Poverty, food insecurity and social prescribing — formative SAQs

SAQ 1 — Screening, the Hunger Vital Sign and the social-prescribing response (10 marks)

A four-year-old girl is brought to your clinic for routine immunisation. Her mother, recently made redundant, asks quietly whether you know anywhere that gives food. The child's weight has fallen across centiles since her last visit. [2] [3]

Questions

1. Describe how you would screen this family for food insecurity and broader material hardship, including the validated tool you would use and how you would frame the questions. (4 marks) [3] [5]
2. Outline the five-step social-prescribing pathway you would follow for this family. (3 marks) [6]
3. Explain the clinical significance of the mother's question and the child's centile crossing, including the organic workup you would perform. (3 marks) [2] [4]

Model answer

Screening and framing (4). I would screen routinely and destigmatisingly, framing the questions as universal — "we ask all families these questions because they matter for children's health" — to reduce shame and improve disclosure. For food insecurity I would use the validated two-item Hunger Vital Sign: whether in the past 12 months the family worried food would run out before they had money to buy more, and whether the food bought did not last and there was no money to get more. A "sometimes true" or "often true" to either item is a positive screen. For broader material hardship I would add a validated multi-domain social-needs instrument (such as WE CARE or PRAPARE) covering housing, income, utilities, transport and safety. A systematic review confirms that such screening is feasible and acceptable and identifies need that would otherwise be missed. [3] [5]

The five-step pathway (3). The social-prescribing pathway is screen, assess, co-design, connect and follow up. Screen identifies the hardship; assess clarifies the severity, drivers and any organic or safeguarding concern; co-design asks the family what they need and will accept, respecting autonomy; connect delivers an active referral to food programs, income maximisation, welfare rights and community support, ideally through a link worker; and follow up checks the referral worked, measures whether the hardship resolved, and advocates at the policy level for the structural causes. [6]

Clinical significance and workup (3). The mother's question is a direct disclosure of food insecurity, and the child's centile crossing is faltering growth that may be driven by inadequate nutrition — but each has an organic differential that I must exclude rather than assume the cause is purely social. I would measure and plot growth, take a full feeding and dietary history, check a full blood count and iron studies for anaemia, arrange a developmental screen, and review dental and immunisation status. I would investigate and treat the organic cause while simultaneously activating the food-security and income support response, because the two plans reinforce each other. [2] [4]

SAQ 2 — Mechanism, evidence and policy advocacy (10 marks)

An examiner asks you to explain why poverty is described as the most prevalent risk to child health, and what the evidence is that intervening changes the trajectory. [1] [7]

Questions

1. Explain the toxic-stress mechanism by which material deprivation shapes the developing brain, and why the relationship is described as dose-responsive. (4 marks) [1] [2]
2. Describe the evidence that screening and addressing social determinants in the medical home improves outcomes for children. (3 marks) [5] [6]
3. Outline how you would advocate at the policy level for children in poverty, citing the evidence that structural interventions work. (3 marks) [7]

Model answer

Mechanism and dose-response (4). Poverty, food insecurity and housing instability accumulate as adverse childhood experiences that act on the developing child through a toxic-stress mechanism. The stress response — the HPA axis, immune signalling and neurodevelopment — is persistently activated and dysregulated, so the developing brain is shaped by chronic threat rather than safety. The relationship is dose-responsive: each increment of deprivation adds to the cumulative adversity and produces more dysregulation, which is why infants and young children, whose brains are most plastic, carry the deepest developmental risk. Food insecurity contributes both through direct nutritional inadequacy during rapid brain growth and through the chronic psychological stress of household anxiety, and housing instability adds a distinct mechanism through severed routines, sleep disruption and allostatic load. [1] [2]

Evidence for screening and intervention (3). Sokol's 2019 systematic review confirms that screening children for social determinants of health is feasible and acceptable in paediatric settings and identifies unmet need that would otherwise be missed. Garg's 2015 cluster randomised controlled trial demonstrated that addressing social determinants at well-child visits reduced unmet social needs, and Garg's 2021 review lays out the clinical approaches — screening, referral, care coordination and community partnership — that reduce material hardship. Together these support the fellowship answer that screening every family and delivering social prescribing through the medical home is evidence-based practice. [5] [6]

Policy advocacy (3). I would advocate at three levels: for universal, routine social-needs screening embedded in every medical home; for funded link-worker and community-resource infrastructure that makes a positive screen actionable; and for structural policy on income support, housing and food security. The strongest evidence for structural intervention is Copeland and colleagues' 2022 analysis of a natural experiment showing that childhood family income supplements were associated with improved adult functioning — demonstrating that poverty is modifiable and that income intervention changes long-term trajectories. I would use my professional body's advocacy channels, public statements and local systems advocacy to push for the income, housing and food policies that reduce the dose of adversity at its source. [7]