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

Abstract

Purpose

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

Design

Mixed-methods study.

Setting

Academic pediatric obesity treatment clinic.

Subjects

Convenience sample of caregivers.

Intervention

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

Measures

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

Analysis

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

Results

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

Conclusions

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

Keywords

food insecurity social determinants of health health equity obesity pediatrics

Purpose

Food insecurity (FI) is defined as the “limited or uncertain availability of nutritionally adequate and safe foods.”¹ Approximately 12.5% of children nationally were affected by FI in 2021, which is slightly improved from rates reported during the COVID-19 pandemic.^2,3 More recently, the United States Department of Agriculture (USDA) has defined nutrition insecurity as the “consistent and equitable access to healthy, safe, and affordable foods that promote optimal health and well-being,” which is emerging as unique from, but related to, FI.^4–6 FI has been associated with worse child educational outcomes, increased healthcare utilization, and higher risk of acute and chronic disease.^7–9 Due to these associations, the American Academy of Pediatrics (AAP) currently recommends routine screening using a brief, two-item screening tool and intervening in clinical settings to address FI.¹⁰ A variety of interventions are available, including enrollment assistance for federal nutrition programs, referrals to community resources, and direct food provision, such as the establishment of a clinic-based food pantry.¹⁰ Given AAP recommendations and rising child FI rates during the COVID-19 pandemic, FI is increasingly screened for and addressed in many pediatric care settings.^11,12

Prior studies evaluating the implementation of FI screening processes and interventions in clinical settings include a diversity of approaches and measure a broad array of utilization and health outcomes. Some evidence suggests healthcare-based interventions in adult and pediatric settings increased food program utilization, and in some instances, improved patient health and reduced acute care utilization.^13,14 Additional studies evaluating the method of resource connection for patients found that an in-person resource navigator may be no more effective than distributing resource sheets in clinic.¹⁴ While these studies support some best practices for implementing FI screening and interventions in clinical practice, studies also report a discordance between FI screening outcome and family acceptance of FI resources or external referrals.¹⁵ For example, some families who screen positive for FI in clinic subsequently decline resources, while other families that screen negative for FI would be interested in receiving food resources or referrals.^16,17 With more clinical practices adopting FI screening and intervention strategies, processes that both identify families in need of food resources and those who would benefit from receiving food assistance need further exploration.

The implementation of clinic-based FI interventions and referrals from clinical settings is slowed by limited evidence demonstrating the effectiveness of the various FI interventions and many barriers faced by families when accessing FI resources beyond the clinical setting.^14,18,19 Therefore, we were interested in exploring the implementation and effects of direct, clinic-based food distributions to families. Our team established a clinic-based food pantry, offering a bag of healthy, non-perishable food to families attending a pediatric weight management program. While we screened for FI, all families were offered a bag of food irrespective of screening outcome.

We leveraged a mixed-methods approach to better understand the implementation and effects of this novel clinic-based food pantry. First, we aimed to quantitatively describe FI screening outcomes relative to food pantry utilization, factors associated with acceptance of the clinic-based food pantry and reported benefits after utilization. Based on prior studies, we hypothesized that many families screening negative would utilize the food pantry and that factors associated with utilization would include caregiver perceived health and severity of social need.^16,17,20 Second, we utilized qualitative interviews to further explore caregiver experiences with the food pantry, including those who screened negative and positive for FI. We aimed to gain a richer understanding of reasons for food pantry utilization and perceived benefits to families after using the food pantry, in order to inform future tailoring of clinic-based food interventions.

Methods

Study Design

This was a mixed-method, cross-sectional, descriptive study of families utilizing a clinic-based food pantry within the Duke Healthy Lifestyles Program, a pediatric obesity treatment program in Durham, NC, from August 2020 – March 2021. The program serves a racially and ethnically diverse population of children and adolescents with an age and gender-specific BMI ≥ 95^th percentile and most patients have Medicaid insurance. The Duke University Health System Institutional Review Board approved all study procedures (Pro00104226).

Sample

A convenience sample of children and caregivers who presented for an in-person Healthy Lifestyles visit were approached for study participation. Eligibility criteria included attendance at a visit with a medical provider or dietician, and the child had to be ≤ 18 years old. Caregivers could be the parent or guardian, or another family member who was heavily involved in the child’s care. Caregivers and children were excluded if they did not speak and read English. If multiple children presented to clinic for a visit, only one child was randomly selected.

Participating caregivers completed a baseline survey on paper after completing the food pantry screening form in clinic (N = 120). If they chose to utilize the food pantry, they were asked to complete a 1-month follow-up survey, which was completed independently online or via phone with a trained research coordinator (N = 47; 12 caregivers were lost to follow up).

For qualitative interviews, a convenience sample of caregivers who had indicated willingness to participate in an interview at the initial clinic visit were contacted via phone after the 1-month survey was completed. The sample was selected to balance FI screening outcomes (positive vs. negative). Interviews were completed until thematic saturation was reached (N = 14), which was determined when consistent concepts were heard during interviews without new major findings. Of the 60 eligible interview participants, 17 could not be reached, 6 were lost to follow up, 8 declined participation, and 15 were not approached to either achieve balanced FI screening and food pantry utilization responses in the sample, or because saturation was reached.

Intervention

A clinic-based food pantry was integrated as the new standard of care in the Healthy Lifestyles clinic beginning in August 2020. All caregivers of children with an in-person clinic visit were screened for FI using the Hunger Vital Sign and all were offered a bag of non-perishable food items irrespective of FI screening outcome once in the clinic room.²¹ Families requesting food subsequently received a plain, canvas bag with food items privately in their clinic room.

Measures

Baseline Survey

Caregivers were screened for FI using the Hunger Vital Sign.²¹ A positive screen was defined as a positive response (often true or sometimes true) to either question (Supplemental Table 1). Caregivers responded to the question, “Would you like a bag of food today?” as the new standard of clinical care. A chart review was conducted for all children enrolled in the study to collect sociodemographic characteristics including age at enrollment, sex, race/ethnicity, and insurance type. Body mass index (kg/m²) at the baseline visit was abstracted from the medical record due to the clinical population served.

The baseline survey was designed to explore factors associated with utilization of the clinic-based food pantry based upon prior studies.¹⁶ We measured self-rated caregiver health and willingness to disclose FI due to availability of the food pantry. Caregivers reported enrollment in federal nutrition programs and if they received food from a community-based food pantry. Caregivers reported stress related to worrying they would run out of food (range 1-10, 10 indicating more stress) and the severity of FI was measured using the USDA 10-item Household Food Security Survey (HFSS).²² Caregivers selected the primary reason(s) for either requesting or declining the food pantry from a list of possible options, with an open-ended option available to write in a reason not already listed. Variables and response categorizations are included in Supplemental Table 1.

One-Month Survey

The 1-month follow-up survey sought to examine possible benefits of food pantry utilization based upon prior literature.²³ Measures included increased family food supply, having sufficient food for the month, increased trust in the provider, intended repeat utilization of the food pantry, likelihood of returning to clinic due to availability of the food pantry and new food resources utilized. Ability to spend more financial resources on other essential needs and type of resource they were able to purchase were also measured. Comfort with discussing food needs with the child’s provider and meeting a health goal after receiving food was reported. Caregiver’s food-related stress over the last month was again measured. Variables and response categorizations are included in Supplemental Table 1.

Qualitative Interview Guide

A semi-structured interview guide (Supplemental Table 2) was developed to qualitatively explore comfort with clinical FI screening and food pantry utilization, reasons for utilizing the clinic-based food pantry and reported family benefits. All interviews were conducted by the first author via video-conferencing software or over the phone. All interviews were audio recorded for accuracy.

Data Analysis

We utilized descriptive statistics to describe characteristics of the overall study population including child sociodemographic characteristics and baseline survey responses. Categorical variables are presented as counts (percent), while continuous variables are presented as means (standard deviation, SD). Food stress was reported as a median (interquartile range, IQR) due to a skewed distribution.

We used bivariate analyses to describe the overlap between FI screening outcome and food pantry utilization and to examine factors associated with food pantry utilization. To test if either sociodemographic factors or baseline survey factors were associated with food pantry utilization, we compared categorical variables via Chi-square tests (X²), means of continuous variables via t-tests, and medians via Mann-Whitney U test. We utilized bivariate analyses to explore reported benefits of food pantry utilization stratified by FI screening outcome. All analyses were completed using STAT/SE 16.0 (StataCorp, College Station, TX) and statistical significance was defined as P < .05.

For qualitative analysis, rapid qualitative analysis was used due to timeliness of the findings in the context of increasing FI screening and interventions in the clinical setting due to the COVID-19 pandemic.²⁴ Rapid qualitative analysis allows for quick, efficient data analysis utilizing a systematic approach to data synthesis in a deductive fashion to summarize all responses.²⁵ Summary templates were created by summarizing main interviewee points when listening to interview recordings. To ensure consistency, approximately 20% of interviews were analyzed by two authors (LS and RC), compared for discrepancies, and discussed to reach consensus. All interview summaries were input into a summary matrix, which was reviewed and coded to identify themes. Among those utilizing the food pantry, themes were then analyzed by screening outcome (e.g., screened positive for FI and utilized food pantry and screened negative for FI and utilized food pantry). Final themes were conceptualized and iteratively revised by two authors (LS and RC) and agreed upon by the authorship team.

Results

Quantitative Results

Study Population

The final quantitative sample included 120 caregivers of children and adolescents who were 67.6% Non-Hispanic Black and 21.3% Non-Hispanic White, with two-thirds having Medicaid insurance (Table 1). According to the USDA HFSS, the majority of families were food secure (62.5%), while the remainder reported FI (15.8% marginal food security, 15.0% low food security, and 6.7% very low food security; Table 1). Among those who screened negative for FI by the Hunger Vital Sign screening tool (N = 85), 9.4% had marginal food security and 2.4% had low food security, while 88.2% reported food security using the HFSS. Among those screening positive (N = 35), 31.4% had marginal food security, 45.7% had low food security, and 22.9% had very low food security.

Table 1.

Child Demographic Characteristics, Food Insecurity Screening Outcome and Food Resource Use at Baseline, Stratified by Food Pantry Utilization.

N (%)	Total Study Population N = 120	Declined Food Pantry N = 61	Utilized Food Pantry N = 59	dF	Test Value^a	P
Age^b	11.8 (3.4)	12.4 (3.4)	11.2 (3.3)	118	1.924	.057
Household size^b	4.0 (1.4)	4.1 (1.4)	3.9 (1.5)	117	.585	.560
BMI^b	35.8 (9.9)	36.3 (8.9)	35.2 (10.8)	112	.581	.562
Female sex	68 (56.7)	35 (43.3)	33 (56.6)	1	.026	.873
Race/ethnicity
Non-Hispanic white	23 (21.3)	14 (24.6)	9 (16.4)	3	5.468	.141
Non-Hispanic black	73 (67.6)	34 (59.7)	39 (70.9)
Hispanic	11 (9.8)	8 (14.0)	3 (5.5)
Other	5 (4.5)	1 (1.8)	4 (7.3)
Missing	8	4	4
Insurance type
Medicaid	80 (66.7)	31 (50.8)	49 (83.1)	1	14.021	<.001
Private	40 (33.3)	30 (49.2)	10 (17.0)	1	14.021	<.001
10-item HFSS^c
Food secure	75 (62.5)	50 (82.0)	25 (42.4)	3	24.170	<.001
Marginal food security	19 (15.8)	8 (13.1)	11 (18.6)
Low food security	18 (15.0)	2 (3.3)	16 (27.1)
Very low food security	8 (6.7)	1 (1.6)	7 (11.8)
Food resources utilized
SNAP/WIC/SSI/TANF	39 (32.5)	15 (24.6)	24 (40.7)	2	4.845	.089
NSLP/P-EBT	69 (57.5)	27 (44.3)	42 (71.2)	2	12.599	.002
Food pantry	10 (8.3)	2 (3.3)	8 (14.6)	1	4.150	.042
Food-related stress^d	1 (2)	1 (0)	2 (4)	—	−3.906	<.001
Self-reported caregiver health
Excellent	2 (1.8)	2 (3.5)	0 (0)	5	12.033	.034
Very good	12 (10.9)	8 (13.8)	4 (7.7)
Good	54 (49.1)	33 (56.9)	21 (40.4)
Fair	37 (33.6)	15 (25.9)	22 (42.3)
Poor	4 (3.6)	0 (0)	4 (7.7)
Don’t know	1 (.9)	0 (0)	1 (1.9)
Missing	10	3	7
Willingness to disclose FI due to food pantry
Yes	25 (21.9)	13 (22.0)	12 (21.8)	2	.211	.900
No	80 (70.2)	42 (71.2)	38 (69.1)
Don’t know	9 (7.9)	4 (6.8)	5 (9.1)

dF, degrees of freedom; HFSS, Household Food Security Survey; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants and Children; SSI, Supplemental Security Income; TANF, Temporary Assistance for Needy Families; NSLP, National School Lunch Program; P-EBT, Pandemic Electronic Benefit Transfer; FI, food insecurity.

^aEither X² statistic, t statistic or Mann-Whitney U z statistic is presented as appropriate.

^bPresented as mean (standard deviation).

^cHFSS is a 10-question survey developed by the USDA to measure severity of food insecurity among households with children.

^dPresented as median (IQR).

FI Screening Outcome and Food Pantry Utilization

Approximately half (N = 61; 50.8%) of all families declined the food pantry and 90.2% of these families screened negative for FI (Figure 1). Among the families utilizing the food pantry, approximately half screened negative for FI (N = 30; 50.8%; Figure 1).

Figure 1.

The overlap between food insecurity screening outcome and food pantry utilization.

Associations of Baseline Characteristics With Food Pantry Utilization

Families utilizing the food pantry were more likely to have a child with Medicaid insurance (83.1%) than those who declined the food pantry (50.8%; X²₁ = 14.0, P < .001; Table 1). Caregivers utilizing the food pantry reported a higher level of food related stress (median 2, IQR 4) compared to caregivers who declined the food pantry (median 1, IQR 0; z statistic = −3.9, P < .001). Additionally, 27.1% of families utilizing the food pantry had low food security and 11.8% had very low food security; while 3.3% and 1.6% of families declining the food pantry had low or very low food security, respectively (X²₃ = 24.2, P < .001; Table 1). Caregivers who utilized the food pantry were more likely to report they had fair or poor health (42.3% and 7.7%, respectively), compared to caregivers who declined the food pantry (25.9% and 0%, respectively (X²₅ = 12.0, P = .034; Table 1).

Motivation for Food Pantry Use or Decline

The most common reasons for pantry utilization included the family running out of food (20.3%), having many expenses (32.2%) and convenient access to food (23.7%), while fewer reported wanting to try healthy foods (15.3%), or because the food was free (5.1%; Figure 2). The most common reason for declining was not having food needs (84.2%), while less common reasons included wanting others with more need to have the food (3.5%) and their needs had resolved (5.3%).

Figure 2.

Caregivers’ reason for declining and utilizing the clinic-based food pantry in the healthy lifestyles program. ^N may not sum to total N as caregivers could select multiple reasons for utilizing the food pantry. *4 missing responses for reason caregiver declined the food pantry. Take From Others: Caregiver did not want to take available food resources from others who may be in need. Need Resolved: Caregiver felt that their needs were met at that time.

Benefits of Food Pantry Utilization

The benefits experienced by families utilizing the food pantry (N = 47) are summarized in Table 2. While many families already had enough food for the month prior to receiving food (42.6%), 36.2% of families reported having enough food to get through the month due to the food received in clinic (Table 2). Over half of caregivers (57.5%) reported they had more trust in the clinic and child’s provider after receiving food from the clinic. Caregivers also reported feeling more comfortable discussing their family’s food needs due to the availability of the food pantry, with 25.5% reporting they were significantly more comfortable and 40.4% reporting they felt somewhat more comfortable (Table 2). Over half of families were able to meet a health goal set in the clinical setting (63.8%), intended to use the food pantry at their next visit (63.8%) and reported being more likely to return to clinic for their next visit (63.8%) because of the availability of the food pantry.

Table 2.

Self-Reported Child and Caregiver Benefits One Month After Food Pantry Utilization, Stratified by Food Insecurity Screening Outcome.

N (%)	Experienced Outcome N = 47	Screened Negative for FI N = 23	Screened Positive for FI N = 24
Increase in food supply	34 (75.6)	18 (81.8)	16 (69.6)
Enough food for the month
Yes	17 (36.2)	6 (26.1)	11 (45.8)
No	8 (17.0)	3 (13.0)	5 (20.8)
Already had enough food for month	20 (42.6)	14 (60.9)	6 (25.0)
Change in resource allocation^a
Utilities	4 (8.5)	1 (4.3)	3 (12.5)
Housing	3 (6.4)	2 (8.7)	1 (4.2)
Transportation	7 (14.9)	3 (6.4)	4 (16.7)
Clothing	3 (6.4)	1 (4.3)	2 (8.3)
Other	3 (6.4)	1 (4.3)	2 (8.3)
None	24 (51.1)	11 (47.8)	13 (54.2)
Don’t know	4 (8.5)	3 (6.4)	1 (4.2)
Food-related stress^b	1 (3)	1 (1)	2 (3.5)
Increased trust in provider	27 (57.5)	16 (69.6)	11 (45.8)
Comfort discussing food needs
Significantly more comfortable	12 (25.5)	8 (34.8)	4 (25.5)
Somewhat more comfortable	19 (40.4)	6 (26.1)	13 (40.4)
Not more or less comfortable	15 (31.9)	8 (34.8)	7 (31.9)
Somewhat less comfortable	0 (0)	0 (0)	0 (0)
Significantly less comfortable	1 (2.1)	1 (4.4)	0 (0)
Discussed food referral	13 (27.7)	3 (13.0)	10 (41.7)
New community resources^a
SNAP/WIC	3 (6.4)	1 (4.3)	2 (8.3)
School lunch	12 (25.5)	7 (25.9)	5 (10.6)
Food pantry	2 (4.3)	0 (0)	2 (4.3)
Other	6 (12.8)	2 (4.3)	4 (14.8)
None	27 (57.4)	14 (60.9)	13 (27.7)
Met health goal	30 (63.8)	15 (65.2)	15 (62.5)
Intended repeat pantry utilization	30 (63.8)	16 (69.6)	14 (58.3)
Increased likelihood of attending subsequent visit	30 (63.8)	16 (69.6)	14 (58.3)

FI, food insecurity; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants and Children.

^aDoes not sum to 100%, as caregivers could select more than one.

^bCaregiver reported daily stress from 1-10, with 1 being no stress and 10 being significant stress; results reported as median (IQR).

Qualitative Results

Fourteen caregivers completed interviews, including six who screened positive for FI, 12 who utilized the food pantry, and two caregivers who screened positive for FI, but did not utilize the food pantry. According to the HFSS, 14.3% experienced marginal food security, 21.4% experienced low food security and 21.4% experienced very low food security. These caregivers had children who were predominately Non-Hispanic Black (76.9%) and had Medicaid insurance (85.7%).

Comfort With FI Screening and Concurrent Offering of Food Pantry Utilization

Many families reported they did not expect to be screened for FI at their visit and some reported experiencing shame reporting FI to their provider (Table 3). However, all families ultimately reported feeling comfortable responding to FI screening questions and being offered and receiving a bag of food in the clinical setting. One caregiver said,

“I guess it was concerning because I felt like if I said no, I didn’t have enough food, that I was going to be judged in a way. When I realized that I could get a little bit of food from there. That made me feel a little more comfortable.”

Table 3.

Qualitative Themes With Exemplar Quotes From Families Utilizing the Clinic-Based Food Pantry Overall and Stratified by Food Insecurity Screening Outcome.

Overall Themes (N = 14)
Caregivers were not expecting food insecurity screening (N = 10)
“I was just caught off guard that one time because it hadn’t been happening.”
“I was surprised…I just didn’t know that would be one of the questions that was going to be asked.”
Some caregivers reported shame (N = 5), but were comfortable accepting food (N = 13)
“I guess it was concerning because I felt like if I said no, I didn’t have enough food, that I was going to be judged in a way. When I realized that I could get a little bit of food from there. That made me feel a little more comfortable.”
“It was smooth, and everything just, it was not a wait. It was, she gave it to us nicely and we received it like a blessing.”
Children consumed healthier foods (N = 4 for negative FI screen, N = 3 for positive FI screen)
Children met health goals (N = 3 for negative FI screen, N = 4 for positive FI screen)
“They were healthier choices; I did like that… it introduces the kids to other things that they could eat that is better for them.”
“It [food] helped [achieve goals], yes it did… everything that y’all had in the bag was right on that nutritional food pyramid thing and that helped me to build around that.”

Themes Among Families Screening Positive for FI (N = 6)
Caregivers felt better reporting food needs in clinic
“Made me more willing because I knew it would be a solution, like a partial solution to the problem. It would be helpful.”
“It made it easier for me to make the choice that I wanted to get the food or not. Like I knew there would be an option.”
Families were out or almost out of food
“Because we needed it.”
“That day, we were really low [on food] … honestly, right before I had came to the doctor, I was wondering, do I put this five dollars for gas, or do I get some peanut butter and jelly for dinner tonight.”

Themes Among Families Screening Negative for FI (N = 6)
Caregivers were concerned they could run out of food or were seeking healthy options
“I think it just gave me the opportunity to try something I normally wouldn’t buy.”
“At the time I wasn’t working as much and I just didn’t know if like, especially with the holiday coming up and the way my hours were, it was hard enough to get food at that time.”
Families experienced no effect on overall food supply
“I guess it just keeps us stocked, because I still have it, and honestly we ate some of it. We have already eaten most of it, but I do still have some of it left.”
“I mean, I guess technically it [food] increased it, but I did not need it if that is the point”

Motivation for Food Pantry Utilization

Families who screened positive for FI primarily requested food, as one caregiver described, “because we needed it,” or because they knew they would run out during the month. Families screening negative for FI requested food because they were worried they could run out of food in the future, or because they were interested in trying new, healthy food options (Table 3).

Benefits from Food Pantry Utilization

About half of families reported an impact on their child’s health, with their child eating healthier foods due to the availability of the food pantry (N = 4 for negative FI screen, N = 3 for positive FI screen; Table 3). A caregiver described this impact as,

“It gave her a better nutritional choice to have versus me running out to get fast food… [our family ate] more healthier foods.”

Additionally, approximately half of caregivers were able to better meet lifestyle goals discussed in clinic because they received food from the pantry (N = 3 for negative FI screen, N = 4 for positive FI screen; Table 3).

Discussion

This study of the implementation of a clinic-based food pantry in a pediatric weight management program identified both that families were comfortable utilizing the food pantry and that many families who desired food assistance screened negative for FI. Using a mixed-methods approach, we found the most common reasons for food pantry utilization across FI screening statuses were running out of food, having many other expenses, and conveniently accessing needed food. In particular, families screening negative for FI, yet utilizing the food pantry, described worrying they could run out of food or wanting to seek out healthier food options. Caregiver-reported benefits included improved child health, increased comfort discussing food needs in clinic, and higher reported likelihood of attending their next visit. These findings suggest that screening families for FI alone as a means to identify recipients of FI interventions may not distribute resources to all families who perceive benefit from food assistance in clinical settings.

We found that about half of families utilizing the clinic-based food pantry screened negative for FI, which is similar to other studies examining the incongruence between FI screening outcomes and caregiver interest in food resources.^16,17,26 Caregivers may be uncomfortable answering standardized questions about their food needs, but may be more comfortable expressing interest in food resources when they know they are available in clinic, in line with our qualitative findings. Additionally, this incongruence may be partially driven by families experiencing FI and accepting food resources for the first time, as the study occurred shortly after the beginning of the COVID-19 pandemic. While standard FI screening questions are highly sensitive for FI identification, our findings show that these objective questions do not capture all families who feel that they benefit from clinic-based food distributions.^21,27 Our findings additionally suggest that food pantry utilization has health and well-being benefits beyond meeting an acute food need, which would not be captured by FI screening outcome, but may have importance to patients and clinicians. Future research should evaluate the inclusion of subjective measures, such as perceived benefit or subjective food need, in clinical FI screening processes, alongside the objective Hunger Vital Sign tool. Given the potential benefits of food pantry utilization found in this study, additional studies are needed to examine the feasibility and benefit of offering resources to all families without requiring standardized FI screening questions. Considering the realities of limited food resources in clinical settings, it will be important to simultaneously triage resources to families with the most urgent and greatest needs should standardized FI screening be altered.

A greater understanding of caregivers’ motivations for accepting or declining resources offered in clinical settings will be needed to effectively intervene upon and direct limited resources to families with interest in receiving them.¹⁷ In this study, we identified experiencing low or very low food security, greater self-reported food-related stress, and worse caregiver self-rated health as factors associated with food pantry utilization. Prior evidence of broad social needs screening (e.g., transportation, housing, food) and assistance demonstrated interested caregivers were more likely to report worse health and screen positive for a greater number of social risks.¹⁶ Therefore, greater social needs and worse self-perceived health may together be factors that promote resource acceptance in clinical settings. These results may also indicate caregivers protect their children from the direct experience of food insufficiency by decreasing their own food intake or, as suggested by other literature, by deferring purchase of medications for their own health, precipitating poorer health.^28,29 These findings highlight a need to intervene upon food needs identified in pediatric clinical settings with robust community strategies beyond clinical referrals that acknowledge the complex social situations families are experiencing. Future research should continue to explore the relationship between self-rated caregiver health, food security and resource acceptance to develop intervention strategies that more fully support families. In contrast, caregivers reported declining the food pantry largely because they had no food need. As many studies have demonstrated that caregivers are agreeable to FI screening when interventions are offered,^30–32 our results suggest caregiver decline is not commonly motivated by shame, stigma, or discomfort due to expressing need in the clinical setting. However, more studies exploring the factors leading patients to decline clinic-based resources, particularly when screening positive for FI, are needed to inform clinical intervention strategies that are patient-centered and acceptable to caregivers.

Despite the acceleration of clinics adopting clinic-based food interventions following the COVID-19 pandemic, there is very little evidence on the effectiveness of such interventions.³³ Similar to other studies showing onsite farmers market vouchers may lead to improved hemoglobin-A1C and body mass index in adults,¹⁴ we found that many families utilizing the food pantry reported being able to better meet lifestyle goals set in clinic due to the availability of healthier foods. This finding was true for families screening both positive and negative for FI and is particularly important as community food pantries often distribute calorie-dense foods limiting families’ ability to improve dietary quality when experiencing FI.^34,35 Further research is needed to measure this effect quantitatively and over time, in order to better understand this association with improved health. Future studies should also utilize tools that measure nutrition insecurity in addition to FI. Additionally, families reported feeling more comfortable discussing food needs with clinicians due to food pantry availability, suggesting notifying patients of existing interventions at the time of screening may reduce known stigma associated with reporting FI.³⁶ As clinics explore ways to enhance patient care in fast-paced settings, they can consider making caregivers aware of available food interventions concurrently with screening to increase patient comfort with reporting and discussing needs.

While this study utilized a mixed-methods design to explore a clinic-based FI intervention, there are some limitations. We conducted this study in a pediatric weight management program where families are presenting for obesity treatment and may be more aware of their food choices. These families may be seeking out healthier food options, contributing to increased food pantry acceptance, irrespective of FI screening. This limits the generalizability to other pediatric care settings; however, as 14 million children have unhealthy weight, this population is commonly served in all pediatric healthcare settings.³⁷ Additionally, as our qualitative sample was limited to 14 individuals, future studies should include larger and more diverse samples to explore perceptions of FI screening, motivations for use of clinic-based food resources, and reported benefits, as well as any additional themes that may emerge beyond our included population. We also included only English-speaking participants for this small pilot investigation. Therefore, we cannot extend these findings to Spanish-speaking families who may experience unique challenges. Finally, this study enrolled a convenience sample of participants in both the quantitative and qualitative study who may have been particularly interested in sharing their experiences with nutrition and FI.

Conclusion

Clinical FI screening and interventions have accelerated in pediatric care settings due to the COVID-19 pandemic and increased awareness of the detrimental health impact of childhood FI. We found that many more families requested food from a clinic-based food pantry than would have been identified by the most commonly used FI screening tool. Additionally, our results underscore the benefits of clinic-based food pantry implementation, including increased patient comfort discussing FI and ability to meet lifestyle goals in households experiencing FI. Further research is needed to optimize current FI screening processes and distribution of available clinic-based and community resources to interested families who may benefit.

So What?

What is Already Known on This Topic?

Discordance between food insecurity screening outcomes and caregiver interest in receiving food resources has been reported. It is unclear what leads caregivers to express interest in clinic-based food resources and the potential benefits of direct food distributions.

What Does This Article Add?

Nearly half of families utilizing a clinic-based food pantry screened negative for food insecurity. Caregivers utilizing the food pantry reported severe food insecurity, poor self-rated health, felt comfortable discussing food needs and their children consumed more healthy foods. This suggests offering a clinic-based food pantry may identify more families in need of food resources and caregivers and children benefit from food received in clinical settings.

What are the Implications for Health Promotion Practice or Research?

Clinical practices looking to intervene upon food insecurity should consider strategies that offer food resources universally to all patients irrespective of food insecurity screening status. Future studies should evaluate the effectiveness of universal food intervention offering strategies on child and caregiver health in a variety of clinical settings.

Supplemental Material

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

Supplemental Material for Families Benefit After Utilization of a Clinic-Based Food Pantry Irrespective of Food Insecurity Experiences in a Pediatric Obesity Treatment Program by Lilianna Suarez, Sarah Armstrong, Rachel Fleming, Janna Howard, and Rushina Cholera in American Journal of Health Promotion.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by a grant from BlueCross BlueShield of North Carolina Foundation to support the clinic-based food pantry. Dr Cholera was supported by K12HD105253 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

ORCID iD

Lilianna Suarez

Supplemental Material

Supplemental material for this article is available online.

References

United States Department of Agriculture . Measurement. Economic Research Service. Washington, DC: United States Department of Agriculture. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/measurement.aspx. Accessed 9 July 2023.

Bauer

. Hungry at Thanksgiving: A Fall 2020 Update on Food Insecurity in the U.S. Washington D.C.: Brookings Institution. https://www.hamiltonproject.org/blog/hungry_at_thanksgiving_a_fall_2020_update_on_food_insecurity_in_the_u.s (2020).

Coleman-Jensen

Rabbitt

Gregory

Singh

. Household Food Security in the United States in 2021. September 2022. Washington, DC: US Department of Agriculture, Economic Research Service.

U.S. Department of Agriculture . Food and Security Nutrition. Washington, DC: U.S. Department of Agriculture. https://www.usda.gov/sites/default/files/documents/usda-actions-nutrition-security-infographic.pdf.

Mozaffarian

. Measuring and Addressing Nutrition Security to Achieve Health and Health Equity. Washington, DC: Health Affairs Health Policy Brief; 2023.

Mozaffarian

Fleischhacker

Andrés

. Prioritizing nutrition security in the US. JAMA. 2021;325(16):1605-1606. doi:10.1001/jama.2021.1915

Thomas

MMC

Miller

Morrissey

. Food insecurity and child health. Pediatrics. 2019;144(4):e20190397. doi:10.1542/peds.2019-0397

Peltz

Garg

. Food insecurity and health care use. Pediatrics. 2019;144(4):e20190347. doi:10.1542/peds.2019-0347

South

Palakshappa

Brown

. Relationship between food insecurity and high blood pressure in a national sample of children and adolescents. Pediatr Nephrol. 2019;34(9):1583-1590. doi:10.1007/s00467-019-04253-3

10.

Council on Community Pediatrics and Committee on Nutrition . Promoting food security for all children. Pediatrics. 2015;136(5):e1431-e1438. doi:10.1542/peds.2015-3301

11.

Barnidge

LaBarge

Krupsky

Arthur

. Screening for food insecurity in pediatric clinical settings: opportunities and barriers. J Community Health. 2017;42(1):51-57. doi:10.1007/s10900-016-0229-z

12.

Palakshappa

Vasan

Khan

Seifu

Feudtner

Fiks

. Clinicians’ perceptions of screening for food insecurity in suburban pediatric practice. Pediatrics. 2017;140(1):e20170319. doi:10.1542/peds.2017-0319

13.

Oronce

CIA

Miake-Lye

Begashaw

Booth

Shrank

Shekelle

. Interventions to address food insecurity among adults in Canada and the us: a systematic review and meta-analysis. JAMA Health Forum. 2021;2(8):e212001. doi:10.1001/jamahealthforum.2021.2001

14.

De Marchis

Torres

Benesch

, et al. Interventions addressing food insecurity in health care settings: a systematic review. Ann Fam Med. 2019;17(5):436-447. doi:10.1370/afm.2412

15.

De Marchis

Alderwick

Gottlieb

. Do patients want help addressing social risks? J Am Board Fam Med. 2020;33(2):170-175. doi:10.3122/jabfm.2020.02.190309

16.

De Marchis

Hessler

Fichtenberg

, et al. Assessment of social risk factors and interest in receiving health care-based social assistance among adult patients and adult caregivers of pediatric patients. JAMA Netw Open. 2020;3(10):e2021201. doi:10.1001/jamanetworkopen.2020.21201

17.

Bottino

Rhodes

Kreatsoulas

Cox

Fleegler

. Food insecurity screening in pediatric primary care: can offering referrals help identify families in need? Article. Acad Pediatr. 2017;17(5):497-503. doi:10.1016/j.acap.2016.10.006

18.

Kreuter

Thompson

McQueen

Garg

. Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. Annu Rev Publ Health. 2021;42:329-344. doi:10.1146/annurev-publhealth-090419-102204

19.

DeMartini

Beck

Kahn

Klein

. Food insecure families: description of access and barriers to food from one pediatric primary care center. J Community Health. 2013;38(6):1182-1187. doi:10.1007/s10900-013-9731-8

20.

Tuzzio

Wellman

De Marchis

, et al. Social risk factors and desire for assistance among patients receiving subsidized health care insurance in a US-based integrated delivery System. Ann Fam Med. 2022;20(2):137-144. doi:10.1370/afm.2774

21.

Hager

Quigg

Black

, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146

22.

United States Department of Agriculture. Survey Tools . Economic Research Service. Washington, DC: United States Department of Agriculture. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/survey-tools/#adult. 2023; Accessed 26 April 2020.

23.

Hickey

Phan

Beck

Burkhardt

Klein

. A mixed-methods evaluation of a novel food pantry in a pediatric primary care center. Clin Pediatr. 2020;59(3):278-284. doi:10.1177/0009922819900960

24.

Vindrola-Padros

Johnson

. Rapid techniques in qualitative research: a critical review of the literature. Qual Health Res. 2020;30(10):1596-1604. doi:10.1177/1049732320921835

25.

Hamilton

. Qualitative Methods in Rapid Turn-Around Health Services Research. PowerPoint Slides. Health Services Research & Development Cyberseminar. Washington D.C.: U.S. Department of Veterans Affairs. https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=780 (2013).

26.

Ray

Gitz

Davis

Miller

. Nonresponse to health-related social needs screening questions. Pediatrics. 2020;146(3):e20200174. doi:10.1542/peds.2020-0174

27.

Gattu

Paik

Wang

Ray

Lichenstein

Black

. The hunger vital sign identifies household food insecurity among children in emergency departments and primary care. Children. 2019;6(10):107. doi:10.3390/children6100107

28.

Fram

Frongillo

Jones

, et al. Children are aware of food insecurity and take responsibility for managing food resources. J Nutr. 2011;141(6):1114-1119. doi:10.3945/jn.110.135988

29.

Herman

Afulani

Coleman-Jensen

Harrison

. Food insecurity and cost-related medication underuse among nonelderly adults in a nationally representative sample. Am J Public Health. 2015;105(10):e48-e59. doi:10.2105/ajph.2015.302712

30.

Cullen

Attridge

Fein

. Food for thought: a qualitative evaluation of caregiver preferences for food insecurity screening and resource referral. Acad Pediatr. 2020;20(8):1157-1162. doi:10.1016/j.acap.2020.04.006

31.

Palakshappa

Doupnik

Vasan

, et al. Suburban families' experience with food insecurity screening in primary care practices. Pediatrics. 2017;140(1):e20170320. doi:10.1542/peds.2017-0320

32.

Orr

Chauvenet

Ozgun

Pamanes-Duran

Flower

. Caregivers’ experiences with food insecurity screening and impact of food insecurity resources. Clin Pediatr. 2019;58(14):1484-1492. doi:10.1177/0009922819850483

33.

Cavaliere

Martin

Smith

Hake

. Key Drivers to Improve Food Security and Health Outcomes: An Evidence Review of Food Bank - Health Care Partnerships and Related Interventions. Chicago IL: Feeding America and Institute for Hunger Research & Solutions at Foodshare. https://hungerandhealth.feedingamerica.org/resource/foodbank-health-care-partnerships-evidence-review/ (2021).

34.

Morales

Berkowitz

. The relationship between food insecurity, dietary patterns, and obesity. Curr Nutr Rep. 2016;5(1):54-60. doi:10.1007/s13668-016-0153-y

35.

Oliver

McKeever

Shenkman

Diewald

. Barriers to healthy eating in a community that relies on an emergency food pantry. J Nutr Educ Behav. 2020;52(3):299-306. doi:10.1016/j.jneb.2019.10.005

36.

Barnidge

Krupsky

LaBarge

Arthur

. Food insecurity screening in pediatric clinical settings: a caregivers’ perspective. Matern Child Health J. 2020;24(1):101-109. doi:10.1007/s10995-019-02785-6

37.

Stierman

Afful

Carroll

, et al. National Health and Nutrition Examination Survey 2017–March 2020 Prepandemic Data Files Development of Files and Prevalence Estimates for Selected Health Outcomes. Hyattsville, MD: National Center for Health Statistics; 2021. NHSR No 158. https://stacks.cdc.gov/view/cdc/106273.

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