PWH and how food insecurity interventions may alleviate relevant comorbidities. Given the growing interest among health systems in addressing food insecurity, if the intervention is found to be efficacious, it could be broadly disseminated across HIV clinical care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04943861 . Registered on June 29, 2021.

"More than just giving them a piece of paper": Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

BACKGROUND

Primary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.

OBJECTIVE

To characterize referrals to community-based organizations by primary care practices.

DESIGN

Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.

PARTICIPANTS

Administrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.

MAIN MEASURES

Approaches used in primary care to implement social needs referral to community-based organizations.

RESULTS

Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.

CONCLUSION AND RELEVANCE

Referrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.