An Embedded Multiple Case Study: Facilitating Uptake of Food Insecurity Screening Initiatives in Low Resource Primary Care Settings

Abstract Background Food insecurity (FI), limited access to healthy food, is a social determinant of health linked to poor dietary health and difficulty with disease management. Healthcare experts support the adoption of validated screening tools within primary care clinics to identify and connect FI patients to food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that can guide wide-scale program implementation. Methods This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with N = 19 clinical staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis. Findings: Programs outcomes included: the number of patients screened and identified as FI; the number of patients referred to and participated in the onsite food assistance program. Overall, neither case achieved intended reach or participation. Limited financial, human and infrastructure support were implementation barriers. Existing community collaborations and clinic-level autonomy were critical facilitators during implementation that contributed to the flexibility of program activities. Programs were tailored to each context to assist in implementation feasibility, but contributed to low program fidelity. Conclusions Programs were highly adaptable and each context enhanced implementation feasibility across settings. These characteristics have the potential to support program uptake in other settings, but should be used with caution to preserve program fidelity and to achieve intended outcomes. A foundational model for the development and testing of standard clinical practice was the product of this study.