Background
In 2018, approximately 11.1% of all US households and 13.9% of households with children experienced one of the most common social determinants of health (SDH), food insecurity [
1]. The US Department of Agriculture (USDA) defines food insecurity in two levels. The first, low food security, represents reduced quality, variety, or desirability of diet yet little or no indication of reduced food intake. The second is very low food security, which includes reports of multiple indications of disrupted eating patterns and reduced food intake [
2]. Food insecurity is most often the result of a combination of financial and structural barriers and research demonstrates that it affects the health and well-being of individuals by contributing to higher rates of obesity, fewer heathy foods served at meals, lower quality diets, mental distress, and functional limitations [
3‐
6]. These consequences differ based on demographic characteristics (i.e., race, ethnicity, and age) contributing to health inequities across populations [
7,
8]. In addition to these consequences, food insecurity is directly associated with dietary behaviors and perceptions [
9,
10]. Despite some food insecure individuals perceiving healthy eating as beneficial to health, many also view it as inconvenient [
9]. Balancing a value for healthy eating with the need to stretch food budgets sometimes results in dietary behaviors (i.e., reducing fruit and vegetable purchases) that have negative implications for health [
11,
12].
Based on the potential for food insecurity and other SDH to impact health outcomes, screening in primary care settings has been discussed as a means to help providers identify needs and address issues through referrals to additional resources [
13]. In 2015, the American Academy of Pediatrics (AAP) recommended screening for food insecurity in children through the use of a two-item screener called the Hunger Vital Sign™ screening tool, which addresses worry about food insecurity and experiencing food insecurity [
14]. The Hunger Vital Sign™ has been used in a variety of clinical settings, with mixed results in acceptability by patients and providers and in effectiveness for identification of food insecurity and subsequent referral to resources. Barriers related to using this tool include patient refusals, patient discomfort in talking about food needs with providers, perceptions of ineligibility for supportive services, and challenges in implementation of referral processes for families who indicate a need for food resources [
15‐
17].
Despite these barriers, screening for food insecurity and other SDH in primary care settings may result in more referrals and thus the potential for more individuals or families to access needed community resources [
18]. In addition, screening may help providers better understand factors influencing their patients’ health outcomes, and further, identify the need for resources that go beyond provision of food for a family. However, even with the potential value of screening for food insecurity, implementation can have substantial operational cost. The value of such screening is ultimately defined by the usefulness of the data collected. Brief SDH screening items, like those recommended by the AAP and other bodies, provide limited information about a person’s actual needs and little is known about the demographic, attitudinal, or behavioral characteristics associated with a positive screen for food insecurity. The present analysis aimed to identify needs and behaviors related to the endorsement of two food insecurity screener questions like those included in the Hunger Vital Sign™. The goal of this work is not to validate a new screening tool, but instead to identify potential intervention targets in those individuals endorsing screening items.
Results
Sample characteristics
The study population included 442 people. Most participants were female (75.9%) and unmarried (84.4%). The average age of respondents was 51 years old (SD = 13.2 years), and 67.5% of the total respondents were Black. The average household size was slightly less than the national average in 2015(2.5 people per household), at 2.46 people in the food insecure group, and 2.19 people in the food secure group. Nearly two-thirds of the respondents (62.2%) reported having a high school education or less, and less than 39% of respondents were employed for wages. Nearly all respondents (95.2%) had health insurance at the time of survey data collection.
Demographics and attitudes
A summary of participant characteristics delineated by food insecurity status is included in Table
1. Participants were considered part of the food insecure group if they endorsed at least one of the two food insecurity questions, and in the food secure group if they did not endorse either item. Over half of the respondents (57%) answered affirmatively to at least one of the two food insecurity screening items. These participants (
n = 252) were considered food insecure for this analysis. Those in the food insecure group were more likely to report having a chronic illness, though only marginally significant (
p = 0.06), and significantly less likely to describe a fresh healthy diet as “easy”, “affordable,” or “convenient” (
p < 0.001).
Diet and food behaviors
Those in the food insecure group had significantly lower HEI-2010 scores (p < 0.001), indicating a lower overall diet quality. Most in the food insecure group (73%) received SNAP benefits. Food insecure participants shopped with significantly more frequency (4.9 days per month) than their counterparts who were categorized as food secure (3.8 days per month) (p < 0.05). Despite shopping more frequently, fewer food insecure participants utilized their own car for food shopping than those who were food secure (46.4% compared to 61.6%, respectively) (p = 0.002).
Multivariable analyses
Using a logistic regression model, we estimated the association between several variables and the food insecure classification based on the two-item screener. Table
2 displays the odds ratios and associated
p-values for 11 characteristics included in the model. Affirmative attitudes related to convenience of shopping for healthy foods [OR = 0.74; 95% CI = (0.55,1.00)] and ease of eating healthy foods [OR = 0.73; 95% CI = (0.56, 0.95)] were associated with decreased odds of reporting food insecurity. Similarly, those that used their own car when shopping for food had lower odds of reporting food insecurity [OR = 0.55; 95% CI = (0.35, 0.87)].
Compared to those who did not report having any chronic disease, among those with a with a chronic disease, we see a 59% increase in the odds of food insecurity [OR = 1.59; 95% CI = (1.04, 2.42)]. As shopping frequency increased, the odds of food insecurity also increased [OR = 1.10; 95% CI = (1.03, 1.18)]. The odds of reporting food insecurity also increased when participants experienced a significant life event within the past 12 months [OR = 1.88; 95% CI = (1.22,2.90)]. Participants that received SNAP benefits are expected to have an 81% increase in the odds of reporting food insecurity, compared to those not receiving SNAP benefits [OR = 1.81; 95% CI = 1.14, 2.86)]. HEI-2010 scores, education, and perceptions of affordability and time associated with healthy foods did not produce statistically significant results.
Discussion
This cross-sectional survey found that over half of the participants experienced food insecurity. Study participants were from households located in two midwestern urban neighborhoods with low access to healthy food retailers. Our finding that those with chronic conditions have higher odds of food insecurity underscores the clinical relevance of brief screening. These results also highlight the fact that universal clinic-based screening by providers serving these communities may identify high levels of need beyond food resources, which may present new challenges and opportunities.
One of the most common actions taken in response to a positive screen for food insecurity in the clinical setting is referral to Supplemental Nutrition Assistance Program (SNAP) [
17,
23]. The fact that nearly three-quarters of the households experiencing food insecurity in our survey were already receiving SNAP suggests that this approach is necessary but not always sufficient for meeting food needs. Residual food insecurity in the SNAP population has been linked to factors including negative income shocks or changes in household composition [
24]. It might also be driven by associations with other non-random correlates of SNAP participation [
25]. Other supplemental low cost or no cost food sources, including community-based food pantries and nutrition incentive programs like
Double Up Food Bucks [
26,
27], should be included in the food insecurity referral model.
Another explanation for this finding is that SNAP benefits may not surmount food access barriers beyond costs. Those who described a fresh and healthy diet as affordable, easy, or convenient had lower odds of screening positive for food insecurity. These attitudes related to ease or convenience may align with food insecure respondents’ greater number of shopping trips and the greater need to use transportation other than their own car. Other research on shopping patterns has shown that food insecure families travel shorter distances to complete their grocery shopping [
28], which may indicate transportation barriers as limitations to shopping in stores beyond that of corner or convenience stores that tend to offer fewer healthy options. However, findings on the type of retailers that food insecure individuals frequent for food purchasing have been mixed [
12,
13,
28]. As such, responses to food insecurity needs may be most successful when they include instrumental supports (e.g., bus passes, taxi vouchers, food delivery, ready-to-eat meal kits) that help people work around barriers, and motivational interviewing to support changes in attitudes toward and perceptions of healthy eating and food shopping behaviors. Supports to reduce the transportation barrier related to food access also has implications for access to health care and other services that may otherwise be limited by lack of transportation. Findings emphasize the value of clinical-community linkages that extend healthcare services to include strategic connections with community services. This may include connections to food-related services such as food pantries, nutrition education and navigation [
29], nutrition incentive programs like
Double Up Food Bucks, community gardens, and food stores that offer healthy foods at affordable prices as well as non-food related services such as transportation and financial supports [
30]. The common approach of providing a list of resources related to social needs without facilitation of accessing these resources is likely not enough to generate lasting improvement [
17].
It is important to recognize that food insecurity does not exist in a vacuum and may be a “symptom” of larger socioeconomic struggles. Consistent with previous research, our analysis found that significant life events, such as death of a loved one, legal troubles, change in finances, or job loss were nearly twice as common in those experiencing food insecurity [
31]. The cross-sectional nature of these data does not allow us to determine the direction of causation, but food insecurity is likely an indication of many needs, beyond just food [
32]. Given the limited ability to control some of these life changes, resources related to coping or perhaps alleviating some of the burden that these events put on families may be feasible ways to prevent food insecurity among patients and their families.
Based on the current analysis, we argue that the value of brief screening for food security in primary care starts with needs identification and referral yet expands to included considerations related to strategically connecting patient needs with both food and non-food related supports. These screenings reveal much more than worry about food. Accordingly, they provide a tool for tailoring health care delivery to effectively support patients or families in higher need of social, financial, and community resources.
Limitations
First, this study used two independent validated food insecurity items rather than a validated scale like the Hunger Vital Sign™ tool. This measurement approach was selected to meet the needs of the primary study from which this data is drawn. As such, the results do not fully generalize to the food insecure populations generated from more standardized measurement approaches. Secondly, the cross-sectional nature of the study limits us to discussion of associations rather than causation. Next, given that food security can be transient, an individual could endorse at least one of the given questions at the time of interview, perhaps if they were feeling the effects more strongly at that point, and fluctuate throughout the year. However, the US Economic Research Service (ERS) reports that many households who experience food insecurity at some point in the year experienced this for 7 months during the year, suggesting that although perhaps transient, food insecurity can be persistent [
1]. Thus, there may still be benefit in understanding that individuals have experienced food insecurity within the year, coupled with additional barriers or lack of resources.
The measure of food insecurity applied in this research included the use of two separately validated, nationally used items, rather than the use of one tool. Surveys utilized in this study were developed prior to the wide adoption and standardization of the two-item Hunger Vital Sign™. Finally, results provide insight into characteristics associated with food insecurity among a community sample rather than a clinical population. However, half of the study population reported a chronic illness and over 90% are insured.
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