Karin Seyfert

Development and Validation of an Arab Family Food Security Scale

The objective of this article was to describe 1) the validation of 2 similar but not identical food security modules used to collect data from 2 vulnerable populations, southern Lebanon residents (n = 815) and Palestinian refugees in Lebanon (n = 2501), and 2) the development and validation of an Arab Family Food Security Scale (AFFSS). The surveys used a cluster-randomized sampling design. The 2 food security subscales underwent face and construct validity. In addition, both of these tools and the AFFSS underwent psychometric assessment for internal validity by using statistical methods based on Item Response Theory. The food security questions tested by focus groups were understood and accepted in all regions of Lebanon. The food security subscales and the AFFSS had acceptable levels of internal consistency. The psychometric assessment confirmed that the 7 items of the AFFSS had good internal validity and reasonable reliability with item in-fits from 0.73 to 1.16. Food insecurity was identified among 42% of southern Lebanese and 62% of Palestinian refugee households. The determinants and consequences of food security measured in this study provide additional support for the validity of the modules. Using multivariate logistic regression, the higher the mean monthly income per household member and the higher the educational attainment of the head of household, the lower the risk of food insecurity [ORs (95% CIs): 0.99 (0.98, 0.99) and 0.66 (0.54, 0.80), respectively]. There was a strong significant association between food insecurity and lower food expenditure and lower intake of all food categories except for legumes, which was significantly associated in the opposite direction (P < 0.001). The odds of borrowing money and accepting gifts/donations were significantly higher among moderately and severely food-insecure households (P < 0.000). The AFFSS has been validated within Lebanon and can potentially be extended to other Arab-speaking populations.

Associations between life conditions and multi-morbidity in marginalized populations: the case of Palestinian refugees

Background: Evidence suggests that higher multi-morbidity rates among people with low socioeconomic status produces and maintains poverty. Our research explores the relationship between socioeconomic deprivation and multi-morbidity among Palestinian refugees in Lebanon, a marginalized and impoverished population. Methods: A representative sample of Palestinian refugees in Lebanon was surveyed, interviewing 2501 respondents (97% response rate). Multi-morbidity was measured by mental health, chronic and acute illnesses and disability. Multinomial logistic regression models assessed the association between indicators of poverty and multi-morbidities. Results: Findings showed that 14% of respondents never went to school, 41% of households reported water leakage and 10% suffered from severe food insecurity. Participants with an elementary education or less and those completing intermediate school were more than twice as likely to report two health problems than those with secondary education or more (OR: 2.60, CI: 1.73–3.91; OR: 2.47, CI: 1.62–3.77, respectively). Those living in households with water leakage were nearly twice as likely to have three or more health reports (OR = 1.88, CI = 1.45–2.44); this pattern was more pronounced for severely food insecure households (OR = 3.41, CI = 1.83–6.35). Conclusion: We identified a positive gradient between socioeconomic status and multi-morbidity within a refugee population. These findings reflect inequalities produced by the health and social systems in Lebanon, a problem expected to worsen following the massive influx of refugees from Syria. Ending legal discrimination and funding infrastructural, housing and health service improvements may counteract the effects of deprivation. Addressing this problem requires providing a decent livelihood for refugees in Lebanon.

Prevalence and Correlates of Food Insecurity among Palestinian Refugees in Lebanon: Data from a Household Survey.

Lebanon hosts the highest per capita refugee concentration worldwide. The Palestinian presence in Lebanon dates from 1948 and they remain a marginalized population. No information on their food security status has been reported previously. A survey of a representative sample of Palestinian refugee households in Lebanon (n = 2501) was conducted using a stratified two stage cluster sampling approach. We measured food insecurity using a modified USDA household food security module, locally validated. We collected data on household demographic, socioeconomic, health, housing, coping strategies and household intake of food groups and analysed these by food security status. About 41% (CI: 39-43) of households reported being food insecure and 20% (CI: 18-22) severely food insecure. Poor households were more likely to be severely food insecure (OR 1.41 (1.06-1.86)) while higher education of the head of household was significantly associated with protection against severe food insecurity (OR 0.66 (0.52-0.84)). Additionally, higher food expenditure and possession of food-related assets were significantly associated with food security (OR 0.93 (0.89-0.97) and OR 0.74 (0.59-0.92), respectively). After adjusting for confounders, households where at least one member suffered from an acute illness remained significantly more likely to be severely food insecure (OR 1.31(1.02-1.66)), as were households whose proxy respondent reported poor mental health (OR 2.64 (2.07-3.38)) and poor self-reported health (OR 1.62 (1.22-2.13). Severely food insecure households were more likely to eat cheaper foods when compared to non-severely food insecure households (p<0.001) and were more likely to rely on gifts (p<0.001) or welfare (p<0.001). They were also more likely to have exhausted all coping strategies, indicating significantly more frequently that they could not do anything (p = 0.0102). Food insecurity is a significant problem among Palestinian refugees in Lebanon and is likely to be exacerbated at this time when the Syrian crisis amplifies the problem.

Food insecurity among Iraqi refugees living in Lebanon, 10 years after the invasion of Iraq: data from a household survey

Iraqi refugees in Lebanon are vulnerable to food insecurity because of their limited rights and fragile livelihoods. The objective of the present study was to assess household food insecurity among Iraqi refugees living in Lebanon, almost 10 years after the invasion of Iraq. A representative survey of 800 UN High Commissioner for Refugees-registered refugee households in Lebanon was conducted using multi-stage cluster random sampling. We measured food insecurity using a modified US Department of Agriculture household food security module. We collected data on household demographic, socio-economic, health, housing and dietary diversity status and analysed these factors by food security status. Hb level was measured in a subset of children below 5 years of age (n 85). Weighted data were used in univariate and multivariate analyses. Among the Iraqi refugee households surveyed (n 630), 20·1% (95% CI 17·3, 23·2) were found to be food secure, 35·5% (95% CI 32·0, 39·2) moderately food insecure and 44·4% (95% CI 40·8, 48·1) severely food insecure. Severe food insecurity was associated with the respondents good self-reported health (OR 0·3, 95% CI 0·2, 0·5), length of stay as a refugee (OR 1·1, 95% CI 1·0, 1·2), very poor housing quality (OR 3·3, 95% CI 1·6, 6·5) and the number of children in the household (OR 1·2, 95% CI 1·0, 1·4), and resulted in poor dietary diversity (P< 0·0001). Anaemia was found in 41% (95% CI 30·6, 51·9) of children below 5 years of age, but was not associated with food insecurity. High food insecurity, low diet quality and high prevalence of anaemia in Iraqi refugees living in Lebanon call for urgent programmes to address the food and health situation of this population with restricted rights.

Food insecurity among Palestinian refugees living in Lebanon: a household survey

Background Although the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has been providing food aid to the most vulnerable Palestinian families since 1978, Palestinian refugees in Lebanon are still prone to food insecurity because of their fragile livelihoods and high rates of poverty. For refugees living in Lebanon, food security has only been assessed in studies undertaken after the various conflicts, and the focus was on food availability in markets. Food insecurity within households has not been assessed directly. We aimed to estimate the prevalence of food insecurity and associated factors in the households of Palestinian refugees in Lebanon. Methods We undertook a socioeconomic survey of 2575 households of Palestinian refugees during July and August, 2010. A multistage cluster random sampling approach was used to select Palestinian households living in camps and gatherings in Lebanon. We adapted the survey module used to assess food security in the USA to the context of Palestinian refugees living in Lebanon; the module was validated with Rasch modelling. We constructed a four-item scale to classify households according to their severity of food insecurity. The questionnaire was also used to obtain information about socioeconomic, demographic, and health variables, and frequency of food consumption in households. Reported proportions and percentages are population estimates calculated with inverse probability weighting to take account of the differences in sampling proportions, selection probability, and response rates. We used Stata (version 12), with incorporation of stratification, sampling stages, and weighting information, for both bivariate (adjusted Wald to assess difference in means and χ 2 to test associations) and multivariate analyses (logistic regression models) of the survey data. This study was approved by the Institutional Review Board of the American University of Beirut, Beirut, Lebanon. Verbal informed consent was obtained from a household proxy respondent to whom the questionnaire was administered. Findings 2501 (97%) of 2575 eligible households of Palestinian refugees provided informed consent and completed the questionnaire. 63% (95% CI 60–65) of households reported some food insecurity and 13% (11–14) severe food insecurity. 59% (56–62) of households lived below the national poverty line—ie, on less than US

Health and living conditions of Palestinian refugees residing in camps and gatherings in Lebanon: a cross-sectional survey

6 per person per day. The prevalence of severe food insecurity was 15% (14–18) in these households. 20% (15–27) of households with the head of the family in an elementary occupation (according to the International Standard Classification of Occupations, such as manual labourer, cleaner, and porter) reported severe food insecurity compared with 2% (2–7) in which the head of the household had a professional occupation (odds ratio 11·2, 95% CI 3·2–39·8; p=0·0001). 14% (13–16) of households in which the head had attended school for less than 10 years reported severe food insecurity compared with 8% (6–12) in which the head had attended school for 10 years or more (2·0, 1·3–2·5; p=0·004). 16% (13–21) of households with women as the head of the family had severe food insecurity compared with 11% (10–13) of those with men as the head (1·5, 1·1–2·1; p=0·0058). Households that were severely food insecure were more likely than those that were not to have at least one household member with a chronic disease (83% [78–87] vs 75% [70–79]; 1·6, 1·2–2·3; p=0·0033), disability (22% [17–30] vs 16% [14–19]; 1·5, 1·0–2·2; p=0·0439), and recent acute illness (66% [61–71] vs 57% [53–60]; 1·5, 1·1–2·0; p=0·0071). Respondents from households with severe food insecurity had lower scores on the five-item mental health inventory (p Interpretation Because food insecurity is common in households of Palestinian refugees in Lebanon and is related to low household income, female sex, and low socioeconomic group of the head of the family, food aid programmes need to be improved to reduce household food insecurity. The intake of fresh foods, particularly fruit and meat, needs to be increased to avoid micronutrient deficiencies. Special attention should be given to households of low socioeconomic status. Funding European Union.

Socio-Economic Survey of Palestinian Refugees in Lebanon

Background Palestinian refugees have lived in camps and gatherings in Lebanon for more than 60 years. They are socially, politically, and economically disadvantaged as a result of discriminatory laws and decades of marginalisation, as shown by the absence of property rights and being banned from more than 30 occupations. In Palestinian refugee camps and gatherings, the provision of housing, water, electricity, refuse, and other services are inadequate and contribute to poor health. The association between physical and mental health and living conditions of Palestinian refugees in Lebanon was assessed. Methods A cross-sectional survey of a representative sample of Palestinian refugees living in all the camps and gatherings in Lebanon was done with multistage cluster sampling during July and August, 2010. Within clusters, households were selected with a random-walk algorithm from a sampling frame provided by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). Trained Palestinian social workers interviewed a proxy respondent (generally the female homemaker) from each household face to face using a structured questionnaire. Respondents answered questions about the health and sociodemographics of all household members, housing conditions, and household expenditures and assets (including the ownership of household appliances). The questionnaire included housing indicators for water leakage and type of construction materials. Health was assessed with household reports of chronic and acute illnesses, and mental health of the respondent was assessed with the five-item mental health inventory. Logistic regression models were used to analyse the association between chronic or mental health problems and housing conditions; other covariates were controlled for. This study was approved by the Institutional Review Board of the American University of Beirut. Informed oral consent was obtained from proxy respondents. Findings A total of 2575 households were randomly selected from a sampling frame and 2501 (97%) responded to the survey. An estimated 31% of 11 092 individuals surveyed had had chronic illnesses and 24% had had acute illnesses in the 6 months before the survey. 82% of 2501 proxy respondents were women; 52% of respondents reported chronic illness, 28% reported acute illness, and 55% were psychologically distressed. 42% of dwellings had water leaking from the roof or walls and 8% were composed of building materials that are dangerous to health (eg, asbestos). Multivariate analysis of predictors of chronic illness showed that the prevalence of chronic illnesses was significantly positively correlated with water leakage (odds ratio 1·24; 95% CI 1·04–1·48) and negatively correlated with household assets (0·85; 0·79–0·91), supporting the link between poverty and health in these communities. Respondents with poor mental health were more likely than were those with good mental health to live in crowded households (1·46; 1·27–1·67), reside in homes with water leakage (1·36; 1·14–1·62), report having chronic (1·98; 1·55–2·48) and acute illnesses (1·31; 1·02–1·68), and have fewer household assets (0·88; 0·84–0·94). Interpretation Palestinian refugees living in Lebanon struggle with poor health, which is exacerbated by substandard housing and other forms of social and economic marginalisation. Initiatives to improve their housing and economic conditions are needed. Additionally, the increased efforts to assess the social roots of poor physical and mental health and develop appropriate interventions are timely. Funding European Union.