March 2022

In This Issue: HSR&D Research on Social Determinants
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Implementing a VHA-Community Partnered Intervention to Address Food Insecurity

Feature Article

Takeaway: This study will evaluate current approaches to identifying and assisting Veterans experiencing food insecurity. Investigators also will work to identify and pilot test strategies to integrate VA-community partnered interventions to screen and address food insecurity in clinical practice.

Food insecurity has been associated with a wide range of adverse health outcomes, as well as delayed or missed care, increased acute care utilization, and higher healthcare costs. Concerningly, food insecurity is frequently under-recognized in clinical settings. Prior research also has shown that clinicians and other care team members often feel ill-equipped to address food insecurity even after it has been identified. As such, there is a critical need to determine how to most effectively connect Veterans who are experiencing food insecurity with resources and referrals to relevant VA and community services.

In October 2017, VA launched a national food insecurity clinical reminder intended to screen all non-institutionalized Veterans receiving VA healthcare. However, little is known about Veteran populations at highest risk for food insecurity; variation in screening across VA sites; how sites respond when a Veteran screens positive for food insecurity; or what VA practices following a positive screen best improve Veterans’ food security status, experiences of care, and health outcomes.

This Career Development Award (October 2020 – September 2025) employs a multi-stage mixed-methods framework to address these knowledge gaps. Specific study aims include:

• Examine variations across VA Medical Centers (VAMCs) nationally in implementation of the food insecurity clinical reminder and characterize implementation experiences and community referral processes.
• Understand Veterans’ experiences of food insecurity and their interactions with VA and community resources following a positive screen.
• Develop and pilot test an intervention model to optimize screening and referral processes for connecting Veterans experiencing food insecurity to relevant VA and community resources.

Methods

Aim 1 includes analyses of national VA electronic health record data, as well as interviews with key leadership and frontline staff at eight VAMCs across the country. Aim 2 uses longitudinal interviews with a subset of Veterans who screen positive for food insecurity across the same eight VAMCs. Aim 3 will design and test the feasibility and acceptability of a VA-community partnered intervention.

Findings

Early findings show that of the roughly 3.3 million Veterans screened for food insecurity in the first 18 months following implementation of the VA food insecurity clinical reminder, more than 44,000 were identified as food insecure on their initial screen (1% of men; 2% of women). Veterans of color and women were at significantly higher risk for food insecurity. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation, and those with housing instability also had higher odds of food insecurity, as did Veterans with a BMI <18.5, diabetes, depression, and PTSD. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (49% vs. 6%).

Of note, the prevalence of food insecurity identified by this early work is markedly lower than rates found in prior studies. This may reflect differences in the single-item question used in the VA food insecurity clinical reminder during the period of these analyses, compared with other studies. In April 2021, which post-dates the findings from this initial study, VA updated the food insecurity clinical reminder to use a two-question instrument that has been validated to assess risk for food insecurity in clinical settings. Current work is exploring how the prevalence and correlates of food insecurity identified within VA may change with this new instrument.

Other early findings include significant variation in rates of positive screens across individual VA medical facilities, which likely reflects several factors including both geographical variation in the community-level prevalence of food insecurity, as well as facility-level differences in screening practices and populations of Veterans served. Additionally, although the VA food insecurity clinical reminder questions and follow-up prompts are uniform across VA medical centers, there is local variation in who administers the screening (e.g., clinician, nurse, medical assistant, social worker, dietitian) and how.

Anticipated Impact

Findings will lay the foundation for a future multi-site trial of the piloted intervention, and help inform evidence-based best practices for addressing food insecurity both within and outside VA.

Alicia Cohen, MD, MSc, FAAFP

Principal Investigator: Alicia Cohen, MD, MSc, FAAFP, is a Core Investigator at the HSR&D Center of Innovation in Long-Term Services and Supports in Providence, RI, and a Primary Care Provider at the VA Providence Homeless PACT (Patient Aligned Care Team) and Women’s Health PACT.

Publications

Cohen AJ, Dosa DM, Rudolph JL, et al. Risk factors for Veteran food insecurity: Findings from a National US Department of Veterans Affairs Food Insecurity Screener. Public Health Nutrition. 2021:1-10.

View study abstract