Final Research Plan
Food Insecurity: Preventive Services
July 28, 2022
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
* For consideration of variation by population and intervention characteristics, see the “Approach to Assessing Health Equity and Variation in Evidence Across Populations” section.
† Intermediate outcomes include behavioral, physiologic, decision making, patient participation, and healthcare utilization outcomes.
- Does identifying food insecurity in healthcare improve health outcomes?
- What is the performance of risk assessment or screening tools to identify food insecurity?
- What are the harms or unintended consequences of assessment for food insecurity?
- What is the effect of healthcare-related interventions to address food insecurity on food security, intermediate outcomes, or health outcomes?
- What are the effects of improvements in food security outcomes on intermediate and health outcomes?
- What are the effects of improvements in intermediate outcomes on health outcomes?
- What are the harms or unintended consequences of healthcare-related interventions to address food insecurity?
Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework.
- What risk assessment or screening tools are commonly used in clinical practice to identify food insecurity? What are the benefits and limitations of these tools (e.g., ease of administration)?
- What factors inform the appropriate reassessment interval for food insecurity?
- What are important moderators that affect the effectiveness or harms of food insecurity assessment and healthcare-related interventions?
- What is the acceptability (e.g., satisfaction) of food insecurity assessment and healthcare-related interventions to patients and providers?
- What is the uptake of services (e.g., rate of adoption or receipt of benefits) after food insecurity is identified?
- What are the patient, provider, and health system facilitators and barriers to implementing assessment for food insecurity?
- What are the patient, provider, health system, and community facilitators and barriers to implementing interventions to address food insecurity?
To the extent possible, we plan to describe the population, screening, and intervention characteristics of the included studies. Data on population characteristics will help us explore the degree to which the findings are representative of persons at risk for food insecurity as well as investigate differences in benefit and harms by different population groups. These groups include, but are not limited to, categorizations by age; racial, ethnic, and cultural identity; socioeconomic and insurance status; presence of other social needs; and type of chronic condition. In addition, we will consider contextual questions through a health equity lens with attention to differences across populations. Heterogeneity around assessment and screening may include temporality of food insecurity, level of food insecurity, screening for nutrition insecurity in addition to food insecurity, stand-alone screening for food insecurity vs. screening bundled with other social risk factor assessment, and details around implementation of screening (e.g., use of electronic health records, training of assessor, or mode of assessment). Heterogeneity around interventions may include setting of intervention (healthcare vs. community), type of intervention, and components in intervention (e.g., addresses nutrition or food access). Additional contextual questions will address moderators that affect the effectiveness or harms of food insecurity assessment and healthcare-related interventions (Contextual Question 3), facilitators and barriers to implementation of food insecurity assessment (Contextual Question 6), and healthcare interventions (Contextual Question 7).
The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions.
|Assessment||KQs 1–3: Risk assessment or screening for food with or without nutrition insecurity using tool that addresses food insecurity with other social risk factors or food insecurity alone||KQs 1–3:
|Interventions||KQs 4, 5:
||KQs 4, 5:
|Comparators||KQs 1, 4: Control group (can include historical control, active control/comparator)§
KQ 2: Any reference standard
KQs 3, 5: No comparator required if explicitly addresses harms
|KQs 1, 4: No control/comparator
KQ 2: No reference standard
|Outcomes||KQs 1, 4:
KQ 2: Test accuracy, predictive validity, and discriminationKQs 3, 5: Any harms or unintended consequences
|KQs 1, 4:
KQs 1–3: Screening conducted in clinical setting or identified through healthcare delivery or payment system (e.g., health plan data)KQs 4, 5: Interventions or programs integrated into, associated with, or referred from healthcare
|Study designs||KQs 1, 4:
KQ 2: Diagnostic test accuracy or risk assessment studiesKQs 3, 5: Randomized or clinically controlled trials, nonrandomized studies, and quasiexperimental studies
|KQs 1, 4: Randomized or clinically controlled trials, nonrandomized studies with less than 12-week followup
KQ 2: Test performance studies without reference standardKQs 3, 5: Case series, case reports, or editorials
|Study quality||Fair to good||Poor|
* For all KQs, populations of interest include persons at higher risk for food insecurity (e.g., by age, race and ethnicity, health status, or other social risk factors).
† Healthcare-related interventions are those in which the patient’s food insecurity was identified through healthcare and/or the intervention itself is provided directly via a healthcare system, based within a healthcare system, or delivered in partnership with a healthcare system.
§ Does not apply to pre-post study design.
Abbreviation: KQ=key question.
A draft Research Plan was posted on the USPSTF website for public comment from February 22 to March 21, 2022. In response to public comment, the USPSTF added a few additional outcomes to KQs 1 and 4, including food access, clinical decision making, and patient adherence. The USPSTF also added moderators of benefits and harms of assessment/screening (in addition to interventions) to CQ3 and added “facilitators” in addition to barriers for CQ6 and CQ7. A few commenters asked for inclusion of interventions to address food insecurity beyond the scope of the USPSTF. The USPSTF added a section, “Approach to Assessing Health Equity and Variation in Evidence Across Populations,” that addresses how the review would address health equity, heterogeneity by population, as well as heterogeneity of screening or interventions for food insecurity. Last, the USPSTF made minor clarifying changes to the questions and inclusion criteria.