Every individual has the right to adequate food and to be free from hunger regardless of their socio-economic or socio-cultural status, as proclaimed in 1948 in the United Nations (UN) Universal Declaration of Human Rights (UDHR) and reiterated in the International Covenant on Economic, Social and Cultural Rights (ICESCR) [1
]. This right implies that food is to be available not just in sufficient quantity and quality (and safe), but also “acceptable within a given culture”, and access to it should be sustainable and not interfere with other human rights [1
]. This right is clearly linked to food security in many groups of people, including migrants and refugees.
External and internal conflicts, together with natural disasters, have generated vast numbers of internally and internationally displaced persons [2
]. These populations, whether in their home countries or dispersed internationally as refugees, present challenges to the international community and host countries in terms of meeting their nutritional needs. There are also migrants able to choose to move for education or temporary employment or able to emigrate and secure permanent residency. The number of people ‘on the move’ as migrants and refugees is currently at its highest level since the period immediately after World War II [3
]. Over the past two decades, the number of international migrants globally (including refugees who comprise about 10% of international migrants) has increased from 174 million in 2000 to 272 million in 2019 [4
] (prior to COVID-19).
Due to the rising number of migrants and refugees, food security among these groups has become an increasing concern for international aid agencies and host country governments. Although more than half of all international migrants worldwide are hosted in high-income countries (HICs) [4
], a substantial proportion of refugees are hosted in low- or middle-income countries, such as Turkey, Uganda, Palestine, and Pakistan [3
]. Those refugees who do eventually settle in HICs (such as the USA, UK, and Australia) can still face problems in terms of food security, including nutrition [5
]. Research among migrant/refugee populations to discern the reasons for continued food insecurity for these populations in HICs is a necessary prelude to addressing any problem effectively. It is this area that this systematic review explores.
Among migrant and refugee populations, the factors that have been implicated in food security include: language barriers, culturally determined dietary preferences which may remain unsatisfied in the new country, and a lack of familiarity with nutritionally sound substitutes [5
]. Language barriers and difficulties with adaptation to a new cultural environment (including foods) are common to both migrants and refugees [6
] and are associated with food insecurity. The culture of migrants/refugees also has a great impact on their choice of foods [8
]. People from different cultural backgrounds have different food patterns and preferences, and access to traditional foods may be of importance for identity, nutrition, health, and cultural reasons [9
]. Researchers have found that migrants/refugees often consume traditional food as a way of retaining their cultural identity [10
]. In the absence of familiar foods, however, migrants may be less able to make nutritionally optimal choices [5
], especially in the context of language difficulties.
The Middle East and North Africa cover an extensive geographic region stretching from Morocco to Iran, involving 20 countries [14
]. Since the 1960s, the ongoing conflicts and a variety of divisions in MENA have significantly altered the stability in the region [14
], leading to a situation where a substantial proportion of refugees all over the world being from MENA countries. The UN High Commissioner for Refugees (UNHCR) states that about two-thirds of refugees (67%) come from Syria (6.7 m), Afghanistan (2.7 m), South Sudan (2.3 m), Myanmar (1.1 m), Somalia (900,000), Sudan (725,000), and the Democratic Republic of the Congo (720,300) [14
]. That five of the seven major countries are Middle Eastern (ME) and African countries highlights the political instability in the Middle East and North Africa that triggers mass displacement [14
Refugee status, especially when combined with a different cultural and linguistic background, has also been known to be associated with food insecurity [6
]. The MENA region has historically been a crossroads of different cultures and religions (Judaism, Christianity, and Islam), resulting in specific religiously restricted dietary requirements, such as for Halal and Kosher food [16
]. Studies conducted in lower-income host countries (such as Turkey, Lebanon, Jordan, Syria) which accommodate the larger proportion of refugees have found food insecurity to be a major concern among ME refugees and revealed a need for improved food and financial assistance to these vulnerable populations [17
]. Food insecurity can also be high among some refugee populations in their countries of origin (e.g., South Sudan [20
]), which can have enduring impacts that range from developmental delays to physical and mental health concerns in refugees who have experienced such deprivation.
Food insecurity and nutritional inadequacy among refugees have been recorded in a number of studies, including in the UK [21
] and Australia [6
], as well as in the USA [22
] and Canada [24
]. However, studies involving migrants/refugees from MENA countries were relatively few compared to those involving older immigrant populations or populations from other regions in the world (e.g., Liberians [22
], and Cambodians and Brazilians [23
] in the USA, and Latinos in Canada [24
]). According to Asbu et al. [15
], there are gaps in knowledge about the health status of MENA migrants who have recently arrived in HICs. It is only in comparatively recent times that researchers have sought to investigate experiences of the migrant and refugee arrivals in terms of food insecurity, nutrition, and health [6
]. Such efforts, however, have often been marred by limitations in terms of sample size and composition as well as a tendency to encompass a mix of cultural and ethnic backgrounds, and hence a failure to focus solely on MENA refugees and/or migrants. This review focused on MENA migrants and refugees as they are amongst the most recently arrived groups, and little is known about them in the literature. While some comparisons may be drawn with other more general studies, the scope of this review was to explore the experiences of MENA migrants and refugees.
In order to address this issue fully and establish the level of evidence that has been conducted in this area, this review aims to determine the prevalence, determinants, and effects of food insecurity among MENA migrants and refugees in HICs.
This systematic review identifies the prevalence, determinants, and effects of food insecurity among MENA migrants and refugees in HICs. Three studies met the inclusion criteria and were included in this systematic review [13
]. All studies were conducted in USA, two among Sudanese migrant children or families [13
], and one among Somali refugee women [29
]. The rates of reported food insecurity ranged from 40% to 71% and were significantly higher than the general population. All three studies [13
] showed that food insecurity had adverse health outcomes in migrants and refugees and noted that cultural norms, religion, and food preference play an important role in predicting food security and dietary habits of MENA migrants, including refugees.
All three included studies [13
] revealed a significantly high prevalence of food insecurity among MENA refugees and migrants in an HIC. These results are consistent with other studies [6
] conducted in other HICs. In the UK, for example, a 2002 survey conducted among refugee families in East London found that all households sampled were food-insecure, and 60% of their children were experiencing hunger [21
], while a 2018 systematic review by Lawlis et al. [6
] reported food insecurity issues among refugees who had resettled in Australia. Framing food security in terms of food availability, access, utilization and stability, the 2018 review [6
] described many factors associated with food insecurity, including cost and availability of traditional foods, difficulty accessing appropriate food outlets, limited food knowledge, low income, and lack of social support. Conducted among refugee groups (undifferentiated by ethnicity), the review reported that the prevalence of food insecurity varied from 35% to 90%, with severe hunger levels experienced by 11% to 40% of the participants [6
Although USDA HFSS 18-item measure [31
] is a highly sensitive and frequently utilized food security assessment tool, the studies by Dharod et al. [29
] and Anderson et al. [13
] elected to use the modified 10-item Radimer-Cornell Hunger Scale, while the study by Alasagheirin and Clark [30
] used two items of the USDA HFSS 6-item short-form survey to measure food security. This variability in measurement tools could lead to some inconsistency in reporting the prevalence of food insecurity among studies and when comparing the study findings. Lawlis et al. [6
] recommended, the adoption of a more rigorous measure of food insecurity than the currently used 2-item tool of the 2011–2012 Australian Health Survey which the authors believe may lead to underestimations of food insecurity. A study that included Sub-Saharan African migrants in Ottawa, Canada [25
], echoed the findings of the three included studies in that almost half of the migrants were food insecure. This review found that food insecurity was most highly associated with their ethnicity (more than any other factor). This highlighted that a confluence of factors forms ethnically identified disadvantage. These include food availability, affordability, lower levels of migrant/refugee educational attainment (literacy and numeracy), recency of arrival (<5 years), reliance on social security, and lone motherhood [25
]. The disadvantage created impedes food security. Again, it should be noted that food security is not just about having enough food to eat (that is, freedom from hunger), it should also be safe, nutritious, culturally acceptable, and obtained from a sustainable food system [6
]. As the results of this review revealed, this is not always easily achievable. Many migrants (other than refugees) find themselves in a similar situation in HICs to a varying extent. Again, sample variations from refugees alone to a mixture of refugee and other migrant cohorts (such as business migrants, migrant under accepted employment schemes) or a failure to include participant income information in the data collected hamper comparison between groups, as well as with the general population or other subsets of population, and may contribute to some confounding of income impacts with ethnicity in relation to the causes of food insecurity. Many studies have noted that migrants (including refugees) generally have for some time been over-represented among those who endure higher levels of food insecurity. For example, a 2000 study by Kasper et al. investigated food insecurity among legal Latino and Asian immigrants (n = 630) and reported that 40% were food insecure without hunger and 41% were food insecure with hunger. Food insecurity was associated with low income, poor English, Latino ethnicity, and receipt of food assistance programs (‘food stamps’) [33
]. Language difficulties can contribute to difficulty in securing employment and a lower than expected (or required) uptake of or participation in food assistance measures [34
], but also to continued unemployment and poverty, and greater prevalence of developmental difficulties and chronic ill-health [35
Two of the included studies [29
] indicated a positive association between overweight and/obesity and food insecurity. This paradox has previously been confirmed in other groups, including US women, and Brazilian women and children, and the poor [36
], but not among refugees and migrants as such. In the USA, for example, it has been found that it is neither ethnicity nor race that is the best predictor of obesity, but poverty [41
]. Again, one study [30
] found both wasting and obesity were over-represented among the sample population. This could lead to further detailed study to determine the factors (and their relative importance) that are most highly related to family/individual diet or lifestyle that produce such adverse dietary outcomes, factors such as opportunity (proximity of suitable food store, transport, location of fast food outlets, the ready availability of poorer nutritional quality foods), high cost of culturally appropriate foods, language, and income impact etc.
Alasagheirin and Clark [30
] explored the impacts of food insecurity in greater depth than the other two included studies [13
]. Other health impacts of food insecurity included bone density and body composition, poor skeletal growth, and higher metabolic risks [30
]. Alasagheirin and Clark [30
] noted that many children had transited through refugee camps in Egypt or Kenya, and deprivation in such situations could have affected growth and BMC to date, and these effects could be worsened by the observed low activity in the country of reception or compensated for (even if partly) by better nutrition and higher activity levels. As noted earlier, both high cholesterol and low bone mineral density have long term ramifications for those who continue to demonstrate such patterns [42
The methodological quality of the included studies was partially adequate, with deficits found to have predominantly occurred due to the adoption of a non-probability sampling method. Furthermore, the findings cannot be generalized to the general population due to small sample sizes. Anderson et al. [13
] used a cross-sectional study method instead of a prospective longitudinal study which led to an inability to make any causal inference. Although Dharod et al. [29
] and Anderson et al. [13
] used a snowball sampling technique which offers an advantage in accessing ‘hard to reach’ populations, this has limitations associated with the use of non-probability sampling techniques. None of the studies involved accessing a strictly representative sample. Authors of all three studies cited a small sample size (or smaller than desired sample size) as a limiting factor in analyzing and evaluating their research [13
]. One study noted that a larger and more representative sample would be required to support their results [30
]. Anderson and colleagues noted that a broader examination of cultural factors was needed for future research [13
The current review had strengths and limitations. First, four databases were searched in order to gain a full collection of articles that reported on food security research among MENA migrants/refugees in high-income countries. Second, no limits were placed on publications in terms of date, age, gender, or language. Third, the included studies, whilst not comparable across the full range of their results, nevertheless added to available information related to recent MENA immigrants (including refugees) to HICs and their nutritional status (outlined above).
Some limitations of this systematic review were noted, such as a failure to find the full texts of two studies that may be potentially relevant but were then excluded as we were unable to contact the authors despite repeated attempts. Secondly, a range of food security measurement tools other than the complete USDA Household Food Security Survey 18-item tool was used by included studies, making comparisons challenging. Dharod et al. [29
] and Anderson et al. [13
] used a modified 10-item Radimer-Cornell Hunger Scale, while Alasagheirin and Clark [30
] used only two items of the USDA HFSS 6-item short-form survey. This variability of measurement tools could lead to some inconsistency when comparing the studies’ findings.