BACKGROUND:

Food insecurity (FI) remains a major public health problem. With the rise in suburban poverty, a greater understanding of parents’ experiences of FI in suburban settings is needed to effectively screen and address FI in suburban practices.

METHODS:

We conducted 23 semistructured interviews with parents of children <4 years of age who presented for well-child care in 6 suburban pediatric practices and screened positive for FI. In the interviews, we elicited parents’ perceptions of screening for FI, how FI impacted the family, and recommendations for how practices could more effectively address FI. All interviews were audio recorded and transcribed. We used a modified grounded theory approach to code the interviews inductively and identified emerging themes through an iterative process. Interviews continued until thematic saturation was achieved.

RESULTS:

Of the 23 parents interviewed, all were women, with 39% white and 39% African American. Three primary themes emerged: Parents expressed initial surprise at screening followed by comfort discussing their unmet food needs; parents experience shame, frustration, and helplessness regarding FI, but discussing FI with their clinician helped alleviate these feelings; parents suggested practices could help them more directly access food resources, which, depending on income, may not be available to them through government programs.

CONCLUSIONS:

Although most parents were comfortable discussing FI, they felt it was important for clinicians to acknowledge their frustrations with FI and facilitate access to a range of food resources.

What’s Known on This Subject:

Increasing research has identified strategies to address food insecurity (FI) in urban settings, but less is known in suburban settings. To effectively address FI in suburban practices, a greater understanding of families’ experiences and perceptions of FI screening is needed.

What This Study Adds:

Suburban parents were comfortable discussing FI with clinicians. Parents felt clinicians should recognize their feelings of frustration with FI and frame screening around the possibility of offering support, ideally by helping to streamline access to food.

Food insecurity (FI), the lack of consistent access to enough food for an active and healthy life, is a major public health problem.1,3 Households with children are at higher risk, and 16.6% of US households with children suffer from FI.3,4 Numerous studies have found that FI is an important social determinant of health (SDH) associated with negative child outcomes.4,9 Given the prevalence and potential negative consequences of FI, the American Academy of Pediatrics (AAP) recommends that all clinicians screen and address FI during routine visits.10 

Although clinicians recognize the importance of addressing families’ unmet social needs, few routinely address FI or other SDH.11,14 Strategies have been developed from growing research for addressing FI in urban primary care practices, and families have been accepting of these programs.15,22 Little is known about parents’ perceptions of screening in suburban practices, where differences in parents’ or community resources may limit the generalizability of strategies implemented in urban practices.23,25 This lack of understanding is important, because poverty has increased in suburban communities at a faster rate than urban or rural communities over the last decade, and nearly half of pediatricians practice in the suburbs.26,28 

To effectively address families’ needs and avoid unintended consequences of screening,29,30 a greater understanding of families’ experiences with FI and perceptions of how to address FI in suburban practices is required. We conducted this study to determine parents and/or guardians’ perceptions of FI screening in suburban pediatric practices.

This qualitative study was part of a prospective study in which we implemented FI screenings in 6 suburban pediatric practices within the Children’s Hospital of Philadelphia Pediatric Research Consortium, a primary care practice–based research network.31 These practices were purposely selected because of their varied patient populations and settings in the counties surrounding Philadelphia. All of the practices used the EpicCare electronic health record (EHR); (Verona, WI). The AAP-recommended 2-item FI screen was embedded in the 2-, 15-, and 36-month well-child documentation in the EHR.10 Clinicians at participating practices screened parents whose children were presenting for one of these visits. An affirmative response to either question is considered a positive screen, and the results of the screen were recorded in the EHR. There were a total of 122 families that screened positive for FI in the study and were eligible for interviews. Families who screened positive for FI were eligible to be referred to a community partner who assisted with applying for Supplemental Nutrition Assistance Program (SNAP).

All parents and/or guardians were eligible for inclusion in this study if they: (1) screened positive for FI, (2) were 18 years of age or older, and (3) were English speakers. Parents who screened positive for FI were identified through weekly review of the EHR. Any family who screened positive for FI in the larger study (N = 122) and met the inclusion criteria was eligible to participate in this study. Of the 23 parents who participated in interviews, 15 consented to referral to our community partner and 8 declined. A study team member contacted parents by phone to explain the study purpose and procedures, review eligibility criteria, and determine parents’ interest in participating. Parents who agreed were scheduled for an individual interview by phone. Parents received a $25 gift card for participating in interviews.

Through a detailed review of the literature, consultation with outside experts, and input from the practice-based research network parent board, we developed an interview guide. The guide was designed to elicit parents’ perceptions of FI screening in primary care practices, assess how FI affected the family, and seek recommendations for how practices could address FI. With verbal informed consent, we conducted 23 open-ended, semistructured individual interviews by phone between February 2015 and June 2016. A researcher trained in qualitative interview techniques conducted all interviews by using the guide. At the time of the interview, parents reported their age, race/ethnicity, highest education level achieved, relationship to the child, the number of adults and children who lived in the home, and whether anyone in the household was currently receiving SNAP or Supplemental Nutrition Program for Women, Infants, and Children (WIC).

All interviews were digitally recorded, transcribed, deidentified, and entered into QSR NVivo 10 software (QSR International, Burlington, MA) for data analysis. We used a modified grounded theory approach to code the interviews inductively without using a previous set of codes. A coding scheme and dictionary were developed by using the first 5 interviews, and codes were evaluated and revised after each coding session, which is consistent with a constant comparative method.32 Two researchers coded each transcript independently and assigned codes to specific comments in each transcript on the basis of the coding scheme. Through an iterative process, the team regularly reviewed codes, identified emerging themes, and resolved any discrepancies through consensus. Interviews continued until thematic saturation was reached. The Children’s Hospital of Philadelphia institutional review board deemed this study of interviews with adults exempt from human subjects research.

We conducted 23 interviews with food-insecure parents. All 23 participants were women (22 mothers, 1 grandmother) with a mean age of 31 years. The majority of participants were white or African American. Four reported receiving only SNAP, 4 only received WIC, 10 received SNAP and WIC, and 5 were not receiving either (Table 1). We identified 3 primary themes. We provide representative quotations for these themes below, with additional supporting quotations in Table 2.

TABLE 1

Study Participants’ Characteristics

Parents/Guardians (N = 23)
Relationship to child  
 Mother 22 (96%) 
 Grandmother 1 (4%) 
Age, mean (range) 31 y (20–52 y) 
No. people in the home, mean (range) 4.1 (2–6) 
No. children in the home, mean (range) 2.5 (1–5) 
Race  
 White 9 (39%) 
 African American 9 (39%) 
 Hispanic 2 (9%) 
 Other 3 (13%) 
Education  
 Less then college 6 (23%) 
 Some college 9 (39%) 
 College graduate 8 (35%) 
Currently receiving SNAP, yes 14 (61%) 
Currently receiving WIC, yes 14 (61%) 
Clinic  
 1 6 (26%) 
 2 3 (13%) 
 3 1 (4%) 
 4 8 (35%) 
 5 4 (17%) 
 6 1 (4%) 
Parents/Guardians (N = 23)
Relationship to child  
 Mother 22 (96%) 
 Grandmother 1 (4%) 
Age, mean (range) 31 y (20–52 y) 
No. people in the home, mean (range) 4.1 (2–6) 
No. children in the home, mean (range) 2.5 (1–5) 
Race  
 White 9 (39%) 
 African American 9 (39%) 
 Hispanic 2 (9%) 
 Other 3 (13%) 
Education  
 Less then college 6 (23%) 
 Some college 9 (39%) 
 College graduate 8 (35%) 
Currently receiving SNAP, yes 14 (61%) 
Currently receiving WIC, yes 14 (61%) 
Clinic  
 1 6 (26%) 
 2 3 (13%) 
 3 1 (4%) 
 4 8 (35%) 
 5 4 (17%) 
 6 1 (4%) 
TABLE 2

Parents’ Perceptions of FI Screening in Suburban Practices

1. Parents Expressed Initial Surprise at FI Screening Followed by Comfort Discussing Families’ Unmet Food Needs 
Representative quotations “The food question coming up in an appointment does give you pause. It’s going to worry you. But if that is also coupled with like a liaison being in the office, then maybe it would be more like oh, well, we have help to offer you if you need it.” 
“I was really kind of shocked because when she did ask me, I was struggling at the time. I didn’t want to lie, but I didn’t want to be completely honest because I didn’t want her to think I was neglecting my child.” 
2. Parents Experience Shame, Frustration, and Helplessness Regarding FI, but Discussing FI With Their Clinician Helps Alleviate These Feelings 
 Shame and embarrassment resulting from an inability to provide food for their children 
Representative quotations “[My children] will ask for things, and I just have to tell them that we don’t have the money for it. Or they’ll ask for food and I don’t have it in the house because I have to wait until we have money again to get it. So I know it frustrates them.” 
“As a parent, it’s horrible. Because you don’t want to see your children in need of anything. Of course, I keep it together for them.” 
“It’s so hard, because even just walking in [the food pantry], you don’t want to be seen. What if it gets out that you’ve got to go to the food pantry? I know it’s silly, because you shouldn’t be proud. But we’re all taught that you should prepare yourself for kids and life. I really wasn’t prepared for this.” 
 Frustration with inadequate benefits or not qualifying for benefits 
Representative quotations “It’s difficult, especially with providing milk for her right now. She’s on WIC, and that runs out. Sometimes I’ve spent my last $5 on a half-gallon of milk for her.” 
“Even programs like WIC, they give you $6.00 for fruits and vegetables. And I’m like, are you kidding me? So I can get a bag of grapes and a box of strawberries.” 
“Obviously, we were hoping to qualify for [SNAP], because we are literally going into debt almost $1000 a month between paying our mortgage and everything else. And we’re not living high on the hog, we’re not taking vacations.” 
 Helplessness and tension about family finances 
Representative quotations “Every month our rent is late. Every month it’s a struggle. It’s just financially everything at this point is a struggle. We have a car payment we’re a month and half late on. It’s just trying to keep afloat is the struggle.” 
“We don’t have the extra money throughout the month to buy food. Basically what we make pays rent and hopefully the utilities. So it’s definitely tough.” 
“Because we’re middle-class, there are no resources for us. My husband makes too much. But they don’t take into consideration the other costs we have with a child with disabilities, with me having injuries, with me not being able to work.” 
 Discussing FI with their pediatrician did relieve some of these feelings of shame, frustration, and helplessness 
Representative quotations “I like that it came up in my son’s doctor’s appointment with his doctor that I trust.” 
“I was a little shocked because usually they don’t ask that. But it gave me an opportunity to say something to somebody who might be able to make a difference.” 
3. Parents Suggested Practices Could Help Them More Directly Access Food Resources, Which, Depending on Income, May Not Be Available to Them Through Government Programs 
Representative quotations “I know a lot of people might not know about food banks, but they should print out little papers saying there’s places that you can go and you can get food. Just leave it out on the desk and say, please take one.” 
“Sometimes when I have to go for my 6-month review [at WIC], they don’t tell me what I need to bring to the next appointment. I’m just supposed to know. And that’s really frustrating.” 
“I think a doctor should be able to write something to a government agency, like WIC, and say look, this family is not bringing in enough for food.” 
1. Parents Expressed Initial Surprise at FI Screening Followed by Comfort Discussing Families’ Unmet Food Needs 
Representative quotations “The food question coming up in an appointment does give you pause. It’s going to worry you. But if that is also coupled with like a liaison being in the office, then maybe it would be more like oh, well, we have help to offer you if you need it.” 
“I was really kind of shocked because when she did ask me, I was struggling at the time. I didn’t want to lie, but I didn’t want to be completely honest because I didn’t want her to think I was neglecting my child.” 
2. Parents Experience Shame, Frustration, and Helplessness Regarding FI, but Discussing FI With Their Clinician Helps Alleviate These Feelings 
 Shame and embarrassment resulting from an inability to provide food for their children 
Representative quotations “[My children] will ask for things, and I just have to tell them that we don’t have the money for it. Or they’ll ask for food and I don’t have it in the house because I have to wait until we have money again to get it. So I know it frustrates them.” 
“As a parent, it’s horrible. Because you don’t want to see your children in need of anything. Of course, I keep it together for them.” 
“It’s so hard, because even just walking in [the food pantry], you don’t want to be seen. What if it gets out that you’ve got to go to the food pantry? I know it’s silly, because you shouldn’t be proud. But we’re all taught that you should prepare yourself for kids and life. I really wasn’t prepared for this.” 
 Frustration with inadequate benefits or not qualifying for benefits 
Representative quotations “It’s difficult, especially with providing milk for her right now. She’s on WIC, and that runs out. Sometimes I’ve spent my last $5 on a half-gallon of milk for her.” 
“Even programs like WIC, they give you $6.00 for fruits and vegetables. And I’m like, are you kidding me? So I can get a bag of grapes and a box of strawberries.” 
“Obviously, we were hoping to qualify for [SNAP], because we are literally going into debt almost $1000 a month between paying our mortgage and everything else. And we’re not living high on the hog, we’re not taking vacations.” 
 Helplessness and tension about family finances 
Representative quotations “Every month our rent is late. Every month it’s a struggle. It’s just financially everything at this point is a struggle. We have a car payment we’re a month and half late on. It’s just trying to keep afloat is the struggle.” 
“We don’t have the extra money throughout the month to buy food. Basically what we make pays rent and hopefully the utilities. So it’s definitely tough.” 
“Because we’re middle-class, there are no resources for us. My husband makes too much. But they don’t take into consideration the other costs we have with a child with disabilities, with me having injuries, with me not being able to work.” 
 Discussing FI with their pediatrician did relieve some of these feelings of shame, frustration, and helplessness 
Representative quotations “I like that it came up in my son’s doctor’s appointment with his doctor that I trust.” 
“I was a little shocked because usually they don’t ask that. But it gave me an opportunity to say something to somebody who might be able to make a difference.” 
3. Parents Suggested Practices Could Help Them More Directly Access Food Resources, Which, Depending on Income, May Not Be Available to Them Through Government Programs 
Representative quotations “I know a lot of people might not know about food banks, but they should print out little papers saying there’s places that you can go and you can get food. Just leave it out on the desk and say, please take one.” 
“Sometimes when I have to go for my 6-month review [at WIC], they don’t tell me what I need to bring to the next appointment. I’m just supposed to know. And that’s really frustrating.” 
“I think a doctor should be able to write something to a government agency, like WIC, and say look, this family is not bringing in enough for food.” 

Approximately half of the parents reported initial surprise when clinicians screened the family for FI because parents had not considered the questions a routine part of care. Accompanying these feelings of surprise, parents raised concerns that clinicians may refer them to child protective services. As 1 mother reported, “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.” To make parents more comfortable, parents suggested immediately clarifying that screening would be used to offer support and not to refer for child protective services.

Despite these initial feelings of surprise, most parents expressed comfort discussing FI with their clinician. These participants acknowledged that some parents may get offended, but they felt screening was important for the clinician to do because of the potential effect FI could have on their children. Reflecting a common sentiment, another mother stated that her doctor asking about FI was “kind of scary because maybe they’ll call Children’s Services, but if the [clinician is] helping us out, then yeah the office should be asking [about FI].” Three participants suggested screening as part of a form as opposed to asking parents directly, which they felt would facilitate more subtle assessments and elicit more honest responses.

In almost all interviews, parents felt clinicians screening for FI should be aware of the feelings of shame, frustration, and helplessness that accompany FI. We identified 4 subthemes within this primary theme.

Shame and Embarrassment Resulting From an Inability to Provide Food for Their Children

Some parents wanted their clinicians to be aware of the shame or embarrassment parents feel about not being able to provide consistent access to food for their children. One mother reported that FI “doesn’t feel good. Because you’re here trying to be a good parent and provide for your kids and you feel like a failure.” Other parents discussed the shame of having to rely on family or other sources, such as food pantries, to provide food. Another mother described her feelings of having to ask her family for support and stated that asking her family members for help was “hard because I always say I’ll pay them back. And I really never get to. I hate saying I will and never do.” Several parents discussed trying to protect their children from FI by making sure their children ate first or not discussing food or financial issues in front of their children. These parents recognized that FI could still have a negative impact on their children. Yet another parent described, “I can say it won’t affect [my child], but it’s still gonna have a negative impact on him because he knows mommy is worried and stressed out.”

Frustration With Inadequate Benefits or Not Qualifying for Benefits

Parents felt both appreciation and frustration with nutrition assistance programs such as SNAP and WIC. Some parents were appreciative of the assistance they received from these benefits. “I love the day I get my food stamps,” one mother said. “I get so excited. My mind can be at ease for a little bit.” However, several parents noted frustration with office staff or the amount of paperwork required to receive benefits. Nine parents reported their biggest concern was inadequate benefits. “We do get food stamps, and they last us 2 or 3 weeks,” one parent stated, “so the last week is a struggle. I know that [SNAP is] not meant to be all your food, but for some of us it really is.” Eight parents reported frustration with earning too much income to qualify for assistance but still being unable to provide food. As one mother reported, “What happens is we make too much for WIC and any form of public assistance, but we don’t make enough to cover our bills. I have my master’s degree, but unless I have a teaching contract, it doesn’t pay for me to be working because of child care costs.”

Helplessness and Tension About Family Finances

Several parents wanted clinicians to know about their feelings of helplessness after recently becoming food insecure. Parents had not expected to be in their current financial situation and felt that bills outside their control led to their financial constraints. “My husband is working 2 full-time jobs,” a mother lamented, “but it’s still not enough to pay our bills. We got our home at the top of the real estate bubble. When I stopped working [when we had children], then we were feeling the crunch of having to pay the mortgage and all the bills.” Several parents noted that they felt helpless trying to address their financial constraints. As another parent noted, “I don’t think anything can be done. We’re paying more and more. It’s more money that we don’t have.”

Several parents expressed that helplessness about their finances led to tension in the home. Three parents noted a tension between competing priorities. One mother noted, “It’s hard because you have so many bills. I have the baby. I have the vehicle, the car insurance. They are all a priority.” Another mother reported that the tension in the home manifested as arguments between her and her husband. “My husband was upset with me yesterday for a $100 grocery bill,” she stated, “and I just bought fruits, vegetables, and basic stuff. I wasn’t getting gourmet ingredients. So there’s a lot of tension.”

Discussing FI With Their Pediatrician Did Relieve Some of These Feelings of Shame, Frustration, and Helplessness

Several parents reported that discussing FI with their pediatrician partially alleviated some of the feelings of shame, frustration, and helplessness. These parents discussed how they trusted their clinician. Talking to their clinician helped them recognize other families were struggling with FI and the practice cared about the broader social issues affecting families. One mother stated, “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.” Another mother reported, “It was just good to find that someone cared.”

Although most parents had not considered their pediatrician’s office as a resource, parents suggested clinicians could address FI by helping families access resources. For those families who are eligible and not receiving benefits, assistance could be provided by helping families apply for SNAP and WIC. Several parents noted the difficulty in understanding how to apply and described the process as “daunting.” One participant described her frustration the first time she tried to apply for SNAP and stated, “What happens is you call one person and they send you to someone else and that person sends you to someone else. [The clinic] referring you to someone that either has the resources or knows who to refer you to would be useful.” Despite this frustration, even when prompted, those interviewed did not have specific suggestions for a referral workflow through primary care that would be most helpful.

In addition, most participants suggested increasing the amount of information about local resources (eg, food pantries). Parents felt this information was particularly important for families who did not qualify for public assistance or families who remained food insecure despite receiving SNAP and/or WIC. One participant thought the clinic “could have more information about where to go if [families] are having trouble. If a family says yes [to the FI screen] then you hand them the information. Especially if they can’t qualify for food stamps.”

The AAP recommends that all pediatricians screen and address FI during routine visits,10 but little research is available about screening in suburban pediatric practices. To provide a family-centered approach and effectively address FI,29,30 a greater understanding of families’ experiences and needs in suburban settings is required. This study evaluated parents’ perceptions of FI screening in 6 suburban practices and found that, despite being initially surprised about screening, most parents felt comfortable discussing unmet food needs with clinicians. Parents wanted clinicians to be aware of the feelings of shame, frustration, and helplessness that FI elicits. To more effectively address FI, parents suggested that practices could help them access food resources, which, depending on income, may not be available to them through government programs.

Research from previous studies have found that clinicians are often hesitant to screen for FI and psychosocial risk factors because of concerns about offending families.14,33 In this study, we found that although most parents were initially surprised, they ultimately felt comfortable discussing FI with clinicians and talking to their clinician alleviated some of the feelings of shame parents had about FI. Parents’ main concern with screening was being reported to child protective services, a concern noted in previous studies.15,19 Immediately clarifying and assuring families that screening is not punitive but is being done to provide support could improve parent comfort in responding to screening questions. Because parents often arrive at the clinic with feelings of shame and embarrassment, asking questions in a nonjudgmental, supportive manner and understanding if parents are comfortable discussing FI while their children are present is also important. Researchers for previous studies have used trainings with clinicians to improve interactions between parents and clinicians regarding SDH screening.13,15,34 Opportunities to learn techniques for nonjudgmental communication during medical training or through quality improvement programs may be helpful in supporting effective screening. Also, as screening programs expand to more practices and an increasing number of visits,10,26 families may expect FI screening as a routine part of care. Integrating FI questions in the EHR could help facilitate routine screening,35,36 and primary care practices or the AAP could work with EHR companies to include FI screens as a default process in previsit screeners or well-child templates.

In talking to suburban parents, pediatricians should be aware of parents’ mixed feelings about SNAP and WIC. Parents were appreciative of the support they received from these programs, which is consistent with findings that SNAP and WIC decrease FI.10,37,40 At the same time, parents reported frustration that SNAP and WIC benefits were not adequate. Advocacy to change the frequency with which families receive benefits (biweekly instead of monthly) or providing financial counseling,41 in addition to assisting families with applying for SNAP and WIC, may be needed to more effectively address FI for suburban families. Another issue raised by parents was frustration over not being eligible for benefits and feeling helpless about what else families could do. Over the last decade, the number of near-poor individuals has increased in the suburbs, and many families may be ineligible for benefits despite being food insecure.27,28 Nationally, 30% of food-insecure households have incomes >185% of the federal poverty level, which is the income eligibility cutoff for many government programs.10 In this context, providing information about local resources with less stringent eligibility requirements may be most helpful.

To effectively address FI in suburban practices, parents suggested practices could help them directly access food resources. Specially, parents told us that practices could be most helpful by providing information about who to contact to apply for benefits, what documentation to bring to an appointment with WIC or SNAP, and a list of locations and transportation routes (public and private) for food pantries. Even when prompted, parents did not report a specific preference for how clinics should provide this information, but advocating for families who may have difficulty navigating the system or colocating services at the practices may be needed.19,21 In terms of food resources, studies in urban settings have revealed that providing lists of local resources can increase the number of services families receive.18,42 Because suburban families are often unaware of local resources and suburban communities often have fewer resources available that address poverty,25,28 providing information about local resources may be particularly important in suburban practices.

Several limitations of our study warrant consideration. First, although our sample size was sufficient to reach saturation on qualitative themes,43 external validity is limited because of our modest sample and lack of parents with limited English proficiency. Second, all caregivers were identified in the suburbs of 1 major metropolitan area. Although the practices were purposely selected because of their varied locations and the diversity of their patient populations, results may not generalize to other populations and settings. Third, we only interviewed families who self-identified as food insecure. Some families may not have felt comfortable disclosing FI with their child’s clinician and screened negative for FI. Understanding those families’ perceptions of screening is particularly important for future research.

To effectively address FI in suburban practices and provide family-centered care, a greater understanding of parents’ experiences with FI in suburban communities is needed. We found that suburban parents were comfortable discussing unmet food needs with their clinician but felt it was important for clinicians to clarify that screening was to offer support and acknowledge the feelings of shame that accompany FI. Parents suggested practices should help them directly access food resources, which, depending on income, may not be available to them through government programs.

     
  • AAP

    American Academy of Pediatrics

  •  
  • EHR

    electronic health record

  •  
  • FI

    food insecurity

  •  
  • SDH

    social determinants of health

  •  
  • SNAP

    Supplemental Nutrition Assistance Program

  •  
  • WIC

    Supplemental Nutrition Program for Women, Infants, and Children

Dr Palakshappa conceptualized and designed the study, conducted data collection and the initial analyses, and drafted the initial manuscript; Drs Doupnik and Vasan and Ms Seifu assisted in data collection and analyses and critically reviewed and revised the manuscript; Drs Khan, Feudtner, and Fiks contributed in conceptualizing and designing the study, assisted in the analyses, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: This study was supported by the 2015 Academic Pediatric Association Bright Futures 2015 Young Investigator Award Program and by the Maternal and Child Health Bureau in partnership with the American Academy of Pediatrics (U04MC07853-03).

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-0319.

We want to thank the network of primary care clinicians, their patients, and their families for their contribution to this project. Clinical research was facilitated through the Pediatric Research Consortium at The Children’s Hospital of Philadelphia. We also want to thank the University of Pennsylvania Mixed Methods Research Laboratory for assistance with analyzing the data.

1
Hamilton
WL
,
Cook
JT
,
Thompson
WW
, et al
.
Household Food Security in the United States in 1995: Summary Report of the Food Security Measurement Project
.
Washington, DC
:
U.S. Department of Agriculture, Food and Consumer Service
;
1997
2
Gundersen
C
.
Food insecurity is an ongoing national concern.
Adv Nutr
.
2013
;
4
(
1
):
36
41
[PubMed]
3
Coleman-Jensen
A
,
Rabbitt
MP
,
Gregory
CA
,
Singh
A
.
Household Food Security in the United States in 2015, ERR-215
.
Washington, DC
:
U.S. Department of Agriculture, Economic Research Service
;
2016
4
Gundersen
C
,
Kreider
B
.
Bounding the effects of food insecurity on children’s health outcomes.
J Health Econ
.
2009
;
28
(
5
):
971
983
[PubMed]
5
Cook
JT
,
Frank
DA
,
Berkowitz
C
, et al
.
Food insecurity is associated with adverse health outcomes among human infants and toddlers.
J Nutr
.
2004
;
134
(
6
):
1432
1438
[PubMed]
6
Cook
JT
,
Frank
DA
.
Food security, poverty, and human development in the United States.
Ann N Y Acad Sci
.
2008
;
1136
:
193
209
[PubMed]
7
Rose-Jacobs
R
,
Black
MM
,
Casey
PH
, et al
.
Household food insecurity: associations with at-risk infant and toddler development.
Pediatrics
.
2008
;
121
(
1
):
65
72
[PubMed]
8
Jyoti
DF
,
Frongillo
EA
,
Jones
SJ
.
Food insecurity affects school children’s academic performance, weight gain, and social skills.
J Nutr
.
2005
;
135
(
12
):
2831
2839
[PubMed]
9
Alaimo
K
,
Olson
CM
,
Frongillo
EA
.
Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents.
J Nutr
.
2002
;
132
(
4
):
719
725
[PubMed]
10
Council on Community Pediatrics
;
Committee on Nutrition
.
Promoting food security for all children.
Pediatrics
.
2015
;
136
(
5
). Available at: www.pediatrics.org/cgi/content/full/136/5/e1431
[PubMed]
11
Goldstein
D
,
Holmes
J
. Physicians’ daily life report. Available at: www.rwjf.org/content/dam/web-assets/2011/11/2011-physicians–daily-life-report. Accessed December 12, 2016
12
Garg
A
,
Butz
AM
,
Dworkin
PH
,
Lewis
RA
,
Serwint
JR
.
Screening for basic social needs at a medical home for low-income children.
Clin Pediatr (Phila)
.
2009
;
48
(
1
):
32
36
[PubMed]
13
Klein
MD
,
Kahn
RS
,
Baker
RC
,
Fink
EE
,
Parrish
DS
,
White
DC
.
Training in social determinants of health in primary care: does it change resident behavior?
Acad Pediatr
.
2011
;
11
(
5
):
387
393
[PubMed]
14
Hoisington
AT
,
Braverman
MT
,
Hargunani
DE
,
Adams
EJ
,
Alto
CL
.
Health care providers’ attention to food insecurity in households with children.
Prev Med
.
2012
;
55
(
3
):
219
222
[PubMed]
15
Burkhardt
MC
,
Beck
AF
,
Conway
PH
,
Kahn
RS
,
Klein
MD
.
Enhancing accurate identification of food insecurity using quality-improvement techniques.
Pediatrics
.
2012
;
129
(
2
). Available at: www.pediatrics.org/cgi/content/full/129/2/e504
[PubMed]
16
Fleegler
EW
,
Lieu
TA
,
Wise
PH
,
Muret-Wagstaff
S
.
Families’ health-related social problems and missed referral opportunities.
Pediatrics
.
2007
;
119
(
6
). Available at: www.pediatrics.org/cgi/content/full/119/6/e1332
[PubMed]
17
Hassan
A
,
Scherer
EA
,
Pikcilingis
A
, et al
.
Improving social determinants of health: effectiveness of a web-based intervention.
Am J Prev Med
.
2015
;
49
(
6
):
822
831
[PubMed]
18
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT.
Pediatrics
.
2015
;
135
(
2
). Available at: www.pediatrics.org/cgi/content/full/135/2/e296
[PubMed]
19
Gottlieb
LM
,
Hessler
D
,
Long
D
, et al
.
Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial.
JAMA Pediatr
.
2016
;
170
(
11
):
e162521
[PubMed]
20
Beck
AF
,
Tschudy
MM
,
Coker
TR
, et al
.
Determinants of health and pediatric primary care practices.
Pediatrics
.
2016
;
137
(
3
):
e20153673
[PubMed]
21
Fierman
AH
,
Beck
AF
,
Chung
EK
, et al
.
Redesigning health care practices to address childhood poverty.
Acad Pediatr
.
2016
;
16
(
suppl 3
):
S136
S146
[PubMed]
22
Colvin
JD
,
Bettenhausen
JL
,
Anderson-Carpenter
KD
,
Collie-Akers
V
,
Chung
PJ
.
Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents.
Acad Pediatr
.
2016
;
16
(
2
):
161
167
[PubMed]
23
Felland
LE
,
Lauer
JR
,
Cunningham
PJ
.
Suburban poverty and the health care safety net.
Res Brief
.
2009
;(
13
):
1
12
24
Feinglass
J
,
Nonzee
NJ
,
Murphy
KR
,
Endress
R
,
Simon
MA
.
Access to care outcomes: a telephone interview study of a suburban safety net program for the uninsured.
J Community Health
.
2014
;
39
(
1
):
108
117
[PubMed]
25
Murphy
AK
,
Wallace
D
.
Opportunities for making ends meet and upward mobility: differences in organizational deprivation across urban and suburban poor neighborhoods.
Soc Sci Q
.
2010
;
91
(
5
):
1164
1186
[PubMed]
26
Council on Community Pediatrics
.
Poverty and child health in the United States.
Pediatrics
.
2016
;
137
(
4
):
e20160339
[PubMed]
27
Murphy
AK
,
Allard
SW
.
The changing geography of poverty.
Focus
.
2015
;
32
(
1
):
19
23
28
Kneebone
E
,
Lou
C
.
Suburban—and Poor: The Changing Landscape of Race and Poverty in the U.S.
Planning
.
2014
:
6
:
17
-
21
29
Cheng
TL
,
Emmanuel
MA
,
Levy
DJ
,
Jenkins
RR
.
Child health disparities: what can a clinician do?
Pediatrics
.
2015
;
136
(
5
):
961
968
[PubMed]
30
Garg
A
,
Boynton-Jarrett
R
,
Dworkin
PH
.
Avoiding the unintended consequences of screening for social determinants of health.
JAMA
.
2016
;
316
(
8
):
813
814
[PubMed]
31
Fiks
AG
,
Grundmeier
RW
,
Margolis
B
, et al
.
Comparative effectiveness research using the electronic medical record: an emerging area of investigation in pediatric primary care.
J Pediatr
.
2012
;
160
(
5
):
719
724
[PubMed]
32
Boeije
H
.
A purposeful approach to the constant comparative method in the analysis of qualitative interviews.
Qual Quant
.
2002
;
36
(
4
):
391
409
33
Hochstein
M
,
Sareen
H
,
Olson
L
, et al
. Periodic survey #46: a comparison of barriers to the provision of developmental assessments and psychosocial screenings during pediatric health supervision. Available at: www.aap.org/en-us/professional-resources/Research/Pages/PS46_AcomparisonofBarrierstotheProvisionofDevelopmentalAssessmentsandpsychosocialscreeningsduringpediatrichealthsupervision.aspx. Accessed January 1, 2017
34
Klein
MD
,
Alcamo
AM
,
Beck
AF
, et al
.
Can a video curriculum on the social determinants of health affect residents’ practice and families’ perceptions of care?
Acad Pediatr
.
2014
;
14
(
2
):
159
166
[PubMed]
35
Beck
AF
,
Klein
MD
,
Kahn
RS
.
Identifying social risk via a clinical social history embedded in the electronic health record.
Clin Pediatr (Phila)
.
2012
;
51
(
10
):
972
977
[PubMed]
36
Henize
AW
,
Beck
AF
,
Klein
MD
,
Adams
M
,
Kahn
RS
.
A road map to address the social determinants of health through community collaboration.
Pediatrics
.
2015
;
136
(
4
). Available at: www.pediatrics.org/cgi/content/full/136/4/e993
[PubMed]
37
Frank
DA
,
Chilton
M
,
Casey
PH
, et al
.
Nutritional-assistance programs play a critical role in reducing food insecurity.
Pediatrics
.
2010
;
125
(
5
). Available at: www.pediatrics.org/cgi/content/full/125/5/e1267
[PubMed]
38
Mabli
J
,
Worthington
J
.
Supplemental nutrition assistance program participation and child food security.
Pediatrics
.
2014
;
133
(
4
):
610
619
[PubMed]
39
Nord
M
.
How much does the Supplemental Nutrition Assistance Program alleviate food insecurity? Evidence from recent programme leavers.
Public Health Nutr
.
2012
;
15
(
5
):
811
817
[PubMed]
40
Black
MM
,
Quigg
AM
,
Cook
J
, et al
.
WIC participation and attenuation of stress-related child health risks of household food insecurity and caregiver depressive symptoms.
Arch Pediatr Adolesc Med
.
2012
;
166
(
5
):
444
451
[PubMed]
41
Thornton
RL
,
Glover
CM
,
Cené
CW
,
Glik
DC
,
Henderson
JA
,
Williams
DR
.
Evaluating strategies for reducing health disparities by addressing the social determinants of health.
Health Aff (Millwood)
.
2016
;
35
(
8
):
1416
1423
[PubMed]
42
Garg
A
,
Butz
AM
,
Dworkin
PH
,
Lewis
RA
,
Thompson
RE
,
Serwint
JR
.
Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project.
Pediatrics
.
2007
;
120
(
3
):
547
558
[PubMed]
43
Guest
G
,
Bunce
A
,
Johnson
L
.
How many interviews are enough? An experiment with data saturation and variability.
Field Methods
.
2006
;
18
:
59
82

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.