Refugees experience elevated risk of chronic disease post-resettlement. Understanding contributors to refugee knowledge of the connection between food and health may help promote healthful resettlement. A random survey was conducted with Cambodian refugee and asylee women in Lowell, MA (n = 160). Knowledge of the connection between health and food categories (meat with fat, soda, fast food, high-sodium sauces, salt, vegetables, fruit, and whole grains) was assessed. High food security, literacy, and having participated in nutrition education were related to higher knowledge. Approaches to refugee health should include improving food security and should be tailored to varied literacy levels.

Refugees bring significant economic and cultural benefits to communities and yet face elevated risk of chronic disease and barriers to good health in the U.S. Community-based participatory research (CBPR) can benefit refugee communities and provide training/mentoring opportunities for students. The Cambodian Women's Health Study was a four-phase, multi-year CBPR university-community collaboration with the Massachusetts Cambodian community that focused on health, nutrition, pregnancy, and food security among primarily young women of Cambodian heritage ages 15-30 years old. Phase 1 was a focus group discussion (FGD, n = 4) and cross-sectional survey (n = 56) with pregnant women. Phase 2 was a cross-sectional survey (n = 107) with nonpregnant women. Phase 3 was a series of FGD (seven FGD, n = 38) with women. Phase 4 was a student-led translational nutrition intervention (three classes) with women (n = 11) and men (n = 10). The study design included compensation and support for the community partner and included structured mentoring of students (six graduates, eight undergraduates) in CBPR methods, adult learning, and cultural humility. Benefits to the community agency included enhanced research capacity, including supervising student research assistants, and robust compensation. Benefits to students included intensive mentoring and training. Successes included cost-effectiveness and strong recruitment and experiences with participants. Challenges included issues with student-led recruitment and organization that required additional mentoring and reflection. To work toward socially just and equitable research and interventions, CBPR collaborative efforts should include intentional meaningful compensation and community capacity-building as well as structured mentoring and training for student researchers and should build on existing work and relationships within communities.

Abstract Background: Cambodian refugees arrived in the U.S. with limited English proficiency, low educational attainment, poor health status, and significant trauma. Combined with poor healthcare access, this fostered an environment for continued reliance on cultural health practices. Maternal health, including the postpartum period, was particularly influenced by traditional Cambodian medicine. This study investigated associations between sociodemographic factors and Cambodian women’s knowledge, beliefs, and practices related to sra thnam, a traditional postpartum medicine used in the Cambodian diaspora. Methods: This cross-sectional study was conducted with Cambodian women ages 15-35 years (N=162) living in Massachusetts. A community-academic team developed study materials and administered surveys and focus groups on knowledge, beliefs, and use of sra thnam. Focus group discussions were entered into NVivo 10. Survey data was analyzed using Stata version 14.0 and SPSS version 27. A series of statistical analyses were performed to assess associations between participant use of sra thnam and socio-demographic, health, and psychometric factors. Results: Knowledge of sra thnam was almost universal (92%), with 44% these participants reporting ever consuming it. Pregnant women (N=56) reported not having consumed sra thnam during the current pregnancy and after childbirth, 52% reported an intention to consume sra thnam, 42.9% did not, and 5.4% were uncertain. After adjusting for covariates, being born in the U.S., having at least one child, older age, and larger households were predictive of ever consuming sra thnam. Conclusion: These findings show traditional postpartum knowledge and practices are common among Cambodian women living in the U.S. These practices may have benefits, as well as pose some risks, for maternal health. Given that perceptions of pregnancy, childbirth, and postpartum experiences are nested in culture, it is important that healthcare providers are aware of traditional health beliefs and practices in refugee and immigrant communities. Greater understanding of traditional postpartum practices can facilitate culturally relevant support and health care services to mothers.

Research on geographic differences in health focuses largely on children less than five years; little is known about adolescents-and even less regarding younger adolescents-a vulnerable group at a critical stage of the life course. Africa's rapid population growth and urbanization rates, coupled with stagnant rates of undernutrition, further indicate the need for country-specific data on rural-urban health disparities to inform development policies. This study examined rural-urban disparities in body mass index-for-age-and-sex (BAZ) and height-for-age-and-sex z-scores (HAZ) among younger adolescents in Tanzania. Participants were randomly selected adolescents aged 10-14 years (N = 1,125) residing in Kilosa (rural) and Moshi (urban) districts of Tanzania. Individual and household-level data were collected using surveys and anthropometric data was collected on all adolescents. Age, sex, household living conditions, and assets were self-reported. BAZ and HAZ were calculated using the WHO reference guide. The prevalence of undernutrition was 10.9% among rural and 5.1% among urban adolescents (p<0.001). Similarly, stunting prevalence was greater in rural (64.5%) than urban (3.1%) adolescents (p<0.001). After adjusting for covariates, rural residence was significantly and inversely associated with BAZ (B = -0.29, 95% CI: -0.52, -0.70, p = 0.01), as well as with HAZ (B = -1.79, 95% CI: -2.03, -1.54, p<0.001). Self-identified males had lower BAZ (B = -0.23, 95% CI: -0.34, -0.11, p<0.001) and HAZ (B = -0.22, 95% CI: -0.35, -0.09, p = 0.001) than self-identified female adolescents. Rural-urban disparities in nutritional status were significant and gendered. Findings confirm place of residence as a key determinant of BAZ and HAZ among younger adolescents in Tanzania. Targeted gender-sensitive interventions are needed to limit growth faltering and improve health outcomes in rural settings.

Low-income families have elevated rates of both food insecurity and chronic diseases. Food purchases and consumption throughout the month may contribute to both outcomes. Four sets of focus groups (n = 21) aimed to better understand budgeting and purchasing strategies of Supplemental Nutrition Assistance Program participants. Content analysis was used to identify themes of food affordability and household purchasing power. Participants with consistent access to food reported budgeting, planning meals, strategically using public benefits, and limiting non-essential purchases. Individuals who used a combination of strategies such as meal planning, budgeting, and utilizing sales and coupons reported being better able to afford food throughout the month than those who did not.

Objective In the U.S., immigrant diets are influenced by multiple factors, including ongoing nutrition transitions in their home countries and experiences with food insecurity. Massachusetts is home to one of the largest populations of Brazilians in the U.S. Brazil has experienced a nutrition transition with increased rates of overweight and obesity, and immigrants to the U.S. face dietary changes that put them at increased risk of chronic disease. This exploratory study among Brazilian immigrants in Lowell, MA examines relationships between access to food in Brazil prior to immigration, as well as personal characteristics. It also provides qualitative context for potential health and food issues among Brazilian immigrants in the U.S. Methods An exploratory mixed methods study of Brazilian immigrant food experiences in Brazil and the U.S. was conducted among English as a Second or Other Language students in Lowell, MA. Two focus groups were held to explore food experiences, and all focus group members (n=16) completed a survey of basic demographic information, including past food experiences. Descriptive statistics were used to describe the population. Pearson's chi square tested differences in past food experiences by personal characteristics. Results Nine of the 16 respondents (56%) had at least a high school education and 4/16 (25%) reported that they were literate in English. Almost all (15/16; 94%) reported that they often had enough to eat in Brazil, but only 9/16 (56%) reported that they often could afford the kinds of food that they wanted to eat in Brazil. High school graduates were more likely to report that they often had the kind of food they wanted to eat in Brazil, compared with non‐graduates (p=0.06). Participants expressed concern about gaining weight in the U.S. and indicated that they felt self‐identified Brazilian foods were more healthy than American‐style foods. They commented that imported Brazilian foods were more expensive in the U.S., but that vegetables, rice, beans, and meat were much less expensive in the U.S. While participants indicated that eating healthfully is important, they also acknowledged that they are gaining weight in the U.S. Conclusion Based on the findings of this small exploratory study of Brazilians in the U.S., potential areas for research and/or nutrition intervention with Brazilians include: assessing how past food experiences affect approaches to food in the relatively low‐cost U.S. food environment; examining how the cost of food impacts healthfulness of food choices in the U.S.; and further exploring definitions of healthful cultural eating in the U.S. Such future work could help improve the health of immigrants from countries that have already undergone a nutrition transition. Support or Funding Information This work is supported by the Center for Excellence in Learning, Teaching, Scholarship, and Service at Framingham State University. It is also supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, the Massachusetts Agricultural Experiment Station and the Department of Nutrition of the University of Massachusetts Amherst, under project number MAS00994

Over the past 30 years, the rate of childhood obesity has risen dramatically. Despite recent declines in prevalence among preschool-aged children, child obesity is still a significant public health concern. Healthy People 2020 objectives include increasing fruit and vegetable consumption among children over 2 years of age and increasing the number of schools that offer access to fresh fruits and vegetables. To reach these objectives, farm-to-school programs are being implemented across the United States. The purpose of this evaluation was to: (a) identify factors that facilitate adoption of the Farm-to-Preschool and Families program in Springfield, MA, specifically; and (b) provide recommendations and guidelines for successful implementation of Farm-to-Preschool and Families programs generally. Using a combination of classroom observations of preschoolers, teacher and food service interviews, and administrator surveys, the findings suggest that having a strong programmatic infrastructure, administrative support, and external support from families is important to sustain a Farm-to-Preschool and Families program.

In 2012, Springfield, MA received CDC funding to promote healthy behaviors and health equity via expansion of the LWS initiative. Strategies include: (1) opening a full‐line grocery store, (2) increasing access to fresh produce, (3) increasing pedestrian way usage, and (4) creating a comprehensive pedestrian/bicycle plan. While strategies are designed to impact the city, several neighborhoods were specifically targeted because of significant health disparities. A baseline survey was administered in summer 2013 to examine eating and activity behaviors, food access and acquisition, and neighborhood characteristics. A follow‐up survey was administered in fall 2014 and was available in multiple languages. Of the 280 baseline surveys, 45% were from targeted neighborhoods. These residents reported a higher proportion of people who take over an hour to get to a full‐line grocery and walk for transportation; a lower percentage of residents who feel safe; and more barriers to purchasing fresh produce than residents in surrounding neighborhoods. Although all of Springfield will benefit from increased awareness of healthy behaviors, access to healthy foods and opportunities for increased physical activity, this neighborhood‐level information will aid in focusing targeted interventions. Results will inform future city‐wide and neighborhood‐level policy advocacy, educational programming, and contribute to ongoing media campaigns.

Background: Use of alcohol‐based tinctures is common during pregnancy and the postpartum period among Cambodians and other Southeast Asian populations. The consumption of alcohol‐based tinctures among Cambodians living in the U.S. has not been widely examined. This study investigates the association between household food security status and the consumption of a specific alcohol‐based medicinal tincture, sraa tenam, among Cambodian young women in Massachusetts.Method: Cambodian women aged 15‐30 years (n=127) were surveyed in this cross‐sectional study. Household food security was assessed using the U.S. Household Food Security 6‐item module. Participants provided data on their knowledge, attitudes, and practices of alcohol‐based medicinal tinctures. Multivariate logistic regression tested the association between the consumption of sraa tenam, an alcohol‐based medicinal tincture, and household food security scores, after adjusting for age, country of birth, and insurance coverage.Results: Approximately one‐fourth (25.6%) of the sample lived in low/very low food secure households. Forty‐two percent (42%) reported that they had consumed sraa tenam. Women with higher household food security scores were more likely to report consuming this alcohol‐based medicinal tincture compared to those with lower scores (β 0.423; 95% CI: 1.00, 2.33; p<0.05), after controlling for covariates.Conclusion: Consumption of an alcohol‐based medicinal tincture, sraa tenam, was associated with household food security status among Cambodian women in Massachusetts. Household food insecurity status may be an indicator of low utilization of conventional health care, leading to greater use of traditional medicine as a coping mechanism. Alcohol‐based tinctures have both risks and benefits: the use of alcohol in tinctures may contribute to nutritional deficiencies, and yet, alcohol‐based fermented tinctures may also have potential health benefits with levels of alcohol that may be too low to pose a risk to maternal and infant health. The overall risks and benefits of alcohol‐based medicinal tinctures need to be carefully investigated to support optimal maternal and child health. Raising awareness of traditional practices among health practitioners that serve SE Asian populations may also be important.Grant Funding Source: USDA

Background: Urban population growth has outpaced expectations in developing countries, changing physical, social, and economic landscapes with implications on health across gender. Comparative studies on gender differences in nutritional status by geographic location present mixed findings.Objective: This study examines gender differentials in undernutrition across rural‐urban residence in a sample of Tanzanian adolescents.Methods: This cross‐sectional study examines predictors of poor nutritional status across urban and rural adolescents aged 10‐14 (n=892) in Tanzania. Undernutrition was classified as BMI for Age <5th percentile of the NCHS/WHO reference. Logistic regression analysis tested the association between undernutrition, gender, and urban‐rural residence after adjusting for covariates.Results: The prevalence of undernutrition was 23.7 % among rural and 11.8% among urban adolescents (p<0.05). Among males, prevalence of undernutrition was 28.8% for rural and 17.5% for urban adolescents (p<0.05). The rates for rural females were 18.4% compared to 6% for urban peers (p<0.05). Overall, males more likely to be undernourished than females after adjusting for urban/rural residence and age [OR=2.15 (95%CI: 1.49, 3.09); p<0.05].Conclusions: Our findings suggest that adolescents in rural settings experience higher rates of undernutrition than urban youth. In particular, programs and policies aiming to improve public health in Tanzania should target rural males. Longitudinal studies are needed to determine whether the gender differential observed in adolescent nutritional status in developing countries has a physiological explanation and whether growth trajectories differ across urban‐rural settings.Grant Funding Source: Supported by UNICEF/Tanzania, and the Commonwealth Honors College and the Department of Nutrition of the University of Massachusetts Amherst

Cambodians were resettled in the U.S. as a consequence of domestic civil strife in the 1970s. Refugees in the U.S. experience poorer health outcomes than U.S. born residents or other immigrants. Trauma from war, displacement, and loss of family may be associated with higher incidences of chronic disease. Intergenerational health risks can predispose children of survivors to poor health. For many, dietary practices may contribute to poor health outcomes. Implementation of culturally sensitive nutrition education can be an important strategy to motivate dietary behavioral change. The purpose of this study is to better understand young Cambodian women’s beliefs, attitudes and perspectives of what constitutes a healthy diet. Semi‐structured focus groups (n=7) with 38 Cambodian women 15 to 30 years old were conducted in Lowell, Massachusetts in 2013 and 2014. Five groups were held in English, and two in Khmer. Content analysis identified three broad categories from transcribed data: healthy food, unhealthy food and motivators for food choices, with discussions including both traditional and participant identified American foods. Within these categories, emergent themes were food safety and sugar, which were categorized as both healthy and unhealthy, while appearance and behavior were the most prevalent motivators impacting food choices. These findings contribute important culturally informed knowledge that can be used to help develop meaningful nutrition interventions for young Cambodian women.Grant Funding Source: Supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, the Massachusetts Agricultural Experiment Station and the Nutrition Department of the University of Massachusetts Amherst.

Objective: (1) To understand the perceptions of, access to, and utilization of healthful cultural foods and safety nets in immigrant and Puerto Rican families. (2) To assess the overlap between healthful cultural foods and safety nets in these families.Methods: Focus groups were held with Puerto Ricans and immigrants from the Dominican Republic (3 groups, 16 participants) and with Cambodian (9 focus groups, 66 participants) and Brazilian (2 focus groups, 16 participants) immigrants in Massachusetts. Directed content analysis was used to identify themes about perceptions, access, and utilization for healthful cultural foods and safety nets. Overlapping themes were identified between healthful cultural foods and safety nets.Results: Participants from all groups valued healthful cultural foods. Cambodians and Brazilians considered American‐style foods less healthful than cultural foods, while Latinas identified some cultural foods as less healthful. All groups were able to access healthful cultural foods but some found it challenging to afford them. Cambodians worried about quality and safety. Cambodians and Latinas reported using safety nets such as food stamps (SNAP), WIC, families, and food pantries. They reported that while both SNAP and WIC helped them afford healthful cultural foods, benefits were inadequate, and that food quality decreased over the month.Conclusions: Intervention programs targeted to these populations should build on current knowledge and practices that value healthful cultural foods and take into consideration barriers. Barriers to accessing and utilizing government safety nets such as SNAP and WIC appear to limit diet quality at some points in the month for immigrant and Puerto Rican families.Grant Funding Source: USDA National Institute of Food and Agriculture, Projects MAS00991 and MAS00994

Background: The Cambodian refugee population in the United States is at increased risk for household food insecurity and adverse mental health. There is limited literature regarding the association between food insecurity and mental health in young Cambodian women.Objectives: The objective of this study was to investigate the association between depression status and household food insecurity among young Cambodian women in Massachusetts.Methods: A cross‐sectional survey was conducted with young women of Cambodian heritage ages 15‐30 years of age (n=127). The dependent variable, household food security score, was measured using the USDA 6‐item module. The independent variable, depression score, was ascertained using the Harvard Trauma Scale. Multivariable linear regression was used to determine the association between depression status and household food security score, controlling for age and pregnancy status.Results: Of 127 women, 25.6% lived in low/very low food secure households. The mean depression score was 23.8. Lower depression scores were observed among pregnant women compared to non‐pregnant women (24.3 vs. 30.9, p<0.05). Women with higher depression scores were more likely to be food insecure than women with lower depression scores (β ‐0.475; 95% CI: ‐0.949, ‐0.002), after controlling for age and pregnancy status.Conclusion: Household food security scores were positively associated with depression among Cambodian young women. This finding suggests the role of depression as a potential indicator of household food security status. Future research on these associations among refugee women living in the United States are warranted.Grant Funding Source: USDA

Social safety nets like SNAP, WIC, and fuel assistance can alleviate food insecurity and improve household resources. They may not prevent health consequences of food insecurity unless they promote purchase and consumption of healthful foods. Social stigma around use of benefits can prevent vulnerable families from utilizing benefits, which may further complicate food insecurity. We analyzed focus group transcripts (6 focus groups, 21 participants) with low‐income, largely food insecure individuals in Massachusetts to assess use of social safety nets and related social stigma. We used directed content analysis to examine pre‐identified themes and to identify new themes. Pre‐ identified themes included the use of SNAP and WIC to extend resources and stigmatization of the use of social safety nets by the members of the community. New themes were utilization of fuel assistance to free up resources, saving SNAP for special and healthy foods, stigmatization of low cost foods by children, stigma within the community for resource allocation of benefit users, and self‐stigmatization. Different stigma associated with the use of social benefits and purchase of low cost foods might prevent low‐income individuals from utilizing. In this context, allocation of certain benefits, such as SNAP, to purchase low quality foods might lead to health complication in the future.Funding source: USDA‐CSREES #H994

Young and emerging adults in refugee families are at high risk of poor health outcomes due to combined pre‐migration experiences and the U.S. food environment. Pregnancy is a key time to intervene. This study assessed dietary practices of pregnant young women of Cambodian heritage in Massachusetts (15–30YO) and assessed relationships with characteristics through a cross‐sectional survey (n=35). Most respondents consumed high‐calorie, nutrient‐poor American‐style foods >;1x/month (fast food, hot dogs, pizza, and chicken nuggets, 69%), sweetened beverages >;1x/week (54%), and white rice >;1x/day (87%). Half consumed dairy products >;1x/day. Having a child >;3YO and higher acculturation were positively related to consuming American‐style foods and dairy products. These young women navigate multiple cultures and the U.S. food environment. Exposure to dominant U.S. culture likely influences both positive (calcium consumption) and negative (American‐style food consumption) dietary practices, while cultural heritage likely influences white rice consumption. Nutrition education efforts should address healthy cultural and American‐style dietary practices for pregnant young and emerging adults in refugee families. Funding: USDA‐CSREES #H991.

Low‐income households are at risk of food insecurity and altered food related behaviors. This study examined the relationship between food security status and specific food purchasing practices. Participants in the Massachusetts Expanded Food and Nutrition Education Program (EFNEP) completed a pre‐curriculum survey. Household food security was assessed by the USDA 6‐item food security module. We asked additional questions about how often participants could afford healthy foods, fruits and vegetables, and the same foods throughout the month. In the pre‐EFNEP survey, 41% (n=58) were food insecure and 66% (n=38) had marginal/low/very low food security. Overall, 22% (n=13) that could always or often afford healthy foods, 26% (n=15) that could always or often afford fruit and vegetables, and 24% (n=14) that could always or often afford the same foods all month experienced low/very low/marginal food security. Those with marginal/low/very low food security were less likely than fully food secure to report they could always afford healthy foods, fruits and vegetables, and the same foods all month. Food purchasing behaviors can be affected by the strain of limited resources. Nutrition education can provide skills and knowledge to low‐income, food insecure populations so they may better manage resources to afford foods they need throughout the month.UMass Amherst Office of Faculty Development

While household food insecurity is public health concern, there is limited data on the food security status of refugee populations in the U.S. Refugees from Cambodia were resettled in the U.S. in the 1980's. This study assessed the food security status of pregnant and post‐partum Cambodian women (15–30 YO) in Massachusetts. We held focus group discussions and administered surveys to study participants. Household food insecurity was measured using the 6‐item form of the U.S. Household Food Security Survey (HFSS) and a modified version of the Household Food Insecurity Access Scale (HFIAS). In this sample, 37.5% lived in food insecure households, 35.5% reported frequent consumption of less preferred food due to insufficient resources, and 31.3% reported that they sometimes/often worried that food would run out. Our findings suggest that the HFSS and HFIAS captured different aspects of the food security construct. Although responses to some questions in the HFSS were significantly correlated with responses to similar questions in the HFIAS, the variation in participant responses was different across measures. This mixed method approach provided valuable insight on the range of food security experiences among Cambodian women. We found a high prevalence of food insecurity among pregnant Cambodian women living in MA, which may have negative implications for maternal and child health.

Resettled refugees have high rates of chronic disease, which may be partially due to persistent food insecurity. This study describes food experiences on arrival in the U.S. and current food security status and examines characteristics related to food insecurity in a well-established refugee community. Focus groups and a survey assessed food security status and personal characteristics of Cambodian women in Lowell, MA, USA. Multivariate logistic regression was used to examine relationships with food insecurity. Current rates of food insecurity are high. In multivariate models, food insecurity was positively associated with being depressed and being widowed, and negatively associated with higher income and acculturation. Early arrivers (1980s) had difficulty in the U.S. food system on arrival, while later arrivers (1990s–2000s) did not. Refugee agencies should consider strategically devoting resources to ensure successful early transition to the U.S. food environment and long-term food security of refugees.