Lessons Learned from Implementation of the Food Insecurity Screening and Referral Program at Kaiser Permanente Colorado

Understanding the Reasons Why Patients With Food Insecurity Decline Social Assistance at a Large Academic Medical Center

Introduction

Despite the recent expansions of clinical screening for food insecurity, research shows large discrepancies between the number of patients who report food insecurity and those who request assistance. In this qualitative study of patients with food insecurity who declined social assistance, the authors aimed to understand the patients' reasons for not seeking food-related assistance and explore their perspectives on addressing food insecurity with their healthcare provider.

Methods

At a large academic medical center in southeast Michigan, the authors conducted semistructured, in-depth interviews with 31 English-speaking adult primary care patients who had screened positive for food insecurity at a previous clinic encounter and subsequently declined assistance from a trained social worker. The interview guide explored patients' reasons for declining social assistance, perspectives on clinical screening for food insecurity and other social risk factors, and the extent to which they discussed their needs with their provider. Interviews were recorded, transcribed, and analyzed using the constant comparative method to reveal emergent themes.

Results

The mean age of the participants was 48.2 years, and 71% were women. The most prominent reasons for patients with food insecurity not seeking social assistance were the belief that the potential resources would be redundant or not helpful and previous negative experiences with receiving food assistance. Several patients also did not remember or know that they had declined assistance. Most patients believed that healthcare providers should be knowledgeable about patients' food insecurity status to better inform care delivery. However, patients expressed discomfort, fear, or embarrassment in revealing this information and emphasized the importance of providers fostering a supportive and empathetic healthcare environment.

Conclusions

Strategies to connect patients with food assistance must target multiple levels, including improving assistance methods, increasing provider knowledge, and prioritizing patient comfort.

Incident Food Insecurity and Associated Risk Factors After Surgical Trauma

INTRODUCTION

Food insecurity, defined as a lack of access to adequate nutrition, impacts approximately 30% of the global population. Despite clear evidence regarding the benefit of proper nutrition on clinical outcomes, the burden of incident food insecurity after surgical intervention in previously food secure patients is unknown. The goal of the study was to quantify incident food insecurity post operatively and to identify associated risk factors.

METHODS

A multicenter, prospective, longitudinal study was conducted among adult surgical trauma patients at tertiary care public and private hospitals in India. The primary outcome was new food insecurity from initial admission for traumatic injury to 6 mo post operatively. Cox proportional hazards models were used to evaluate associations between clinical and sociodemographic variables and incident food insecurity.

RESULTS

Of 774 patients enrolled, 20% were food insecure at baseline. During the follow-up period, 21% of patients who were food secure at baseline experienced new food insecurity. Incident food insecurity was associated with longer length of stay (hazard ratio (HR): 3.76, 95% confidence interval (CI): 1.62-8.74; P = 0.002), intensive care unit admission (HR: 1.87, 95% CI: 1.05-3.31; P = 0.032), receiving welfare support (HR: 2.00, 95% CI: 1.00-3.98; P = 0.049) and daily wage, rather than salaried, employment (HR: 2.95, 95% CI: 1.24-7.06; P = 0.015). Higher total household income was associated with maintaining food security (HR: 0.24, 95% CI: 0.13-0.44; P < 0.001). Hospitalization-related financial toxicity was significantly associated with incident food insecurity (HR: 3.07, 95% CI: 2.09-4.50; P < 0.001).

CONCLUSIONS

High levels of incident food insecurity were observed among surgical trauma patients. This highlights the need for serial food insecurity assessment post discharge. In lieu of serial follow-up, risk factors associated with incident food insecurity can be used to identify high-risk patients prior to discharge to facilitate connection to food insecurity interventions such as food prescription programs, monetary support, and nutritional welfare policies.

Enhancing Referrals to the Supplemental Nutrition Assistance Program through Clinical Integration of a Standards-Based Decision Support System

BACKGROUND

 The Supplemental Nutrition Assistance Program (SNAP) is one of the most successful national programs to reduce poverty and improve health outcomes, but millions of Americans who qualify still do not have access to SNAP, and limited data are available to determine how referrals to the program can be completed successfully.

OBJECTIVES

 We aimed to design and develop a standards-based digital care coordination platform to support closed-loop social services referrals between patients and social and health care providers and demonstrate the feasibility to screen, diagnose, plan, and complete interventions with selected patients in real settings.

METHODS

 We partnered with community members to design the platform through Community Engagement Studios and with a Federally Qualified Health Center, Local Mental Health Authority, and Food Bank to determine the features and workflow requirements of the platform design. We customized currently available systems to use Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs) that could exchange information in real time across providers and participants.

RESULTS

 The platform was successfully demonstrated through a pilot where patients were recruited in clinical settings and referred to a Food Bank that provided SNAP application assistance to study participants. We translated the requirements of the platform to national standards and required workflows of providers and patients. Study participants were notified electronically of the specific steps to follow to complete their SNAP applications while receiving support from specialists from the Food Bank.

CONCLUSION

 The pilot demonstrated the feasibility of collecting granular social service referral information that can be used to better address gaps in social care. The pilot also highlighted the importance of further coordination on the usage and harmonization of needs assessment nationally and that current digital systems are still not ready to fully utilize national Social Determinants of Health data standards.

The Social Risk ACTIONS Framework: Characterizing Responses to Social Risks by Health Care Delivery Organizations

Social risks refer to individuals' social and economic conditions shaped by underlying social determinants of health. Health care delivery organizations increasingly screen patients for social risks given their potential impact on health outcomes. However, it can be challenging to meaningfully address patients' needs. Existing frameworks do not comprehensively describe and classify ways in which health care delivery organizations can address social risks after screening. Addressing this gap, the authors developed the Social Risk ACTIONS framework (Actionability Characteristics To Inform Organizations' Next steps after Screening) describing 4 dimensions of actionability: Level of action, Actor, Purpose of action, and Action. First, social risk actions can occur at 3 organizational levels (ie, patient encounter, clinical practice/institution, community). Second, social risk actions are initiated by different staff members, referred to as "actors" (ie, clinical care professionals with direct patient contact, clinical/institutional leaders, and researchers). Third, social risk actions can serve one or more purposes: strengthening relationships with patients, tailoring care, modifying the social risk itself, or facilitating population health, research, or advocacy. Finally, specific actions on social risks vary by level, actor, and purpose. This article presents the Social Risk ACTIONS framework, applies its concepts to 2 social risks (food insecurity and homelessness), and discusses its broader applications and implications. The framework offers an approach for leaders of health care delivery organizations to assess current efforts and identify additional opportunities to address social risks. Future work should validate this framework with patients, clinicians, and health care leaders, and incorporate implementation challenges to social risk action.

Community-Specific Video Training for Primary Care Settings: Increasing Capacity and Motivation to Address Food Insecurity

BACKGROUND

Food insecurity (FI) is the most common health-related social need (HRSN) and is frequently identified in primary care through screening and referral. However, health care workers often do not have the knowledge, motivation, capability, or opportunity necessary to discuss FI with patients in patient-centered ways.

METHODS

An educational module for health care workers on FI was created using user-centered design and tested with health care workers, using the COM-B model as an evaluation framework.

RESULTS

Watching the module's video increased participant knowledge, capability, and motivation to address FI with patients.

DISCUSSION

This preliminary pilot study suggests that simple training modules could help with the effectiveness of efforts to address HRSNs, such as FI, by increasing health care workers' capacity to discuss, screen, and refer patients. Findings warrant expanded studies to assess the effectiveness of such modules on patient-level outcomes.

CONCLUSION

This type of educational module on FI or other HRSNs holds promise as a time- and cost-efficient strategy for improving screening and referral processes, ultimately alleviating FI for more patients and improving health outcomes.

Food insecurity and quality of life in patients with sickle cell disease

Little is known about the relationship between quality of life (QOL) and food insecurity (FI) among patients with sickle cell disease (SCD). We hypothesized FI is associated with lower QOL in children and young adults with SCD. Overall (N = 99), 22% screened positive for FI. Supplemental Nutrition Assistance Program (SNAP) enrollment was 50 and 71% among people from food secure and FI households, respectively. A higher FI score was correlated with lower overall QOL (r = -0.22, p = .03), specifically lower QOL in worry and communication domains. Interventions for FI beyond SNAP may be important for QOL among people living with SCD.

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.

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.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic

INTRODUCTION

This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care.

METHODS

This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit.

RESULTS

Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96).

CONCLUSIONS

There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

"Food Is Medicine" Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review

"Food Is Medicine" (FIM) represents a spectrum of food-based interventions integrated into health care for patients with specific health conditions and often social needs. Programs include medically tailored meals, groceries, and produce prescriptions, with varying levels of nutrition and culinary education. Supportive advances include expanded care pathways and payment models, e-screening for food and nutrition security, and curricular and accreditation requirements for medical nutrition education. Evidence supports positive effects of FIM on food insecurity, diet quality, glucose control, hypertension, body weight, disease self-management, self-perceived physical and mental health, and cost-effectiveness or cost savings. However, most studies to date are quasiexperimental or pre/post interventions; larger randomized trials are ongoing. New national and local programs and policies are rapidly accelerating FIM within health care. Remaining research gaps require rigorous, iterative evaluation. Successful incorporation of FIM into health care will require multiparty partnerships to assess, optimize, and scale these promising treatments to advance health and health equity.

Screening for Food Insecurity: A Curriculum for Medical Students

Introduction

Food insecurity (FI) is defined as a lack of access to enough food for an active, healthy life. We sought to determine how a longitudinal FI screening curriculum impacts medical students' knowledge, attitudes, and behavior in screening for FI.

Methods

This was a prospective, single-institution study. The curriculum consisted of three components completed over 3 years. We administered a survey to the intervention cohort before and after the curriculum and analyzed their written reflections. We also evaluated whether students screened for FI during an objective structured clinical exam (OSCE) and compared their performance to a control cohort, which did not receive the curriculum.

Results

Preintervention, students felt screening for FI was important for physicians to do with their patients, but most felt uncomfortable addressing it in clinical settings. Postintervention, there was a statistically significant increase in mean scores for knowledge questions (45.24% vs 74.74%, P<.001, pre- and postintervention, respectively). Students also felt more confident in their abilities to screen and follow up about FI. Additionally, compared to the control cohort, the intervention cohort screened for FI more often during their OSCE (28.21% vs 10.71%, P<.001).

Conclusion

A longitudinal curriculum using minimal curricular time can improve students' knowledge, attitudes, and behavior when screening for FI. Students who received the curriculum were more likely to recognize the need for and perform FI screening. Based on these findings, we anticipate that the curriculum will increase the likelihood of students identifying, screening for, and intervening in cases of FI in future clinical encounters.

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.

Food Insecurity Screening in Primary Care: Patterns During the COVID-19 Pandemic by Encounter Modality

INTRODUCTION

Screening for food insecurity in clinical settings is recommended, but implementation varies widely. This study evaluated the prevalence of screening for food insecurity and other social risks in telehealth versus in-person encounters during the COVID-19 pandemic and changes in screening before versus after widespread COVID-19 vaccine availability.

METHODS

These cross-sectional analyses used electronic health record and ancillary clinic data from a national network of 400+ community health centers with a shared electronic health record. Food insecurity screening was characterized in 2022 in a sample of 275,465 first encounters for routine primary care at any network clinic during March 11, 2020-December 31, 2021. An adjusted multivariate multilevel probit model estimated screening prevalence on the basis of encounter mode (in-person versus telehealth) and time period (initial pandemic versus after vaccine availability) in a random subsample of 11,000 encounters.

RESULTS

Encounter mode was related to food insecurity screening (p<0.0001), with an estimated 9.2% screening rate during in-person encounters, compared with 5.1% at telehealth encounters. There was an interaction between time period and encounter mode (p<0.0001), with higher screening prevalence at in-person versus telehealth encounters after COVID-19 vaccines were available (11.7% vs 4.9%) than before vaccines were available (7.8% vs 5.2%).

CONCLUSIONS

Food insecurity screening in first primary care encounters is low overall, with lower rates during telehealth visits and the earlier phase of the COVID-19 pandemic. Future research should explore the methods for enhancing social risk screening in telehealth encounters.

Service Awareness Among Older Adults Experiencing Barriers to Food and Eating

OBJECTIVE

To explore (1) the services older adults use to address the barriers to food access they face and (2) how they found out about these services.

DESIGN

Semistructured, basic descriptive qualitative in-person interviews.

SETTING

Senior center and participants' homes.

PARTICIPANTS

A convenience sample of 24 older adults recruited from suburban and urban settings. Primarily Black females, living alone, and able to leave home without help.

PHENOMENON OF INTEREST

Financial and nonfinancial barriers to food access, awareness of services available.

ANALYSIS

Codes were assigned to portions of the text in which participants described how they learned about a service. These codes were categorized into one of the 3 larger themes that emerged: (1) intentionally sought by the participant, (2) intentional outreach by the service, and (3) encounters in daily life and environment.

RESULTS

Most connections to services were made through encounters in participants' daily life and environment; for example, word of mouth from family, friends or neighbors; connection through other services; referral from health care professionals; and seeing the service in their neighborhood.

CONCLUSIONS AND IMPLICATIONS

Robust social networks, medical screening, and referral may promote awareness of food assistance services. Future research and outreach should target those who are most isolated.

Models of social prescribing to address non-medical needs in adults: a scoping review

BACKGROUND

The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers.

METHODS

We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates.

RESULTS

148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems.

CONCLUSIONS

There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs.

Dose response relationship between food insecurity and quality of life in United States adults: 2016-2017

BACKGROUND

Food insecurity is associated with worse general health rating, but little research exists investigating whether there is a dose response relationship across levels of food security and mental and physical health domains at the population level.

METHODS

Data from the Medical Expenditure Panel Survey (2016-2017) with US adults aged 18 years and older was used. The physical component score (PCS) and mental component score (MCS) of Quality of Life, served as the outcome measures. Four categories of food insecurity (high, marginal, low, very low food security) served as the primary independent variable. Linear regression was used to run unadjusted followed by adjusted models. Separate models were run for PCS and MCS.

RESULTS

In a sample of US adults, 16.1% reported some degree of food insecurity. For PCS, marginal (β = - 2.54 (p < 0.001), low (β = - 3.41, (p < 0.001), and very low (β = - 5.62, (p < 0.001) food security was associated with worse PCS scores, compared to adults with high food security. For MCS, marginal (β = - 3.90 (p < 0.001), low (β = - 4.79, (p < 0.001), and very low (β = - 9.72, (p < 0.001) food security was associated with worse MCS scores, compared to adults with high food security.

CONCLUSION

Increasing levels of food insecurity were associated with decreased physical and mental health quality of life scores. This relationship was not explained by demographic factors, socioeconomic factors, insurance, or comorbidity burden. This study suggests work is needed to mitigate the impact of social risk, such as food insecurity, on quality of life in adults, and understand pathways and mechanisms for this relationship.

Perspectives of Health Care Staff on Predictors of Success in a Food Prescription Program: A Qualitative Study

Partnerships between food prescription programs and food banks can address food insecurity and support health; however, few studies have examined the experience and perceptions of health care partners about these programs. Our objective was to analyze secondary qualitative data from clinicians and clinic staff involved in implementing a food prescription program in Houston, Texas. We collected data from 17 health care clinics from May 2018 through March 2021 to learn how implementation of the food prescription program was perceived, and we received 252 responses. Principal themes were the importance of a value-based care strategy, patient and food pantry barriers to success, the importance of interorganizational care coordination, and the need to integrate food prescriptions into clinic workflow. Insights of clinicians and clinic staff on implementation of food prescription programs can inform program development and dissemination.

Sustaining and scaling a clinic-based approach to address health-related social needs

Objective

Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use.

Methods

Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources).

Results

Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources.

Conclusion

An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.

Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination

Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.

Consensus from an expert panel on how to identify and support food insecurity during pregnancy: A modified Delphi study

BACKGROUND

Food insecurity and hunger during pregnancy have significant implications for the health of the mother and baby. Assisting clinicians when they encounter women who are experiencing hunger or food insecurity during their pregnancy will increase the opportunity for better birth and pregnancy outcomes. At present there are no guidelines for Australian clinicians on how to do this.

METHODS

This study uses a modified Delphi technique, allowing diverse participation in the process, to create consensus on the ways to address and respond to food insecurity during pregnancy. This modified Delphi collected data via two rounds of consensus. The opinions collected from the first round were thematically categorised and grouped. The topics were integrated into the survey for the second round and circulated to participants. During the second round, priorities were scored by giving five points to the topic considered most important, and one point to the least important.

RESULTS

Through two rounds of consultation, the panel achieved consensus on how to identify food insecurity during pregnancy, with some clear items of consensus related to interventions that could be implemented to address food insecurity during pregnancy. Experts achieved consensus on items that have importance at the institution and policy level, as well as services that exist in the community. The consensus across the spectrum of opportunities for assistance, from the clinical, to community-provided assistance, and on to government policy and practice demonstrate the complexity of this issue, and the multipronged approach that will be required to address it.

CONCLUSION

This is the first time such a consultation with experts on hunger and food insecurity during pregnancy has been conducted in Australia. Items that achieved consensus and the importance of the issue suggest several ways forward when working with pregnant women who are hungry and/or food insecure.

Strengthening Food and Nutrition Security to Promote Public Health in the United States: A Position Paper From the American College of Physicians

Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.

Addressing Food Insecurity to Optimize Nutritional Status

Chronic health conditions related to diet are linked with increased risk for COVID-19 infection, complications, and mortality. Adherence to a healthy diet pattern can be protective, but a major barrier to healthy eating is the high cost of healthy foods. Access to healthy foods is especially limited in households that experience food insecurity, not having enough food or resources to get food. Individuals who live in these households are also at increased risk for a number of health conditions. Addressing food insecurity within lifestyle medicine practice is needed to achieve optimal nutrition status. Emerging food as medicine and other food access programs are promising but coverage of such programs is lacking through healthcare insurers. Medicaid waivers are a potential solution and have been utilized in a handful of states.

Connecting Families at Risk for Food Insecurity With Nutrition Assistance Through a Clinical-Community Direct Referral Model

OBJECTIVE

To assess the feasibility of a clinical-community direct referral model to enroll eligible households in the Supplemental Nutrition Assistance Program (SNAP).

METHODS

Pediatric clinics screening for food insecurity (n = 27) invited families experiencing food insecurity to participate in a direct referral to a local organization that assists with SNAP applications. A food stamp specialist telephoned participants to determine SNAP eligibility, assist with the application, and/or provide other supports. Referrals, eligibility determination, enrollment, and estimated benefits were tracked.

RESULTS

A total of 486 families were referred to the community partner; 72% (n = 351) were successfully contacted by a food stamp specialist, with 17% (n = 83) applying for SNAP benefits. Another 16% (n = 79) were already enrolled in SNAP but received an additional service.

CONCLUSIONS AND IMPLICATIONS

This referral model was feasible and increased the number of families who received nutrition assistance. This approach could be adapted for other health-related social needs.

An embedded multiple case study: using CFIR to map clinical food security screening constructs for the development of primary care practice guidelines

BACKGROUND

Food insecurity (FI), the limited access to healthy food to live an active and healthy life, is a social determinant of health linked to poor dietary health and difficulty with disease management in the United States (U.S.). Healthcare experts support the adoption of validated screening tools within primary care practice to identify and connect FI patients to healthy and affordable food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that may guide wide-scale program implementation.

METHODS

This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with N = 19 healthcare staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis.

RESULTS

Programs outcomes included: the number of patients screened, identified as FI and that participated in the onsite food assistance program. Study participants reported limited internal resources as implementation barriers for program activities. The implementation climate that leveraged the strength of community collaborations and aligned internal, implementation climate were critical facilitators that contributed to the flexibility of program activities that were tailored to fill gaps in resources and meet patient and clinician needs.

CONCLUSION

Highly adaptable programs and the healthcare context enhanced implementation feasibility across settings. These characteristics can support program uptake in other settings, but should be used with caution to preserve program fidelity. A foundational model for the development and testing of standard clinical practice was the product of this study.

Telehealth and food insecurity screenings: challenges and lessons learned

Food insecurity remains a persistent problem in the United States and affected 35.2 million Americans in 2019. In the wake of COVID-19, food insecurity has increased in many communities. Given that food insecurity exacerbates poor health or health conditions, screening of food insecurity within medical settings is frequently identified within the literature as an important first step in effectively addressing this social concern and improving the health outcomes of patients. However, health care providers often do not screen for food insecurity for a variety of reasons. In this article review, we discuss the challenges associated with incorporating food insecurity screenings within the medical model and how the COVID-19 pandemic has exacerbated these challenges. Specifically, the COVID-19 pandemic has substantially increased the delivery of health care services via telehealth, making screening for food insecurity even more difficult via remote videoconferencing. We examine the strengths and weaknesses of telehealth and their implications for food insecurity screenings. We discuss how these implications might inform future research regarding the use of telehealth as a means of screening patients for social determinants of health in the COVID-19 era. Given that the use of telehealth is not expected to back to pre-pandemic levels, it is important to understand how to best screen for social determinants of health via videoconferencing.

Stakeholders' Perspectives on the Current Status of Partnerships between the Food Banking and Healthcare Systems to Address Food Insecurity in the U.S

One in eight people in the U.S. experience food insecurity (FI). To date, the food banking sector has been at the forefront of efforts to address FI, but the healthcare sector is becoming increasingly involved in such efforts. The extent of collaboration between the two sectors remains unclear. We explored food banking stakeholders’ views on the current state of partnerships between the two sectors. We used purposive sampling to recruit ten key informants for semi-structured interviews. We also conducted a national online survey to gather data from food bank directors (n = 137). Thematic analysis generated two major themes: (1) Healthcare and food banking stakeholders are coordinating to achieve collective impact, and (2) Food banking-healthcare partnerships are leveraging various resources and vested interests within the medical community. We found evidence of ongoing partnerships between the two sectors and opportunities to strengthen these partnerships through the support of backbone organizations.

Implementing food bank and healthcare partnerships: a pilot study of perspectives from charitable food systems in Texas

Background

Partnerships between charitable food systems and healthcare systems have been forming across the country to support individuals and families experiencing food insecurity, yet little research has focused on these partnerships, particularly from a food bank perspective. The objective of this exploratory pilot study was to identify implementation challenges and facilitators of charitable food system and healthcare partnerships from the food bank perspective.

Method

Texas food banks with existing food bank/healthcare partnerships were identify through website review and support from Feeding Texas. Interview questions were tailored to each interview, but all focused on identify program components of the food bank/healthcare partnership and implementation barriers/facilitators of the partnership. In total, six interviews were conducted with food bank/healthcare partnership leaders (n = 4) and charitable food system experts (n = 2) about their experiences of working with food bank/healthcare partnerships. All interviews were completed via Zoom and took between 30 and 60 min to completed. Detailed notes were taking during each interview, and immediately discussed with the complete research time to formulate broad implementation themes.

Results

Interviews suggest unique implementation challenges exist at all levels of food bank/healthcare partnerships including the partnership, program, and system levels. Partnership-level implementation challenges focused on issues of partnership scale and data collection, sharing, and analysis. Program-level implementation challenges focused on food and produce expectations. Structural-level implementation challenges included issues of food safety, subsidized food regulations, and patient privacy. Implementation facilitators included leadership support, mission compatibility/organizational readiness, food insecurity training, and identify of partnership champions.

Conclusions

This study adds to the growing interest in food bank/healthcare partnership as it highlights unique implementation challenges and facilitators for cross-sector partnerships between healthcare systems and community-based charitable food systems. Ultimately, we believe that collaborative discussion among leaders of charitable food systems and healthcare systems is needed to overcome outlined implementation challenges to better facilitate sustainable, equitable implementation of food bank/healthcare partnerships.

Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review

Introduction

Unmet health-related social needs contribute to high patient morbidity and poor population health. A potential solution to improve population health includes the adoption of care delivery models that alleviate unmet needs through screening, referral, and tracking of patients in health care settings, yet the overall impact of such models has remained unexplored. This review addresses an existing gap in the literature regarding the effectiveness of these models and assesses their overall impact on outcomes related to experience of care, population health, and costs.

Methods

In March 2020, we searched for peer-reviewed articles published in PubMed over the past 10 years. Studies were included if they 1) used a screening tool for identifying unmet health-related social needs in a health care setting, 2) referred patients with positive screens to appropriate resources for addressing identified unmet health-related social needs, and 3) reported any outcomes related to patient experience of care, population health, or cost.

Results

Of 1,821 articles identified, 35 met the inclusion criteria. All but 1 study demonstrated a tendency toward high risk of bias. Improved outcomes related to experience of care (eg, change in social needs, patient satisfaction, n = 34), population health (eg, diet quality, blood cholesterol levels, n = 7), and cost (eg, program costs, cost-effectiveness, n = 3) were reported. In some studies (n = 5), improved outcomes were found among participants who received direct referrals or additional assistance with indirect referrals compared with those who received indirect referrals only.

Conclusion

Effective collaborations between health care organizations and community-based organizations are essential to facilitate necessary patient connection to resources for addressing their unmet needs. Although evidence indicated a positive influence of screening and referral programs on outcomes related to experience of care and population health, no definitive conclusions can be made on overall impact because of the potentially high risk of bias in the included studies.

Evaluation of a COVID-influenced Curriculum to Address Food Insecurity in a Detroit Family Medicine Residency Clinic

CONTEXT

To date, numerous projects have demonstrated that an ongoing limited access to nutritionally dense food (i.e., "food insecurity") plays a key role in the overall health and wellbeing of lower income at-risk populations.

METHODS

For this 2019-2020 pilot project, the resident physician authors first created and administered a simple five-item questionnaire screening process to systematically identify food insecure patients in their metropolitan Detroit residency clinic. A sample of patients who had been identified as food insecure and pre-diabetic were then provided improved access to healthy foods, supplemented by a six-week program of nutritional education classes using a nationally recognized "Cooking Matters'' six-week long curriculum with a licensed chef and nutrition educator.

RESULTS

After institutional review board approval, the authors enrolled a sample of 10 adults. The authors successfully measured both pre- and post-program Hemoglobin A1c (HbA1C) levels for all participants who completed the required course and subsequent clinic follow up visits. Using a series of initial non-parametric Wilcoxon Signed Rank matched pair tests, post-program follow-up at three months revealed statistically significant reductions in documented HbA1c levels from baseline for six enrolled patients (W=1, Z = - 2.226, p = 0.026) and six-month follow up (i.e., more than four months after completion of the program) (W = 1, Z = - 2.060, p = 0.039). In post-program surveys, each respondent indicated that they found the class content to be generally beneficial to increase their nutritional knowledge.

CONCLUSIONS

In the authors' setting, this food insecurity program has subsequently led to a more formal screening process to evaluate and identify food insecure patients. The authors discuss the scheduling difficulties they experienced from the COVID-19 pandemic for their sample patients. However, these pilot results suggest that prolonged benefits may require ongoing "virtual" teaching sessions with pre-diabetic patients to address the complex factors influencing food insecurity levels identified in similar inner-city settings.

Assessment of Social Risk Factors and Interest in Receiving Health Care-Based Social Assistance Among Adult Patients and Adult Caregivers of Pediatric Patients

IMPORTANCE

Health care organizations are increasingly incorporating social risk screening into patient care. Studies have reported wide variations in patients' interest in receiving health care-based assistance for identified social risks. However, no study to date has examined the factors associated with patients' interest in receiving assistance, including whether interest in receiving assistance varies based on specific patient demographic characteristics. Targeted research on this topic could improve the success of health care-based programs that offer social care services.

OBJECTIVE

To identify participant characteristics associated with interest in receiving health care-based social risk assistance.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted in 7 primary care clinics and 4 emergency departments in 9 US states between July 2, 2018, and February 13, 2019. A convenience sample of adult patients and adult caregivers of pediatric patients completed a screening survey that measured social risk factors and participants' interest in receiving assistance for identified social risks. Participants were randomly selected to receive 1 of 2 versions of the survey, which differed based on the order in which questions about social risks and interest in receiving assistance were presented. Multivariable logistic regression analyses were used to evaluate the associations between covariates and participants' interest in receiving assistance, stratified by social risk screening results. Data were analyzed from September 8, 2019, to July 30, 2020.

EXPOSURES

Social risk screening questions assessed risk factors comprising housing, food, transportation, utilities, and exposure to interpersonal violence. Additional questions assessed participants' interest in receiving assistance and their perspectives on health care-based social risk screening.

MAIN OUTCOMES AND MEASURES

Participant interest in receiving health care-based social risk assistance.

RESULTS

A total of 1021 adult participants with complete survey responses were included in the analysis. Of those, 709 of 1004 participants (70.6%) were female, and 544 of 1007 participants (54.0%) were aged 18 to 44 years. Overall, 353 of 662 participants (53.3%) with positive screening results for 1 or more social risk factors were interested in receiving assistance, whereas 31 of 359 participants (8.6%) with negative screening results for all social risks were interested in receiving assistance. Participants with positive screening results for 1 or more social risk factors had a higher likelihood of being interested in receiving assistance if they answered the question about interest in receiving assistance before they answered the questions about social risk factors (adjusted odds ratio [aOR], 1.48; 95% CI, 1.05-2.07), had positive screening results for a higher number of social risk factors (aOR, 2.40; 95% CI, 1.68-3.42), reported lower household income levels (aOR, 7.78; 95% CI, 2.96-20.44), or self-identified as having non-Hispanic Black ancestry (aOR, 2.22; 95% CI, 1.37-3.60). Among those with negative screening results for all social risk factors, the interest in receiving assistance was higher if the participants reported lower household income levels (aOR, 12.38; 95% CI, 2.94-52.15), previous exposure to health care-based social risk screening (aOR, 2.35; 95% CI, 1.47-3.74), higher perceived appropriateness of social risk screening (aOR, 3.69; 95% CI, 1.08-12.55), or worse health status (aOR, 4.22; 95% CI, 1.09-16.31).

CONCLUSIONS AND RELEVANCE

In this study, multiple factors were associated with participants' interest in receiving social risk assistance. These findings may have implications for how and when social risk assistance is offered to patients. As the health care system's role in addressing social risk factors evolves, an understanding of patients' perspectives regarding screening and their interest in receiving assistance may be important to implementing patient-centered interventions.

Beyond clinical food prescriptions and mobile markets: parent views on the role of a healthcare institution in increasing healthy eating in food insecure families

Background

Children in food-insecure families face increased barriers to meeting recommendations for fruit and vegetable consumption. Hospitals and pediatric healthcare institutions have attempted to alleviate food-insecurity through various internal programs like food prescriptions, yet little evidence for these programs exist. Consistent with a patient-centered perspective, we sought to develop a comprehensive understanding of barriers to fruit and vegetable consumption and a parent-driven agenda for healthcare system action.

Methods

We conducted six qualitative focus group discussions (four in English, two in Spanish) with 29 parents and caregivers of patients who had screened positive for food-insecurity during visits to a large pediatric healthcare system in a midwestern U.S. city. Our iterative analysis process consisted of audio-recording, transcribing and coding discussions, aiming to produce a) a conceptual framework of barriers to fruit and vegetable consumption and b) a synthesis of participant programmatic suggestions for their healthcare system.

Results

Participants were 90% female, 38% Black/African American and 41% Hispanic/Latino. Barriers to fruit and vegetable consumption in their families fell into three intersecting themes: affordability, accessibility and desirability. Participant-generated intervention recommendations were multilevel, suggesting healthcare systems focus not only on clinic and community-based action, but also advocacy for broader policies that alleviate barriers to acquiring healthy foods.

Conclusion

Parents envision an expanded role for healthcare systems in ensuring their children benefit from a healthy diet. Findings offer critical insight on why clinic-driven programs aimed to address healthy eating may have failed and healthcare organizations may more effectively intervene by adopting a multilevel strategy.

Keiki Produce Prescription (KPRx) Program Feasibility Study to Reduce Food Insecurity and Obesity Risk

One in 6 US children experience food insecurity, signifying that at some time during the last year their household did not have sufficient food, money, or resources to feed their family. These children experience little intake of fresh fruits and vegetables (FV), a risk factor for chronic disease, including obesity. Produce prescription programs provide vouchers to purchase fresh FV at participating retailers. The Keiki Produce Prescription (KPRx) Program feasibility study was conducted through a partnership between the Waianae Coast Comprehensive Health Center's Pediatrics and Health Promotion Department's Farmers'Market and the University of Hawai'i nutrition faculty. Pediatricians provided patients with a prescription (Rx) to purchase FV from the Farmers' Market ($24 per month for three months). Of the 193 Rx distributed, 125 patients participated in part of the program, while 34 completed the full program. Parents, pediatricians, clinic staff, and community members expressed overwhelming support of the program. Parents of participating children completed an exit interview that identified themes surrounding motivation to participate, benefits to child and family, and future recommendations. It identified the need to improve program retention efforts. Participants reported lifestyle benefits for both the child and family and recommended educational resources. Aresearch protocol was developed to address the following objectives: (1) streamline referrals, (2) enhance retention, (3) quantify program impact, and (4) identify barriers to participation. Subsidies have the potential to increase FV consumption, improve overall health, reduce chronic diseases in adulthood, and result in substantial healthcare cost savings.

Food Insecurity Among Veterans: Resources to Screen and Intervene

A screener was created in the VA electronic health record clinical reminder system to facilitate an interdisciplinary approach to identifying and addressing food insecurity.

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers

INTRODUCTION

Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

METHODS

This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

RESULTS

Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

CONCLUSIONS

A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers

INTRODUCTION

This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.

METHODS

As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.

RESULTS

Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.

CONCLUSIONS

Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Challenges and Successes with Food Resource Referrals for Food-Insecure Patients with Diabetes

INTRODUCTION

Clinics increasingly screen patients for food insecurity, but little is known about the efficacy of referring food-insecure patients to community-based food resources.

OBJECTIVE

To evaluate the implementation of a tailored community food resource referral program in a safety-net diabetes clinic.

METHODS

We conducted semistructured phone interviews with food-insecure patients participating in a screening and referral program in a diabetes clinic affiliated with a safety-net hospital. In this qualitative study, we describe barriers to and facilitators of successful food resource referrals from the patient's perspective.

RESULTS

The prevalence of food insecurity was high (60%). Provision of written and verbal information alone about community food resources resulted in low linkage rates (0%-4%), even with individually tailored referrals. Misperceptions about eligibility, fears around government program registration, inaccessibility, lack of information retention, competing priorities, an inability to cook, stigma, and a perceived sense of stability with existing food support were major barriers to use. Personnel-guided, in-clinic enrollment to a food resource facilitated a higher connection rate (31%).

DISCUSSION

Results of this study suggest that screening for food insecurity followed by a list of food resources for those screening positive may not adequately address patient barriers to using community-based food resources. For food insecurity screening programs in the clinical setting to be effective, systems must not only distribute food resource information but also assist patients in enrollment processes.

Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States

Food insecurity affects 1 in 8 US households and has clear implications for population health disparities. We present a person-centered, multilevel framework for understanding how individuals living in food-insecure households cope with inadequate access to food themselves and within their households, communities, and broader food system. Many of these coping strategies can have an adverse impact on health, particularly when the coping strategies are sustained over time; others may be salutary for health. There exist multiple opportunities for aligning programs and policies so that they simultaneously support food security and improved diet quality in the interest of supporting improved health outcomes. Improved access to these programs and policies may reduce the need to rely on individual- and household-level strategies that may have negative implications for health across the life course.