Pediatrician Survey Findings

Addressing Food Insecurity Among Children —

Pediatrician Beliefs, Practices, and Resource Needs

January 2021

FRAC n Pediatrician Survey Findings n January 2021 n www.FRAC.org 1

Pediatrician Survey Findings
Addressing Food Insecurity Among Children —
Pediatrician Beliefs, Practices, and Resource Needs

About FRAC Acknowledgments

The Food Research & Action Center (FRAC) is the FRAC gratefully acknowledges the Anthem Foundation
leading national organization working for more for support of our work to help medical providers screen
effective public and private policies to eradicate domestic and intervene to address food insecurity.
hunger and undernutrition. For more information about
FRAC, or to sign up for FRAC’s Weekly News Digest,
visit www.frac.org.

About American Academy About Author

of Pediatrics This report was prepared by Kimberly Montez, M.D.,
M.P.H., FAAP, with support from Dana Bennett-Tejes, M.A.,
The American Academy of Pediatrics (AAP) is an
organization of 66 ,000 pediatricians committed to the the AAP Council on Community Pediatrics Manager, and
optimal physical, mental, and social health and well-being Alexandra Ashbrook, J.D., Director of Special Projects and
for all infants, children, adolescents, and young adults. For Initiatives at FRAC.
more information about AAP, go to www.aap.org.

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INTRODUCTION

I
n its policy statement, Promoting Food Insecurity to screen (18.6 percent) and intervene (21.7 percent)
for All Children, the American Academy of for food insecurity. The overwhelming majority
Pediatrics (AAP) recommends that pediatricians (81.1 percent) report not knowing if a family follows
screen for food insecurity and intervene accordingly. through on a referral.
To identify current practices and the capacity to address
food insecurity among children and families, the Background and Purpose
AAP and the Food Research & Action Center (FRAC)
The AAP and FRAC are revising their free, online
conducted an online survey. This report provides a
toolkit, which was originally published in 2017, to
snapshot of the findings based on the responses of 327
enable pediatricians to address food insecurity among
currently practicing pediatricians.
children and families. The AAP and FRAC conducted
an online survey to gain insight and feedback from
Summary of Key Findings pediatricians to help inform the toolkit’s revision.
n Pediatricians believe they have a critical role
to play in addressing food insecurity. All of the The online survey had two primary purposes:
surveyed pediatricians agree or strongly agree that 1. Assess current beliefs about and knowledge of
food insecurity contributes to poor health outcomes food insecurity, the health consequences of food
among children, and 96.0 percent of them agree or
insecurity, and federal nutrition programs;
strongly agree that patients should be screened for
food insecurity in a pediatric clinical setting. 2. Identify current practices and capacity for screening
n Pediatricians view the federal nutrition programs and intervening for food insecurity among children
as playing an important role in addressing and families (including current screening questions
food insecurity. Ninety-six and 98.2 percent of or tools that are related to assessing for the
respondents strongly agree or agree that patients presence of food insecurity).
should be referred to the Supplemental Nutrition
Assistance Program (SNAP) and the Special Distribution, Eligibility, and
Supplemental Nutrition Program for Women, Infants, Responses
and Children (WIC), respectively.
The online survey was sent via email in July 2019 to
n Pediatricians widely screen patients for food a variety of pediatric providers through seven AAP
insecurity. Of those surveyed, 74.0 percent report listservs (e.g., the Council on Community Pediatrics, the
working in practices that screen some or all patients Council on School Health, community-based initiatives,
for food insecurity, although the screening tools vary. and Chapter Leader Link) and was composed of
n Pediatricians need training and resources to approximately 7,700 mutually inclusive members.
improve their efforts to address food insecurity. Overall, 327 currently practicing pediatricians
Many of the surveyed pediatricians feel unprepared completed the survey.

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FINDINGS
Sample Description (Questions 1–7) report a wide range of years in practice. Table 1
includes additional information on the characteristics of
Overall, survey respondents provide representation respondents and the patients served. For instance, the
from a wide range of geographic areas and medical overwhelming majority of pediatricians identify as being
settings. Of particular importance to this project, the vast female (73.0 percent) and White (over 70 percent). Most
majority of respondents are working with vulnerable pediatricians have been in practice for 20 years or less
populations: 59.6 percent work with a population in (51.4 percent). More than 61 percent of pediatricians
which at least 60 percent of patients are enrolled in practice in an urban setting, and approximately 15
Medicaid. In addition to having representation from a percent practice in rural communities.
variety of practice settings (see Table 1), respondents

TABLE 1: Characteristics of Survey Respondents (n=327)

Gender Percent (n)
Female 73.0 (239)
Male 27.0 (88)
Race/Ethnicity Percent (n)
African American/Black 5.8 (19)
American Indian/Native Hawaiian/Alaska Native/other Pacific Islander 1.8 (6)
Asian 11.6 (38)
Hispanic/Latinx 10.1 (33)
White 70.6 (231)
Years in Practice Percent (n)
Less than 5 years 11.9 (39)
6–10 years 13.8 (45)
11–15 years 11.3 (37)
16–20 years 14.4 (147)
21–25 years 12.8 (42)
26–30 years 15.3 (50)
>30 years 20.5 (67)
Type of Practice Percent (n)
Academic or university-affiliated medical center, hospital, or clinic 23.2 (76)
Governmental hospital or clinic 7.0 (23)
Nonprofit community health center 11.3 (37)
Private practice hospital or clinic 58.4 (191)
Location of Practice Percent (n)
Rural 15.3 (50)
Suburban 23.3 (76)
Urban 61.4 (201)
Percent Patient Population Enrolled in Medicaid Percent (n)
0–19% 7.7 (25)
20–39% 14.4 (47)
40–59% 12.8 (42)
60–79% 18.3 (60)
80–100% 41.3 (135)
Unsure 5.5 (18)

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Attitudes and Skills Related to Food Insecurity (Questions 8–14)
Respondents were asked to indicate their level of insecurity contributes to poor health outcomes among
agreement with a number of items related to food children, and 96.0 percent agree or strongly agree
insecurity, including impact of food insecurity on health, that patients should be screened for food insecurity
screening for food insecurity, management of food in a clinical pediatric setting. However, 18.6 percent
insecurity and referral to federal nutrition programs. of surveyed pediatricians do not feel prepared to
Overall, the findings presented in Figure 1 indicate that screen for food insecurity, and 21.7 percent do not feel
pediatricians recognize the impact of food insecurity prepared to address it. Of the responses, 96.0 percent
and feel it is important to screen but feel unprepared and 98.2 percent of pediatricians feel patients identified
to screen or address food insecurity. Almost all as having food insecurity should be connected with
pediatricians agree that patients with food insecurity SNAP and WIC, respectively, while 78.9 percent feel
should be connected with SNAP and WIC. patients identified as having food insecurity should
be connected with emergency food resources at their
More specifically, 100.0 percent of surveyed
medical practice.
pediatricians agree or strongly agree that food

FIGURE 1: Pediatrician Attitudes and Skills Related to Food Insecurity (n=327)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Food insecurity contributes to poor health 88.4%

11.6%

75.0%
It is important to screen for food insecurity 21.0%
4.0%

38.2%
Strongly agree
34.2%
I feel prepared to screen for food insecurity 8.8%
Agree
16.2%
2.4%
Neutral

27.8% Disagree
40.1%
I feel prepared to address food insecurity 10.4% Stongly disagree
17.4%
4.3%

69.7%
Patients with food insecurity should be connected to SNAP 26.3%
4.0%

77.4%
Patients with food insecurity should be connected to WIC 20.8%
1.8%

56.0%
Patients with food insecurity should be connected to food resources 22.9%
16.2%
4.9%

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 Current Food Insecurity Screening Practices (Questions 15–21)
Survey respondents were asked whether they were majority of surveyed pediatricians (66.0 percent) have
familiar with AAP’s Policy Statement, Promoting Food some familiarity with AAP’s Policy Statement, and the
Security for All Children, and whether their practice/ overwhelming majority (74.0 percent) work at practices
hospital screens patients for food insecurity. The that screen some or all patients for food insecurity.
findings are presented in Figure 2 and Figure 3. The

FIGURE 2: Familiarity With AAP’s Policy FIGURE 3: Are Patients Screened for Food
Statement Promoting Food Security (n=327) Insecurity at Your Practice? (n=327)

4% 4%
14% 15% 14% 15% Extremely Extremely Yes, all Yes, all
22% 22%
Very Very 33% 33%Yes, some Yes, some
20% 20% 21% 21%
Somewhat Somewhat No No

30% 30%
Not so familiar Not so familiar 41% 41% Not sure Not sure

Not at all Not at all

Subsample of respondents who report screening for food insecurity in

their practice or hospital
The 242 respondents who report that they screen As shown in Figure 4, pediatricians report that their
all or some patients for food insecurity were asked practice or hospital screens for food insecurity at well-
during what type of visits patients are screened for child checks or annually (75.6 percent), when there is
food insecurity. Out of these, an additional four people a medical or social concern, such as a family reporting
did not answer or did not know the answer to these multiple unmet social needs (42.0 percent), at new
questions, leaving a total of 238 respondents. Multiple patient visits (28.2 percent), as part of Early Periodic
responses were permitted. Screening, Diagnostic and Treatment (EPSDT) services
(22.3 percent), at all visits (12.6 percent), and at sick
visits (7.1 percent).
FIGURE 4: What Type of Visits Do Pediatricians Screen for Food Insecurity (n=238)

80% 75.6%
70%
60%
50%
42.0%
40%
30% 28.2%
22.3%
20% * EPSDT = Early
12.6%
7.1% Periodic Screening,
10% 2.5% Diagnostic and
0% Treatment
Well-Child Visit EPSDT* Sick Visit New Patient All Visits Medical or Other
or Annually Screen Visit Social Concern

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Pediatricians who said that they screen for food Education (WE CARE),1 the Hunger Vital SignTM,2 and the
insecurity were then asked how they gleaned Survey of Well-being of Young Children (SWYC).3 Out
information from patients. The following were provided of the 242 respondents who report that they screen
as examples of screening instruments: Well Child Care, for food insecurity, two people did not answer the
Evaluation, Community Resources, Advocacy, Referral, questions, leaving a total of 240 respondents.

FIGURE 5: What Food Insecurity Screener Does Your Hospital or Clinic Use? (n=240)

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

WE CARE 8.8%

Hunger Vital SignTM 42.1%

SWYC 27.1%

We don’t ask formally 9.6%

Other 5.0%

Not sure 7.5%

As shown in Figure 6, 170 pediatricians FIGURE 6: How Does Your Hospital or Clinic Screen
report patients are screened in writing, Patients For Food Insecurity? (n=240)
as part of an electronic survey, or as
part of questions asked on other health
assessment tools; 144 pediatricians
report patients are screened verbally 70.8%
60.0%
by the pediatrician or another staff
member; 55 pediatricians report that
patients are screened with questions
that are embedded in the electronic 22.9%
health record; and three report not
knowing how patients are screened.
1.3%
Multiple answers were permitted.
Verbally In Writing Electronic Not sure
Medical Record

1
The Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) food insecurity screening question is “Do
you always have enough food for your family?”
2
The two-item Hunger Vital SignTM statements are: 1) “Within the past 12 months we worried whether our food would run out before we got
money to buy more”; and 2) “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
3
The Survey of Well-being of Young Children (SWYC) food insecurity screening question is “Within the past 12 months we worried whether our
food would run out before we got money to buy more.”

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Pediatricians who report that they screen for food and the adolescent together; 6.3 percent report
insecurity were asked how they screen adolescents. screening both the caregiver and adolescent separately.
As shown in Figure 7 the majority of respondents Out of the 242 respondents who report screening for
(33.8 percent) report screening depending on the food insecurity, two people did not answer the questions,
situation; 23.3 percent report screening only the leaving a total of 240 respondents. Multiple responses
caregiver; 15 percent report screening both the caregiver were permitted.

FIGURE 7: How are Adolescents Screened? (n=240)

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%

Adolescent only
Caregiver only
Both, together
Both, separately
Depends
I don’t know
Not screened

All respondents were asked about the barriers that they Over half of the respondents report that time constraints
face in routinely screening or addressing food insecurity are a barrier. In addition, 27.8 percent report that none of
among patients in their practice. Out of 327 respondents, the items listed in the survey were barriers to routinely
only 309 answered the question. The responses are in screening, and 20.1 percent report that resources for
Table 2. Multiple responses were allowed. addressing food insecurity are unavailable or unknown.

TABLE 2: Barriers to Routinely Screening for Food Insecurity (n=309)

Barriers (multiple responses were permitted) Percent (n)
Time constraints 51.8 (160)
None of the above 27.8 (86)
Resources addressing food insecurity are unavailable or unknown to me 20.1 (62)
I am worried that doing so will open up a range of issues about which I may not be able to address 14.6 (45)
There is lack of buy-in from other staff to address food insecurity 13.3 (41)
The electronic medical record (EMR) system we use does not include food insecurity
12.6 (39)
screening or adding it is cost-prohibitive
I don’t know enough about food insecurity 12.0 (37)
I don’t know how to ask questions about food insecurity 11.3 (35)
I’m worried that questions about food insecurity are too sensitive for my patients 9.7 (30)
There is lack of buy-in from leadership to address food insecurity 7.1 (22)
Other (e.g., workflow, not on my radar, etc.) 5.5 (17)
Insurance does not cover addressing food insecurity 4.9 (15)
I don’t think food insecurity affects enough of my patients 3.6 (11)
I don’t’ think food insecurity affects the health of my patients 2.6 (8)
Food insecurity shouldn’t be addressed in a medical setting 0.32 (1)

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Current Food Insecurity Intervening Practices (Questions 22–24)
The following set of questions in the survey, asked of all shown in Table 3, the most common ways respondents
respondents, was designed to determine what actions report intervening include referral to a social worker,
pediatricians take at their clinic or hospital when they federal nutrition assistance programs, and an emergency
have identified patients as having food insecurity. As food source. Multiple responses were allowed.

TABLE 3: How Pediatricians Intervene When Patients are Identified as

Having Food Insecurity (n=318)

Actions (multiple responses were permitted) Percent (n)

Refer to a Social Worker 55.7 (177)

Refer to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 55.0 (175)

Refer to the Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) 49.1 (156)

Refer to an emergency food resource, such as a food bank or food pantry 46.9 (149)

Provide a brochure on available food and nutrition resources 32.7 (104)

Refer to free summer meal sites 29.6 (94)

Connect directly to an existing community-based partner who helps the patient access nutrition resources 23.6 (75)

Refer to free or reduced-price school meals program 21.7 (69)

Provide specific health information to the WIC clinic (e.g., height, weight, hemoglobin) 18.6 (59)

Refer to a community-based anti-hunger organization 17.3 (55)

Refer to a community health worker or Health Lead 16.7 (53)

Refer to a Registered Dietitian or nutritionist 14.8 (47)

Provide a hotline number (e.g., 211, National Hunger Hotline) 12.6 (40)

Refer to a trained staff member 12.3 (39)

Provide onsite application assistance for SNAP 11.0 (35)

Refer to afterschool snack or meal sites 10.4 (33)

Provide emergency food (e.g., food box, food bag, snacks) 10.1 (32)

Refer to an onsite food program (e.g., food pharmacy or pantry) 8.5 (27)

Provide a food voucher or certificate (e.g., Veggie RX, grocery store gift card, farmer’s market coupon) 7.9 (25)

I don’t know what my practice/hospital does 6.3 (20)

Refer to child care meals program 5.0 (16)

Provide onsite access to free summer meals 4.1 (13)

We do not provide referrals or food at my practice/hospital 4.1 (13)

Other 3.5 (11)

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For patients identified as having food insecurity or at referral modality is verbally (46.0 percent), followed
risk for food insecurity, pediatricians make referrals by paper (33.3 percent), and then via a nurse or
for food assistance resources in a variety of different other nonclinical staff. More than one response
manners. As shown in Table 4, the most common was allowed.

TABLE 4: How Pediatricians Make Referrals for Patients Identified as

Having Food Insecurity (n=315)

Referral modality (multiple responses were permitted) Percent (n)

Verbally 46.0 (145)

Paper 33.3 (105)

Nurse, health worker, or other non-clinician staff members make the referral 28.6 (90)

Clinician makes referral 19.4 (61)

Introduce or walk family to another provider or service located in the same building 18.7 (59)

Send patient’s contact info to a partner organization for follow-up 18.4 (58)

Through the electronic medical record (EMR) 17.5 (55)

I don’t know what my practice/hospital does 12.4 (39)

Make appointment for family 7.3 (23)

We do not provide such referrals 6.0 (19)

Automated referral (e.g., fax) 1.6 (5)

Other 1.6 (5)

Pediatricians were asked how they know that a family they often do not know (81.1 percent), followed by the
has followed through on a food assistance referral. As family letting the pediatrician know (28.8 percent).
shown in Figure 8, the overwhelming majority report that

FIGURE 8: How Do You Know Families Follow Through on Referrals? (n=312)

90%
81.1%
80%

70%

60%

50%

40%
28.8%
30%

20%

10% 6.1% 5.4% 2.2%

0%
Family lets us know Provider/service Noted in EMR Often don’t know Other
informs us

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CONCLUSION
The pediatric community is well-positioned — as a body SNAP and WIC, and many refer patients to SNAP
of trusted experts who regularly interact with children (49.1 percent) and WIC (55.0 percent). Nearly half of the
and their families — to identify food insecurity and to surveyed pediatricians report making referrals for food
take actions to help address food insecurity and its assistance verbally. The overwhelming majority report
harmful impacts. The 327 practicing pediatricians caring not knowing if a family follows through on a referral.
for children who completed this survey overwhelmingly Time constraints and lack of knowledge or availability
agree that it is important to screen for food insecurity of resources are the two most common barriers to
given its harmful impacts on child health. However, screening.
significant gaps were revealed in terms of confidence
The results of this survey reinforce how pediatricians
levels among respondents in addressing food insecurity:
view addressing food insecurity as an integral, important,
18.6 percent of pediatricians felt unprepared to screen,
and critical part of patient health care. The findings of
and 21.7 percent felt unprepared to intervene.
the survey reveal that most pediatricians are screening
Seventy-four percent of the respondents report that they families for food insecurity. Despite this good news,
screen some or all of their patients for food insecurity, however, work remains to develop consistent protocols
although screening varied significantly by tool, timing, for screening patients, utilizing standardized tools,
and modality. In terms of intervening on behalf of patients sharing resources, better connecting patients to
identified as having food insecurity or at risk of food nutrition programs, and tracking the uptake of these
insecurity, almost all of the pediatricians strongly agree vital nutritional supports.
or agree that patients should be referred to

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