FoodRx: A mixed–methods approach to improving food insecurity in cancer care

Abstract

Background: One in four cancer survivors report food insecurity. Cancer's devastating financial hardship is a major social and healthcare concern due to the importance of nutrition in cancer care. Objective: We aimed to understand the barriers to and facilitators for addressing food insecurity in the cancer care workflow in the academic health center of the United States' largest allopathic medical school and National Cancer Institute–designated comprehensive cancer center. Methods: Electronic health records (EHR) were extracted from the Indiana University Health Data Warehouse for patients of all ages with a cancer diagnosis between 01/01/2021 and 05/15/2024. EHR data included patient demographic and clinical characteristics. Univariable analyses of dietitian and social work referrals utilized binary logistic regression models. Qualitative data collection is underway via focus groups with oncology clinicians through September 30, 2024. A systems engineering tool is used to characterize the clinical work system factors for addressing food insecurity in cancer care: people, environments, tasks, tools, and their interactions. Rapid qualitative analysis is applied to iteratively collect and analyze data until saturation using content and thematic analysis guided by the Sort and Sift Think and Shift approach. Results: Food insecure cancer survivors (n = 984) were 49% and 81% more likely to be referred to a dietitian [OR 1.49; 95% CI (0.83, 2.69); p = 0.040] or a social worker [OR 1.81; 95% CI (1.08, 3.04); p = 0.004], respectively, compared to food secure peers (n = 18,260). Quantitative results informed semi–structured focus group and interview questions. Two focus groups have been conducted with n = 4 physicians and n = 3 advanced practice providers in oncology. Emerging themes include long travel distances for patients and not knowing what resources are available where patients live. Conclusion: These comprehensive findings highlight gaps and opportunities from a healthcare workflow lens for informing the co–design, implementation, and evaluation of food insecurity interventions embedded in cancer care.