Little is known about screening in clinical settings for food insecurity (FI) among households of children with diabetes. This study evaluated the acceptability and feasibility of an FI screening initiative in a pediatric diabetes clinic that was implemented to help diabetes dietitian educators tailor management plans for families of children with type 1 or type 2 diabetes facing FI.
The initiative comprised three validated screening questions, a care algorithm, a community resource handout, and a poster. In total, 50 families of children and adolescents aged 0–18 years with type 1 or type 2 diabetes were screened for FI. In-person semi-structured interviews combining open-ended and Likert-scale questions were conducted with 37 of the screened families and the three diabetes dietitian educators who conducted the screening. Perceived barriers and facilitators of the screening initiative were identified using content analysis, and Likert-scale questionnaires rated interviewees’ comfort level with the screening questions. A reflective journal kept by an onsite research interviewer also facilitated the data interpretation process.
Most families felt comfortable answering the screening questions. Families with FI appreciated the opportunity to express their concerns and learn about affordable food resources. However, ∼20% of these families described stigma and fear of judgment by clinicians if they screened positive for FI. Diabetes educators also felt comfortable with the screening questions but reported lack of time to screen all families and to follow-up with resources after a positive screen. A self-reported intake form was recommended to ensure that everyone is systematically screened.
A standardized and respectful method of assessing FI could help clinicians better tailor treatment plans and support for families of children with diabetes who face FI. Based on these findings, similar FI screening initiatives should be implemented in other clinical settings as part of routine clinical practice.
Food insecurity (FI) is consistently more prevalent among households of people living with diabetes than families or adults without chronic disease (1–4), and it is particularly high among households of children with diabetes (5). With healthy eating at the cornerstone of all diabetes care strategies for both adults and children, FI can have a significant negative impact on diabetes management. Current evidence indicates that people with diabetes and FI are at increased risk for poor glycemic control (A1C >7%), hypoglycemia (6), hyperglycemia (7), and chronic diseases related to diabetes complications (8). In children, poor glycemic control can have severe consequences such as hypoglycemia and ketoacidosis, leading to hospital admissions (5), as well as various chronic complications later in life (9).
The importance of routine screening for FI in the diabetes population is increasingly being recognized (10,11). FI screening has been suggested to help clinicians tailor diabetes management plans for households with FI (11–13). Clinicians who are aware of a family’s FI status can develop more realistic dietary recommendations (4,14); adjust medication regimens (15); identify patients at increased risk of poor FI-related health outcomes such as asthma, depression, and obesity (16); and provide specific information on affordable sources of healthy foods (17). The Council on Community Pediatrics recommends universal screening for FI among children (18). The American Diabetes Association recommends that clinicians assess FI status, apply that information to treatment decisions, and refer patients to community resources (19). Guidelines of both the Canadian Diabetes Association and the International Society for Pediatric and Adolescent Diabetes recognize that the ability to adopt healthy lifestyles is influenced by socioeconomic factors (20,21). However, despite the implications for children’s health, FI screening is not yet part of routine clinical practice (22), and how to screen and the efficacy of screening strategies are still understudied (23).
To date, only a few pilot studies have evaluated FI screening initiatives in routine diabetes care. In California, an FI screening initiative was implemented among 561 low-income adults with diabetes. After 3 months, the authors observed a significant (18%) reduction in the number of participants with an A1C >7%. Conversations between clinicians and patients about optimizing diabetes management on a budget and the provision of nutrition information handouts to patients were key to the success of the intervention (24). Another FI screening assessment of 33 adults with diabetes in Toronto, Canada, revealed that FI screening may be more time-consuming for clinicians and patients, but the information provided by patients after screening is extremely helpful for clinicians. Most patients (71%) felt comfortable answering the screening questions and appreciated receiving handouts about affordable community resources (25).
Although these findings are promising, few studies have focused on screening children with diabetes in pediatric settings for FI. Therefore, this study evaluated the implementation of an FI screening initiative in a diabetes pediatric clinic. The specific aims were 1) to assess the acceptability and feasibility of the screening initiative from the perspective of both families and diabetes dietitian educators and 2) to identify perceived facilitators and barriers to the implementation of the screening initiative.
Methods
Screening Initiative
The initiative was implemented in a diabetes outpatient clinic at a pediatric hospital in Ontario, Canada, that had no routine procedure to directly assess FI. The screening initiative had four components: 1) a screening tool consisting of three validated FI questions (Table 1), 2) a care algorithm, 3) a community resource handout listing local resources for affordable food items, and 4) a poster (see enzagucciardi.blog.ryerson.ca/food-insecurity-screening-and-diabetes).
1. Within the past 6 months, did you ever worry whether your food would run out before you got money to buy more? |
2. Within the past 6 months, was there ever a time when the food you bought just didn’t last and you didn’t have money to get more? |
3. Within the past 6 months, did you or others in your household cut the size of your meals or skip meals because there wasn’t enough money for food? |
1. Within the past 6 months, did you ever worry whether your food would run out before you got money to buy more? |
2. Within the past 6 months, was there ever a time when the food you bought just didn’t last and you didn’t have money to get more? |
3. Within the past 6 months, did you or others in your household cut the size of your meals or skip meals because there wasn’t enough money for food? |
Source: U.S. Household Food Security Survey Module (26).
Screening questions were based on the U.S. Department of Agriculture’s Household Food Security Survey Module (26). Variations of these questions have been validated in several studies (27–32). Before using them in this study, the questions were pilot-tested and modified to adjust the period of inquiry from 12 months to 6 months because the shorter time period was easier for participants to reflect on (25). The algorithm was developed based on a systematic review identifying emerging practices to better support self-management among individuals with diabetes and FI (25). The community resource handout was designed to help educators and families find support services in their local area. Posters were displayed in the clinic’s waiting area to increase awareness, reduce stigma, and encourage families to disclose their FI status.
Three diabetes dietitian educators working in the clinic incorporated the screening initiative into their practice during both initial and follow-up appointments. Before implementation, they participated in a training session to review the screening questions, adapt the care algorithm to their clinical setting, and discuss the community resource handout. Educators were instructed to 1) ask the screening questions to all families who came through the clinic during the study, and 2) if families were found to have FI, provide diabetes management recommendations, discuss the challenges of their FI status, and go over the resource handout with them. The initiative was implemented among newly diagnosed and returning families attending the clinic. On average, it took ∼3 minutes to ask the screening questions. Families who answered “yes” to at least one of three questions were categorized as having FI.
Participants
At the end of each scheduled visit, the educators informed families about the screening initiative and sought their consent for screening and participation in a follow-up interview. Eligibility criteria for families included 1) completion of screening for FI by a diabetes educator, 2) a child or adolescent aged 0–18 years with a diagnosis of type 1 or type 2 diabetes regardless of FI status, and 3) speaking English or having an interpreter present (or access to Language Line, a remote translation service) for non–English-speaking parents or guardians. Educators helped recruit families by posting flyers at the diabetes clinic and asking patients during clinic visits. After the screening initiative ended, the three educators who had implemented the screening were interviewed.
Data Collection
Data were collected between September 2017 and January 2018 through semi-structured interviews with 37 families. Interviews included open-ended and Likert-scale questions, for a total of 10 items (Table 2). Likert scales were used to rate families’ comfort level when answering the screening questions, while open-ended questions asked families to explain why they chose the rating, comment on the specific intervention components, and elaborate on their screening experiences. Interviews were conducted in person by an onsite research interview in a private space at the diabetes clinic. Because of scheduling conflicts, three families were interviewed via telephone. Before the interview, each family completed a demographics questionnaire. Interviews lasted ∼20–30 minutes.
Screening questions |
1. How comfortable were you answering the screening questions? |
1 – Not comfortable at all |
2 – Somewhat uncomfortable |
3 – Somewhat comfortable |
4 – Comfortable |
5 – Very comfortable |
2. What was it about answering these questions that made you comfortable/uncomfortable? |
3. Can you please describe how it made you feel when the care provider asked you these questions? |
4. After your care provider asked you these questions, were your needs or concerns satisfactorily addressed during the appointment? |
5. Which of your care providers would you feel most comfortable asking you these questions? Do you have a preference? Can you explain why? |
Community resources handout |
6. Did your care provider offer you any information or handouts? What was this information or handout? |
7. How useful was this information to you? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
8. For those who screened food secure: Please describe what resources, if any, that you use or have used in the past, to keep your food costs down? |
For those who screened food insecure: Please describe what resources, if any, do you use or have used in the past, to help cope with not having enough food or being worried about not having enough food for you and your family? What strategies do you use to extend your budget? |
Poster |
Show poster. |
9. How would this poster make you feel if you saw it up on the wall at the SickKids diabetes clinic? |
a. What do you think of the pictures? The messages? |
b. Would you let your care provider know if you were having difficulty buying enough healthy foods (refer to phrase on poster)? |
Conclusion |
10. Is there anything else you would like to add? Do you have any questions for me regarding your experience being asked these questions? |
Screening questions |
1. How comfortable were you answering the screening questions? |
1 – Not comfortable at all |
2 – Somewhat uncomfortable |
3 – Somewhat comfortable |
4 – Comfortable |
5 – Very comfortable |
2. What was it about answering these questions that made you comfortable/uncomfortable? |
3. Can you please describe how it made you feel when the care provider asked you these questions? |
4. After your care provider asked you these questions, were your needs or concerns satisfactorily addressed during the appointment? |
5. Which of your care providers would you feel most comfortable asking you these questions? Do you have a preference? Can you explain why? |
Community resources handout |
6. Did your care provider offer you any information or handouts? What was this information or handout? |
7. How useful was this information to you? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
8. For those who screened food secure: Please describe what resources, if any, that you use or have used in the past, to keep your food costs down? |
For those who screened food insecure: Please describe what resources, if any, do you use or have used in the past, to help cope with not having enough food or being worried about not having enough food for you and your family? What strategies do you use to extend your budget? |
Poster |
Show poster. |
9. How would this poster make you feel if you saw it up on the wall at the SickKids diabetes clinic? |
a. What do you think of the pictures? The messages? |
b. Would you let your care provider know if you were having difficulty buying enough healthy foods (refer to phrase on poster)? |
Conclusion |
10. Is there anything else you would like to add? Do you have any questions for me regarding your experience being asked these questions? |
The same research coordinator conducted in-person semi-structured interviews with the three participating diabetes dietitian educators. These interviews were conducted individually and included 12 items (Table 3). Likert-type scales probed how comfortable the educators were in asking the screening questions, whereas open-ended questions asked educators to comment on barriers and facilitators to screening, explain whether the screening components were appropriate in terms of improving the care and support they provided to families, and describe their responses to a positive screen. On average, interviews lasted 15–30 minutes. Families received a $25 gift card for their time, and each educator received $40 as compensation. The research ethics boards at the hospital clinic and the partnering university approved the study protocol. All participants provided informed consent before participating.
Screening questions |
1. During the initiative, how often did you screen families for food insecurity using the screening questions? |
1 – Never |
2 – Almost never |
3 – Occasionally |
4 – Almost always |
5 – Always |
If answer to Q1 is 1 – Never to 4 – Almost always, then ask Q2, followed by Q3. If answer to Q1 is 5 – Always, go directly to Q3. |
2. Can you describe why you did not use the screening questions with all families? |
Probes: What informed your decision of whether to screen families? Or what prevented you from assessing food insecurity? |
3. How comfortable were you screening families for food insecurity? |
1 – Not comfortable at all |
2 – Somewhat uncomfortable |
3 – Somewhat comfortable |
4 – Comfortable |
5 – Very comfortable |
A. Could you please elaborate on your response? |
Probes: What factors helped, such as the screening questions used, family’s response to these questions, your experience asking the questions? What factors reduced your comfort, such as the family’s response? No response? Have you seen this family before? |
4. Can you describe how families responded when you asked them the screening questions? |
5. Can you describe your response to a positive screen? |
6. Do you think asking these screening questions affected your rapport with families in any way? If so, how? |
Probes: Were the families surprised? Did they feel offended, embarrassed, or appreciative? |
7. Would you consider incorporating these screening questions into your routine visits with patients/families receiving diabetes care moving forward? |
Care algorithm |
8. Can you describe how you used the care algorithm to assist in planning your patients’ care or providing them with the support they may need during the screening initiative? |
9. How useful was the algorithm in terms of enhancing the care and support that you were able to provide patients/families that were food insecure? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
A. Can you please elaborate on your response? |
Community resources handout |
10. These questions refer to the package of handouts and list of community food resources provided to you. Did you use any of the resources or handouts provided for this initiative with food insecure families? |
11. How receptive were patients/families to receiving this information? |
12. How useful was it to have these resources and handouts available when screening families for food insecurity? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
A. Can you please elaborate on your answer? |
Screening questions |
1. During the initiative, how often did you screen families for food insecurity using the screening questions? |
1 – Never |
2 – Almost never |
3 – Occasionally |
4 – Almost always |
5 – Always |
If answer to Q1 is 1 – Never to 4 – Almost always, then ask Q2, followed by Q3. If answer to Q1 is 5 – Always, go directly to Q3. |
2. Can you describe why you did not use the screening questions with all families? |
Probes: What informed your decision of whether to screen families? Or what prevented you from assessing food insecurity? |
3. How comfortable were you screening families for food insecurity? |
1 – Not comfortable at all |
2 – Somewhat uncomfortable |
3 – Somewhat comfortable |
4 – Comfortable |
5 – Very comfortable |
A. Could you please elaborate on your response? |
Probes: What factors helped, such as the screening questions used, family’s response to these questions, your experience asking the questions? What factors reduced your comfort, such as the family’s response? No response? Have you seen this family before? |
4. Can you describe how families responded when you asked them the screening questions? |
5. Can you describe your response to a positive screen? |
6. Do you think asking these screening questions affected your rapport with families in any way? If so, how? |
Probes: Were the families surprised? Did they feel offended, embarrassed, or appreciative? |
7. Would you consider incorporating these screening questions into your routine visits with patients/families receiving diabetes care moving forward? |
Care algorithm |
8. Can you describe how you used the care algorithm to assist in planning your patients’ care or providing them with the support they may need during the screening initiative? |
9. How useful was the algorithm in terms of enhancing the care and support that you were able to provide patients/families that were food insecure? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
A. Can you please elaborate on your response? |
Community resources handout |
10. These questions refer to the package of handouts and list of community food resources provided to you. Did you use any of the resources or handouts provided for this initiative with food insecure families? |
11. How receptive were patients/families to receiving this information? |
12. How useful was it to have these resources and handouts available when screening families for food insecurity? |
1 – Not useful at all |
2 – Somewhat useful |
3 – Useful |
4 – Very useful |
A. Can you please elaborate on your answer? |
Data Analysis
All interviews were audio-recorded and then transcribed by three research assistants under the supervision of the first author, who checked the process for accuracy and consistency. An inductive approach was used to analyze the data, including text coding and developing categories (33). The first author identified and categorized interview data codes through a line-by-line analysis of all transcripts. To validate this analysis, three research assistants repeated this process by individually reviewing interview transcripts. These data were then used by all research team members to reach a consensus on a summary of themes and develop a working analytical framework (34). All interviews were coded using NVivo version 12 software (QSR International). The insights provided by a reflective journal kept by the onsite research coordinator, based on informal discussions and conversations with both diabetes educators and families, also facilitated the data interpretation process.
Results
Although the educators were asked to screen all patients who came through the clinic for the research study, the high volume of patients booked and the busy clinic flow often prevented educators from screening everyone. For instance, in addition to the dietitian, families often had multiple same-day appointments with their physician and/or nurse, and a positive screen would entail a prolonged discussion of the impacts of FI on diabetes management and a review of the community resources to help mitigate their circumstances. Consequently, it was left to the discretion of the educators when to screen for FI, depending on the time they had with the patient.
In total, 50 families were asked to be screened for FI, and all of them agreed to participate. Of the 50 screened families, 37 families (74%) agreed to be interviewed. Table 4 lists the demographic characteristics of the families interviewed; 15 of them (40.5%) were found to have FI. Families with FI were much more likely to have immigrated to Canada, to include single or separated parents with a lower education level, and to be unemployed. The results are organized below based on the themes that emerged from the data analysis (Table 5). They are grouped by themes of acceptability and feasibility with supporting quotes, which are tagged to identify the dietitians (e.g., D1 = dietitian #1), participants/families, and FI status (e.g., P1, FI = participant/family #1, food insecure).
. | Food Secure (n = 22) . | Food Insecure (n = 15) . | ||||
---|---|---|---|---|---|---|
n . | % . | Mean (SD) . | n . | % . | Mean (SD) . | |
Parents/guardians | ||||||
Age, years | — | — | 44.1 (7.6) | — | — | 44 (8.3) |
Sex | ||||||
Female | 17 | 77.2 | — | 14 | 93.3 | — |
Male | 5 | 22.7 | — | 1 | 6.6 | — |
Marital status | ||||||
Single | 1 | 4.5 | — | 6 | 40 | — |
Married | 18 | 81.8 | — | 7 | 46.6 | — |
Common law | 2 | 9.0 | — | 0 | 0 | — |
Separated/divorced | 1 | 4.5 | — | 2 | 13.3 | — |
Education level | ||||||
High school or less | 3 | 13.6 | — | 6 | 40 | — |
College/university | 13 | 59.0 | — | 8 | 53.3 | — |
Graduate school | 6 | 27.2 | — | 1 | 6.6 | — |
Employment status | ||||||
Unemployed | 2 | 9.0 | — | 5 | 33.3 | — |
Part-time | 3 | 13.6 | — | 1 | 6.6 | — |
Full-time | 10 | 45.4 | — | 4 | 26.6 | — |
Self-employed | 3 | 13.6 | — | 2 | 13.3 | — |
Retired | 2 | 9.0 | — | 0 | 0 | — |
Homemaker | 2 | 9.0 | — | 3 | 20 | — |
Immigration status | ||||||
Immigrant | 12 | 54.5 | — | 12 | 80 | — |
Canadian-born | 10 | 45.4 | — | 3 | 20 | — |
Number of people in household | — | — | 4.4 (1.0) | — | — | 3.7 (2.4) |
Patients (children) | ||||||
Age, years | — | — | 11.3 (3.8) | — | — | 11.8 (3.7) |
Sex | ||||||
Female | 14 | 63.6 | — | 6 | 40 | — |
Male | 8 | 36.3 | — | 9 | 60 | — |
Number of years with diabetes | — | — | 5.3 (3.8) | — | — | 4.2 (3.0) |
. | Food Secure (n = 22) . | Food Insecure (n = 15) . | ||||
---|---|---|---|---|---|---|
n . | % . | Mean (SD) . | n . | % . | Mean (SD) . | |
Parents/guardians | ||||||
Age, years | — | — | 44.1 (7.6) | — | — | 44 (8.3) |
Sex | ||||||
Female | 17 | 77.2 | — | 14 | 93.3 | — |
Male | 5 | 22.7 | — | 1 | 6.6 | — |
Marital status | ||||||
Single | 1 | 4.5 | — | 6 | 40 | — |
Married | 18 | 81.8 | — | 7 | 46.6 | — |
Common law | 2 | 9.0 | — | 0 | 0 | — |
Separated/divorced | 1 | 4.5 | — | 2 | 13.3 | — |
Education level | ||||||
High school or less | 3 | 13.6 | — | 6 | 40 | — |
College/university | 13 | 59.0 | — | 8 | 53.3 | — |
Graduate school | 6 | 27.2 | — | 1 | 6.6 | — |
Employment status | ||||||
Unemployed | 2 | 9.0 | — | 5 | 33.3 | — |
Part-time | 3 | 13.6 | — | 1 | 6.6 | — |
Full-time | 10 | 45.4 | — | 4 | 26.6 | — |
Self-employed | 3 | 13.6 | — | 2 | 13.3 | — |
Retired | 2 | 9.0 | — | 0 | 0 | — |
Homemaker | 2 | 9.0 | — | 3 | 20 | — |
Immigration status | ||||||
Immigrant | 12 | 54.5 | — | 12 | 80 | — |
Canadian-born | 10 | 45.4 | — | 3 | 20 | — |
Number of people in household | — | — | 4.4 (1.0) | — | — | 3.7 (2.4) |
Patients (children) | ||||||
Age, years | — | — | 11.3 (3.8) | — | — | 11.8 (3.7) |
Sex | ||||||
Female | 14 | 63.6 | — | 6 | 40 | — |
Male | 8 | 36.3 | — | 9 | 60 | — |
Number of years with diabetes | — | — | 5.3 (3.8) | — | — | 4.2 (3.0) |
Acceptability . | |
---|---|
Feeling comfortable | • Most families did not consider FI questions intrusive. |
• Families with FI felt relieved that educators were aware of the issue. | |
• Educators felt comfortable when asking FI questions. | |
Feeling uncomfortable | • A few families with FI felt that care providers were judgmental. |
• A few families with FI felt uncomfortable answering FI questions because of the presence of their children. | |
• One educator felt uncomfortable asking FI questions when families were not their patients. | |
Trusting relationship | • Both educators and families recognized that building a trusting relationship was key to make families with FI more likely to disclose their FI status. |
Poster | • Looking at the poster gave families with FI hope to better cope with their FI circumstances. |
• Sadness was the most common feeling associated with the poster among food secure families. | |
• Displaying the poster can persuade families with FI to disclose their FI status. | |
Feasibility | |
Utility of FI screening | • Screening provided families with FI opportunities to discuss their concerns and become aware of affordable food resources. |
• Educators valued the opportunity to listen to patients’ challenges, which helped them to better tailor treatment plans and avoid false assumptions. | |
• One educator felt that standardized screening was not necessary and chose to rely on their subjective assumptions. | |
Time constraints | • On occasion, lack of time prevented educators from screening. |
• Sometimes, educators did not screen for FI because they did not want to delay families’ appointment with the endocrinologist. | |
• Educators often did not have the time to follow up with families with FI and provide information on affordable resources. |
Acceptability . | |
---|---|
Feeling comfortable | • Most families did not consider FI questions intrusive. |
• Families with FI felt relieved that educators were aware of the issue. | |
• Educators felt comfortable when asking FI questions. | |
Feeling uncomfortable | • A few families with FI felt that care providers were judgmental. |
• A few families with FI felt uncomfortable answering FI questions because of the presence of their children. | |
• One educator felt uncomfortable asking FI questions when families were not their patients. | |
Trusting relationship | • Both educators and families recognized that building a trusting relationship was key to make families with FI more likely to disclose their FI status. |
Poster | • Looking at the poster gave families with FI hope to better cope with their FI circumstances. |
• Sadness was the most common feeling associated with the poster among food secure families. | |
• Displaying the poster can persuade families with FI to disclose their FI status. | |
Feasibility | |
Utility of FI screening | • Screening provided families with FI opportunities to discuss their concerns and become aware of affordable food resources. |
• Educators valued the opportunity to listen to patients’ challenges, which helped them to better tailor treatment plans and avoid false assumptions. | |
• One educator felt that standardized screening was not necessary and chose to rely on their subjective assumptions. | |
Time constraints | • On occasion, lack of time prevented educators from screening. |
• Sometimes, educators did not screen for FI because they did not want to delay families’ appointment with the endocrinologist. | |
• Educators often did not have the time to follow up with families with FI and provide information on affordable resources. |
Acceptability of the Screening Initiative
Feeling Comfortable
Although screening for FI involves disclosing sensitive information, most families felt comfortable answering the screening questions. As shown in Figure 1, most families reported feeling either “very comfortable” (70.2%) or “comfortable” (16.2%) when answering screening questions. However, food secure families (77.2%) were more likely than families with FI (60%) to feel “very comfortable.” Even if they recognized the sensitivity of the topic, most families did not seem uncomfortable because they understood that the diabetes educators were concerned about the well-being of their children: “Questions were not intrusive; they were something to help you out” (P9, FI). Families with FI especially felt relieved when asked about their FI status because when the educators were aware of their challenges, they could help: “When you see other people who are there to help and support you, you feel somewhat relieved, because you know that there are resources you can turn to; you are not alone” (P20, FI). Educators also felt comfortable with the screening questions and did not report negative reactions from families they screened: “Overall, families were pretty accepting; I cannot really think of any examples of people I thought … seemed offended” (D1). However, one educator felt less inclined to ask FI questions when not familiar with patients: “[I did not screen patients], if I did not have a relationship with them; if patients were not mine, I did not feel comfortable” (D2).
Feeling Uncomfortable
About 20% of families with FI reported feeling either “somewhat uncomfortable” or “not comfortable at all” (Figure 1) answering the screening questions. Some were afraid of being stigmatized: “You know, I don’t want to appear as though I’m poverty stricken, and at the same time, you’re embarrassed to tell people that you’re struggling” (P14, FI). A few families with FI confided in the research coordinator that they felt uncomfortable answering screening questions because they perceived their educators as judgmental and lacking empathy. In contrast, food secure families were comfortable answering the questions because they felt that running out of food was not a concern: “It’s just that I didn’t have to deal with that insecurity of not having the food; so, answering the questions did not really affect me emotionally” (P4, FS). Some families with FI felt uncomfortable discussing their FI status in front of their children: “I felt embarrassed; I worried that my child would worry. It was very uncomfortable. It would have been different, however, if she [her daughter] wasn’t there” (P14, FI). The participating diabetes educators were very aware of this issue: “I think one of the challenges to overcome is how to best ask in front of children, because it would put the parent in the position to be … on the spot. Ideally, it would be in a situation where the children weren’t present” (D1).
Building a Trusting Relationship
Both food secure families and those with FI made it clear that building a trusting relationship was key to make them feel more comfortable and more likely to disclose their FI status: “When we first started, [my daughter] was younger; we got a lot of interaction with our nurse. So, she was able to build enough rapport that if she [the nurse] had asked those questions, we would have been more open to [it]” (P23, FS). Educators also stressed the importance of developing a close relationship with families because strong rapport makes it easier for diabetes educators to notice signals of financial insecurity: “We do end up having really close relationships with our families; of course, their situation can change any time, but I feel that if it changes, because of this close relationship we have, they would tell us” (D3). However, strong relationships between clinicians and families may not always develop.
Poster
Most of the participants provided positive feedback about the FI poster, which gave families with FI hope: “The poster makes me hopeful; it shows me that there are resources or someone who is concerned for us” (P20, FI). Food secure families tended to feel sad about the poster: “It made me feel sad. I think it’s very poignant and it targeted my emotion about the fact that people struggle to afford food” (P24, FS). Both food secure families and those with FI believed that the poster could raise awareness about FI and facilitate disclosure: “If this [the poster] is readily available and posted everywhere, people’s walls come down, because they’re like, ‘OK, maybe it’s not just me, there are 4 million other Canadians’; so, you’re not alone” (P23, FS).
Feasibility of the Screening Initiative
Utility of Screening Questions
Screening questions provided opportunities to discuss a sensitive topic and allowed families with FI to express their worries: “To some extent, there was a degree of relief that someone is listening and that there may be help; when you unburden problems, it is always helpful to share a difficulty” (P35, FI). Food secure families made similar comments: “The goal is to get as much information to help and support. Questions give them [families with FI] the opportunity to open a line of communication” (P23, FS). Families with FI also noted that the screening process made them more aware of affordable food resources: “It is reassuring to know that there will be resources available; she [the dietitian] made some helpful suggestions on where I might be able to look for things like fresh food on a regular basis and a meal for my husband” (P35, FI).
Diabetes educators said the opportunity to exchange useful information was valuable and helped them tailor their recommendations: “I explained how we can give them [families] suggestions to access healthy food and cheaper options. I also asked them how they were balancing their funds to access food; so, it would be a lot of back and forth” (D3). Educators also noted that systematic FI screening can help to avoid false assumptions: “My feeling is that it should be asked to everyone. You can’t really assume, because there are some people who we would think have the resources, but their circumstances have changed” (D1). However, one educator believed that standardized screening was not necessary. This educator felt confident with the subjective screening process already being used and believed screening should be left to the discretion and judgment of clinicians: “It was just really not necessary to screen everyone, simply because it just didn’t really relate to all of them; some patients were not food insecure, and it would have been a waste of time” (D2). Still, subjective assumptions may be misleading and prevent families with FI from accessing affordable food resources.
Time Constraints
Participating educators sometimes skipped screening questions because they felt that they did not have enough time: “Sometimes, I would just forget. You get caught up in other things, and then it slips your mind, because it’s not a part of your regular practice” (D1). In other situations, diabetes educators did not screen because they did not want to make families late for their doctor appointment: “If the patients were in some sort of rush or the doctor was ready to see them, I felt like things were just crunched” (D1). Educators also referred to lack of time for following up after a positive screen, which prevented them from suggesting affordable food community programs: “We didn’t have time to direct the patients to community resources based on where they live, because that takes a long time” (D3). As a result, the onsite research interviewer was the one who often provided families with FI with information about resources, which took ∼20–45 minutes.
To overcome the challenges posed by time constraints, diabetes educators proposed incorporating screening into a self-reported intake form that families fill out when they come to the clinic: “I think that [including screening questions] would be probably the best and the most effective way; they [the assessment questions] are asking a lot of very personal and sensitive questions anyways” (D1). Another recommendation was to direct families with FI to the hospital’s family resource center, where staff and volunteers could provide more appropriate guidance on how to access affordable resources.
Discussion
This evaluation of a FI screening initiative in a pediatric diabetes clinic revealed that the initiative was acceptable and feasible to families of children with diabetes. Most families felt comfortable answering the screening questions, and families with FI expressed a sense of relief. However, ∼20% of families with FI reported feeling uncomfortable answering screening questions. Many feared being judged by clinicians and did not like answering the questions in the presence of their children. The issue is sensitive, so being respectful and nonjudgmental about how families choose to prioritize their spending is crucial to encourage them to reveal their FI status (10). Establishing trust is also essential because parents may fear that Child Protective Services will take their children (7). To increase parental comfort, clinicians should immediately explain that screening will be used to provide support and that parents will not be reported to Child Protective Services (35). Our results also confirm that FI posters can reduce stigma and encourage families with FI to disclose their status (25,36).
Overall, diabetes educators were also comfortable assessing FI status and said that screening helped them elicit useful information and avoid false assumptions of food security. However, one educator was skeptical about the necessity of implementing systematic routine screening and felt uncomfortable screening without having already established a rapport with the family. Yet, families may differ in terms of interaction style preferences and capacity to engage with clinicians (37); as such, families with FI may not always develop a close relationship with their clinicians. Thus, self-completed intake forms may be a more sensitive screening method than in-person screening. Health professionals also need to recognize that FI is typically cyclical and episodic, that subjective assumptions are fallible, and that systematic screening has the potential to remove clinician bias (38). Clinician judgment may stigmatize the screening process (39) and cost families with FI a crucial opportunity to discuss their challenges and become informed of affordable resources. To overcome skepticism, it is essential to increase clinician awareness about the prevalence of FI in their communities (40). Clinician discomfort in respectfully discussing the social needs of families with FI is often due to lack of training (39). Developing skills such as motivational interviewing (41), learning techniques for nonjudgmental communication (35), and having FI screening completed (via self-completed intake forms) before the visit may help clinicians feel more comfortable (42).
Lack of time was identified as the most common barrier to FI screening. To increase screening uptake, educators proposed including FI questions on a self-reported intake form. The time burden tends to be lower for self-administered formats (42), but participants may need assistance for difficulties with literacy or vision. In terms of disclosure rates, there are no clear indications on which screening modality yields better results (42), but the only study that directly compared screening formats in a pediatric setting found that computer-based self-reporting was marginally more effective than face-to-face assessment (43). A computer-based model may also facilitate the integration of FI screening into families’ electronic medical records (EMRs), which in turn supports routine screening and continuity of practice among clinicians because it helps them share information about families (25,44). An automated EMR default process may also decrease stigma because families with FI start to consider screening a routine part of care (35).
Lack of time also prevented diabetes educators from following up with families with FI. Research has shown that a lack of adequate resources to address identified needs is a source of clinician discomfort (42); it reduces their self-efficacy and lowers their motivation to discuss FI (45), which could lead to frustration for families and clinicians (39). Participating educators suggested referring families with FI to the onsite family resource center to ensure community linkage. Patient advocates could be trained to function as navigators in clinical settings, acting as a bridge between health centers and community programs (46). Patient advocates do not require advanced medical training and are not expected to give medical advice; they can include community members or patient peers, thereby reducing costs (47). Alternatively, clinics trying to incorporate FI screening could implement an efficient referral process by partnering with community-based organizations. For example, a Kaiser Permanente Colorado pilot program involved two pediatric clinics partnering with Hunger Free Colorado, a statewide hunger advocacy group. Patients with a positive FI screen were referred to the Hunger Free Colorado hotline, and hotline navigators would assess their eligibility for food assistance programs and refer them to community resources (40).
Because one of the educators did not screen unless a rapport was already established with families, this may have influenced the reporting of acceptability toward screening. Similarly, families who accepted being interviewed were presumably more at ease discussing personal matters with a care provider they knew well. The possibility that some clinicians may prefer to establish a relationship with their patients before screening raises the question of whether screening for FI is more appropriate at the initial clinical visit (perhaps using intake forms) or after a rapport has been established between patient and care provider. Furthermore, the optimal workforce administering FI screening is also still uncertain (42), and future studies should evaluate whether and how different clinic staff members and settings affect disclosure rates. Likewise, the ideal interval between screenings for FI has not been identified, and screening frequency recommendations vary across populations and settings (42). More frequent screening may be necessary for lower-income populations, which may be more susceptible to changes in school lunch programs (48), employment trends, and social assistance policies (49). Finally, a key priority for future research is assessing the effectiveness of FI screening and referral practices on diabetes self-management behaviors and outcomes.
Conclusion
These findings suggest that a standardized and respectful method of FI screening is acceptable and feasible in clinical practice. Clinicians are willing to incorporate FI screening, especially if a standardized tool is available and if appropriate resources to address social adversities are available and perceived as effective. However, the results also revealed that the time burden can be a significant barrier to screening in busy pediatric clinics. To increase efficiency, participating diabetes educators proposed administering a self-reported intake form and referring families with FI to an onsite family resource center. Each clinic implementing routine FI screening should consider the time and human resources necessary to minimize the disruption of clinician workflow and ensure that families with FI and their children with diabetes receive treatment plans that are tailored to their circumstances and linked to community resources.
Duality of Interest
No potential conflicts of interest relevant to this article were reported.
Funding
This work was supported by a grant from the Lawson Foundation (grant GRT 2016-110).
Author Contributions
M.V. analyzed the data and wrote the first draft, with contributions from V.P., S.S., and E.G. L.D. collected the data. All authors reviewed and commented on subsequent drafts of the manuscript. E.G. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.