Food Insecurity Screening and Intervention in United States Children's Hospitals

Food insecurity in children with heart disease

PURPOSE OF REVIEW

This review discusses the epidemiology of food insecurity (FI) and its consequences in children with congenital heart disease. We aimed to highlight current interventions to screen and address food insecurity in the context of pediatric cardiology and to offer strategies for providers to engage in this meaningful work.

RECENT FINDINGS

Food insecurity is consistently associated with poor health outcomes in children. In the United States, 17.3% of households with children experience FI. Nonwhite and single-parent families are disproportionately affected. Interestingly, because of a low-quality diet, FI is associated with childhood obesity, putting affected children at increased risk for cardiovascular morbidity and mortality over time. Children with congenital heart disease are susceptible to poor outcomes due to unique altered metabolic demands, increased risk for growth impairment, frequent need for specialized feeding regimens, and additional morbidity associated with heart surgery in underweight children.

SUMMARY

Today, the burden of screening for FI is most commonly placed on general pediatricians. Considering the importance of nutrition to cardiovascular health and general wellbeing, and the ease with which screening can be performed, pediatric cardiologists and other subspecialists should take a more active role in FI screening.

Food Insecurity and Community-Based Food Resources Among Caregivers of Hospitalized Children

OBJECTIVE

Children's hospitals are implementing interventions to connect families to community-based resources. This study describes food insecurity (FI) and food resource knowledge, need, and use among families with a hospitalized child.

METHODS

Between November 2020 and June 2022, 637 caregivers of hospitalized children in an urban 42-ZIP-code area were surveyed as part of a randomized controlled trial. The United States Department of Agriculture 18-item Household Food Security Survey was used to evaluate 12-month food security (food secure [score of 0=FS]; marginally secure [1-2=MFS]; insecure [3-18=FI]). Food resource knowledge, need, and use were described by food security status and examined using Cochran-Armitage tests. The distribution of local resources was obtained from a database and mapped by ZIP code.

RESULTS

Comparing FI (35.0%) with MFS (17.6%) and FS (47.4%) groups, the rates of resource knowledge were lower (70.2% vs 78.5%, 80.5%), and the rates of need (55.1% vs 30.6%, 14.2%) and use (55.3% vs 51.4%, 40.8%) were higher. Rates of food resource knowledge increased linearly with increasing food security (FI to MFS to FS; P = .008), whereas the rates of resource need (P < .001) and use (P = .001) decreased with increasing food security. There were 311 community-based organizations across 36 ZIP codes with participants (range/ZIP code = 0-20, median = 8).

CONCLUSIONS

Half of families with a hospitalized child experienced FI or MFS. Although families exhibited high food resource knowledge, nearly half of families with FI had unmet food needs or had never used resources.

Disparities and Biases in Food Insecurity Screening Among Admitted Children

BACKGROUND AND OBJECTIVES

Food insecurity (FI) has increasingly become a focus for hospitalized patients. The best methods for screening practices, particularly in hospitalized children, are unknown. The purpose of the study was to evaluate results of an electronic medical record (EMR) embedded, brief screening tool for FI among inpatients.

METHODS

This was a cross-sectional study from August 2020 to September 2022 for all children admitted to a quaternary children's hospital. Primary outcomes were proportion of those screened for FI and those identified to have a positive screen. FI was evaluated by The Hunger Vital Sign, a validated 2-question screen verbally obtained in the nursing intake form in the EMR. Covariates include demographic variables of age, sex, race, ethnicity, primary language, and insurance. Statistical analyses including all univariate outcome and bivariate comparisons were performed with SAS 9.4.

RESULTS

There were 31 553 patient encounters with 81.7% screened for FI. Patients had a median age of 6.3 years, were mostly male (54.2%), White (60.6%), non-Hispanic (92.7%), English-speaking (94.3%), and had government insurance (79.8%). Younger (0-2 years), non-White, and noninsured patients were all screened significantly less often for FI (all P < .001). A total of 3.4% were identified as having FI. Patients who were older, non-White, Hispanic, non-English speaking, and had nonprivate insurance had higher FI (all P < .001).

CONCLUSIONS

Despite the use of an EMR screening tool intended to be universal, we found variation in how we screen for FI. At times, we missed those who would benefit the most from intervention, and thus it may be subject to implementation bias.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients.

METHODS

We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation.

RESULTS

The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults.

CONCLUSIONS

Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review

Household food insecurity has significant negative implications across the lifespan. While routine screening is recommended, particularly in healthcare, guidelines are lacking on selection of screening tools and best-practice implementation across different contexts in non-stigmatizing ways. The objective of this scoping review was to synthesize evidence on household food insecurity screening tools, including psychometrics, implementation in a range of settings, and experiences of carrying out screening or being screened. Four electronic databases were searched for studies in English published from 1990 until June 2023. A total of 58 papers were included, 21 of which focused on tool development and validation, and 37 papers described implementation and perceptions of screening. Most papers were from the USA and described screening in healthcare settings. There was a lack of evidence regarding screening in settings utilized by Indigenous people. The two-item Hunger Vital Sign emerged as the most used and most valid tool across settings. While there is minimal discomfort associated with screening, screening rates in practice are still low. Barriers and facilitators of screening were identified at the setting, system, provider, and recipient level and were mapped onto the COM-B model of behavior change. This review identifies practical strategies to optimize screening and disclosure.

Food insecurity screening practices in a pediatric gastroenterology population

Food insecurity is a rising concern for US households and leads to adverse child health outcomes. Pediatric gastroenterology providers are uniquely equipped to help guide families experiencing this challenge given their specialized training in nutritional support and dietary therapy for disease management. Hence, this study aimed to evaluate food insecurity screening practices from the perspectives of patient caregivers and healthcare providers in a tertiary pediatric gastroenterology practice. A survey was administered to 1279 caregivers and 121 providers. Of the 248 completed caregiver responses, 10%-15% reported being asked about food insecurity. Among the 36 healthcare provider responses, 53% expressed comfort in conducting food insecurity screening but only 14% routinely screened. The most cited barrier to screening was the lack of readily available patient resources. Further research is imperative to address these screening barriers and assess the impact of food insecurity screening and interventions on pediatric gastrointestinal health outcomes.

Evaluating Screening to Assess Endorsement of Food Insecurity in the Inpatient Setting

OBJECTIVE

Rates of food insecurity (FI) from screening in the inpatient setting is often not reflective of community prevalence, indicating that screening likely misses families with FI. We aimed to determine the combination of FI screening questions and methods that would result in identifying a percentage of FI families that matched or exceeded our area prevalence (approximately 20%).

METHODS

Research staff approached eligible English- and Spanish-speaking families across 4 inpatient units once weekly and screened for FI using a randomly selected method (face-to-face, phone, paper, and tablet). We asked questions from the 6-Item USDA Survey, Hunger Vital Sign screener, and questions utilized by our social workers.

RESULTS

We screened 361 families; 19.4% (N = 70) endorsed FI. Differences in rates were not significant by method. Differences in FI rates based on screening questions were: 17.7% for the 6-item USDA survey, 16.0% for Hunger Vital Sign, and 3.1% for the social work questions. When considering method and screening questions together, the 6-Item USDA on paper had the highest positivity rate of 20.9%. A higher percentage of Spanish-speaking families endorsed FI (61.1%) compared to 17.2% of English-speaking families (P < .01). Positivity also varied significantly by self-identified race (P < .01). Caregivers that identified as Hispanic or Latino were significantly more likely to endorse FI than those that did not (P < .01).

CONCLUSIONS

The positivity rate for FI while screening inpatient families using the 6-Item screening questions on paper matched our community prevalence of FI (approximately 20%).

Feasibility and Impact Assessment of a Food Insecurity Protocol in a Large Urban Pediatric Primary Care Network

INTRODUCTION/OBJECTIVES

In 2022, 1 in 6 households with children experienced food insecurity (FI) in the United States. The negative impact of FI on child health is well documented and pediatric clinicians are encouraged to actively screen and intervene in clinical settings. This study aims to evaluate the feasibility and impact of a FI management protocol implemented in 2017 at a pediatric primary care health network serving patients who are Medicaid-eligible in Washington, DC.

METHODS

In 2019, an 18-item electronic survey was sent to a convenience sample of 42 pediatric clinicians within the health network to understand their knowledge, attitudes, and behaviors surrounding implementation. Both quantitative and qualitative responses were collected and analyzed. We report frequencies of the Likert-type responses, including perceived compliance with protocol components and intervention efficacy. We evaluated the relationship between FI knowledge level and rates of clinician documentation compliance by chi square and Cramer's V statistic for effect size. Open-ended responses were reviewed, and common themes were identified and used to provide context for quantitative results.

RESULTS AND CONCLUSIONS

Out of 42 clinicians invited to complete the survey, 35 completed responses. All respondents reported universal screening for FI (100%) at routine examinations, 80% reported frequently electronically documenting FI in medical records, and 91% of clinicians reported frequently referring families who screened positive for FI to at least one FI resource, with 24% reporting that resources met families' needs. Open-ended responses revealed increased awareness of FI prevalence and of patient experiences in households experiencing FI, increased satisfaction with clinical management of FI, but also concerns around having limited clinical time to do the protocol and the usefulness and accessibility of referred resources. In conclusion, implementing this pilot FI protocol was feasible, but clinicians perceived limited impact of the protocol on alleviating FI and desired more robust intervention options. Further improvements include shifting the burden of performing the protocol away from the clinician, such as by streamlining the protocol or identifying a resource staff member, and establishing more accessible and effective FI interventions such as "Food as Medicine" offerings in partnership with community organizations.