Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy
2.2. Study Selection, Data Extraction, and Analysis
3. Results
3.1. Overview of Included Studies
3.1.1. Tool Development and Validation
3.1.2. Screening Implementation and Experiences
3.2. Validity of Screening Tools
Author Year Country/City/State | Name of Screening Tool | Comparator Measure Name (# Items) | Sensitivity % (95%CI) | Specificity % (95%CI) | Validity of Indicators | Summary of Findings |
---|---|---|---|---|---|---|
Primary development papers | ||||||
Frongillo 1997 US New York State [35] | 1. Radimer/ Cornell 2. Community Childhood Hunger Identification Project (CCHIP) 3. NHANES III | Two researchers categorized participants based on interview information including 24 h dietary recall and food stores in the house | Radimer/Cornell 89 CCHIP 86 NHANES III 32 | Radimer/ Cornell 63 CCHIP 73 NHANES III 90 | Radimer/Cornell and CCHIP had good specificity and excellent sensitivity of the definitive criterion measure. NHANES III item had excellent specificity. | |
Gundersen 2017 US National [36] | Question combinations from the 18 item HFSSM | HFSSM (18) | Items 1 + 2 97.0–98.7 * Items 2 + 3 96.4–98.7 * Items 1 + 3 98.8–99.8 * | Items 1 + 2 73.7–94.4 * Items 2 + 3 82.5–94.5 * Items 1 + 3 73.8–93.1 * | Accuracy Items 1 + 2 84.1–94.6 * Items 2 + 3 88.6–94.9 * Items 1 + 3 84.8–93.6 * | 2-item FI screen can accurately identify HFI. Any combinations have acceptable sensitivity and specificity for widespread clinical use; each combination has advantages. |
Hager 2010 US [37] | Question combinations of 1 and 2 questions from the 18 item HFSSM. Based on affirmative responses in food insecure HH two questions selected | HFSSM (18) | Q1 only: 93 Q2 only: 82 Q1 and Q2: 78 Q1 or Q2: 97 | Q1 only: 85 Q2 only: 95 Q1 and Q2: 96 Q1 or Q2: 83 | 2-item FI screen (HVS) was sensitive, specific and valid among low-income families with young children. | |
Kerz 2021 Australia Brisbane, QLD [38] | Combination of questions from - AHS single question - HFSSM (18) [AUS] - FAO FIES (8) - HVS (2) Based on +ve responses for FI participants—8 questions had +ve responses between 70–90% and were used to create 2-question combinations. 26 combinations were tested | HFSSM (18) | HFSSM 2 + 3: 96.0# HFSSM 3 + 4: 96.0 HFSSM 3 + HVS1: 92.0 HFSSM 3 + FIES3: 92.2 HFSSM 2 + FIES3: 96.0 HFSSM 1 or 2: 96.0 HFSSM 1 and 2: 69.0 HFSSM 2 or FIES3: 96.0 HFSSM 2 and FIES3: 63.0 | HFSSM 2 + 3: 90.3 HFSSM 3 + 4: 90.3 HFSSM 3 + HVS 1: 90.1 HFSSM 3 + FIES 3: 95.9 HFSSM 2 + FIES 3: 87.3% HFSSM 1 or 2: 90.3 HFSSM 1 and 2: 100 HFSSM 2 or FIES 3: 87.3 HFSSM 2 and FIES3: 98.0 | Tetrachoric correlation using the HFSSM and the potential two-question combinations; HFSSM questions 2 and 3 (r = 0.979) and HFSSM question 2 and FAO-FIES question 3 (r = 0.961). | HFSSM Q2 + 3 has high sensitivity and specificity and may assist practitioners in pediatric healthcare settings in identifying clients who are at risk of FI. |
McKay 2022 Australia [39] | 2 item screening (various combinations of items from HFSSM) | HFSSM (10) | Q1 + Q2 All HH 82.4% HH with children 77.8% Q2 + Q3 All HH 93.3% HH with children 88.9% Q1 + Q3 All HH 85.7% HH with children 100% | Q1 + Q2 All HH 98.3% HH with children 98.1% Q2 + Q3 All HH 98.3% HH with children 99.1% Q1 + Q3 All HH 99.6% HH with children 98.1% | Accuracy Q1 + Q2 All HH 97.3% HH with children 82.3% Q2 + Q3 All HH 98.0% HH with children 91.1% Q1 + Q3 All HH 98.7% HH with children 99.6% | Q1 + 3 demonstrated best accuracy and reflects both worry about food shortages and cost pressures that have been identified as of concern for food insecure and hungry pregnant women. A 2-item FS screener, created by combining Q1 + 3 of the 10-item USDA tool was found to be sensitive and specific to identify FI pregnant people. |
Urke 2014 Canada Arctic Circle [34] | Investigated each item of the 18-item adapted HFSSM | Modified HFSSM 18 item to improve acceptability among Inuit | 1. In the last 12 months, were there times when it was not possible to feed the children a healthy meal because there was not enough money? (a) Adult survey 92.3 (b) Child survey sub-sample 88.5 2. In the last 12 months, were there times when you could only feed your children less expensive foods because you were running out of money to buy food? (a) Adult survey 94.8 (b) Child survey sub-sample 96.9 3. In the last 12 months, were there times when the food for you and your family just did not last and there was no money to buy more? 93.0 4. In the last 12 months, did you ever worry whether the food for you and your family would run out before you had enough money to buy more? 91.9 | 1a. 97.3 1b. 95.4 2a. 81.9 2b. 80.6 3. 93.4 4. 89.1 | PPV/NPV/Accuracy 1a. 97.3/92.1/94.7 1b. 95.8/87.3/91.6 2a. 85.0/93.6/88.6 2b. 85.7/95.6/89.5 3. 95.9/88.9/93.2 4. 85.7/95.6/89.5 | Screening for child FI #1 best. Adult FI #3 best 1 question from each of the adult and child modules in the 18-item HFSSM can assess FI. Basing a rapid FI assessment on both adult and child items gives a more accurate picture of the FS situation in a family. |
Validation papers | ||||||
Baer 2015 USA Boston MD [53] | HVS | HFSSM (18) for 18–25 yr olds (parents) FSSM (10) for 18–25 yr olds (not parents) FSSM—(9) for youths aged 12–17 used with 15–17 yr olds | 88.5 | 84.1 | PPV 72.8 NPV 93.8 | Sensitivity lower than expected; specificity comparable. Moderate PPV—patients who screen +ve may benefit from more extensive questioning to determine presence and severity of FI |
Bayoumi 2021 Canada Toronto [51] | Single FI item from NutriSTEP “I have difficulty buying food I want to feed my child because food is expensive” | HVS (2) | 84.9 (72.4, 93.3) | 91.2 (89.4, 92.8) | False +ve 8.8 (7.2, 10.8) PPV 31.3 (26.7, 36.2), NPV 99.2 (98.5, 99.6) NLR 0.2 (0.1, 0.3) PLR 9.6 (7.7. 12.0) Accuracy 90.9 (89.1, 92.5) | Single NutriSTEP FI question may be an effective screening tool in clinical practice to identify MFS in families with young children. |
Crichton US [54] | HVS | Community-level FI statistics (USDA Food Access Research Atlas) based on individual residential zip codes | Q1 only 21 Q2 only 23 Q1 or Q2 25 | Q1 only 88 Q2 only 83 Q1 or Q2 80 | PPV Q1 67 Q2 60 Q1 or Q2 58 NPV Q1 only 49 Q2 only 49 Q1 or Q2 50 Accuracy Q1 only 52 Q2 only 51 Q1 or Q2 51 | Discordance between HVS and the USDA’s food access atlas data, not confident in the ability of the screening tool to accurately detect food security in population with trauma. |
Gattu 2019 US [55] | HVS | HFSSM (18) | 96.7 | 86.2 | PPV 65.7 NPV 99 | The HVS identifies children at risk of FI in primary care and ED. |
Harle 2023 US [48] | Epic EHR food insecurity screener (HVS as questions) | HFSSM (6) | 94.5 (91.2- 96.8) | 93.1 (90.6- 95.2) | AUC 0.938 95% CI 0.921- 0.955 | EHR-based FI screening was accurate compared to single-domain screener. |
Harrison 2021 US [56] | HFSSM-2 (HVS) | HFSSM (18) | Q1 only: 92 (94–100) Q2 only: 88 (80–97) Q1 + Q2: 83 (72–93) Q1 or Q2: 98 (94–100) | Q1 only: 95 (92–98) Q2 only: 95 (92–97) Q1 + Q2: 98 (97–100) Q1 or Q2: 91 (87–94) | PPV Q1 only 80 (70–90) Q2 only 78 (67–89) Q1 + Q2 93 (86–100) Q1 or Q2 70 (59–80) NPV Q1 only 98 (97–100) Q2 only 97 (95–99) Q1 + Q2 96 (94–99) Q1 or Q2–99 (98–100) | HFSS-2–high sensitivity, specificity, PPV, NPV–supports the use of HFSS-2 for adults in the general medical population. |
Kleinman 2007 US Chelsea MA [52] | Single Q: Hunger Screening Tool “In the past month, was there any day when you or anyone in your family went hungry because you did not have enough money for food?” | HFSSM (18) | 83 | 80 | 77% time to time reliability (kappa= 0.54) cf HFSSM time to time reliability of 83% (kappa = 0.66) | Single-question screening tool can identify family hunger as part of routine healthcare in a primary care pediatric clinic serving a low-income community. |
Lane 2014 US Baltimore MD [47] | Single Q: “In the last year, did you worry that your food would run out before you got money or food stamps to buy more?” | HFSSM (18) | 59 | 87 | PPV 70 NPV 81 PLR 4.5 NLR 0.47 Stability kappa 0.69 substantial agreement between clinic and lab based administered tools | Single question screen in a primary care setting can effectively identify families with FI. |
Makelarski 2017 US Chicago Ill [49] | 12-month HVS and AAP 30-day HVS and AAP | HFSSM (6) | 12 month: AAP 76 (65, 85) HVS 94 (86, 98) AAP (HH with children) 78 (61, 90) AAP (HH no children) 71 (52, 86) HVS same for both groups: 94 (81, 99) 30 day AAP 72 (56, 84) HVS 91 (79, 98) AAP (HH with children) 67 (46, 83) AAP (HH no children) 79 (49, 95) HVS (HH with children) 93 (76, 99) HVS (HH no children 100 (78, 100) 12-month recall study AAP tool admin. after HFSS and the HVS 67 (46, 83) AAP tool admin. before HFSS and HVS 79 (54, 94) | 12 month: AAP 93 (85, 97) HVS 82 (72, 90) 30 days: AAP 96 (88, 99) HVS 83 (73, 91) | 12 month: AAP NLR 0.3 (0.2, 0.4) HVS NLR 0.1 (0.0, 0.2) AAP PLR 11 (5, 23) HVS 5 (3, 8) Of those who screened negative with the AAP tool but positive with the HVS tool, 92% screened positive because they selected “sometimes true” for 1 or both HVS survey items 30 day AAP NLR 0.3 (0.2, 0.5) HVS NLR 0.1 (0.0, 0.3) AAP PLR 17 (16, 53) HVS PLR 5 (3, 9) Of those who were missed by the AAP tool but captured by the HVS, 90% screened positive because they selected “sometimes true” for 1 or both HVS survey items | In an urban population with a high prevalence of FI the 12-month and 30-day recall versions of the tool recommended by AAP lacked sensitivity, HVS 12-month and 30-day recall versions were highly sensitive in this population. Both tools, 12-month recall version was more sensitive and at least as specific as the 30-day recall. |
Radandt 2018 US Seattle WA [32] | HVS | HFSSM (6) | 95.4 | 83.5 | The 2-item FI screen was found to be sensitive and reasonably specific, to identify FI families in a pediatric dentistry clinic. | |
Swindle 2013 US [31] | Two questions of the six item HFSSM | HFSSM (6) | 78.6 | 97.4 | Internal consistency α = 0.82 | A 2-item screen for FI conducted by childcare providers was valid. |
Tran 2022 US [57] | NutriSTEP FS question “I have difficulty buying food I want to feed my child because food is expensive” | HVS (2) USDA HFSSM (18) Canada HFSS (18) | NutriSTEP v. HVS—67.7% v. HFSSM 82.1% v. Canadian HFSS 67.6% HVS v. HFSSM 92.9% | NutriSTEP v. HVS 87.1% v. HFSSM 94.1% v. Canadian HFSS 92.9% HVS v. Canadian HFSS 85.3% | FI NutriSTEP/HFSSM 92% PPV FI NutriSTEP/Canada HFSS 92% PPV FI NutriSTEP/HVS 84% PPV FS NutriSTEP/HFSSM 86.5% NPV FS NutriSTEP/Canada HFSS 70.3% NPV FS NutriSTEP/HVS 73% NPV FI HVS/HFSSM 83.9% PPV FI HVS/Canada HFSS 93.5% PPV FS HVS/HFSSM 93.5% NPV FS HVS/Canada HFSS 83.9% NPV | NutriSTEP FS question had good validity in identifying FI cf. USDA HFSSM. HVS yielded high sensitivity and specificity, cf. Canada HFSS. HVS over-detected FI, NutriSTEP under-detected FI cf. USDA HFSSM. Sensitivity and specificity of NutriSTEP FS question were in the good and excellent range cf USDA HFSSM, indicating the NutriSTEP adequately assessed FI. |
Vaudin US [33] | Expanded Food Security Screener (FSS-Exp) | Follow up visit | NS | NS | NS | The final FSS-Exp tool has the potential to be used in healthcare settings to identify community-dwelling older adults who are in need of nutritional support. |
Vest 2021 US [50] | HFI Screening question from EHR (HVS) and ICD-10 Z codes | HFSSM (6) | HVS 73.0 (55.9, 86.2) ICD Z score 100 (96.4, 100) | HVS PPV 50 (27.2, 72.8) AUC 0.698 (0.555, 0.841) p < 0.05 ICD Z score PPV 100 (29.2, 100) AUC 0.523 (0.487, 0.550) | The two screening approaches did not perform well overall in this sample of safety-net patients. ICD-10 Z codes underestimated prevalence of social risk factors and are limited in their potential to effectively infer the presence of a social factor for a patient. Social risk factor screening questions were very specific but had higher sensitivity than ICD-10 Z codes. The screening questions performed better than ICD-10 Z codes but did not reach the level of being diagnostically useful. The combination of screening questions and ICD-10 Z codes resulted in small improvements in performance. | |
Young Australia Sydney NSW [30] | Two questions of the HFSSM (6) | HFSSM (6) | 100 (75, 100) | 78 (61, 90) | NPV: 100 (88, 100) Internal reliability 2-item α = 0.94 6-item α = 0.90 Correlation Co-efficient between two tools: ρ = 0.895; 95% CI 0.821, 0.940; p < 0.0001) κ agreement of responses between the two questionnaires was 0.650 (p < 0.0001). | The two-item FS is a valid, reliable, and sensitive tool for clinical use in people living with HIV to identify FI. |
Wording of Tools
- 1.
- Within the past 12 months, we worried whether our food would run out before we got money to buy more.
- 2.
- Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.
- ●
- often true
- ●
- sometimes true
- ●
- never true
- ●
- don’t know/refused
- 1.
- Within the past 12 months, have you ever worried that food will run out before you are able to buy more?
- 2.
- Within the past 12 months, have you run out of food and not had enough money to buy more?
3.3. Perceptions of Screening Tools and Tool Implementation
3.3.1. Recipient/Patient/Client Factors
“I don’t want to put ‘yes’ on [the FI screener] knowing there’s probably people who can’t even get their kid one package of bacon. I feel like those resources should go to those people, but I don’t know what you do about the people in the middle who don’t qualify for SNAP [Supplemental Nutrition Assistance Program] but aren’t quite able to get what they need…”[59] (p. 4)
“…there was a doctor who made me feel very uncomfortable, and like she didn’t care about my concerns…She just blatantly said that there were people in society that had worse problems than I did, and I should not be so emotional about it…”[66] (p. 600)
“Your heart skips a beat when your doctor asks. You automatically go to oh, my God. Somebody’s going to try and take my kids”[63] (p. 3)
“I love [my pediatrician]. He wasn’t judgmental or raise his eyebrows. He made me feel okay with it and said a lot of people are experiencing FI”[62] (p. 5)
“I feel comfortable with the social worker. They’re there to help you and make sure everything’s okay and they’re less intimidating I think than maybe a doctor or nurse…”[59] (p. 5)
3.3.2. Clinician/Provider Factors
“It’s a really personal question. You’re asking about money…it’s awkward”[72] (p. 4)
“[I did not screen patients], if I did not have a relationship with them; if patients were not mine, I did not feel comfortable”[65] (p. 344)
“I just feel like once you ask about food insecurity, I feel like from there, it will… There may be other needs. ‘Okay, then here’s this food pantry.’ And then it’s like, ‘Yeah, I understand the food pantry is there, but I don’t know how to get there,’ or ‘I don’t have internet.’ I feel like there needs to be someone, like a case manager, being able to provide other supports and services as well”[75] (p. 6)
“There’s a lot of other things to talk about during the visit, and [there’s] just not the time to identify social determinants”—Healthcare worker[68] (p. 90)
“…it wasn’t just a yes or no answer… the patient proceeded to then tell me more about what their experience [with food insecurity] was like”[64] (p. 259)
“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”[65] (p. 345)
“I thought it was really high yield because it was something I hadn’t particularly asked about before, and it was nice to have an exact script to use, and then it really got into something that I felt like I could help the family with”[60] (p. 26)
3.3.3. Setting Factors
“It’s helpful to have multiple people who are responsible for asking this because it establishes that as a culture that this is an important part of healthcare”[75] (p. 3)
“Caretaker comfort levels and disclosure of social risk are higher with tablet-based screening”[79] (p. 5)
“Unfortunately, it’s (screening) not very private. And what I mean by that is that it’s open to more medical assistants that are sitting at that station and potentially another patient getting vitals next to them…So as they’re asking them the questions, there are more people around and it’s not very private. Sometimes we do have that response of no, no, no I’m fine and then they get inside and they tell the doctor maybe something different”—Clinician[83] (p. 10)
“[Physicians] should be more concerned about the problems that are going on, the things that can be done to help health-wise”[59], (p. 5)
“I feel comfortable with the social worker. They’re there to help you and make sure everything’s okay and they’re less intimidating I think than maybe a doctor or nurse”[59], (p. 5)
“It’s really convincing the employer that this is necessary and making the argument to the hospital system or to the business that this is necessary”—Female physician, private practice, 16 years[74] (p. 15)
“We’ve got endless numbers of short, categorical screening questions that we tend to check off on checklists and do a very poor job of actually counselling people and their problems. This just adds to the number of those sorts of things that none of us ever has enough time to deal with adequately. A lot of these things we screen for, at the root of it are serious economic, social, and family problems”[74] (p. 14)
3.3.4. Systems Factors
“Combining structured screening with broad resource and referral availability for all families may be a promising approach”[69] (p. 1490)
“We are tremendously understaffed in terms of social services. We have one social worker for a clinic that has >15,000 visits per year. This fact seems overlooked”[13] (p. 53)
“At first it was like, ‘oh my, another question.’ But truly, it wasn’t that much additional time”[72] (p. 5)
4. Discussion
4.1. Screening Tool Selection
4.2. Systematic Implementation of HFI Screening
- Ensure that screening is embedded in service delivery that is person-centered, culturally safe, and trauma-informed
- 2.
- Orientate staff towards FI as a modifiable determinant of health, wellbeing, and development
- 3.
- Provide systems-level and organizational structures to facilitate universal screening
- 4.
- Build organizational partnerships and pathways for referral to address immediate food needs and longer-term determinants of FI
4.3. Strengths and Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Population | Participants being screened for (clients/recipients) or undertaking the screening (clinicians, healthcare workers, professionals, teachers, early education and care providers) for HFI (across the life span) |
Concept | Screening for HFI |
Context | High-income countries in any relevant setting including healthcare and community settings |
Inclusion | Exclusion |
---|---|
High-income countries as indicated by World Bank criteria [25] | Low- and middle-income countries |
Across the lifespan (including children/youth) | Involves screening tools for diagnostic criteria or symptomatology that do not focus on screening for food insecurity |
Utilizes a screening instrument with the intent to specifically assess household food (in)security (main focus of the study is screening/identifying people who experience food insecurity) | Interventions that target food insecurity (unless they include screening) Generic social determinants of health screening unless HFI is reported separately |
Involves screening or case finding in any setting in which screening for health may occur (e.g., tertiary, secondary, and primary healthcare or, more broadly, in community settings, schools, etc.) | |
Reports on the type of screening tool used | |
Reports on the experiences of screening or being screened for food insecurity | Reports on prevalence rates only |
Reports on quality improvement projects or workforce development to implement food insecurity screening |
1. | Choose a screening tool that is fit-for-purpose and has high specificity and sensitivity for the population to be screened |
2. | In most settings, use a minimum of two questions, with at least one question capturing marginal FI and one capturing severe FI |
3. | Undertake universal screening, ensure that all users of a service are screened to reduce stigma |
4. | Choose a modality that works for both the users of the service (e.g., literacy, English language, and privacy needs) and for the workflow of the organization |
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Baker, S.; Gallegos, D.; Rebuli, M.A.; Taylor, A.J.; Mahoney, R. Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review. Nutrients 2024, 16, 1684. https://doi.org/10.3390/nu16111684
Baker S, Gallegos D, Rebuli MA, Taylor AJ, Mahoney R. Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review. Nutrients. 2024; 16(11):1684. https://doi.org/10.3390/nu16111684
Chicago/Turabian StyleBaker, Sabine, Danielle Gallegos, Megan A. Rebuli, Amanda J. Taylor, and Ray Mahoney. 2024. "Food Insecurity Screening in High-Income Countries, Tool Validity, and Implementation: A Scoping Review" Nutrients 16, no. 11: 1684. https://doi.org/10.3390/nu16111684