Potential determinants of food security among refugees in the U.S.: an examination of pre- and post- resettlement factors

Abstract

The objectives of this paper are: 1) to examine the socio-demographic characteristics and prevalence of food insecurity in three groups of refugees resettled in the U.S.; 2) to describe themes that arose as potential determinants of food insecurity for refugees; and 3) to posit a conceptual model of the potential determinants of food insecurity for refugees and how they interrelate. This is a case study based on the analysis of three nutritional assessment studies conducted with Asian and African refugees (n = 97 combined). A mixed methods approach was adopted with a semi-structured interview questionnaire, containing both quantitative and open-ended qualitative questions. Interviews were conducted in-home by community interviewers. Seventy percent (n = 69) of the sample, which represented a group that has been resettled in the U.S. for an average of 8 years, experienced some level of food insecurity. Themes related to previous food shortage in refugee camps, health care costs, and remittance of resources to relatives back home emerged as factors impacting food security and demonstrating its lack for those who have been resettled for even as many as 8 years. Pre-resettlement factors and transnational remittance have been understudied as they relate to the food security status of resettled refugees. With greater investigation, the knowledge acquired of these factors could impact the way resettlement programs design education, training and counseling for refugees.

Appendices

Appendix

Food Access, Food Insecurity and Dietary Habits among Refugees in Guilford County

Semi-structured Interview Guide

The semi-structured interviews will be conducted with Liberian, Montagnard, or Sudanese women.

For an interview, recruit women that meet the following criteria:

• Is 18 years or older

• Has at least one child 12 years-old or younger

• Is the main meal preparer of the household

• Lives in Guilford County, NC

SCRIPT:

Hello. My name is.

We want to do an interview with you to understand your day to day activities, especially your food related activities such as food shopping, cooking methods and main dishes you cook at home.

Before I start with an interview, first, let’s go through the consent process. We would like to have your written consent for this interview. As mentioned in the consent form, whatever information you share with us or discuss during an interview will not be shared with anyone.

SCRIPT:

As mentioned in the consent form, I will tape record our conversation; this will help me to have an interactive conversation with you without worrying about missing information.

During the interview, if you have any questions at any time, please feel free to ask.

Also, as mentioned in the consent form, you can discontinue the interview if you feel uncomfortable or do not feel like participating in the interview.

• I. SOCIO-DEMOGRAPHICS

SCRIPT:

So, first I will start with some personal questions such as your age, education, monthly income and other things.

• 1. What is your full name? _____________________

• 2. What is your age? ____________ (note down in years)

• 3. Are you working: ⋄ Yes (3a, 3b & 3c) ⋄ No (3d)

  3a. If yes, is it part time or full time? __________

  3b. If yes, where do you work? ______________

  3c. If yes, what is your total monthly income including those of others in the household?_________

  3d. If no, What is the total monthly income of all adults in the household?_______

• 4. What is your religion? ____________________

• 5. What is your marital status? (Circle the option)

• 1) Married

• 2) Single

• 3) Divorced

• 4) Have a partner

  5) Other, ____________________

• 6. What about education; did you go to school:⋄ Yes (6a) ⋄ No

  6a. If yes, how many grades did you complete? _________

  Or what is your last degree? ________________

• 7. Currently, are you taking any classes:⋄ Yes (explain)_________________________ ⋄ No

• 8. Do you have a car? ⋄ Yes ⋄ No

• 9. Do you have a driving license? ⋄ Yes ⋄ No

• 10. How many members live in this household (including both adults and children)? ________________

• 11. How many children do you have? _____________

  • a. What is the age of your children: 1^st Child: _____________;2^nd Child: ____________; 3^rd Child: ____________; 4^th Child: ____________; 5^th Child: ____________

  • b. Are you currently pregnant?⋄ Yes ⋄ No

• 12. Do you get Food Stamps? ⋄ Yes ⋄ No

• 13. Do you get WIC vouchers? ⋄ Yes ⋄ No

• 14. Do you have health or medical insurance? (ex. Medicaid) ⋄ Yes ⋄ No

• 15. Do your children have health or medical insurance? (ex. Medicaid) ⋄ Yes ⋄ No

• 16. Where were you born (country of birth)?________

• 17. In which year did you come to the U.S.?________

• 18. What is your current immigration status? (Circle one) RefugeeAsyleeImmigrantOther

• 19. What was your immigration status when you first arrived here?_____________________________

  • a. Describe the process you had to go through for this_____________________________

• 20. What language(s) do you speak at home? ___________

• 21. What do you think about your English speaking skills? Is it very good, good, fair, poor or very poor (Circle the option): 1. Very good 2. Good 3. Fair 4. Poor 5. Very poor

• II. FOOD SHOPPING

SCRIPT: Now I would like to know about your food shopping habits.

• 22. First, can you tell me the name and location of all the stores and places (including flea market/farmer’s market, convenience/gas station or corner stores) from where you buy food?

A. Name of the store

B. Location (address)

C. How frequently you go to this store Examples: everyday, once a week, twice a week, every two weeks, monthly,

D. How you go to this store (by car, bus, walking, getting a ride) Make sure: by car refers to “did you drive yourself or did someone take you to the store”

E. What food items you usually buy from this store and WHY

• 23. So to begin with, what you think of the lifestyle here in the U.S., how different or similar is it from your home country?

• A. What things you like about U.S.?

• B. What things you dislike about U.S.?

• 24. Now, specifically what you think about food stores or food shopping here in the U.S.?

• A. How different or similar are the food stores in the U.S. compared to the food markets back in your country?

  Prompts:

  • a. Size of the stores

  • b. Open market vs. covered stores

  • c. Distance to the stores

  • d. Corner stores or stores in neighborhood

  • e. Ability to bargain

  • f. Taste and freshness of the food

  • g. Food choices: more variety, less variety

  • h. Cost of food in the U.S. and back in your country. What food items are expensive here in the U.S., and what items were expensive in your home country?

• 25. Specially, when you go to the regular grocery store like Wal-Mart, how do you go about doing food shopping? Can you walk me through the whole thing or explain what you do once you are in the store?

  Prompts:

  • a. Do you go to specific sections or do you look for new things?

  • b. How do you check prices?

  • c. Do you compare brands?

  • d. Do you make a list before you go to the store?

  • e. Do your friends/neighbors/husband or your children help you with the shopping?

  • f. Do you check the store flier?

  • g. Do you buy only the items that you know?

  • h. What do you do when you don’t find the item that you are looking for?

• 26. Especially related to food shopping, what are some of the issues you face here in the U.S.?

  Prompts:

  • a. Language issues

  • b. Store staff

  • c. Size of the store

  • d. Unfamiliar food choices

  • e. Distance

• III. FOOD BUDGET & MANAGEMENT

• 27. Every month, approximately how much money do you spend on food (not including food stamps)?

  • A. (If they get food stamps) What about food stamps, how much do you get through food stamps?

  • B. Explain, how you use your food stamps? Do you use then all at once or in small amounts at a time?

  • C. What food items you usually buy with food stamps?

• 28. Do you ever worry that there might not be enough food for the whole family because of a tight budget or tight money situation?

  • A. If yes, how often do you feel that, and usually when do you feel that (beginning of the month/week, end of the month etc.)?

  • B. When the money situation is tight, how do you manage the food supply for the whole family?

  • C. What different things you do to stretch your food budget?

    Prompts:

    • a. Gardening

    • b. Sign up for food stamps/WIC

    • c. Go to friends/neighbors for lunch or dinner

    • d. Borrow money from friends/relatives

    • e. Buy food on credit from small store owners

    • f. Other things

• 29. A. What food dishes do you cook everyday or most days of the week?

• B. What food items are the main parts of the meal: meat, rice, curry, vegetables?

• C. What oil or fat do you use in cooking?

• D. What sauces and spices do you use in cooking?

• E. Can you tell me the recipe of one of your main dishes (like a meat or vegetable dish)?

  Prompt: What is the name of the dish, now first tell me all the ingredients and then tell me the steps.

Recipe Name and Ingredients list: __________________

___________________________________________

• IV. DIFFERENCES IN LIFESTYLE AND EATING HABITS

SCRIPT: I will ask you a few questions about your lifestyle before coming to the U.S.

• 25. A. How old were you when you came to the U.S.

  • B. Where did you live or where were you before coming to the U.S. (Note down: Both, name of the town or city and name of the country)?

  • C. How long did you live in that place?

  • D. What was your day like back in _________ (town name)? OR what was your daily routine like in ____________ (town name), OR tell me all the activities or things you did from morning to night back in your country.

  • E. What were main daily activities: walking to market, school, housework, farm work etc.

  • F. Describe living conditions of that place or _________ (town name)

    Prompts:

    • i. Rural vs. urban area

    • ii. Weather description

    • iii. Major occupation in that area

    • iv. What your family used to do: business; farm worker; fishing; teaching; factory worker

    • v. Houses: big vs. small

    • vi. Sources of drinking water

    • vii. Electricity

    • viii. Sewage/plumbing system

• 26. Tell me about your food habits back in your country OR before coming here?

  Prompts:

  • a. What was the main food?

  • b. How many times did you use to eat per day?

  • c. What was the main meal?

  • d. Did you experience scarcity of food?

  • e. What drinks you used to have?

  • f. What dishes you used to cook commonly?

  • g. How common was it to skip meals because of no food?

• 27. So, in comparison to your previous food habits (back in your country or refugee camp) how similar or different are your current food habits?

  Prompts:

  • a. What food habits are similar; why

  • b. What food habits are different; why

  • c. Do you eat the same food as you used to eat back in your country?

  • d. What food items do you miss the most?

  • e. What food items can you get easily here?

  • f. How often do you or your children eat fast food (ex. McDonalds, Wendys, etc.)?

  • g. How many times per week do you or someone in this household cook at home?

• 28. What do you think about your current eating habits?

  Prompts:

  • a. Are they good, healthy, unhealthy? Why?

  • b. Do you have any health concerns? What are these?

  • c. How many times have you visited a doctor in the last year?

  • d. How many times have your children visited the doctor in the last year?

• V. FOOD INSECURITY (validated USDA scale)

ADULT STAGE 1

• HH2.Now I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the past month or in past 30 days.

• The first statement is “We worried whether our food would run out before we got money to buy more.” Was that often true, sometimes true, or never true for your household in the last 30 days?

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• HH3.“The food that we bought just didn’t last, and we didn’t have money to get more.” Was that often, sometimes, or never true for your household in the last 30 days?

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• HH4.“We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 30 days? Give an example of balanced meal (such as: rice and meat, fish, chicken and vegetables stew).

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• Screener for Stage 2 Adult-Referenced Questions: If affirmative response (i.e., "often true" or "sometimes true") to one or more of Questions HH2-HH4, then continue to Adult Stage 2; otherwise, skip to Child Stage 1.

ADULT STAGE 2

• AD1.In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• AD1a. [IF YES ABOVE, ASK]. In the last 30 days, how many days did this happen?

• ___ days

• [ ] DK

• AD2.In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• AD3.In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• AD4.In the last 30 days, did you lose weight because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• Screener for Stage 3 Adult-Referenced Questions: If affirmative response to one or more of questions AD1 through AD4, then continue to Adult Stage 3; Otherwise skip to Child Stage 1..

ADULT STAGE 3

• AD5.In the last 30 days, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• AD5a. [IF YES ABOVE, ASK]. In the last 30 days, how many days did this happen?

• _______ days

• [ ] DK

Transition into Child-Referenced Questions:

• Now I'm going to read you several statements that people have made about the food situation of their children. For these statements, please tell me whether the statement was OFTEN true, SOMETIMES true, or NEVER true in the last one month for (your child/children) living in the household who are under 18 years old.

CHILD STAGE 1

• CH1.“We relied on only a few kinds of low-cost food to feed (our child/the children) because we were running out of money to buy food.” Was that often, sometimes, or never true for your household in the last 30 days?

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• CH2.“We couldn’t feed (our child/the children) a balanced meal, because we couldn’t afford that.” Was that often, sometimes, or never true for your household in the last 30 days? Give an example of balanced meal (such as: rice and meat, fish, chicken and vegetables stew).

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• CH3."(Our child was/The children were) not eating enough because we just couldn't afford enough food." Was that often, sometimes, or never true for your household in the last 30 days?

• [ ] Often true

• [ ] Sometimes true

• [ ] Never true

• [ ] DK or Refused

• Screener for Stage 2 Child Referenced Questions: If affirmative response (i.e., "often true" or "sometimes true") to one or more of questions CH1-CH3, then continue to Child Stage 2; otherwise skip to End of Food Security Module

CHILD STAGE 2

• CH4.In the last 30 days, did you ever cut the size of (your child's/any of the children's) meals because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• CH5.In the last 30 days, did (your child/any of the children) ever skip meals because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

• CH5a. [IF YES ABOVE, ASK]. In the last 30 days, how many days did this happen?

• _______ days

• [ ] DK

• CH6. In the last 30 days, (was your child/were the children) ever hungry but you just couldn't afford more food?

• [ ] Yes

• [ ] No

• [ ] DK

• CH7.In the last 30 days, did (your child/any of the children) ever not eat for a whole day because there wasn't enough money for food?

• [ ] Yes

• [ ] No

• [ ] DK

END OF FOOD SECURITY MODULE

Thank you for your time and efforts. We really appreciate your input. Do you have any questions for me.