LABUN:
Welcome to the first of our short explainers for the Hunger Vital Sign tool. This episode is the origin story for Hunger Vital Sign. I’m your host, Helen Labun, and to take us through the details, we have Richard Sheward, the Director of Innovative Partnerships at Children’s HealthWatch.
SHEWARD:
I'm Richard Sheward, Director of Innovative Partnerships at Children's HealthWatch
LABUN:
To avoid confusion down the road let’t note right now that Hunger Vital Sign began as a screening tool for young children. As the name “Children’s HealthWatch” implies. Over the years, it expanded to become a general tool for all age groups. How did it expand? You’ll have to tune in to future episodes for that. For now, let’s start with Richard recalling one of the best years of the late 20th century, 1998.
SHEWARD:
Children’s HealthWatch was founded in 1998, initially as a research project to understand how economic and household hardships, namely food insecurity, impact the health and development of very young children and their caregivers. Over the years, children's health watch developed a research base, demonstrating that food insecurity in households with young children resulted in a myriad of negative health outcomes. And that there is a really important opportunity for, in this case, pediatricians, to identify families with young children who are at risk for food insecurity.
LABUN:
Now, we can think about Hunger Vital Sign in the context of a range of factors affecting our health, sometimes called social drivers of health, SDOH, or health-related social needs, HRSN. Although the tool we’re focused on for this series is specific to food insecurity, Richard’s group didn’t approach that factor in isolation for the families they worked with.
SHEWARD:
Children's HealthWatch employees trained interviewers who conducted a household level survey with caregivers and their young children under the age of three in either an acute emergency department setting or prior Mary care clinic setting. And the interview that takes place covers a wide range of topics from household level hardships, like food insecurity, housing instability, having trouble keeping the heat or lights on healthcare hardships, financial hardships. The survey asks about the child's health, the caregiver’s health - both physical health, as well as mental health - and public programs that the family may be participating in such as SNAP, formerly known as food stamps, WIC, housing subsidies, energy subsidies, and tax credit. And through these interviews, we're able to understand the connection between household hardships and health outcomes
LABUN:
Within all these details, we have food insecurity. A health provider would want to address this concern well before a child ever shows physical symptoms of malnutrition – and in fact the impacts of food insecurity may not appear until years or even decades later. To help early identification happen, food insecurity had another important attribute – it had a definition. From the U.S. Department of Agriculture, or USDA
SHEWARD:
So, there's a rich history behind the validated USDA food security survey module. The USDA household food security survey module, the HFSS or the USDA 18 item as it's often referred to, was developed in the 1990s. Essentially, it's considered the gold standard in assessing and determining the ranges of food insecurity from Food secure, high food security or marginal food security, to food insecurity, low food security, or very low food insecurity, very low food security
LABUN:
If you’re the USDA and trying to monitor what is happening with food access across the country, then it makes intuitive sense to have detailed ranges of food security and track changes in severity over time. It may not be quite as intuitive to think through these details when asking a patient whether or not they’re hungry – does that need a research team? Turns out, it does. We’re not talking about whether it’s time for lunch, here. What we’re really asking is whether there’s a sustained state of food uncertainty and diminished diet quality in the household that could lead to poor health consequences years down the road – and whether it’s a risk that the health care provider might be able to help address. How is a patient supposed to answer that without more guidance?
You have to think about the timeframe – maybe there’s enough food today, but that can change. Or quality - there may be enough food to eat, but maybe isn’t the right food to meet a growing child’s nutritional needs. And what happens if the children in a household get enough food, but the adults do not. There are long term health impacts around the stress and uncertainty of enough food. Then there’s the tendency to measure by comparison – the internal voice saying “I may not have the food I want for a healthy diet, but I know people worse off than me, so I shouldn’t complain.” And that’s before we even get into whether a question is phrased in a way that people feel comfortable providing honest answers, or perceive that there’s any point to it.
Considerations like these are why someone needed to do research connecting the USDA data, health, and the right questions to ask individual patients. Here enters the research team at the heart of this story.
SHEWARD:
All the credit for the development of the Hunger Vital Sign goes to doctors Erin Hager and Anna Quigg of the University of Maryland in Baltimore, as well as the Children's HealthWatch research team comprised of pediatricians, public health researchers, and child health policy experts together.
LABUN:
We’ve already noted that they had a research system in place for collecting household information.
SHEWARD:
This research group obtained interviewed data from over 30,000 families with young children over the course of time, between 1998 and 2005 in five cities across the U.S. We interviewed families who sought care in the emergency department or primary clinics in five U.S. cities.
LABUN:
John Cook, Principal Investigator from Children’s HealthWatch, described the conclusions of those interviews in a later book, writing: “this led to the troubling conclusion that . . . food insecurity is an ‘invisible epidemic’ of a widely prevalent and serious condition known to pose serious risks to child health and development.” But that’s research data. Just like the original USDA survey is a research tool.
Doing something about the invisible epidemic would require more than waiting for a study or a report describing what’s happening in aggregate. Children’s HealthWatch wanted providers to be able to know what was happening, right then, with the individuals in their exam room. For that, the team needed a tool that would be easy for staff to administer, and act on, in a regular health care setting.
SHEWARD:
Although there exists the US household food security survey module, it's 18 items, it's time consuming to administer, and it has a complex scoring system which limits its use as a clinical or community-based screening tool. The goal of creating the hunger vital sign was to develop a brief screen that would identify families who are at risk of food insecurity.
LABUN:
So, it’s the turn of the 21st century. A scientifically-minded group, concerned about the health of children, has identified a range of factors that impact health and are not easily evident to the providers who are trusted with these children’s health care. One of the factors is food, and it’s a big one. Fortuitously, around this time the US Department of Agriculture has finalized their tool for identifying food insecurity. But food insecurity is a surprisingly complicated condition to pin down. The USDA tool would be impractical for health care providers to use outside of the research context. Our team needed a more practical version.
SHEWARD:
We were looking specifically at five characteristics in developing this tool. Number one, that it would be applicable to families with young children. Number two, that it would be brief. Number three,
LABUN (Actually, numbers three through five)
SHEWARD: number three, that it would have high sensitivity over 90%, that it would have high specificity over 80%. And that it would have convergent validity.
LABUN:
Mmm. We were doing so well until we got to numbers three through five. Sensitivity, specificity, and convergent validity. A trio of lesser-known Greek muses? Close. They’re ways to measure how well a screening tool works. We’ll deal with them in the next episode. For now, let’s stay goal oriented.
SHEWARD:
Because the Hunger Vital Sign is a highly sensitive screening tool, providers are able to identify nearly anyone who lives in a food insecure household when using the Hunger Vital Sign. After screening takes place, the next step would then be a more in-depth assessment of the individual or the household's needs, and ideally a robust intervention grounded in shared decision making that will ultimately alleviate food insecurity.
LABUN:
That’s the goal at an individual practice level. But, as you’ll hear in later episodes, the Hunger Vital Sign is also developed in a way that can be standardized, to support a much larger vision.
SHEWARD:
I hope that health care’s interest in identifying and addressing food and security continues to mature and become more or refined. And that researchers and clinicians work closely with policymakers to continue to codify, systematize, institutionalize this process to ultimately promote health and wellbeing for all families. And that structural social safety nets are adequate and robust enough to address food insecurity when it's identified.
LABUN:
That’s a good note to end on. If you’re curious about how we build up to this grander vision, check out the next episodes, where we bring you there step by step.
To recap the key takeaways:
- Two important things were happening prior to developing the Hunger Vital Sign tool – the creation of a ‘gold standard’ measure for food security by the USDA, and research on a range of household factors that affected the health of young children.
- Researchers knew that these factors had a significant impact, yet were not necessarily apparent to health care providers.
- In response, they set out to develop a screening tool focused on one factor, food insecurity, that could help make this risk more visible to the people involved in supporting a child’s health.
We’ve provided links to additional research, toolkits, and other materials online to help you learn more about the topics in each episode. Click the link in the show notes to find these resources, then check out the next segment that explains what makes a good screening tool.