Nine participants from eight distinct clinics completed a semi-structured telephone interview. Participant and clinic characteristics are presented in Table 1. The majority of participants were based in hospital-affiliated clinics and considered food security to be very important. They reported using both formal and informal mechanisms (i.e. through patient dialogue with no formal screening tool) for screening for food security. The most frequently used codes are in Table 2. The most frequently used codes described staff involved in screening for food insecurity, changes in community resources due to COVID-19, improvements in interventions for addressing food needs, acceptability to patients, and onsite and offsite interventions.

Initial screening for food insecurity was most likely to be carried out by an intake nurse or front office manager using a form that included standard questions on food, nutrition, and other social determinants of health. Some respondents noted that food was part of a general resource screening while others only mentioned screening for food. Intakes were usually completed at the time of the first prenatal care visit.

We have a universal prenatal intake process, where someone coming into care for pregnancy, would first have a visit with a registered nurse who fulfills the role of prenatal care coordinator. She does ask questions about... It's a resource security question, I think is how it's phrased like, "Do you have what you need at home?" And then she'll give the examples of, "Do you have shelter? Do you have electricity? Do you have running water? Is it safe? Do you have food to eat?" So it's a question that's along those lines. And then she also asks people about their diet, what they might typically eat in a day. And if they have any restrictions on their diet or things that they avoid. --Physician A

There was some variation as to whether screening was standard, i.e. developed externally for use across facilities; clinic-specific, i.e. developed by staff within the clinic; or informal, i.e. motivated staff asking about food or resource insecurity but without consistency. The intake was administered on paper or an electronic tablet, either by a clinician or self-administered. Even if a standard form was used, its implementation could be ad hoc depending on the clinical workload. At times, follow up was done by a prenatal care clinician as a supplement to the initial intake. Several options were mentioned, including follow up by a prenatal care nurse, midwife, or physician in reviewing answers or the problem list generated at the initial intake; additional screening and meeting with a social worker; and follow up with community health workers.

Inconsistency in follow up beyond the intake was noted by several respondents, often attributed to staff workflow and the patient load. The consensus was that it was better to have someone assigned to carry out the initial screening because it was more likely to be completed for every patient, although there were also benefits to having multiple staff/clinicians engaged in the process:

Its helpful to have multiple people who are responsible for asking this because it establishes that as a culture that this is an important part of healthcare. Physician B

Additional follow up or screening was clinic or provider-specific, where some were more proactive than others. Clinic readiness to implement food insecurity screening varied, with some reporting a smoother uptake process than others due to clinic level management and workload:

It's been at least 10 years that the clinic has had a prenatal care coordinator, nursing position And I think it was not difficult to start because it philosophically aligned with the way the clinic is run. It's a very team-based, multidisciplinary clinic, so having a nurse intake coordinator, I don't think, was a heavy lift when they implemented that. --Physician A

I think that they would be open to hearing about something like that, but I'm not sure that they would want to add something like another assessment onto the already long list of assessments that everyone is responsible for. --Social Worker A

Perceived embarrassment and stigma associated with being food insecure, especially for patients who are already parents, was reported as a barrier to screening accurately for food insecurity.

I think some of them are not completely honest, you know, because theyre ashamed, or, you know, theyre worried that they cant provide food for the children that they may have, afraid that we might may call DCYF [Division for Children, Youth and Families] on them. Clinical Nurse C

Responses varied with some reporting better outcomes from face-to-face conversations rather than over the phone or on a tablet, especially if other social issues were present. In-person screening was also seen as being more helpful for asking follow up questions about the capacity of the woman or family to access and prepare food.

And how are they going to store that food? Are they living with a friend? Are they living out of a hotel? Do they have a refrigerator? I think there's just a lot of assessing that needs to go on in conjunction with food screening. Like, do you have a clean place to prepare the food? Should we be giving it by a food bank? Do you have the means to cook it? They may be living in a hotel and they only have a microwave. --Clinical Nurse A

In terms of achieving honest perspectives, allowing for privacy during the intake (either one-on-one with a clinician or self-administered) and giving time to develop a trusting relationship with clinicians were seen as relevant factors for improving communication.

We find sometimes, the first visit with the nurse that's their first time here, you're just meeting the person for the first time, it takes a little time to develop a relationship, have them feel comfortable. So they will see myself or the other nurse that works here and then they'll see the social worker and it's a couple weeks later and then the provider will see all of that information. And then the provider will again ask, but she won't ask everything again. She'll just, if I identity that that woman has domestic violence or has no money for food, does not have resources in place, then she'll follow up again. So we're all trying to get the same information and making sure that the woman feels comfortable talking with us. --Clinical Nurse B

Integration of food security with other social risk screening was generally seen as a helpful way to identify women with needs.

I do the ones for people that have a substance use history, even if that's just marijuana...so I pop in just to see how they're doing. And those are questions that I always ask, "Do you need diapers? Do you need food? Anything going on with housing?" All those questions are questions that all of us always ask people. --Social Worker A

We're asking about food. We're also asking about personal safety, depression and housing stability. And to be perfectly honest, I think people are less self-conscious about answering questions about food than they are about the other things --Social Worker B

One consistent area of improvement noted by several respondents was more frequent screening throughout pregnancy. Additionally, improvements in screening tools and processes were desired, both for capturing more patients experiencing food insecurity and for ease of use and appropriate referral:

If somebody had sort of like a plug and play kind of program and was like, Use this questionnaire, identify these resources and refer to these resources, check in one week, three weeks and 12 weeks or whatever. Then I feel like that would be a lot easier than trying to develop it from the ground up because to be honest with you the nurses and the physicians are not trained in this so much. --Physician B

I think having a very specific screening tool would be helpful, to define what severity is this? Is it a patient not having access to purchasing food, or what level of severity of that? Like, do they know where their next meal is coming from or, do they just not have enough funding to buy healthy food, or they're eating more processed food? I think if we could get into specifically what the food needs are, it would be easier to refer them based off of that. --Clinical Nurse A

Respondents also talked about more detailed assessments of food practices and dietary quality to identify specific areas where more targeted interventions may be needed.

So it is one of the resources that we give out to patients when they're newly pregnant, is like this is what healthy eating looks like. It's a nice one that you hang up on the wall that has the food group, how much calcium they should be eating for their pregnancy. So it's a great reference to say like, from this food diagram or food pyramid, are you able to eat in all of these tiers? If they're stuck in the process green one, then we need to make a referral so that they can get, and protein and stuff like that. --Clinical Nurse A

Clinic staff were hesitant to ask about food insecurity if they were not aware of what interventions were available for their patients. Respondents tied screening for food security to strong interventions that address patient needs once they are identified.

But we've noticed that providers are a little more willing to engage with the social needs questions if they have some idea of what the patient is then going to navigate, to be able to get that need met. --Physician A

The primary means by which clinics addressed a food need was through an internal referral to a clinic-based resource specialist, social worker, or other clinician. Clinics benefited from having a clear referral process in place. In addition, some claimed they were better positioned to implement internal referrals because the clinic placed a greater value on food security as part of health care. For internal referrals to be successful, respondents emphasized the importance of a dedicated resource specialist at the clinic.

And if they need to fill out paperwork, she will help guide them and help fill that out with them, which is great, because I think half the time when you try to give a patient resources and make referral, I think the most intimidating part of that is them trying to figure out how to self-navigate through that. And us we can go online and try and figure out what that process is, but having that resource specialist, like she knows what the paperwork is, she knows who the point people are for that resource, and it's just super helpful to have her and know exactly what the process is. And patients are more likely to follow through with that if they have someone helping them through it. Otherwise, they know food banks are out there, but they don't know the 20 steps between knowing that they're there and actually getting food from them. --Clinical Nurse A

Respondents also noted a desire to offer onsite food provision services. Providing food directly to pregnant people while at the clinic for an appointment can help to address urgent hunger needs and overcome transportation and accessibility barriers to community resources. Some clinics had services in place to provide food to patients, snacks during appointments, or cafeteria vouchers.

I mean I have had people say, we need meat and produce, because that's all we get at the food pantry are non-perishables and canned goods. So that's something that we're fortunate to be able to have milk, and sometimes eggs, and frozen meats, and stuff to give to people because they aren't able to get all that stuff a lot of times. --Social Worker A

External referrals to community resources were another means by which clinics addressed food needs among pregnant patients. The most frequently cited resource for pregnant people was the Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC). Clinics relied on easy referrals and strong relationships with WIC to help people access these benefits.

Actually, whether a woman identified concerns about food or not, I would always make a referral to WIC, and for food stamps, and facilitate the initial appointments. Let's see. And I got to tell you, that of all the referrals that I made, that was the easiest referral. That was the smoothest referral that I was ever able to make to anybody because the WIC clinic had somebody who would answer the phone, schedule appointments, ask questions, and then follow up. So that was pretty seamless. --Social Worker B

Respondents noted a need for more accessible services in the community, including better hours at local food shelves. Referrals were more effective when there were strong relationships in place between the clinic and the community organization. Respondents also commented on a need for better coordination between clinics and various community resources.

We have a ton of community resources and a lot of really well-meaning people and we all have the same goal of supporting these moms. We're trying really hard to get all of these resources together in a way where there isnt overlap or gaps. And the thing is that some of these resources are independent, some of them are church based, some of them are state supported, some of them are based on grants. If the grant goes away, they go away. Then we've got the nonprofit hospital. And so what we're finding is there's a lot of bandwidth, there's a lot of goodwill. But we wonder about, is there a way that we could more efficiently coordinate all of it? --Physician B

Transportation was noted as a key barrier that should be addressed when making referrals to community services.

I just feel like once you ask about food insecurity, I feel like from there, it will... There may be other needs. Okay, then here's this food pantry. And then it's like, Yeah, I understand the food pantry is there, but I don't know how to get there, or I don't have internet. I feel like there needs to be someone, like a case manager, being able to provide other supports and services as well. --Care Coordinator A

Another barrier for patients was lack of awareness about available services. Respondents discussed having lists and information about community resources that could be shared with patients and a dedicated staff member who could maintain relationships with community partners and keep up to date about their services.

I think the biggest one is just them not knowing what's out there. Like a lot of them aren't aware that there are food pantries. There's so many like in the community that are near them that they don't even know exists. They don't know that they qualify for WIC or SNAP. So I think it's just like, there's not really a general knowledge of the resources that are out there for them. --Resource Specialist A

Other barriers were related to communication challenges due to patient stress associated with the experience of food insecurity as well as cultural differences leading to varied understandings of food insecurity between clinicians/staff and patients.

I think there's also the psychic challenge of always having to be aware that you have food insecurity. I think that it is depressing and it is exhausting and it is anxiety provoking. And I think that folks get to the point where they just don't want to think and talk about it. And I think that's hard too." --Physician B

The only thing I could think of that could be a barrier is the women that come from a different country. If it's part of their culture not to really share information about that or language barrier, we could be missing some of that with them. Its hard for me to know if we are if they're not being forthcoming about it. --Clinical Nurse B

In general, respondents felt that patients had a relatively high degree of acceptability for discussing food needs with their care team. They noted that patients generally felt comfortable asking for help when they needed it, especially when there was trust between staff and patients.

And I think that's where it comes in that my role is important because I'm the connection for them at the clinic. They see me and talk to me on a regular basis, so they're comfortable talking to me. And that goes for a lot of the other case managers too. If it's someone that they see on a regular basis, then that person is comfortable and has an easier time asking for support and knowing what's available. So again, it's the setting of our clinic just kind of lends itself toward that community friendly relationship, I guess. --Social Worker A

Commitment at the clinic level and staff buy-in facilitated the process of screening and intervention. Clinics that recognized food insecurity as an important health issue for their patients were better able to develop trusting relationships with patients and address their needs.

I actually just really think it's the staff commitment and the team that works here really knows that it's important, nutrition is a very important part of pregnancy and promoting optimal outcomes for pregnancy and health families, so it's really just been a part of our program here since the beginning It's a very small office and I think that patients feel that and feel comfortable with us so they will reach out to myself or the social worker and say, I'm really struggling this month, I don't have money enough to get this or this or this. So we will put them in the right direction, supplement with that gift card if we have to, but it's really just been part of our clinic and training here. --Clinical Nurse B

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Missed opportunities to improve food security for pregnant people: a qualitative study of prenatal care settings in Northern New England during the...