Food insecurity among immigrants and refugees of diverse origins living in metropolitan Atlanta: the roles of acculturation and social connectedness

Abstract

Little is known about the prevalence and correlates of food insecurity among immigrants and refugees. Acculturation and social connectedness may influence food insecurity (lack of access at all times to enough food for an active, healthy life) by affecting a person’s ability to access and use governmental and charitable food assistance programs, as well as other community-based or informal food-related resources. We explored associations of acculturation and social connectedness with food insecurity among diverse immigrants and refugees living in metropolitan Atlanta, a major destination for these populations in recent years. From 2017 to 2018, we surveyed 162 adults attending health fairs or programs hosted by two community-based organizations serving immigrants and refugees. Food insecurity within the past year was assessed using the American Academy of Pediatrics’ two-item questionnaire. Acculturation indicators included heritage culture and American acculturation scores (Vancouver Acculturation Index), English fluency, heritage language fluency, and percentage of lifetime in the USA. Social connectedness was operationalized using measures of religious attendance and social isolation. We conducted a multivariable logistic regression controlling for age, sex, education, household income, employment status, and household size. In the sample, 51.9% identified as Vietnamese, 16.0% Hispanic, 15.4% Burmese, 14.8% Bhutanese or Nepali, and 1.8% other. The average age was 39.10 (standard deviation [SD] =13.83), 34.0% were male, 73.8% had below a Bachelor’s degree, and 49.7% were unemployed. Average scores for American acculturation (mean [M] = 3.26, SD = 1.05, range 1–5) were lower than heritage acculturation (M = 4.34, SD = 0.68, range 1–5). Additionally, 43.4% were fluent in English. Average percentage of life in the USA was 40.59% (SD = 33.48). Regarding social connectedness, 55.9% regularly attended religious services. Average social isolation scores were 3.93 (SD = 1.34, range 3–9). Overall, past-year food insecurity was reported by 17.3% (34.6% in Hispanics, 24.0% in Burmese, 13.1% in Vietnamese, and 8.3% in Bhutanese or Nepali). In adjusted models, food insecurity was associated with English fluency (adjusted odds ratio [aOR] = 0.36, p = .03) and social isolation (aOR = 2.29, p < .001) but not other measures of acculturation or religious attendance. Limited English proficiency may make it more difficult to navigate or use governmental and charitable food assistance programs. Social isolation may hinder individuals from obtaining information about food assistance programs, receiving aid for services navigation, and sharing or borrowing food from family, friends, and neighbors. Interventions should seek to improve access to English language and literacy services, enhance the linguistic and cultural competency of service providers, and build social connectedness among immigrants and refugees.

Implications.

Practice: Interventions should seek to improve access to English language and literacy services, enhance the linguistic and cultural competency of service providers, and build social connectedness among immigrants and refugees.

Policy: Policymakers should consider how English proficiency may influence one’s ability to navigate or use governmental and charitable food assistance programs and how social isolation may hinder individuals from obtaining information about food assistance programs, receiving aid for services navigation, and accessing other resources.

Research: Future studies should collect data disaggregated by country of origin to understand how different communities experience food insecurity and continue to investigate the mechanisms through which social isolation and connectedness may impact food insecurity among immigrants and refugees.

INTRODUCTION

Food insecurity among immigrants and refugees in the USA

Food security, an important social determinant of health, has been defined as access at all times to enough food for an active, healthy life [1]. In 2017, the U.S. Department of Agriculture (USDA) reported that 11.8% (15.0 million) of U.S. households were food insecure at some time during the year; approximately 40.0 million people lived in these food-insecure households [2]. Experiencing food insecurity is associated with poor health outcomes in both children and adults, including mental and behavioral health problems (e.g., impaired cognitive development, depression, suicidal ideation, and poor academic performance), as well as chronic disease conditions (e.g., asthma, hypertension, diabetes, and end-stage renal disease) [3–7]. Additionally, experiencing food insecurity is linked to increased health care expenditures [8].

The U.S. foreign-born population was around 44.5 million in 2017; immigrants made up almost 14% of the U.S. population [9,10]. Some research indicates that foreign-born individuals or children with foreign-born mothers have a higher chance of experiencing food insecurity compared to U.S.-born counterparts [11–16]. These studies, however, have not examined which factors may put foreign-born individuals or children at higher risk for food insecurity. Small-scale studies on immigrants and refugees typically provide varying estimates of food insecurity ranging from 30% to 60% [17].

Acculturation and food insecurity

Acculturation is an important construct that has been linked to food insecurity among immigrants and refugees in the USA. A broad and multifaceted construct, acculturation often refers to the process by which individuals and groups experience changes and adjustments (e.g., in language, cultural practices, and identities) as they come into contact with new cultures and contexts [18–22]. Language use is often considered an indicator of acculturation, and research shows that more frequent everyday use of English language or higher fluency in English is associated with a lower likelihood of experiencing food insecurity among immigrants and refugees, including different Asian immigrant subgroups [16], West African refugees [23], Somali refugees [24], and Latino adults [25]. A possible mechanism explaining this relationship is that those who speak English more fluently can better navigate barriers to employment or governmental and charitable food assistance programs (e.g., Supplemental Nutrition Assistance Program [SNAP] benefits, food pantries, and meal programs), which can help mitigate food insecurity [25,26].

Additionally, research finds that duration in the USA, another indicator of acculturation, is associated with food insecurity. Longer duration in the USA has been shown to be protective against food insecurity among West African refugees [23] and Somali refugees [24]. A large hospital-based study also found that children of newly immigrated mothers were at the highest risk of food insecurity [14]. Similar to English fluency, individuals who have been in the USA for longer may have more knowledge of employment opportunities and access to governmental and charitable food assistance programs.

Existing studies, however, mostly used place of birth, the number of years in the USA, and language use as a proxy or approximation for acculturation. To our knowledge, no study on food insecurity among immigrants and refugees in the USA has utilized validated measures to assess both heritage culture and American culture. National data sets, such as the National Health and Nutrition Examination Survey (NHANES), collect data on country of birth, citizenship, and years of U.S. residence but do not include measurements of degrees of acculturation orientations [27]. The lack of validated measurements limits our ability to fully understand the complex relationships between acculturation and food insecurity.

Social connectedness and food insecurity

In addition to acculturation, another important factor associated with food insecurity is social connectedness. Social connectedness broadly encompasses constructs such as social capital, social integration, social networks, social participation, and social support [28,29]. Social connectedness can be defined as a sense of belonging and subjective bond that a person feels in relation to other individuals and groups [28–30]. This sense of connectedness allows individuals to give and receive information, emotional support, and material aid, facilitates access to opportunities, and nurtures participatory abilities [28–30]. Increased social connectedness is associated with improved physical and mental health outcomes [28–33], including among immigrants and refugees [34–41].

A body of research has established relationships between various aspects of social connectedness and food insecurity [42–50]. For example, those who experience social isolation (e.g., a lack of integration in social networks [51] or a feeling that social needs are not being met [52]) are more likely to experience food insecurity [49]. This may be attributable to the fact that social support and networks enable the use of coping strategies that are protective against food insecurity, such as sharing or borrowing food from family and friends, accessing more affordable foods outside one’s immediate neighborhood, and sharing memberships to discount grocery store [46,50]. Living in a neighborhood with higher social cohesion is also associated with a lower likelihood of experiencing food insecurity [47,48]. Higher social cohesion or higher trust among neighbors may translate into the sharing of resources that mitigate food insecurity [48].

Another key aspect of social connectedness is religious attendance [53–55]. Increased religious attendance has been associated with increased social capital and/or religious social capital [54,56], which, in turn, has been linked to decreased food insecurity [44]. Higher religious attendance also often correlates with higher perceived social support [57–60], which, as mentioned, may be protective against food insecurity. Importantly, faith-based organizations, such as churches, are often crucial providers of community food aid programs (e.g., food pantries and soup kitchens), which can alleviate food insecurity [61–63]. Studies among Puerto Rican households (living in mainland USA) and rural mothers found that increased religious attendance was associated with lower odds of experiencing food insecurity [26,64].

Limited research has focused on social connectedness and food insecurity specifically among immigrants and refugees in the USA. Two studies focusing on Puerto Rican households in mainland USA and rural Latina mothers, respectively, suggested that social connectedness also confers a protective effect against food insecurity in these populations [26,65]. These studies measured social connectedness through attendance at Latino cultural events or the number of people who respondents could count on to provide different types of support. However, another study among Sudanese refugees actually found that household food insecurity was associated with indicators of increased social support (e.g., borrowing of money or household goods) [66]. It is possible that the contrasting findings are due to differences between the populations studied or the measures used. Nevertheless, such complex findings necessitate more research to deepen our understanding of how social connectedness and food insecurity are linked in these populations.

Study aims and hypotheses

The aforementioned research highlights significant gaps in the literature, particularly limited research focusing on social connectedness and food insecurity among immigrants and refugees and limited use of validated acculturation measurements in research on food insecurity. To address these gaps in the literature, the current study examines food insecurity and its associations with various indicators of acculturation (i.e., Vancouver Index of Acculturation, English language fluency, and percentage of life in the USA) and social connectedness (i.e., religious attendance and social isolation) among a diverse sample of immigrants and refugees in metropolitan Atlanta. We hypothesize that food insecurity will be associated with lower U.S. acculturation, lower English fluency, shorter duration of life in the USA, lower religious attendance, and higher social isolation.

METHODS

Setting, recruitment, and data collection

The Emory University Institutional Review Board approved this study. The project was set in metropolitan Atlanta, GA. Metropolitan Atlanta has been designated an “emerging gateway” (i.e., rapidly growing migrant populations during the past 25–30 years) for Hispanic and Asian immigrants and is also the top destination for refugees in the USA in recent years [67–70]. This setting makes it ideal for studying health issues encountered by immigrants and refugees, including food insecurity. To date, we are aware of only one study that examines food insecurity among immigrants and refugees in Atlanta, which focused on recently settled Sudanese refugees with children under 3 years of age and found that 37% of the sample reported experiencing food insecurity [66].

We utilized a community-engaged approach and conducted the study in partnership with two community-based organizations serving immigrant and refugee populations in the region. Our community partners provided feedback on survey instruments, advised the research team on target populations, translated the instruments to appropriate languages (Vietnamese, Spanish, Burmese, and Nepali, which were languages spoken by the majority of clients of community partners), and assisted with data collection and interpretation of results.

As of 2018, census data estimated that around 11% of metropolitan Atlanta residents, or more than 654,000 people, were of Hispanic or Latino origin [71]. The Pew Research Center estimated that the population of Vietnamese in metropolitan Atlanta as of 2015 was 44,000 [72]. There are no current data on the number of Bhutanese/Nepali and Burmese living in metropolitan Atlanta; however, the Centers for Disease Control and Prevention reported that around 5,800 Burmese were resettled in Georgia between 2008 and 2014 [73] and 3,446 Bhutanese refugees were resettled in Georgia between 2008 and 2012 [74].

Between September 2017 and April 2018, using convenience sampling, we recruited and administered surveys to 180 adults of immigrant and/or refugee backgrounds. Of the sample, 54.4% (n = 98) were recruited from two community health fairs sponsored by one of the two partner organizations. The community health fairs were intended for Vietnamese living in metropolitan Atlanta and took place between 9:00 am and 3:00 pm on two Saturdays. The surveys were administered during the fairs, and all participants who took the surveys at the fairs were Vietnamese. The remaining participants (n = 82) were recruited from clients using services at the other partner organization. These participants took the surveys at a personally convenient time and later returned the surveys to research team members.

Participants could choose to take the surveys in English, Vietnamese, Spanish, Burmese, or Nepali. Each survey took approximately 15–20 min to complete. Verbal informed consent was obtained prior to survey administration by study team members who were fluent in English, Vietnamese, Spanish, Burmese, or Nepali. For completing the survey, each study participant recruited from health fairs was entered into a raffle for a chance to win two gift cards worth $50 and one gift card worth $100. Each study participant recruited through services at the other partner organization was given a $5 incentive. Participants’ names and contact information were collected and linked to the survey responses through an ID. For analysis, we excluded those with missing data on the outcome variable (n = 18), yielding a final sample of 162 individuals.

Measures

The survey included questions on food insecurity, acculturation, social connectedness, substance use (e.g., tobacco and alcohol), preventive care utilization, vaccinations (e.g., hepatitis B vaccination and human papillomavirus vaccination), and other sociodemographic information. Variables used in current analyses are described further below.

Outcome variable

Food insecurity was measured using the American Academy of Pediatrics’ two-item questionnaire [75]. We asked, “Within the past 12 months, has your family experienced any of the following events? (a) We worried whether our food would run out before we got money to buy more. (b) The food we bought just did not last and we did not have money to get more.” Those who answered “Yes” to either or both questions were coded as having experienced food insecurity in the past 12 months. The two-item questionnaire demonstrated high sensitivity (97%) and specificity (83%) when evaluated against the gold-standard USDA’s 18-item Household Food Security Survey Module [76].

Acculturation measures

Vancouver Index of Acculturation 

The Vancouver Index of Acculturation [77] was used to measure degrees of acculturation to American and heritage cultures. The index consisted of 20 items; 10 items assessed degrees of identification with and acquisition of heritage culture (e.g., Vietnamese, Burmese, Bhutanese, Nepali, and Mexican) and 10 similar items assessed degrees of identification with and acquisition of host culture (e.g., American). Examples of the items included: “I often participate in my heritage cultural traditions” and “I am comfortable interacting with typical American people.” Response options for each statement ranged from 1 = Strongly disagree to 5 = Strongly agree. The score for each subscale was calculated by dividing the sum of the score on each item by the number of items. Scores for each subscale ranged from 1 to 5. In this sample, Cronbach’s alphas for the heritage acculturation and American acculturation subscales were 0.94 and 0.95, respectively. To our knowledge, the Vancouver Index of Acculturation has not been used in studies assessing food insecurity. However, this index has been used in studies on health behaviors of diverse samples that included Asian (in particular, Vietnamese, South Asians, and those born in Burma), as well as Hispanic, participants [77–82].

Language fluency 

Language fluency was measured through two items: “I do not speak my family’s heritage language or do not speak it well” and “I do not speak English or do not speak it well.” These items were taken from the Multidimensional Acculturative Stress Inventory, which has been validated in Asian and Latino immigrant samples [83]. Responses (1 = Strongly disagree to 5 = Strongly agree) were dichotomized, where 1 = Fluent (i.e., Strongly disagree or Disagree) and 2 = Not fluent (i.e., Neutral, Agree, or Strongly agree). Two variables were created to measure heritage language fluency and English fluency.

Percentage of life in the USA 

We asked participants where they were born (in the USA vs. in another country). If participants were born in another country, we asked them to specify the year they immigrated to the USA. For participants who reported that they were born in the USA, the percentage of life in the USA was set to 100%. For those who reported being born in another country, the percentage of life in the USA was obtained by first subtracting the year of emigration from the year of data collection, then dividing this number by the age of the participant, and, finally multiplying the result by 100%.

Social connectedness

Religious attendance 

Religious attendance was measured by asking, “How often do you attend religious services (e.g., going to a church, mosque, or temple)?” This item was taken from the General Social Survey [84], an annual national survey of social characteristics and attitudes of contemporary Americans. Response options were dichotomized, where 1 = At least once a week and 2 = Once or twice a month were grouped as “Regularly” and 3 = A few times a year, and 4 = Seldom or never were grouped as “Not regularly.”

Social isolation 

Social isolation was measured through a three-item loneliness scale [52], which has been used in several U.S. population-based studies with diverse groups of adults. We asked, “Please indicate the frequency with which you experience each of the following statements: ‘I lack companionship’; ‘I feel left out’; and ‘I feel isolated from others’.” Each statement is scored from 1 to 3 (1 = Hardly ever, 2 = Some of the times, and 3 = Often). The score for the scale was calculated as a sum of the score on each item; scores on the scale ranged from 3 to 9.

Cronbach’s alpha for the scale in the current study was .83.

In previous studies, researchers have assessed discriminant and convergent validity of this scale and found that those experiencing higher loneliness scores were also more likely to experience depressive symptoms and had higher perceived stress scores [52]. In addition, the correlation between the loneliness scale and the self-labeling loneliness statement in the depressive symptoms scale (measured through the Center for Epidemiologic Studies—Depression Scale) was also moderately high [52].

Sociodemographic characteristics

Sociodemographic characteristics included age, sex, highest education attained (1 = Below a Bachelor’s degree and 2 = Bachelor’s degree or above), annual household income (1 = Less than $16,000, 2 = $16,000 to $24,999, 3 = $25,000 to $49,999, and 4 = $50,000 and above), employment status (1 = No employment, 2 = Part-time employment, and 3 = Full-time employment), and the number of people in the household. The choice of these variables was informed by covariates or confounders used in previous research on food insecurity among immigrants and refugees [16,23–26,65,66,85].

Statistical analysis

SAS 9.4 was used for data analysis and all significant alpha levels were set at .05. Variables were examined for distribution and missing values. Descriptive statistics were summarized for participants with completed cases.

We investigated missing patterns in our data set and found that both continuous and categorical predictor variables had missing values and that the missing patterns were arbitrary [86] (see Table 1 for additional information on missing values for each predictor). For these reasons, fully conditional specification method was used for imputation [87]. Twenty imputed data sets were created. Variables that were incorporated in the multiple imputation procedure included all predictors used in the analysis, as well as the outcome variable [88].

Table 1|.

Participant characteristics

	Total sample	Not experiencing food insecurity	Experiencing food insecurity
Characteristics	Mean (SD) or n (%)	Mean (SD) or n (%)	Mean (SD) or n (%)
Sociodemographic
Age (n = 160)	39.10 (13.83)	38.66 (13.88)	41.35 (13.68)
Sex (n = 162)
Male	55 (34.0%)	44 (32.8%)	11 (39.4%)
Female	107 (66.1%)	90 (67.2%)	17 (60.7%)
Highest education (n = 160)
High school degree or below	118 (73.8%)	95 (72.0%)	23 (82.1%)
Bachelor’s degree or above	42 (26.3%)	37 (28.0%)	5 (17.9%)
Annual household income (n = 149)
Less than $16,000	22 (14.8%)	18 (14.5%)	4 (16.0%)
$16,000 to $24,999	40 (26.9%)	32 (25.8%)	8 (32.0%)
$25,000 to $49,999	58 (38.9%)	47 (37.9%)	11 (44.0%)
$50,000 and above	29 (19.5%)	27 (21.8%)	2 (8.0%)
Employment status (n = 161)
No employment	80 (49.7%)	63 (47.4%)	17 (60.7%)
Part-time employment	30 (18.6%)	25 (18.8%)	5 (17.9%)
Full-time employment	51 (31.7%)	45 (33.8%)	6 (21.4%)
Number of people in the household (n = 148)	4.72 (1.81)	4.61 (1.70)	5.19 (2.23)
Acculturation
Heritage culture acculturation scores (n = 152; range 1–5)	4.34 (0.68)	4.32 (0.70)	4.45 (0.54)
American culture acculturation scores (n = 155; range 1–5)	3.26 (1.05)	3.23 (1.09)	3.44 (0.77)
Fluency in language of heritage culture (n = 159)
No	19 (12.0%)	14 (10.7%)	5 (17.9%)
Yes	140 (88.1%)	117 (89.3%)	23 (82.1%)
Fluency in English (n = 159)
No	90 (56.6%)	66 (51.9%)	22 (78.6%)
Yes	69 (43.4%)	63 (48.1%)	6 (21.4%)
Percentage of life in the USA (n = 153)	40.59 (33.48)	41.69 (33.62)	35.25 (32.93)
Social connectedness
Religious attendance (n = 161)
Regularly	90 (55.9%)	71 (53.0%)	19 (70.4%)
Not regularly	71 (44.1%)	63 (47.0%)	8 (29.6%)
Social isolation (n = 160; range 3–9)	3.93 (1.34)	3.75 (1.17)	4.81 (1.75)

SD standard deviation.

After imputed data sets were generated, bivariate analyses were conducted using simple logistic regressions to examine the association between each predictor and the outcome variable. We also examined collinearity using the variance inflation factor (VIF), which measures how much multicollinearity has increased the variance of a slope estimate [89]. We used a cutoff of VIF values above 10 [90] to determine the presence of multicollinearity. Finally, we ran one multiple logistic regression to investigate the associations between the 13 predictors and the outcome variable of being food insecure. Bivariate and multivariable models were fit to each imputed data set, and the final results were created using the average of the pooled results from all imputed data sets [91,92]. We also conducted a complete case analysis to understand whether results changed significantly when multiple imputation was not used.

RESULTS

Of the 162 adults in the sample, 51.9% (n = 84) identified as Vietnamese, 16.0% (n = 26) as Hispanic (i.e. Mexican, Ecuadorian, and Argentinian backgrounds), 15.4% (n = 25) as Burmese, 14.8% (n = 24) as Bhutanese or Nepali, 1.2% (n = 2) as Bengali, and 0.6% (n = 1) as Cambodian. The average age was 39.10 (standard deviation [SD] = 13.83). In the sample, 34.0% (n = 55) were male, 73.8% (n = 118) had an education of below a Bachelor’s degree, and 49.7% (n = 80) were not employed. Average scores for American acculturation (mean [M] = 3.22, SD = 1.05) were lower than heritage acculturation (M = 4.34, SD = 0.68), 43.4% (n = 69) were fluent in English, and average percentage of life in the USA was 40.59% (SD = 33.48). With regard to social connectedness, 55.9% (n = 90) regularly attended religious services, and average social isolation scores were 3.93 (SD = 1.34).

In this sample, 17.3% (n = 28) reported experiencing food insecurity within the past 12 months. Among major ethnic groups in the sample, the prevalence of experiencing food insecurity was 34.6% (n = 9) among those who identified as Hispanic, 24.0% (n = 6) Burmese, 13.1% (n = 11) Vietnamese, and 8.3% (n = 2) Bhutanese or Nepali. After excluding the three individuals who identified as Bengali or Cambodian due to the small cell size, bivariate analysis (not shown in tables) showed that, compared to those who identified as Bhutanese or Nepali, those who identified as Hispanic were more likely to experience food insecurity (crude odds ratio [cOR] = 5.82, 95% confidence interval [CI] = [1.11–30.55], p = .04,). We did not find significant differences in food insecurity either between Vietnamese and Bhutanese/Nepali participants or between Burmese and Bhutanese/Nepali participants. Note that, due to the presence of multicollinearity (indicated by VIF values above 10 [90]), we did not include ethnicity in our multivariable logistic regressions.

In bivariate logistic regressions (Table 2), being fluent in English was associated with lower odds of experiencing food insecurity (cOR = 0.55, 95% CI = [0.34–0.88], p = .01) and higher social isolation was associated with higher odds of experiencing food insecurity (cOR = 1.67, 95% CI = [1.25–2.22], p = .001). Similarly, in the multivariable logistic regression (Table 2), being fluent in English was associated with lower odds of experiencing food insecurity (adjusted odds ratio [aOR] = 0.36, 95% CI = [0.14–0.93], p = .03). Higher social isolation was associated with higher odds of experiencing food insecurity (aOR = 2.29, 95% CI = [1.50–3.49], p < .001). When a complete case analysis was conducted (n = 122), in the multivariable logistic regression, only higher social isolation was associated with higher odds of experiencing food insecurity (aOR = 2.61, 95% CI = [1.44–4.73], p = .002). Being fluent in English was no longer associated with lower odds of experiencing food insecurity (aOR = 0.42, 95% CI = [0.05–3.77], p = .65).

Table 2|.

Unadjusted and adjusted logistic regressions examining the associations between sociodemographic variables, social connectedness indicators, and acculturation indicators and the outcome of experiencing food insecurity in the past 12 months

	Experiencing food insecurity in the past 12 months
Variables	cOR	p	aOR	p
Sociodemographic
Age	1.01 (0.98–1.04)	.50	1.00 (0.94–1.07)	.98
Sex
Male	Reference		Reference
Female	0.87 (0.57–1.32)	.51	0.64 (0.34–1.24)	.19
Highest education
High school degree or below	Reference		Reference
Bachelor’s degree or above	0.75 (0.45–1.27)	.29	0.76 (0.35–1.66)	.49
Annual household income
Less than $16,000	Reference		Reference
$16,000 to $24,999	1.08 (0.56–2.06)	.83	1.51 (0.66–3.46)	.33
$25,000 to $49,999	1.01 (0.54–1.88)	.97	1.54 (0.68–3.49)	.30
S50,000 and above	0.64 (0.27–1.53)	.31	1.04 (0.28–3.89)	.95
Employment status
No employment	Reference		Reference
Part-time employment	0.85 (0.49–1.48)	.58	0.92 (0.45–1.87)	.82
Full-time employment	0.70 (0.43–1.17)	.17	0.75 (0.37–1.53)	.43
Number of people in the household	1.17 (0.93–1.47)	.17	1.16 (0.80–1.66)	.44
Acculturation
Heritage culture acculturation scores	1.34 (0.66–2.74)	.42	0.71 (0.22–2.22)	.55
American culture acculturation scores	1.24 (0.80–1.91)	.33	1.94 (0.89–4.23)	.10
Fluency in language of heritage culture
No	Reference		Reference
Yes	0.74 (0.42–1.29)	.29	1.05 (0.45–2.47)	.91
Fluency in English
No	Reference		Reference
Yes	0.55 (0.34–0.88)	.01	0.36 (0.14–0.93)	.03
Percentage of life in the USA	0.99 (0.98–1.01)	.36	1.00 (0.97–1.03)	.80
Social connectedness
Religious attendance
Regularly	Reference		Reference
Not regularly	0.68 (0.44–1.06)	.09	0.65 (0.33–1.28)	.21
Social isolation	1.67 (1.25–2.22)	.001	2.29 (1.50–3.49)	<.001

aOR adjusted odds ratio; cOR crude odds ratio.

DISCUSSION

Our study assessed food insecurity among a diverse sample of immigrants and refugees in metropolitan Atlanta and documented several important findings. Roughly 17% of the sample reported experiencing food insecurity in the past 12 months. This estimate, however, varied between major ethnic groups and ranged from 8% among those identifying as Bhutanese/Nepali to 35% among those identifying as Hispanic. These statistics highlight the need to collect disaggregated data by countries of origin [93–95] as different communities may experience different barriers to being food secure. In our sample, those identifying as Hispanic experienced the highest prevalence of food insecurity. The USDA estimated that, in 2018, 16.2% of Hispanic households in the USA were food insecure (compared to the national prevalence of 11.1%) [2]. An existing study examined food insecurity among predominantly Mexican migrant workers in South Georgia and found that 62% of the sample reported experiencing food insecurity [96]. Future research should continue to focus on barriers to food security among diverse Hispanic communities in the region.

We found that, among indicators of acculturation, being fluent in English was the only measure associated with lower odds of experiencing food insecurity. This finding is consistent with an existing body of literature on food insecurity among immigrants and refugees in the USA [16,23–26,49]. For example, a population-based study of Asian Americans in California found that, among Chinese, Korean, and Vietnamese households, the prevalence of food insecurity was higher among non-English speaking households compared to their English-speaking counterparts; additionally, South Asians speaking a non-English language at home also had a higher prevalence of food insecurity compared to those who reported speaking English only at home [16]. A study using 10 years of data from the NHANES found that, among Latinos, those who spoke primarily Spanish had higher odds of experiencing food insecurity [25]. Another study with a sample of recently settled West African refugees in the USA showed that those who experienced more language difficulties reported a higher prevalence of food insecurity [23].

Researchers have proposed a few explanations for this relationship. Those who speak English more fluently can better navigate barriers to employment or governmental and charitable food assistance programs (e.g., SNAP or food pantries), which can help mitigate food insecurity [25,26]. Additionally, many researchers consider language fluency to be a proxy measure for cultural orientation and hypothesize that those who do not speak English well may be more inclined to seek culturally appropriate foods from their countries of origin, which may be more expensive [16,23]. Additionally, those who do not speak English well may have lower American acculturation and may feel more stigmatized in seeking food assistance [16,97]. While we did not measure dietary acculturation in our study, we did use the Vancouver Index of Acculturation to assess degrees of acculturation to American and heritage cultures. We did not find any association between scores on degrees of acculturation and food security status. Future research can continue to examine the role of dietary acculturation, cultural stigma, and other aspects of acculturation (e.g., community-level acculturation) in relation to experiencing food insecurity among immigrants and refugees.

Successfully addressing language barriers among immigrants and refugees will likely require a two-pronged approach that connects individuals with English language and literacy services and builds the linguistic and cultural competency of staff at community-based organizations and governmental agencies. In the long-term, building English language and literacy skills, including digital literacy skills, can facilitate access to better paying and more stable employment and make it easier to navigate complex social service systems, including food assistance programs. To fulfill immediate needs, community-based organizations and governmental agencies serving immigrant and refugee populations must also enhance their linguistic and cultural competency. Offering materials and conducting outreach in a wider variety of languages and increasing the availability and quality of interpretation services can help reduce barriers to access among those with limited English proficiency [98]. Increased collaboration between migrant-serving organizations and food access organizations may also be beneficial [98]. Such partnerships can help food organizations support immigrant and refugee populations in more linguistically and culturally relevant ways while ensuring that migrant-serving organizations connect clients with all available resources.

In the sample, higher social isolation was associated with higher odds of food insecurity. This finding is important as not much research has explored the influence of social connectedness on food insecurity in these populations. Furthermore, existing research has yielded mixed findings [26,65,66]. Our findings are consistent with the hypothesis that those who feel less socially isolated are also less likely to experience food insecurity. Less social isolation can mean more social support and cohesion, which can facilitate coping strategies, such as obtaining information about food assistance programs, receiving aid for services navigation, food sharing or borrowing from family, friends, and neighbors, access to more affordable foods outside one’s immediate neighborhoods, membership to a discount grocery store, and other community-based or informal resources [46,48–50].

Reducing social isolation may be an important tool for mitigating food insecurity among immigrant and refugee populations. Eligible immigrants utilize formal social service programs at lower rates than their U.S.-born counterparts for many reasons, including complex application, eligibility, documentation, and recertification requirements, transportation barriers and work schedules, stigma, fear of discrimination and deportation, and previously discussed linguistic and cultural barriers [99]. While increasing the accessibility of formal support systems is critical, informal social networks have many inherent strengths, including the flexibility and adaptability to spontaneously address needs as they arise, shared norms regarding help-seeking behavior, more equitable power dynamics, and greater feelings of trust and reciprocity [100]. One strategy for enhancing social networks is the use of peer support group interventions, which has successfully increased social connectedness among immigrant and refugee populations [100]. For example, gender- and culture-specific peer support groups increased social integration and coping strategies and reduced loneliness among Sudanese and Somali refugees in Canada [101]. Community health worker (CHA) interventions have also improved health outcomes among immigrant and refugee populations [102]. As knowledgeable and trusted community members, CHAs may be well suited to lead peer support groups and facilitate the development of new linkages among participants in linguistically and culturally relevant ways.

Additionally, we note that contrary to our hypothesis, in our sample, religious attendance was not associated with food insecurity. Some studies have shown that faith-based organizations often provide community food aid programs that help reduce food insecurity [61–63]. It is possible that the particular religious institutions that our participants attended did not offer these programs, which may help explain our finding.

Strengths and limitations

The strengths of our study include the involvement of community members in designing and executing the study, which made the survey questions more relevant to the target population. We also incorporated different measurements related to acculturation (including validated measurements). Additionally, we used multiple imputation to handle missing data as opposed to relying on complete case analysis. We also had a diverse sample of participants from different countries of origin.

Nevertheless, our sample size was small, which may have prevented us from having sufficient power to detect associations between variables. We did not hypothesize an effect size or conduct a power analysis prior to study recruitment due to the exploratory nature of the study. Given the results found in our study, future studies can consider using a larger sample and potentially conducting analyses stratified by country of origin for further understanding of food insecurity in different communities. Our study sample was also not meant to be proportionally representative of immigrants and refugees living in the region. Future research could consider more systematic sampling strategies of these populations.

Given the sensitive nature of asking about immigrant status in the current political landscape [103], we did not include immigrant status as a variable. Being able to assess this status, however, could help advance knowledge on which populations (e.g., refugees, workers on nonimmigrant visas, or undocumented migrants) were the most vulnerable to food insecurity. We also note that the U.S. Citizenship and Immigration Services is currently adopting the “public charge” approach, which allows for the denial of applications for lawful permanent residency or entry to the USA based on the likelihood that applicants will rely on public cash assistance or government support [104,105]. Research has shown the “public charge” approach will drastically reduce immigrant families’ use of public assistance programs, including SNAP [106,107]. It is likely that this context will also create barriers for researchers examining questions related to SNAP use among immigrants (the “public charge” regulations do not apply to refugees and asylum seekers) [104].

Our survey was also cross-sectional and, thus, limits the ability to determine temporality. The use of self-reported data could be subject to recall bias and social desirability bias. While we used a professional service from our community organization partners to translate the survey into different languages, we did not use the Brislin’s back-translation method [108] (i.e., a process involving repeated independent translation to another language and back-translation into English by different translators), which could have enhanced cross-cultural equivalence of the survey. Additionally, the survey was limited in scope, and we were not able to exhaustively assess all variables potentially associated with food insecurity, such as dietary acculturation, the use of nutrition assistance programs and services, community-level access to food, or additional dimensions of social connectedness (e.g., using validated scales for social networks, social cohesion, and social capital). Future studies can explore such variables in order to enhance our understanding of food insecurity among immigrants and refugees. These variables can also help researchers identify appropriate targets for policy and community-level interventions to reduce food insecurity among these populations.

Translational implications and conclusions

This study examined food insecurity and its association with indicators of acculturation and social connectedness among a diverse sample of immigrants and refugees in metropolitan Atlanta. English proficiency may influence one’s ability to navigate or use governmental and charitable food assistance programs, and social isolation may hinder individuals from obtaining information about food assistance programs, receiving aid for services navigation, sharing or borrowing food from family, friends, and neighbors, and accessing other resources. Future studies should continue to investigate the mechanisms through which social isolation and connectedness may impact food insecurity among immigrants and refugees. Future studies should also collect disaggregated data to understand how different communities experience food insecurity, focusing in particular on Hispanic communities in the region. Interventions should seek to eliminate barriers to formal social support services and facilitate the development of informal social networks. Improving access to English language and literacy services, enhancing the linguistic and cultural competency of service providers, and building social connectedness through peer support groups and CHAs may all be useful strategies.

Funding:

This research was supported by a Global Health Institute Individual Field Scholar Award from Emory University (PI: M.V.). The funder had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. M.V. is supported by the National Cancer Institute (F31 CA243220-01, PI: M.V.). I.G.R. is supported by the National Heart, Lung, and Blood Institute (T32HL007034 and T32HL130025). C.E. is supported by the Centers for Disease Control and Prevention (U48DP006377; PI: C.E.). C.J.B. is supported by the National Cancer Institute (R01 CA179422-01; PI: C.J.B.; R01 CA215155-01A1; PI: C.J.B.; R01CA239178-01A1; MPIs: C.J.B. and Levine; P30 CA138292; PI: Curran), the Fogarty International Center (1R01TW010664-01; MPIs: C.J.B. and Kegler), and the National Institute of Environmental Health Sciences (D43 ES030927-01; MPIs: C.J.B., Marsit, and Sturua).

Compliance with Ethical Standards

Conflicts of Interest: All the authors declare no conflicts of interest.

Authors’ Contributions: M.V. is responsible for conceptualizing the study, designing the survey, overseeing data collection, performing data analysis, and writing the manuscript. C.E., Y.S., and C.J.B. all contributed to survey designing, data analysis, and manuscript writing. I.R. and H.M.J. contributed to data analysis and manuscript writing.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Emory University Institutional Review Board approved this study (IRB00097364). This article does not contain any studies with animals performed by any of the authors.

Informed Consent: Informed consent was obtained from all individual participants included in the study.