Qualitative Study of Food Insecurity in Hospitalized Pediatric Patients during the COVID-19 Pandemic

Abstract

Objectives:

Food insecurity (FI) is defined as limited or uncertain access to sufficient food for a healthy and active lifestyle. Our objective was to explore how the coronavirus disease 2019 (COVID-19) pandemic affected the FI status of pediatric patients and their families through interviewing caregivers who screen positive for FI.

Methods:

Caregivers of all hospitalized patients at a tertiary children’s hospital who screen positive for FI with a two-question screening tool were approached about enrolling in the study. Those who consented completed a presurvey and participated in a semistructured individual interview. Interviews were audio recorded, transcribed, and analyzed according to the guidelines of thematic analysis using NVivo 12.

Results:

Interviews were conducted with 15 caregivers between July 2021 and January 2022. Caregivers were 100% female and 80% Black, 13% White, and 7% Hispanic/Latinx, with a mean age of 33 years. Seventy-three percent did not experience FI until the COVID-19 pandemic. Themes include lost wages, mothers forced out of the workforce due to childcare limitations, inflation and shortages of goods, increased stress/anxiety for caregivers and children, the centrality of extended family support, and the necessity/inadequacy of federal food programs.

Conclusions:

The COVID-19 pandemic impacted unemployment and poverty and consequently exacerbated FI. Our findings point to the need to focus on proximal societal solutions, such as federal policies aimed at food assistance and childcare. Understanding the challenges related to FI that caregivers and patients experience can improve screening, support, and treatment of patients presenting for care and inform the design of necessary interventions for individuals and communities beyond COVID-19.

Brief Description

Food insecurity, defined as limited or uncertain access to sufficient food for a healthy and active lifestyle, is particularly prevalent among children in the US South. The authors aimed to explore the effects of the coronavirus disease 2019 pandemic upon their patients’ families who were identified with food insecurity. This article explores the views and thoughts of their patients’ families through a qualitative approach to understand the thematic consequences of the coronavirus disease 2019 pandemic on their food security.

Food insecurity (FI) is defined as limited or uncertain access to sufficient food for a healthy and active lifestyle.¹ Families with FI live in both rural and urban areas, and characteristics specific to each of these areas can play a role in FI.^1,2 Families who experience FI are more likely to be African American or Hispanic/Latinx and have a low income, with a sole caregiver who has less than a college degree.^3,4 In addition, FI has been linked to several comorbidities in the pediatric population, and consequently, problems with weight, behavior, and health.^2,3,5 Specifically, FI in children is associated with more hospitalizations, upper respiratory infections, stomachaches, headaches, and iron-deficiency anemia than children in food-secure families.^4,5 Households facing FI are more likely to choose inexpensive food options, which may be less nutrient dense, placing children at higher risk of malnutrition.⁵ In addition, families with FI may have to make difficult choices, including whether to buy food or medical care.⁴

Before the coronavirus disease 2019 (COVID-19) pandemic, approximately one in seven US children lived in households with FI.⁶ The COVID-19 pandemic public health emergency recommendations reinforced social distancing, which carried secondary effects related to health, health care, and the economy, including increased unemployment and inflation.⁷ These disruptions disproportionally affected low-income, food-insecure households, and placed greater stress on households with children. As a result, COVID-19 has increased the number of US children who live in FI households to as many as one in four.⁶

A primary reason cited for the increase in FI is the impact of the COVID-19 pandemic on employment leading to reduced spending on food.^7,8 Most individuals in food-insecure households experienced some level of employment change such as reduced hours and/or transition to virtual work⁸; however, job loss disproportionally affected vulnerable populations.^9,10 For example, the US employment rate in April 2020 was 14.7%, up from 4.4% in the previous month.¹¹ Of those at risk of FI, many experienced loss of income due to inadequate resources for virtual work, and no sick days to isolate if ill with COVID or exposed to COVID. Other reasons cited for increased FI during COVID include self-isolation to avoid infection, increased food costs,¹⁰ and food shortages exacerbated in low-income families who were less able to stock up on items when available.⁹ For children specifically, 93% of households reported virtual learning for children during the pandemic,¹² and consequently, many families did not have access to the National School Lunch Program/National School Breakfast Program, which likely increased the burden for households.¹³

Those experiencing FI and/or risk factors for FI are disproportionately at risk of health challenges,⁹ and the full impact of FI due to the pandemic on mental and physical health is just now being understood. Involuntary job loss is associated with obesity, mental health challenges, and high blood glucose levels.^5,9 In the short term, FI families were at higher risk of COVID-19 infection throughout the pandemic, with more frequent grocery visits when they were not able to buy in bulk.⁹ Caregivers reported increased levels of stress, depression, loneliness, anxiety, and sleep disturbances in children and adolescents.^9,12,14 The Centers for Disease Control and Prevention has reported that the rate of increase in body mass index has nearly doubled since the COVID-19 pandemic.¹⁵

Understanding how the increase in prevalence and severity of FI in the United States during the pandemic has affected children and families is important for designing effective interventions to mitigate the potential harmful outcomes of FI, such as obesity and mental health issues. Hospitalization provides a unique opportunity to identify families experiencing FI. Rates of inpatient FI, the ability to obtain food during a hospitalization, were reported in one study to be greater than the household FI in the same population.^4,16 This presents a unique opportunity to understand the effects of the COVID-19 pandemic and opportunities to intervene. The objective of this study was to explore how the COVID-19 pandemic has affected the FI status of patients and their families through interviews with caregivers of pediatric inpatients who screen positive for FI.

Methods

Caregivers of all of the hospitalized patients at a quaternary children’s hospital in the southeastern United States completed an existing validated two-question screening tool for FI, Hunger Vital Sign, at the time of admission. The Hunger Vital Sign identifies households as being at risk of FI if they answer that either or both of the following two statements is “often true” or “sometimes true” (vs “never true”): (1) Within the past 12 months, we worried whether our food would run out before we got money to buy more. (2) Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.

Caregivers who screened positive for FI and were 18 years or older and English speaking were approached by study staff for enrollment during the period July 2021 through January 2022. If they indicated interest and consented to participate in the study, then they completed a presurvey and participated in a semistructured interview. The interviews were performed by the first author. The exclusion criteria included being non–English speaking, being younger than 18 years, and presenting on weekends. Interviews were audio recorded, transcribed, and analyzed. A codebook was developed jointly by investigators. Transcripts were coded using NVivo12 (Lumivero, Denver, CO), and thematic analysis was used to identify, analyze, and interpret patterns of meaning and themes.

Results

Interviews were conducted with 15 caregivers of hospitalized pediatric patients. The caregivers interviewed were 100% female, and 80% identified as Black, 13% identified as White, and 7% identified as Hispanic. The mean age of the caregivers was 33 years, ranging from 21 to 41 years old. Every caregiver described FI exacerbation since the COVID-19 pandemic, and 73% stated they had not experienced FI until the onset of the COVID-19 pandemic. Themes include lost wages, unique challenges of virtual learning, mothers forced out of workforce due to childcare limitations, inflation and shortages of goods, increased stress/anxiety for caregivers and children, the centrality of extended family support, and the necessity/inadequacy of federal food programs (Table).

Table.

Food insecurity during the COVID-19 pandemic

Theme	Subtheme	Quote
Lost wages	Unemployment	We fabricate metal buildings. It’s slowed production for us because containers, shipping containers, don’t get here. We don’t get supplies. We can’t do what need to do.
		I was working 60 hours, now down to, like, 2 days a week, and I’ll maybe have 16 hours.
		I literally didn’t have a paycheck for a long time.
	Increased work demand	With her bein’ a RN and stuff—some nights, she did have to work over and stuff… she had to work more hours because, I guess, once COVID hit, a lotta people stop working.
		By me bein’ in retail, I work more, so I’m not cookin’, so I’m actually just buyin’ outta pocket … before the pandemic, like I said, I made less money, so I did qualify for EBT, so I had that help and assistance.
	Limit public exposure	When I caught COVID, I had to quit … I had to make sure they was okay. That’s why I had to let [work] go.
	Childcare limitations	I didn’t want my kids in daycare because it only takes one somebody expose.
		When he got put out of school, doing the virtual thing, it’s hard for me to work as well.
Virtual learning	Learning difficulty	Everybody was doin’ virtual, but I feel like, with the virtual, some can’t learn like others can.
	Social isolation	Not being able to see their friends for long was very, very stressful for them, because their friends are very important part of their growth.
		They can’t be too close because of pandemic. I understand that, but they don’t, and it’s stressful to them, too, when you tell them they can’t do something, and they used to be able to do.
	Loss of school meals	[at school] I know that they’re getting breakfast. They’re getting lunch … [now they] snack throughout the day, they go in the kitchen and grab a bag of chips if they’re available instead of grabbing fruit [laughter] or vegetables.
	Increased snacking	They want a snack a hundred times a day on top of meals … food went quickly.
Demand for goods		‘Cause the food prices are high, so it limits what I can get for the month if the price is high. Before the pandemic it was fine … now I gotta choose just what I can get.
	Shortages	They don’t have too much in there, and everything went up tremendously.
	Spending habits	You got to ‘cause you have to get what you can afford. Then the cheap stuff, that’s not what we used to eat.
		Now we don’t have the money to waste on fruit that she’s not gonna eat or vegetables that she’s not gonna eat.
Mental health consequences	Overwork	The financial’s hard too, but emotionally is harder ‘cause I just need a break.
	Stress/anxiety	I don’t know what’s gonna happen to us. If I can’t support him, they might come get him.
	Depression	Increase in my depression medicine, and it’s most stressful because the kids can’t go out and do what they want to do.
		For someone that deals with depression and not getting those positive interactions [laughter], it kind of makes things a lot more difficult.
Physical health consequences	Weight	I lost a lot of weight in the past year.
	Sleep	It’s harder to sleep, not knowing what the next day looks like.
	Nutrition	She’s very picky. If we can’t find it, then she really doesn’t wanna eat.
		He eats less. I don’t know if it’s stress or anxiety or depression.”
Family support	Food sharing	I’m not gonna never not have formula for her ‘cause I have a lotta family members. They’ll help me get formula if I’m not able to get it. They say, “Hey, well we have extra. You come get this. When you go grocery shopping, give us back what you took.”
Federal food programs	Inadequacy	We get food stamps, so that helps us a lot. Whenever we run out of food stamps, halfway through the month, we still got two weeks to figure out what we’re doing.
		It’s the biggest help I have, but it’s still not enough.
	Barriers	I’m glad they gave me back my food stamps. They still cut me off from time to time because they don’t receive the paperwork in time.
		…After I stopped gettin’ unemployment. Then I had to wait and everything to receive the food stamps and everything.

COVID-19, coronavirus disease 2019; EBT, Electronic Benefit Transfer; RN, registered nurse.

Lost Wages

Every caregiver who was interviewed described job disruption due to the pandemic, either experiencing fewer work hours or being laid off completely. For example, as one participant explained, “We fabricate metal buildings. It’s slowed production for us because containers, shipping containers, don’t get here. We don’t get supplies. We can’t do what need to do.” Another described, “I literally didn’t have a paycheck for a long time.”

Conversely, a smaller group, including healthcare providers, experienced increased job demands based on specific workloads. This increased work output and subsequent pay disqualified participants from Supplemental Nutrition Assistance Program (SNAP) without addressing increased food demands. As one store manager explained, “By me being in retail, I work more so I’m not cooking, so I’m actually just buying out of pocket … before the pandemic, like I said, I made less money, so I did qualify for EBT [Electronic Benefit Transfer], so I had that help and assistance.”

A subset of caregivers chose to quit work to avoid risk of infection to protect families’ medical needs, such as with pregnancy, immunodeficiency, and COVID infection. A caregiver commented, “When I caught COVID, I had to quit … I had to make sure they was okay. That’s why I had to let [work] go.” Some caregivers also chose to avoid the infection risk associated with daycare. Others described how childcare limitations affected both children’s development and caregivers’ work decisions, in some cases forcing them out of the workforce. The combination of all of these factors was seen as having an impact in FI.

Unique Challenges of Virtual Learning

Virtual education also led to challenges related to income as well as mental and physical health. One caregiver said, “When he got put out of school, doing the virtual thing, it’s hard for me to work as well.” Most caregivers described the challenges of virtual education, including children’s learning difficulties and social isolation. Virtual education also contributed to caregiver stress because schoolwork often required supervision. One caregiver described, “Everybody was doin’ virtual, but I feel like, with the virtual, some can’t learn like others can. It’s hard on kids in school.” Increased anxiety for children was a theme throughout interviews. One caregiver said, “Not being able to see their friends for long was very, very stressful for them, because their friends are a very important part of their growth.” The stress and anxiety often manifested in behavior changes. One caregiver described social isolation: “It’s stressful to them, too, when you tell them they can’t do something, and they used to be able to do.”

Virtual learning independently contributed to FI when children did not have meals available at school, and caregivers were responsible for providing breakfast, lunch, dinner, and snacks, which created increased demands on their household. Another caregiver emphasized the increased demand and how choices are less nutritious: “[at school] I know that they’re getting breakfast. They’re getting lunch … [now they] snack throughout the day, they go in the kitchen and grab a bag of chips if they’re available instead of grabbing fruit [laughter] or vegetables.”

Inflation and Shortages of Goods

Not only did caregivers speak of less income but many also discussed inflation and decreased purchasing power for consumers. Caregivers described increased prices changing what they ate or could eat, and this often meant less nutritious food. One caregiver described, “‘Cause the food prices are high, so it limits what I can get for the month … before the pandemic it was fine … now I gotta choose just what I can get.” Caregivers described shortages and consequently increased time and expense to secure specific needs. Many simply presented fewer choices and smaller portions to their family. For example, “They don’t have too much in there, and everything went up tremendously, [coughing] so you can’t get as much as you used to no more.” The same participant explained how the family’s eating habits had changed, “You got to ‘cause you have to get what you can afford. Then the cheap stuff, that’s not what we used to eat.” Caregivers were forced to purchase less expensive food and consequently less nutritious food for themselves and their children. “We used to present her with lots of options, like multiple fruits, multiple veggies, one thing she did like. Just lots of options. Now we don’t have the money to waste on fruit that she’s not gonna eat or vegetables that she’s not gonna eat.”

Mental Health Consequences

Caregivers also described the impact of the pandemic on their mental and physical health. Mental health challenges were mentioned by most caregivers, and many described feeling overworked and exhausted. One caregiver said, “Less hours mean less money for in the house, and with the kids, it’s less to eat, less—and it’s more [exhausting] mentally—and anxiety. We don’t know what’s gonna happen.” Most caregivers endorsed stress and anxiety related to the specific need to provide food. Many described fear, depression, and shame for how FI was affecting their families. Another caregiver pointed out, “For someone that deals with depression and not getting those positive interactions [laughter], it kind of makes things a lot more difficult.”

Physical Health Consequences

Some caregivers also described physical health consequences. Caregivers mentioned weight changes—weight gain for some due to consuming lower-quality food and weight loss for others due to prioritizing food for children. Other physical health changes that were discussed included increased blood pressure, poor glycemic control, and difficulty sleeping. One caregiver suggested, “It’s harder to sleep, not knowing what the next day looks like.” Caregivers described the impact specifically on children, which included eating less and frustration with fewer choices, whereas some noted increased frequency and duration of sickness. Another caregiver described her experience with her toddler, “She’s very picky. If we can’t find it, then she really doesn’t wanna eat.” Another described, “He eats less. I don’t know if it’s stress or anxiety or depression.”

Our findings demonstrate that unemployment, inflation, childcare challenges, and physical and mental health concerns have exacerbated FI for families since the onset of the COVID-19 pandemic. FI resources used by participants during the COVID-19 pandemic included support from friends and extended family and federal food programs.

Centrality of Extended Family Support

Many caregivers described the importance of assistance provided by extended family members. Most of those interviewed specifically mentioned requiring help from families when needs were unmet. One caregiver described the security that family provided, “Well, formula, I always make that happen. I’m not gonna never not have formula for her ‘cause I have a lotta family members. They’ll help me get formula if I’m not able to get it.” Another caregiver described, “If we were running low on something, like, say I didn’t get paid this week, but I know I needed milk and bread and all these other things, they’d be like, ‘Hey, well, we have extra. You come get this.’”

Necessity of Federal Food Programs

Many caregivers had access to federal food programs, including the Women, Infants, and Children (WIC) program and SNAP; however, these resources were inadequate to meet families’ increasing needs due to unemployment and poverty caused by the COVID-19 pandemic. One caregiver described, “We get food stamps, so that helps us a lot. Whenever we run out of food stamps, halfway through the month, we still got two weeks to figure out what we’re doing.” When asked about WIC, a caregiver said, “WIC, which comes in handy, but you don’t get much on WIC.” Others described the logistical challenges of securing resources: “I’m glad they gave me back my food stamps. They still cut me off from time to time because they don’t receive the paperwork in time or something like that ‘cause there’s not too many people working.”

Participants’ Suggestions for Resources Needed

Participants were asked for suggestions of resources that could mitigate FI. Some ideas included increasing SNAP, changing the eligibility of federal resources to middle class families in addition to those in poverty, providing assistance in accessing existing food resources, and securing access to food banks and having more convenient locations. Participants were asked for suggestions for ways that the hospital could help specifically, and they suggested that the hospital provide childcare when caring for a hospitalized child, help with formula needs, increase access to food banks, and provide counseling to address mental health challenges.

Discussion

This study uses caregivers’ words and personal insights to explore the unique challenges of the COVID-19 pandemic for families of pediatric patients experiencing FI. A primary reason cited in the literature for the increase in FI is the impact of the COVID-19 pandemic on employment, including involuntary job loss, reduced hours, and transition to virtual work,^7,8 and this idea was endorsed by all of the participants in this study. Participants were caregivers of hospitalized pediatric patients, and consequently, many made drastic lifestyle changes, including voluntary work changes and opting out of childcare to protect the physical health of a vulnerable patient population.

FI was exacerbated by food shortages and increased food costs,¹⁰ as participants described the additional time needed to secure food and the impact on choices. Low-income families were less able to buy in bulk when products became available,⁹ a unique challenge described by participants. Many described inadequacy and inability to access federal resources, including WIC and SNAP, and communicated their dependence on support from extended family to meet needs.

Those experiencing FI are disproportionately at risk of physical and mental health challenges⁹ exacerbated by the COVID-19 pandemic. Involuntary job loss is associated with harmful health outcomes, including obesity and mental health.^5,9 Participants described less nutritious food available due to the increased costs of groceries and the effects of virtual school. Many experienced increased burdens from the loss of the National School Lunch Program/School Breakfast Program.¹³ These effects help explain the reports that the rate of body mass index has nearly doubled since the COVID-19 pandemic.¹⁵

This study corroborates others in the increased levels of stress and depression reported for both caregivers and children.⁹ Caregivers described the loneliness and anxiety their children have experienced, as reported by other studies.^9,12 The physical and mental health effects will have long-term effects and need to be investigated further.

Participants’ experiences reiterate an urgent need for action. Suggestions include increasing SNAP benefits for families experiencing low food security and expanding benefits to include more expensive, nutrient-rich options. Furthermore, participants mentioned that assistance was needed to overcome barriers to accessing existing resources. Other studies have reported that many families that are eligible for public nutrition programs are not enrolled.⁴ Understanding the personal experiences of caregivers of pediatric patients will help direct interventions, including financial assistance, access to existing resources, and mental health support for both caregivers and children. In addition, hospitalization, with an increased rate of FI relative to households,¹⁶ presents a unique opportunity to help families access nutrition resources. A multidisciplinary team that includes social work is important to help families access resources and to secure existing resources.

Our study did have limitations. We included only participants who speak English. FI disproportionately affects minority populations,⁹ and patients who are non–English speaking may have a different experience of FI and resource utilization. The sample size was small, but because the themes were repeated by many of the participants, we believe that these findings shed important light into FI that resulted from the pandemic. In addition, all of the participating caregivers were female. Male caregivers may have different experiences of food insecurity, and this is an area for future research.¹¹

Conclusions

The COVID-19 pandemic has affected unemployment and poverty and consequently exacerbated FI. Solutions point to the need to focus on proximal societal solutions, such as federal policies aimed at food assistance and childcare. Understanding the challenges related to FI that caregivers and patients experience can improve screening and support for patients presenting for care and can inform the design of necessary interventions for individuals and communities.

Key Points.

• The coronavirus disease 2019 pandemic affected families’ access to food through multiple modalities, including unemployment with secondary wages, childcare limitations, and increased work demand for those in healthcare fields.

• The inherent characteristics of quarantining behaviors also had negative effects on social cohesion and support structures that many families would typically depend upon during a time of particular stress.

• Participants’ experiences highlighted the need for urgent and rapid access to expanded federal benefits in the midst of a pandemic like coronavirus disease 2019.