Abstract

Introduction:

Children are disproportionately affected by the rise in poverty rates in the United States. Economic hardships can compromise their development, negatively affect their overall health, and adversely affect their abilities to succeed in school and in life.^1-4 Food insecurity (FI)—the limited or uncertain availability of nutritionally adequate or safe foods— while strongly associated with poverty, is an independent predictor of poor health outcomes for children.^5,6 FI experienced in childhood is associated with poorer overall heath, increased hospitalizations, and increased rates of anxiety, aggression, anemia, asthma, and cognitive delay, among other health outcomes. ^7-13 Unfortunately, a large proportion of American children experience FI, and it often goes unnoticed.¹⁴ Currently, food insecurity in Philadelphia county affects 21.7% of children, exceeding the national average of 16.5%.^15,16

The Emergency Department (ED) of academic medical centers often serves as a point of care entry for impoverished and high-risk families.^17-19 Although there is a growing interest in the healthcare system’s ability to address Social Determinants of Health (SDH), little is known about food insecurity screening in the pediatric ED. The American Academy of Pediatrics and the American Pediatric Association have recommended FI screening in all pediatric settings.^20,21 The implementation of these recommendations has been difficult, particularly in the ED, because of medical provider concerns with time, limited knowledge of local resources, and the possibility of patient and provider discomfort in screening.²² Additionally, there are limited data on how to implement FI screening into practice in a way that maximizes elicitation of social need, while assuring patient and family comfort.²³

In order to compare modalities for FI screening in the pediatric ED, this prospective randomized study compared face-to-face verbal screening to screening using a tablet computer with an optional audio-assist, applying a validated, two-question screen for food insecurity. We also collected information regarding caregiver comfort with screening by modality and location.

Methods:

Results:

Of 2154 approached patients, 130 were excluded as there was no caregiver present, and 204 (10%) refused. Ultimately 1820 caregivers were randomized, 910 to each group. 2 tablet-based questionnaires (0.2%) were incomplete, leading to an overall response rate of 89.9% of eligible respondents (Figure 1). There were no significant differences between age, race, ethnicity, or triage level of acuity between groups (Table 1).

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Figure 1:

Study Flow Diagram

Of the 1818 participants, 20.6% screened positive for FI. There was a higher rate of reported FI for those screened by tablet compared to those screened verbally (23.6% and 17.7%, p=0.002). There were no significant differences in patient age or level of acuity between FI and non-FI groups. Rates of reported FI were higher among caregivers who identified as Black/African American, Hispanic or Latino, and if race was not listed, or if ethnicity was unknown/not reported. Rates of reported FI were lower among caregivers identifying as White and not Hispanic or Latino (Table 2).

Of the 614 (33.8%) caregivers who expressed any preference of screening modality, 83.2% preferred the tablet-based screen over verbal interview; 84.5% of those with FI reported a similar preference (Table 3). A slightly greater proportion of participants reported comfort completing the screen in the ED compared to their child’s doctor’s office, however comfort in both of these settings was rated highly (86.1% vs. 80.2%, p<0.001). Similar findings were noted for the subpopulation reporting FI (77.6% vs 70.7%, p=0.03) (Table 4).

Discussion:

With increasing recognition of the importance of FI and other SDH, there is a growing need for evidence regarding how to most effectively and efficiently identify social risk within medical settings. Maximizing the caregiver comfort and acceptability of screening mechanisms may enhance the accuracy of information collected. Specifically, the perceived anonymity of screening—such as with use of electronic tablet-based self-reporting—may improve disclosure and serve to enhance participant comfort. This study found that there is an overall high rate of acceptability with FI screening in a pediatric ED, and that caretaker comfort levels and disclosure of social risk are higher with tablet-based screening compared to verbal screening.

As FI is a potentially stigmatizing condition, it may elicit concerns regarding social desirability in responses depending on format of screening. In agreement with our study findings, previous studies on intimate partner violence and substance use have shown electronic based screening is acceptable to caregivers, and results in equal or greater disclosures.^27,28 Caregivers have reported discomfort in discussing social risk in front of their children, concerns regarding involvement of Child Protective Services upon disclosure of FI, and discomfort with disclosure has been shown to be most prevalent among those with highest social risk.²⁹ Similarly, prior literature has explored provider-level concern regarding FI screening, including patient discomfort or stigmatization and the time and ability to address social risk, once identified.³⁰ Providers have also reported time required for screening as a barrier.³¹ Tablet-based screening may help ameliorate these concerns, provide similarly accurate responses, and align well with both participant and provider preferences.

Although the majority of the literature regarding social risk screening focuses on routine medical visits, our study demonstrates that the ED is an acceptable screening location and may in fact be preferred by caretakers. We anticipate— similar to the mechanism described above— that the anonymity inherent to being a patient in the ED may serve as a protective factor for families, improving comfort with reporting social risk. This is particularly valuable as families presenting to the ED have a higher rate of social risk and lower access to primary care, in addition to an increased wait time, increasing feasibility of screening as compared to other clinical settings.^32,33 Our study showed rates of FI concordant with city-wide reports, along with low non-response and refusal rates, supporting the accuracy and feasibility of screening in the ED and acute care setting.

To our knowledge, this was the first study of FI or SDH screening to be undertaken with the intention to obtain a representative sample of caretakers of pediatric ED patients across all levels of acuity. This allowed us to compare the ESI triage level between patients whose caregivers report FI. Although it is frequently expected that social need such as FI is associated with higher rates of ED utilization for non-urgent complaints,³⁴ the results of our study do not support this notion as we found no difference in rates of FI based on ESI. This suggests the need for universal screening and intervention rather than targeted screening for patients and families who use the ED for non-urgent complaints.

Conclusion:

While both verbal and tablet-based screening modalities were effective in identifying FI, tablet-based screening had a higher disclosure rate and was participants’ preferred screening method in a pediatric ED. This suggests that written, tablet-based screening is a feasible and effective tool that may allow us to streamline routine inquiry into FI and possibly other SDH while improving detection and enhancing patient and provider comfort. While there is a high level of comfort with screening regardless of clinical setting; it is possible that an added level of anonymity in the ED enhanced participants’ comfort levels. We hope that these results help guide the implementation of FI and other social determinants screening and interventions, particularly in the ED setting.

Supplementary Material

Acknowledgements:

Footnotes

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