J Immigrant Minority Health DOI 10.1007/s10903-014-0056-1
ORIGINAL ARTICLE
Providing Nutrition Education to Recently Resettled Refugees: Piloting a Collaborative Model and Evaluation Methods Sarah Gunnell • Nedra K. Christensen Melanie D. Jewkes • Heidi LeBlanc • Debra Christofferson
•
Ó Springer Science+Business Media New York 2014
Abstract Resettled refugees experience high levels of food insecurity because of low English proficiency, limited job skills, and lack of understanding of the United States food system. This study evaluated integrating Supplemental Nutrition Assistance Program Education (SNAPEd) into English as Second Language (ESL) classes taught at a worksite- training program for recently resettled refugees and the feasibility of using food purchase receipts. A convenience sample of resettled refugees participated in SNAP-Ed one hour for 12 weeks during ESL classes. Food purchase receipts were collected for purchases one week prior to, first three weeks, last three weeks, and one week after classes. Participants were from 17 countries and 50 % completed 12 lessons. Fifty-nine participants turned in receipts and 93 % used SNAP funds. By integrating SNAPEd into ESL classes at a worksite-training center a hard-toreach eligible population was reached. Further validation is needed to use food purchase receipts.
S. Gunnell (&) Health Promotion and Human Development, College of Professional Studies, University of Wisconsin Stevens Point, 1901 North Avenue, Stevens Point, WI 54481, USA e-mail: [email protected] N. K. Christensen Utah State University, Logan, UT, USA M. D. Jewkes Salt Lake County Extension, Utah State University, Salt Lake City, UT, USA H. LeBlanc D. Christofferson Nutrition, Dietetics, and Food Science and Extension, Utah State University, Logan, UT, USA
Keywords Nutrition education Refugees English as second language Supplemental nutrition Assistance program
Background Refugees may resettle in a third country for a variety of reasons. A refugee is defined as ‘‘a person who is outside his/her country of origin and is unable or unwilling to return to that country because of a well-founded fear that he/she will be persecuted because of race, religion, nationality, political opinion, or membership in a particular social group [1].’’ Under the direction of the United Nations High Commission for Refugees (UNHCR), 76,654 refugees resettled in United States (US) in 2009 and 1,265 were placed in Utah [2]. These refugees resettled from Burma (360), Iraq (252), Bhutan (286), Somalia (180), and other war-torn countries [2]. They spent 15–20 years in refugee camps with dependence on international food aid or experienced extended time with no food or water. Resettled refugees often arrive with poor nutritional status, experience food insecurity, and lack access to adequate nutritious food in a culturally acceptable and safe manner. Several studies have reported high rates of food insecurity among recently resettled refugees [3–7]. Consequences of food insecurity include nutrition deficiencies, chronic diseases, obesity, and overall decreased well-being [8, 9]. Contributing factors to food insecurity among resettled refugees include low- income, difficulty obtaining employment, cultural barriers, and limited English proficiency [10, 11]. Decreasing food insecurity in resettled refugee populations is a public health interest and involves efforts beyond increasing income.
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The complexity of societal elements influencing individual food and physical activity choices is illustrated in the Dietary Guidelines for Americans Socio-ecological Framework for Nutrition and Physical Activity Decisions [12]. It focuses on four elements to help Americans make healthy choices: individual factors, environmental settings, sectors of influence, and social and cultural norms and values. This study takes a comprehensive approach and addresses multiple levels of the Social Ecological Model (SEM). It considers individual demographic factors, knowledge and skills, environmental settings such as work and the classroom, sectors of influence, and culture that shape nutrition choices. The Supplemental Nutrition Assistance Program Education (SNAP-Ed) operates under the United States Department of Agriculture (USDA) and is founded on the Dietary Guidelines for Americans. SNAP-Ed teaches participants how to make healthy choices within limited budgets. However, challenges in obtaining SNAP-Ed services include: conflicting work hours, lack of transportation, lack of childcare, low literacy, cultural differences, and language barriers. Federally funded nutrition education programs have been found effective in decreasing food insecurity and improving nutrient intake [13]. SNAP-Ed aligns strategies with other federally funded programs to decrease duplication and reach low-income individuals and families through multiple levels of the SEM. Nutrition education programs for resettled refugees are limited and little research exists on effective delivery and evaluation [14–16]. Integrating nutrition education into English as Second Language (ESL) classes for recently resettled refugees at a work-site training center is a coordinated system-wide approach to address low- income audiences, difficulty obtaining employment, cultural barriers, and limited English proficiency. A multiagency collaboration created a worksite-training center to provide job skills training and ESL classes for resettled refugees in Salt Lake City, Utah. Program requirements included: 18 years of age or older, low-income, case managed through a refugee resettlement agency, need to improve English skills, and good health [17]. Prior to enrolling in the work-site training program, 71 % (72/101) of resettled refugees were in the US for less than 2 years and 40 % (40/101) had 1 year or less of formal education [17]. While English proficiency, job skills, and nutrition education are found to influence food security and food choices, research is limited on how to provide resources to recently resettled refugees [15]. The primary study objective was to evaluate whether integrating SNAP-Ed into ESL classes at a worksite- training program for recently resettled refugees reached a SNAP-Ed eligible population through multiple spheres of the SEM. The secondary
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objective was to pilot the feasibility of using food purchase receipts to evaluate purchasing practices before and after participation in nutrition education classes.
Methods Barriers to providing SNAP-Ed to resettled refugees were identified in the literature and preliminary nutrition education classes at a refugee community center (Table 1). Key stakeholders from SNAP-Ed, the worksite-training center, and the ESL program collaborated resources to facilitate self-sufficiency for recently resettled refugees (Fig. 1). Approval for this study was received through the Utah State University Institutional Review Board. SNAP-Ed nutrition education assistants (NEAs) and ESL instructors informed the participants of the study. All resettled refugees at the work-site training center met SNAP-Ed eligibility requirements and received SNAP-Ed classes, but data was only reported for 98 participants who signed a letter of information. Nutrition Education Classes Four female SNAP-Ed NEAs experienced in working with diverse low-income populations provided 1-h nutrition lessons in English for 12 weeks from February 2011 to May 2011. The Utah Adult Education English for Speakers of Other Languages Standards governed the ESL instruction [18]. Resettled refugees came from 17 different
Table 1 Barriers to nutrition education and instruments to overcome barriers in socio-ecological sphere Barrier
Instruments
Socioecological sphere
Conflicting work hours
Nutrition classes taught as part of work training skill development
Environmental
Lack of transportation
NEAs travel to where refugees meet
Environmental
Low literacy
Pictures and certified ESL instructors
Individual factors
Cultural differences
Cultural training and certified ESL instructors
Social and cultural norms and values
Language
Certified ESL instructors
Individual
Food identification
Taste tests and pictures
Individual
Lack of knowledge of how to prepare food
Cooking demonstrations
Individual
J Immigrant Minority Health Table 2 Demographics of refugees
SNAP-ED Nutrition Education Assistants Nutrition Curriculum Supplies
ESL PROGRAM ESL teachers ESL classes Teaching techniques
WORKSITE TRAINING CENTER Facility Wages Supplies
Fig. 1 Nutrition education collaboration
countries and interpreters were not readily available; therefore, material was delivered in English. Minimum wage was paid to resettled refugees for working and attending mandatory ESL training. The classes were divided into groups based on English ability: level 1 (n = 24), level 2 (n = 23), level 3 (n = 25), and level 4 (n = 26). Participants in level one had no formal education and did not read in their native language while participants in level four had formal education and read in their native language. Certified ESL teachers assisted NEAs in teaching nutrition concepts according to the English level of resettled refugees. A program specialist from the Utah Refugee Services Office provided NEAs training regarding refugee resettlement. Lessons were based on the 2005 USDA Dietary Guidelines for Americans using objectives of SNAP-Ed curriculum for adults and youth. Topics included food safety, fruits, vegetables, protein, dairy, and grains. Nutrition lessons focused on common acculturation challenges of packaged and processed foods. The Healthy Eating, Healthy Living Flipchart developed by the U.S. Committee for Refugees and Immigrants contained culturally relevant nutrition information and was used to explain healthy eating practices [19]. Other visual aides such as pictures, drawings, and models illustrated concepts. Demonstrations of recipes using simple, low-cost ingredients were done to teach preparation and cooking techniques. Religious practices regarding use of animal products and fasting were taken into consideration. Budgeting concepts were integrated into each lesson, including identification of different forms of foods, comparative shopping, and menu planning.
Gender Female = 28 Male = 21 Country
Number of participants
Bhutan
11
Burundi
7
Congo
6
Iraq
5
Karenni
4
Armenia
2
Burma
2
Iran
2
Sudan
2
Central Africa Republic
1
Eritrea
1
Honduras
1
Mexico
1
Nepal Pakistan
1 1
Peru
1
Somalia
1
Evaluation and Food Purchase Receipts Demographic information was taken from ESL class rolls including gender, country of origin, SNAP eligibility, and number of lessons attended. Participants were asked to bring receipts from all food purchased 1 week before, the first 3 weeks, the last 3 weeks, and 1 week after completion of nutrition lessons. There was no incentive to bring in receipts. Participants turned receipts into a designated envelope available daily. Receipts were sorted by week of food purchase and categorized by supermarket, ethnic food store, fast food, and convenience store. Use of SNAP and Women, Infants, and Children (WIC) funds were identified on the receipts. Foods listed on the receipts were entered into a database for future curriculum development and validation of nutrition evaluation tools for recently resettled refugees.
Analysis PASW Statistics v 18, SPPS Inc., Chicago, IL, 2010 was used to analyze nominal demographic data. The food expenditure data was coded according to whether or not the participant turned in receipts. Frequencies were done to describe the types of stores where food was purchased and if the receipts reflected use of SNAP and WIC funds. No comparison before and after nutrition education lessons was done because of inadequate receipts.
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J Immigrant Minority Health Table 3 Food list from receipts
Anchovy
Celery
Gai Choy
Onion
Soybean paste
Apple
Cereal, Kix
Garbanzo beans
Orange
Soybeans
Apple juice
Cereal, Toasted Oats
Garlic
Orange Juice
Spaghetti
Applesauce Apricot
Cereal, Trix Chayote
Ginger Root Gizzard Hearts
Pakasmit Panela
Spinach Splinter Caparid
Asian Chili
Cheese, mozzarella
Grapefruit
Papaya Salad
Star fruit
Asparagus
Cheetos
Grapes
Parsley
Strawberry
Avocado
Chicken
Green jackfruit
Pasta
Sugar
Baby formula
Chicken Drums
Green Peppers
Peaches
Sweet Chili Sauce
Bamboo
Chicken, deli
Greens
Peanut Butter
Tamarind
Bananas
Chile Anaheim
Guava
Peanuts
Tangerine
Bean vermicelli
Chile Serrano
Gum
Pear, Barlett
Tea
Beef bones
Chili Beans, can
Habanero Pepper
Peas, canned
Thai Chile
Beef feet
Chili, dried
Ham
Pediasure
Tilapia
Beef ground
Chimchang
Hamburger
Pineapple
Tofu
Beef heart
Chinese radish
Honey
Pinto Beans
Tomato Paste
Beef ox tail
Chips
Hot dogs
Pistachios
Tomatoes
Beef ribs
Cilantro
Ice cream
Pizza
Tortillas
Beef roast Beef tripe
Cipolline Clementine
Juice, Tampico Ketchup
Platano Popcorn
Trout Turmeric
Beer
Cocoa mix
Lamb chops
Pork belly
Tuna, can
Beets
Coconut
Leeks
Pork hocks
Turnip
Black Beans
Coconut juice
Lemon
Pork tongue
Vermicelli
Bok choy
Coffee
Lemon grass
Pork, ground
Wai Wai Noodle
Ballios
Condensed milk
Lemon Juice
Portable jelly
Water
Bread
Cookies
Lemon Leaves
Potato
Water cress
Bread, Focaccia
Corn
Lentils
Poole
Water, bottled
Bread, French
Corn Dog
Lettuce
Pretzels
Watermelon
Bread, rolls
Crackers
Lima Beans
Punch
White Bread
Brisket
Cream cheese
Limes
Radish
White wine
Broccoli
Cucumbers
Ma-Lou
Ramen Noodles
Yampi
Brownies
Cup noodles
Malaga
Rapini
Yogurt
Butterfish
Daikon
Mango
Rice
Yogurt, drinkable
Buttermilk
Dock Kara Jew
Milk
Rice noodle
Yucca/Cassava
Cabbage Cake
Donut E´clairs
Minneola’s Mint
Rice vermicelli Rice, Jasmine
Zucchini
Caleb Mexicana
Eggplant
Mushrooms
Roti Cana
Candy Bar
Eggs
Mutton
Salad, green
Cantaloupe
Energy Drink
Ngo Gai
Salt
Capri Sun
Fish
Noodle (Wai Wai)
Sardines
Carnitas
Flour
Noodles
Shallot
Carrots
French Fries
Oatmeal
Shrimp
Catfish
Frog
Oil, salad
Sirloin Tip
Cauliflower
Frozen Dinner
Okra
Soda Pop
Results Sixty-seven percent (66/98) of participants completed 11 or more nutrition education lessons, 50 % (49/98) 12 lessons and 17 % (17/98) 11 lessons. Seventeen participants finished the work-site training program before completion of
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the study. Of the participants who completed 12 nutrition lessons, 57 % (28/49) were female and 43 % (21/49) were male and they were from 17 different countries (Table 2). All participants qualified for SNAP and 78 % (38/49) of those who completed 12 lessons reported they used SNAP benefits to purchase food.
J Immigrant Minority Health
Eligible receipts were collected from 59 of the 98 participants. Receipts identified food purchased by 25 participants 1 week prior to nutrition lessons, 49 the first 3 weeks of lessons, 18 the last 3 weeks of lessons, and two 1 week after lessons were completed. Ninety-three percent (55/59) of participant receipts reflected use of SNAP funds and 15 % (9/59) reflected use of WIC funds. Ninety-two percent (54/59) of participant receipts reflected food purchased from supermarkets, 59 % (35/59) from ethnic food stores, two from fast food, and one from convenience stores. There were 211 different foods identified on the receipts (Table 3). The list included foods not common in the typical American diet such as vermicelli, cassava, and beef heart.
Discussion Collaborative Model The model of integrating nutrition education with ESL classes based on the SEM is an innovative method to promote self-sufficiency among resettled refugees. The collaboration of the worksite-training center, ESL program, and SNAP-Ed provided a structured and consistent environment [20]. This model addressed social and cultural norms and values and sectors of influence related to food insecurity for resettled refugees: language, employment, and nutrition education (Table 1) [4]. Dividing resettled refugees into English levels facilitated English skillappropriate teaching. Mandatory ESL class attendance created consistent participation and eliminated work conflict. However, rolling enrollment and participants moving on to jobs contributed to attrition and was problematic in comparing pre and post data. Cultural Considerations Social and cultural norms and values such as religion, heritage, and lifestyle in the SEM were integrated to influence individual choices. Resettled refugees preferred lessons in English and certified ESL instructors assisted the NEAs. The goal was to increase English skills using nutrition as the medium. Pictures, taste tests, and cooking demonstrations helped overcome the language barriers. Resettled refugees improved English skills while learning about nutrition and decreased contributors of food insecurity. There were cultural differences regarding food and nutrition unique to each refugee depending on his or her country of origin, religious background, and past experience. To reach this diverse audience, nutrition lessons focused on common acculturation challenges of unfamiliar, packaged, convenience, high fat, and refined sugar foods
[21, 22]. The ESL instructors coached NEAs to teach in a culturally sensitive manner. In a focus group study of women from Somali, cooking demonstrations and food tasting were desired methods of learning and the same methods were used in this study to address cultural barriers [23]. Evaluation Methods It was difficult to identify measurable outcomes due to limited validated measurement instruments for nutrition education programs for resettled refugees. Typical evaluation tools were challenging to administer due to cultural and language barriers. An easy to administer, low response burden, and meaningful evaluation tool is needed to assess nutrient intake and food related behavior of participants in SNAP-Ed [16]. Recently resettled refugees were continually entering and exiting the program and spoke a variety of languages; therefore, multi-language evaluation tools were not feasible. An evaluation tool independent of language would be more sustainable in this fluctuating environment. Although collection of receipts has been found to underestimate food purchases in previous studies, it had not been tested as a method of assessment among resettled refugees [13]. This study demonstrated resettled refugees were able to bring receipts with minimal explanation and no incentive. Providing an incentive may have increased the consistency and number of participants turning in receipts. Comparison between food purchases before and after nutrition classes was not done because of the lack of receipts received at the end of the study. The distinction between food and non-food purchases was not always clear. Further information was needed to adequately assess food expenditures. While no comparison data was possible with receipts, a food list was compiled and provided insight to the types of foods recently resettled refugees purchased. Not all foods were captured on the food list created from the receipts because of lack of ability to identify specific names of foods, especially receipts from ethnic food stores. Bilingual resettled refugees and experts working with resettled refugees need to establish face validity for the use of food receipts as an evaluation tool [24]. This food list may be used as a basis for developing and validating a culturally sensitive food frequency questionnaire for resettled refugees and incorporating more varieties of food into nutrition education lessons. Interviews with resettled refugees would narrow the list of foods for easy administration and low response burden. Future Research and Programming Parameters in future research using food purchase receipts need to identify how many people live in the household and
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the age of persons for which food is being purchased. Focus group interviews would validate information obtained from receipts and identify other sources of food such as gardens and friends. Data collection of food purchases could be used to quantify changes in food choices based on nutrition education such as purchasing brown rice instead of white rice. Not all ESL programs for resettled refugees are integrated into a worksite- training program. Therefore it is important to consider the frequency and length of time nutrition education classes are taught. Evaluation tools need to measure short-term and long-term nutrition related behaviors. Nutrition lessons need to accommodate inconsistent participation and stand-alone. Evaluation of food related behaviors should focus on specific aspects being taught. SNAP-Ed classes may need to be assessed at 6 weeks instead of 12 weeks owing to attrition.
New Contribution to the Literature Resettled refugees are at high risk for food insecurity and its consequences. Resources for providing nutrition education for resettled refugees are limited. This study provided a model to deliver nutrition education to resettled refugees and facilitate a healthy acculturation process. It addressed contributors to food insecurity including English proficiency, job skills, and nutrition education. This unique model maximizes limited resources available to help resettled refugees become self-sufficient as quickly as possible through multiple spheres of the SEM. Information from food purchase receipts may be used to develop reliable, valid, and sensitive nutrition evaluation tools and guide nutrition education content for resettled refugees. Further research is needed to assess nutrition education program delivery, validate evaluation tools, and decrease food insecurity for recently resettled refugees. Acknowledgments Utah SNAP-Ed Program, Utah State University Extension, Salt Lake County, Salt Lake City, Utah. Granite Peaks Lifelong Learning, Granite School District, Salt Lake City, Utah. Latter-Day Saint Humanitarian Center, Salt Lake City, Utah.
References 1. 1951 Refugee Convention. Office of the United Nations High Commissioner for Refugees. http://www.unhcr.org/pages/49c36 46c125.html. 2. State Profiles Fiscal Year 2007–2009. U.S. Department of Health and Human Services Office of Refugee Resettlement. http:// www.acf.hhs.gov/programs/orr/data/state_profiles.htm. Accessed 1 Oct 2010. 3. Hadley C, Zodhiates A, Sellen DW. Acculturation, economics and food insecurity among refugees resettled in the USA: a case study of West African refugees. Public Health Nutr. 2007;10(4): 405–12. doi:10.1017/S1368980007222943.
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4. Hadley C, Patil CL, Nahayo D. Difficulty in the food environment and the experience of food insecurity among refugees resettled in the United States. Ecol Food Nutr. 2010;49:390–407. doi:10.1080/03670244.2010.507440. 5. Sellen DW, Tedstone AE, Frize J. Food insecurity among refugee families in East London: results of a pilot assessment. Public Health Nutr. 2002;5(05):637–44. doi:10.1079/PHN2002340. 6. Gallegos D, Ellies P, Wright J. Still there’s no food! Food insecurity in a refugee population in Perth, Western Australia. Nutr Diet. 2008;65(1):78–83. doi:10.1111/j.1747-0080.2007.00175.x. 7. Chilton M, Black MM, Berkowitz C, et al. Food insecurity and risk of poor health among US-born children of immigrants. Am J Public Health. 2009;99(3):556–62. doi:10.2105/AJPH.2008.144394. 8. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304–10. doi:10.3945/jn.109.112573. 9. Hampton T. Food insecurity harms health, well-being of millions in the United States. JAMA. October 24;298(16):1851–1853. doi:10.1001/jama.298.16.1851. 10. Vahabi M, Damba C, Rocha C, Montoya EC. Food insecurity among Latin American recent immigrants in Toronto. J Immigr Minor Health. 2011;13(5):929–39. doi:10.1007/s10903-010-9384-y. 11. Hadley C, Sellen D. Food security and child hunger among recently resettled Liberian refugees and asylum seekers: a pilot study. J Immigr Minor Health. 2006;8(4):369–75. doi:10.1007/ s10903-006-9007-9. 12. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 2010. www.dietaryguidelines.gov. Accessed 26 June 2013. 13. Burney J, Haughton B. EFNEP: a nutrition education program that demonstrates cost-benefit. J Am Diet Assoc. 2002;102(1):39–45. doi:10.1016/S0002-8223(02)90014-3. 14. Peterman JN, Silka L, Bermudez OI, Wilde PE, Rogers BL. Acculturation, education, nutrition education, and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. J Am Diet Assoc. 2011;111(9): 1369–74. doi:10.1016/j.jada.2011.06.005. 15. Morrison SD, Haldeman L, Sudha S, Gruber KJ, Bailey R. Cultural adaptation resources for nutrition and health in new immigrants in central North Carolina. J Immigr Minor Health. 2007;9(3):205–12. doi:10.1007/s10903-006-9031-9. 16. Marilyn ST. Evaluating food stamp nutrition education: process for development and validation of evaluation measures. J Nutr Educ Behav. January;38(1):18–24. doi:10.1016/j.jneb.2005.11. 008. 17. Vogel-Ferguson MB. Humanitarian Center Program One Year Evaluation. 2011. 18. Utah State Office of Education. ESOL and EL/Civics Standards. 2010. http://www.schools.utah.gov/adulted/ESOL-and-EL-Civics/ Standards.aspx. Accessed 26 June 2013. 19. Food and Nutrition Outreach Program for Newly Arrived Refugees. Healthy Eating, Healthy Living Flip Chart. US Committee for Refugees and Immigrants. http://www.refugees.org/resources/ for-refugees-immigrants/health/nutrition/refugee-nutrition-out reach.html. Accessed 18 Oct 2012. 20. Jewkes MD, Gunnell S, LeBlanc H, Christofferson D. Teaching nutrition to English language learners: a model for creating longlasting Extension partnerships and reaching diverse audiences. J NEAFCS. 2013;8:65–72. 21. Franzen L, Smith C. Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite. 2009;52(1): 173–83. doi:10.1016/j.appet.2008.09.012. 22. Patil CL, Hadley C, Nahayo PD. Unpacking dietary acculturation among new Americans: results from formative research with African refugees. J Immigr Minor Health. 2008;11(5):342–58. doi:10.1007/s10903-008-9120-z.
J Immigrant Minority Health 23. Van Offelen S, Sherman S, May J, Rhodes F. Designing nutrition education programs for Somali audiences: the role of cultural and religious practices. J Ext. 2011;49(3). http://www.joe.org/joe/ 2011june/a5.php. Accessed 15 Oct 2011.
24. Banna JC, Vera Becerra LE, Kaiser LL, Townsend MS. Using qualitative methods to improve questionnaires for Spanish speakers: assessing face validity of a food behavior checklist. J Am Diet Assoc. 2010;110(1):80–90. doi:10.1016/j.jada.2009.10.002.
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ORIGINAL ARTICLE
Providing Nutrition Education to Recently Resettled Refugees: Piloting a Collaborative Model and Evaluation Methods Sarah Gunnell • Nedra K. Christensen Melanie D. Jewkes • Heidi LeBlanc • Debra Christofferson
•
Ó Springer Science+Business Media New York 2014
Abstract Resettled refugees experience high levels of food insecurity because of low English proficiency, limited job skills, and lack of understanding of the United States food system. This study evaluated integrating Supplemental Nutrition Assistance Program Education (SNAPEd) into English as Second Language (ESL) classes taught at a worksite- training program for recently resettled refugees and the feasibility of using food purchase receipts. A convenience sample of resettled refugees participated in SNAP-Ed one hour for 12 weeks during ESL classes. Food purchase receipts were collected for purchases one week prior to, first three weeks, last three weeks, and one week after classes. Participants were from 17 countries and 50 % completed 12 lessons. Fifty-nine participants turned in receipts and 93 % used SNAP funds. By integrating SNAPEd into ESL classes at a worksite-training center a hard-toreach eligible population was reached. Further validation is needed to use food purchase receipts.
S. Gunnell (&) Health Promotion and Human Development, College of Professional Studies, University of Wisconsin Stevens Point, 1901 North Avenue, Stevens Point, WI 54481, USA e-mail: [email protected] N. K. Christensen Utah State University, Logan, UT, USA M. D. Jewkes Salt Lake County Extension, Utah State University, Salt Lake City, UT, USA H. LeBlanc D. Christofferson Nutrition, Dietetics, and Food Science and Extension, Utah State University, Logan, UT, USA
Keywords Nutrition education Refugees English as second language Supplemental nutrition Assistance program
Background Refugees may resettle in a third country for a variety of reasons. A refugee is defined as ‘‘a person who is outside his/her country of origin and is unable or unwilling to return to that country because of a well-founded fear that he/she will be persecuted because of race, religion, nationality, political opinion, or membership in a particular social group [1].’’ Under the direction of the United Nations High Commission for Refugees (UNHCR), 76,654 refugees resettled in United States (US) in 2009 and 1,265 were placed in Utah [2]. These refugees resettled from Burma (360), Iraq (252), Bhutan (286), Somalia (180), and other war-torn countries [2]. They spent 15–20 years in refugee camps with dependence on international food aid or experienced extended time with no food or water. Resettled refugees often arrive with poor nutritional status, experience food insecurity, and lack access to adequate nutritious food in a culturally acceptable and safe manner. Several studies have reported high rates of food insecurity among recently resettled refugees [3–7]. Consequences of food insecurity include nutrition deficiencies, chronic diseases, obesity, and overall decreased well-being [8, 9]. Contributing factors to food insecurity among resettled refugees include low- income, difficulty obtaining employment, cultural barriers, and limited English proficiency [10, 11]. Decreasing food insecurity in resettled refugee populations is a public health interest and involves efforts beyond increasing income.
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J Immigrant Minority Health
The complexity of societal elements influencing individual food and physical activity choices is illustrated in the Dietary Guidelines for Americans Socio-ecological Framework for Nutrition and Physical Activity Decisions [12]. It focuses on four elements to help Americans make healthy choices: individual factors, environmental settings, sectors of influence, and social and cultural norms and values. This study takes a comprehensive approach and addresses multiple levels of the Social Ecological Model (SEM). It considers individual demographic factors, knowledge and skills, environmental settings such as work and the classroom, sectors of influence, and culture that shape nutrition choices. The Supplemental Nutrition Assistance Program Education (SNAP-Ed) operates under the United States Department of Agriculture (USDA) and is founded on the Dietary Guidelines for Americans. SNAP-Ed teaches participants how to make healthy choices within limited budgets. However, challenges in obtaining SNAP-Ed services include: conflicting work hours, lack of transportation, lack of childcare, low literacy, cultural differences, and language barriers. Federally funded nutrition education programs have been found effective in decreasing food insecurity and improving nutrient intake [13]. SNAP-Ed aligns strategies with other federally funded programs to decrease duplication and reach low-income individuals and families through multiple levels of the SEM. Nutrition education programs for resettled refugees are limited and little research exists on effective delivery and evaluation [14–16]. Integrating nutrition education into English as Second Language (ESL) classes for recently resettled refugees at a work-site training center is a coordinated system-wide approach to address low- income audiences, difficulty obtaining employment, cultural barriers, and limited English proficiency. A multiagency collaboration created a worksite-training center to provide job skills training and ESL classes for resettled refugees in Salt Lake City, Utah. Program requirements included: 18 years of age or older, low-income, case managed through a refugee resettlement agency, need to improve English skills, and good health [17]. Prior to enrolling in the work-site training program, 71 % (72/101) of resettled refugees were in the US for less than 2 years and 40 % (40/101) had 1 year or less of formal education [17]. While English proficiency, job skills, and nutrition education are found to influence food security and food choices, research is limited on how to provide resources to recently resettled refugees [15]. The primary study objective was to evaluate whether integrating SNAP-Ed into ESL classes at a worksite- training program for recently resettled refugees reached a SNAP-Ed eligible population through multiple spheres of the SEM. The secondary
123
objective was to pilot the feasibility of using food purchase receipts to evaluate purchasing practices before and after participation in nutrition education classes.
Methods Barriers to providing SNAP-Ed to resettled refugees were identified in the literature and preliminary nutrition education classes at a refugee community center (Table 1). Key stakeholders from SNAP-Ed, the worksite-training center, and the ESL program collaborated resources to facilitate self-sufficiency for recently resettled refugees (Fig. 1). Approval for this study was received through the Utah State University Institutional Review Board. SNAP-Ed nutrition education assistants (NEAs) and ESL instructors informed the participants of the study. All resettled refugees at the work-site training center met SNAP-Ed eligibility requirements and received SNAP-Ed classes, but data was only reported for 98 participants who signed a letter of information. Nutrition Education Classes Four female SNAP-Ed NEAs experienced in working with diverse low-income populations provided 1-h nutrition lessons in English for 12 weeks from February 2011 to May 2011. The Utah Adult Education English for Speakers of Other Languages Standards governed the ESL instruction [18]. Resettled refugees came from 17 different
Table 1 Barriers to nutrition education and instruments to overcome barriers in socio-ecological sphere Barrier
Instruments
Socioecological sphere
Conflicting work hours
Nutrition classes taught as part of work training skill development
Environmental
Lack of transportation
NEAs travel to where refugees meet
Environmental
Low literacy
Pictures and certified ESL instructors
Individual factors
Cultural differences
Cultural training and certified ESL instructors
Social and cultural norms and values
Language
Certified ESL instructors
Individual
Food identification
Taste tests and pictures
Individual
Lack of knowledge of how to prepare food
Cooking demonstrations
Individual
J Immigrant Minority Health Table 2 Demographics of refugees
SNAP-ED Nutrition Education Assistants Nutrition Curriculum Supplies
ESL PROGRAM ESL teachers ESL classes Teaching techniques
WORKSITE TRAINING CENTER Facility Wages Supplies
Fig. 1 Nutrition education collaboration
countries and interpreters were not readily available; therefore, material was delivered in English. Minimum wage was paid to resettled refugees for working and attending mandatory ESL training. The classes were divided into groups based on English ability: level 1 (n = 24), level 2 (n = 23), level 3 (n = 25), and level 4 (n = 26). Participants in level one had no formal education and did not read in their native language while participants in level four had formal education and read in their native language. Certified ESL teachers assisted NEAs in teaching nutrition concepts according to the English level of resettled refugees. A program specialist from the Utah Refugee Services Office provided NEAs training regarding refugee resettlement. Lessons were based on the 2005 USDA Dietary Guidelines for Americans using objectives of SNAP-Ed curriculum for adults and youth. Topics included food safety, fruits, vegetables, protein, dairy, and grains. Nutrition lessons focused on common acculturation challenges of packaged and processed foods. The Healthy Eating, Healthy Living Flipchart developed by the U.S. Committee for Refugees and Immigrants contained culturally relevant nutrition information and was used to explain healthy eating practices [19]. Other visual aides such as pictures, drawings, and models illustrated concepts. Demonstrations of recipes using simple, low-cost ingredients were done to teach preparation and cooking techniques. Religious practices regarding use of animal products and fasting were taken into consideration. Budgeting concepts were integrated into each lesson, including identification of different forms of foods, comparative shopping, and menu planning.
Gender Female = 28 Male = 21 Country
Number of participants
Bhutan
11
Burundi
7
Congo
6
Iraq
5
Karenni
4
Armenia
2
Burma
2
Iran
2
Sudan
2
Central Africa Republic
1
Eritrea
1
Honduras
1
Mexico
1
Nepal Pakistan
1 1
Peru
1
Somalia
1
Evaluation and Food Purchase Receipts Demographic information was taken from ESL class rolls including gender, country of origin, SNAP eligibility, and number of lessons attended. Participants were asked to bring receipts from all food purchased 1 week before, the first 3 weeks, the last 3 weeks, and 1 week after completion of nutrition lessons. There was no incentive to bring in receipts. Participants turned receipts into a designated envelope available daily. Receipts were sorted by week of food purchase and categorized by supermarket, ethnic food store, fast food, and convenience store. Use of SNAP and Women, Infants, and Children (WIC) funds were identified on the receipts. Foods listed on the receipts were entered into a database for future curriculum development and validation of nutrition evaluation tools for recently resettled refugees.
Analysis PASW Statistics v 18, SPPS Inc., Chicago, IL, 2010 was used to analyze nominal demographic data. The food expenditure data was coded according to whether or not the participant turned in receipts. Frequencies were done to describe the types of stores where food was purchased and if the receipts reflected use of SNAP and WIC funds. No comparison before and after nutrition education lessons was done because of inadequate receipts.
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J Immigrant Minority Health Table 3 Food list from receipts
Anchovy
Celery
Gai Choy
Onion
Soybean paste
Apple
Cereal, Kix
Garbanzo beans
Orange
Soybeans
Apple juice
Cereal, Toasted Oats
Garlic
Orange Juice
Spaghetti
Applesauce Apricot
Cereal, Trix Chayote
Ginger Root Gizzard Hearts
Pakasmit Panela
Spinach Splinter Caparid
Asian Chili
Cheese, mozzarella
Grapefruit
Papaya Salad
Star fruit
Asparagus
Cheetos
Grapes
Parsley
Strawberry
Avocado
Chicken
Green jackfruit
Pasta
Sugar
Baby formula
Chicken Drums
Green Peppers
Peaches
Sweet Chili Sauce
Bamboo
Chicken, deli
Greens
Peanut Butter
Tamarind
Bananas
Chile Anaheim
Guava
Peanuts
Tangerine
Bean vermicelli
Chile Serrano
Gum
Pear, Barlett
Tea
Beef bones
Chili Beans, can
Habanero Pepper
Peas, canned
Thai Chile
Beef feet
Chili, dried
Ham
Pediasure
Tilapia
Beef ground
Chimchang
Hamburger
Pineapple
Tofu
Beef heart
Chinese radish
Honey
Pinto Beans
Tomato Paste
Beef ox tail
Chips
Hot dogs
Pistachios
Tomatoes
Beef ribs
Cilantro
Ice cream
Pizza
Tortillas
Beef roast Beef tripe
Cipolline Clementine
Juice, Tampico Ketchup
Platano Popcorn
Trout Turmeric
Beer
Cocoa mix
Lamb chops
Pork belly
Tuna, can
Beets
Coconut
Leeks
Pork hocks
Turnip
Black Beans
Coconut juice
Lemon
Pork tongue
Vermicelli
Bok choy
Coffee
Lemon grass
Pork, ground
Wai Wai Noodle
Ballios
Condensed milk
Lemon Juice
Portable jelly
Water
Bread
Cookies
Lemon Leaves
Potato
Water cress
Bread, Focaccia
Corn
Lentils
Poole
Water, bottled
Bread, French
Corn Dog
Lettuce
Pretzels
Watermelon
Bread, rolls
Crackers
Lima Beans
Punch
White Bread
Brisket
Cream cheese
Limes
Radish
White wine
Broccoli
Cucumbers
Ma-Lou
Ramen Noodles
Yampi
Brownies
Cup noodles
Malaga
Rapini
Yogurt
Butterfish
Daikon
Mango
Rice
Yogurt, drinkable
Buttermilk
Dock Kara Jew
Milk
Rice noodle
Yucca/Cassava
Cabbage Cake
Donut E´clairs
Minneola’s Mint
Rice vermicelli Rice, Jasmine
Zucchini
Caleb Mexicana
Eggplant
Mushrooms
Roti Cana
Candy Bar
Eggs
Mutton
Salad, green
Cantaloupe
Energy Drink
Ngo Gai
Salt
Capri Sun
Fish
Noodle (Wai Wai)
Sardines
Carnitas
Flour
Noodles
Shallot
Carrots
French Fries
Oatmeal
Shrimp
Catfish
Frog
Oil, salad
Sirloin Tip
Cauliflower
Frozen Dinner
Okra
Soda Pop
Results Sixty-seven percent (66/98) of participants completed 11 or more nutrition education lessons, 50 % (49/98) 12 lessons and 17 % (17/98) 11 lessons. Seventeen participants finished the work-site training program before completion of
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the study. Of the participants who completed 12 nutrition lessons, 57 % (28/49) were female and 43 % (21/49) were male and they were from 17 different countries (Table 2). All participants qualified for SNAP and 78 % (38/49) of those who completed 12 lessons reported they used SNAP benefits to purchase food.
J Immigrant Minority Health
Eligible receipts were collected from 59 of the 98 participants. Receipts identified food purchased by 25 participants 1 week prior to nutrition lessons, 49 the first 3 weeks of lessons, 18 the last 3 weeks of lessons, and two 1 week after lessons were completed. Ninety-three percent (55/59) of participant receipts reflected use of SNAP funds and 15 % (9/59) reflected use of WIC funds. Ninety-two percent (54/59) of participant receipts reflected food purchased from supermarkets, 59 % (35/59) from ethnic food stores, two from fast food, and one from convenience stores. There were 211 different foods identified on the receipts (Table 3). The list included foods not common in the typical American diet such as vermicelli, cassava, and beef heart.
Discussion Collaborative Model The model of integrating nutrition education with ESL classes based on the SEM is an innovative method to promote self-sufficiency among resettled refugees. The collaboration of the worksite-training center, ESL program, and SNAP-Ed provided a structured and consistent environment [20]. This model addressed social and cultural norms and values and sectors of influence related to food insecurity for resettled refugees: language, employment, and nutrition education (Table 1) [4]. Dividing resettled refugees into English levels facilitated English skillappropriate teaching. Mandatory ESL class attendance created consistent participation and eliminated work conflict. However, rolling enrollment and participants moving on to jobs contributed to attrition and was problematic in comparing pre and post data. Cultural Considerations Social and cultural norms and values such as religion, heritage, and lifestyle in the SEM were integrated to influence individual choices. Resettled refugees preferred lessons in English and certified ESL instructors assisted the NEAs. The goal was to increase English skills using nutrition as the medium. Pictures, taste tests, and cooking demonstrations helped overcome the language barriers. Resettled refugees improved English skills while learning about nutrition and decreased contributors of food insecurity. There were cultural differences regarding food and nutrition unique to each refugee depending on his or her country of origin, religious background, and past experience. To reach this diverse audience, nutrition lessons focused on common acculturation challenges of unfamiliar, packaged, convenience, high fat, and refined sugar foods
[21, 22]. The ESL instructors coached NEAs to teach in a culturally sensitive manner. In a focus group study of women from Somali, cooking demonstrations and food tasting were desired methods of learning and the same methods were used in this study to address cultural barriers [23]. Evaluation Methods It was difficult to identify measurable outcomes due to limited validated measurement instruments for nutrition education programs for resettled refugees. Typical evaluation tools were challenging to administer due to cultural and language barriers. An easy to administer, low response burden, and meaningful evaluation tool is needed to assess nutrient intake and food related behavior of participants in SNAP-Ed [16]. Recently resettled refugees were continually entering and exiting the program and spoke a variety of languages; therefore, multi-language evaluation tools were not feasible. An evaluation tool independent of language would be more sustainable in this fluctuating environment. Although collection of receipts has been found to underestimate food purchases in previous studies, it had not been tested as a method of assessment among resettled refugees [13]. This study demonstrated resettled refugees were able to bring receipts with minimal explanation and no incentive. Providing an incentive may have increased the consistency and number of participants turning in receipts. Comparison between food purchases before and after nutrition classes was not done because of the lack of receipts received at the end of the study. The distinction between food and non-food purchases was not always clear. Further information was needed to adequately assess food expenditures. While no comparison data was possible with receipts, a food list was compiled and provided insight to the types of foods recently resettled refugees purchased. Not all foods were captured on the food list created from the receipts because of lack of ability to identify specific names of foods, especially receipts from ethnic food stores. Bilingual resettled refugees and experts working with resettled refugees need to establish face validity for the use of food receipts as an evaluation tool [24]. This food list may be used as a basis for developing and validating a culturally sensitive food frequency questionnaire for resettled refugees and incorporating more varieties of food into nutrition education lessons. Interviews with resettled refugees would narrow the list of foods for easy administration and low response burden. Future Research and Programming Parameters in future research using food purchase receipts need to identify how many people live in the household and
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the age of persons for which food is being purchased. Focus group interviews would validate information obtained from receipts and identify other sources of food such as gardens and friends. Data collection of food purchases could be used to quantify changes in food choices based on nutrition education such as purchasing brown rice instead of white rice. Not all ESL programs for resettled refugees are integrated into a worksite- training program. Therefore it is important to consider the frequency and length of time nutrition education classes are taught. Evaluation tools need to measure short-term and long-term nutrition related behaviors. Nutrition lessons need to accommodate inconsistent participation and stand-alone. Evaluation of food related behaviors should focus on specific aspects being taught. SNAP-Ed classes may need to be assessed at 6 weeks instead of 12 weeks owing to attrition.
New Contribution to the Literature Resettled refugees are at high risk for food insecurity and its consequences. Resources for providing nutrition education for resettled refugees are limited. This study provided a model to deliver nutrition education to resettled refugees and facilitate a healthy acculturation process. It addressed contributors to food insecurity including English proficiency, job skills, and nutrition education. This unique model maximizes limited resources available to help resettled refugees become self-sufficient as quickly as possible through multiple spheres of the SEM. Information from food purchase receipts may be used to develop reliable, valid, and sensitive nutrition evaluation tools and guide nutrition education content for resettled refugees. Further research is needed to assess nutrition education program delivery, validate evaluation tools, and decrease food insecurity for recently resettled refugees. Acknowledgments Utah SNAP-Ed Program, Utah State University Extension, Salt Lake County, Salt Lake City, Utah. Granite Peaks Lifelong Learning, Granite School District, Salt Lake City, Utah. Latter-Day Saint Humanitarian Center, Salt Lake City, Utah.
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