Determinants of food insecurity among Syrian refugee women and their coping strategies

Abstract

Aim

There is limited knowledge on the prevalence, risk factors, and coping strategies of food insecurity among women refugees. The aim of this study was to determine the prevalence, severity, and risk factors of food insecurity among Syrian women refugees living in Türkiye (Turkey) and to evaluate the various coping strategies they use to manage food insecurity.

Methods

This descriptive cross-sectional study was conducted with 251 Syrian women refugees aged 18–64 years living in Türkiye. Data were collected by native Arabic-speaking researchers through online and face-to-face surveys. Sociodemographic data, anthropometric measurements, food insecurity status, and coping strategies were analyzed. ‘Food Insecurity Experience Scale (FIES)’ was used to determine the food insecurity status.

Results

It was found that 28% of the women who participated in the study had food security, 35% had mild, 24% had moderate, and 13% had severe food insecurity. In the group with food insecurity, age, number of children in the family, and average body mass index (BMI) were higher, while education and income level were lower (p < 0,05). For each 1-unit increase in BMI, there was a 0.122 increase in the total FIES score. A 1-unit increase in the number of children was associated with a 0.333 increase in the total FIES score. The most preferred strategies to cope with food insecurity were found to be purchasing less preferred and cheaper foods, and reducing portion sizes.

Conclusion

Food insecurity was found to be prevalent among Syrian women refugees living in Türkiye. Women who are older, have more children, lower income, lower education, and higher BMI are more likely to experience food insecurity. Studies with larger samples and longer follow-up periods are needed to investigate the causes and effects of food insecurity among women refugees.

Introduction

The Syrian crisis has led to massive losses, deaths, and the forced displacement of approximately 6.8 million people, making it one of the most pressing humanitarian and refugee problems in history [1]. As the country with the largest number of Syrian refugees in the world [1], Türkiye hosts around 3.2 million Syrian refugees under temporary protection as of January 2024 [2]. In new settlements, refugees experience challenges and problems in accessing basic rights and services such as food, accommodation, and health [3]. It is asserted that 90% of the Syrian refugees living in Türkiye are unable to fully meet their monthly expenses or basic needs [4].

Food security is one of the basic human rights and is a state in which all human beings can physically, socially, and economically have constant access to sufficient, nutritious, and safe food which is essential to an active and healthy life. The opposite of this concept, that is, food insecurity, is the state of being deprived of continued access to sufficiently nutritious and safe food [5]. Refugees are one of the most vulnerable groups in the context of food insecurity [6]. Various problems such as economic restrictions, the lack of information on new foods, language barriers, and the difficulty in finding cultural foods and their high prices are associated with the emergence and severity of food insecurity among refugees [7]. Food insecurity can give rise to health problems in refugees, including hypertension, hyperlipidemia, mental health problems, overweight, and obesity (especially in women) [8].

As a consequence of receiving insufficient aid, as well as having limited access to resources and services, refugees choose various coping strategies to meet their daily basic needs. Coping strategies are actions taken to solve any matter perceived by individuals and households as a problem, and there are different coping strategies adopted by refugees in stressful situations [9]. Refugees may employ various coping strategies to manage food insecurity, such as choosing less expensive and less preferred foods, reducing the number of meals they eat per day, restricting portion sizes, and skipping meals entirely [10]. In the context of coping with household food insecurity, women may be more exposed to the risk of food insecurity and malnutrition, as they often reduce their own food consumption and portion sizes to ensure that other family members, particularly children, have enough to eat [10, 11]. Women and children constitute more than two-thirds of those forcibly displaced in the Syrian crisis [12], while women constitute 48% of Syrian refugees in Türkiye [2]. Although food insecurity is known to be highly prevalent among refugees, there is limited information on its prevalence among refugee women, its risk factors, and how these women cope with the situation. Therefore, this study aims to identify the prevalence and severity of food insecurity among Syrian refugee women in Türkiye, its risk factors, and the coping strategies used by these women.

Materials and methods

This descriptive cross-sectional study was conducted with Syrian refugee women who were living in Türkiye and were aged 18–64 years. The G*Power 3.1.9.7 software was utilized to calculated the minimum sample size needed for the study. Based on the power analysis conducted with a 95% confidence interval, a minimum of 210 Syrian refugee women was targeted. A total of 251 refugee women were included in this study. The snowball sampling method is commonly used to recruit hard-to-reach populations, such as refugees [13]. Therefore, this method was utilized in this study. Researchers who are native Arabic speakers collected the data both online and through face-to-face interviews using a survey form. The questions on the form were presented to the participants in Arabic. Syrian refugee women aged 18–64 years, who agreed to participate and were living in Türkiye, were included in the study. The women participated in the study on a voluntary basis. Informed consent was obtained from all participants before starting the questionnaires, and all participation was anonymous.

The survey form used in data collection had three parts. The first part consisted of questions on the sociodemographic characteristics of the participants, the second part contained questions on their anthropometric measurements, and the third part comprised questions designed to identify their food insecurity status.

Sociodemographic characteristics

The participants' characteristics, such as age, marital status, number of children (if any), and duration of education, as well as household characteristics like self-evaluated household income status and the number of individuals in the household, were examined.

Anthropometric measurements

The weight (kg) and height (cm) data of the participants were based on their self-reports. The Body Mass Index (BMI) value of each participant was found by using her body weight and height data. In this respect, the BMI value was calculated by dividing weight (kg) by height squared (m²) and was categorized as per the World Health Organization classification (BMI below 18.50 kg/m² = underweight, BMI from 18.50 kg/m² to 24.99 kg/m² = normal weight, BMI from 25.0 kg/m² to 29.99 kg/m² = overweight, BMI equal to 30 kg/m² or above = obese) [14].

Food insecurity and coping strategies

The Food Insecurity Experience Scale (FIES), developed by the United Nations Food and Agriculture Organization (FAO), was used to assess each participant's food insecurity status. The FIES focuses on self-reported food-related behaviors and experiences associated with increased difficulties in accessing food due to resource constraints over the past 12 months. It consists of eight questions, with a negative answer scored as 0 and a positive answer scored as 1 point [15]. The total FIES score, which ranges from 0 to 8 points, is the sum of the points from the eight questions: 0 points indicates food security, 1–3 points indicates mild food insecurity, 4–6 points indicates moderate food insecurity, and 7–8 points indicates severe food insecurity [16]. In this research, the Arabic version of the FIES [17] was used, and the scale had a Cronbach's alpha value of 0.86.

Additionally, the strategies adopted by participants to cope with food insecurity (e.g., choosing less preferred and cheaper food, giving food to their children, skipping meals, reducing portion sizes, borrowing money for food, and skipping the entire day without eating) were examined. These coping strategies were identified by researchers following a comprehensive literature review [18,19,20].

Statistical analysis

The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) 25.0. Based on the FIES scores of the participants, the sample was categorized into two groups: (1) the food-secure group (including food-secure and mildly food-insecure women) and (2) the food-insecure group (including moderately and severely food-insecure women) for inter-group comparisons. The normality of the distributions of the collected data was examined using the Kolmogorov–Smirnov test. The data on the categorical variables are expressed as frequency and percentage values, while differences between the groups were examined using the chi-squared test. Descriptive statistics for the continuous quantitative data are expressed as mean and standard deviation values, and t-tests were used to compare these statistics. Correlations between variables were examined using Pearson’s correlation test if the variables were normally distributed. The results of the analyses were evaluated in a 95% confidence interval. Independent effects of different predictors on FIES scores were examined using multiple linear regression.

Results

A total of 251 Syrian refugee women were included in this study. The mean age of the individuals was 25.9 ± 9.31 years (18–60 years), and the duration of their residence in Türkiye was 8.8 ± 2.56 years. Among the women in the study, 66.1% were single, and 77.1% were university graduates. The mean household size was 5.6 ± 2.23 individuals. Of the families, 68.1% had children, with a mean of 2.6 ± 1.33 children per household. The mean number of employed individuals per household was 1.3 ± 0.84.

It was found that 28% of the women had food security whereas the rest of them experienced some sort of food insecurity (35% mild food insecurity, 24% moderate food insecurity, and 13% severe food insecurity) (Fig. 1).

Fig. 1

Food insecurity status of Syrian refugee women

Table 1 shows the breakdown of the sociodemographic characteristics and BMI data of the participants based on food security status. The mean age of the food-insecure group was significantly higher than that of the food-secure group (p < 0.01). The food-secure group also had a significantly higher number of women whose marital status was single and those who had education levels above 12 years than the food-insecure group (p < 0.01). Moreover, there was a statistically significant difference between the two groups in terms of their self-evaluated household income status (p = 0.006). On the other hand, there was no statistically significant difference between the two groups based on the numbers of their family members, the number of their family members working in an income-generating job, their legal statuses in Türkiye, and their proficiency levels of speaking Turkish (p > 0.05). The food-insecure group had a significantly higher mean number of children than the food-secure group (p < 0.01). The food-insecure group had a significantly higher mean BMI value than the food-secure group (p = 0.018) and a significantly higher number of overweight and obese women (p = 0.001). There was a statistically significant positive correlation between the FIES scores and BMI values of the participants (r: 0.267, p < 0.01).

Table 1 Sociodemographic characteristics and BMI data based on food security status

Table 2 gives the regression table for age, BMI, number of children and FIES total score. Independent variables affecting the FIES total score were examined with linear regression analysis and the regression model was found to be statistically significant (F = 9.59; p < 0.001). When there is a 1 unit increase in BMI value, there is a 0.122 increase in the total FIES value. A 1 unit increase in the number of children creates an increase of 0.333. As a result of the regression analysis, the variables are explained by the model that accounts for 15.0% of the FIES total score (R² = 0.15).

Table 2 Linear regression models of the relationship between FIES total score and age, BMI, number of children

Strategies used by participant women in coping with food insecurity were listed in descending order successively as choosing less preferred and cheaper food (59%), reducing the size of portions (25.1%), giving the food to the child (17.5%), skipping meals (16.7%), borrowing money to pay for food (14.3%), and skipping the entire day without eating (4.4%). The strategies to cope with food insecurity were indicated in Fig. 2 for each group of women. The food-insecure group had significantly higher rates of skipping meals and borrowing money to pay for food than the food-secure group (respectively, p = 0.017 and p = 0.009). However, no statistically significant difference was identified between the two study groups in terms of other coping strategies (p > 0.05).

Fig. 2

Comparison of coping strategies between the food-secure and food-insecure groups

Discussion

In this study conducted with Syrian refugee women living in Türkiye, it was found that 37% of all participants experienced moderate/severe food insecurity. The participants in the food-insecure group had higher a mean age, more children in their families, a higher mean BMI value, a higher rate of women with income levels below their expense levels, and shorter durations of education.

Food insecurity is a significant problem among refugees and can lead to negative physical and mental health outcomes [18]. It was found that 34.4% of Syrian refugee women living in Lebanon experienced moderate to severe food insecurity [10]. Additionally, 63% of Syrian refugees in Jordan faced moderate to severe food insecurity in the first quarter of 2023 [21]. In this study, 37% of the participants experienced moderate to severe food insecurity. Despite Jordan ranking 47th and Türkiye ranking 49th among 113 countries in the Global Food Security Index [22], the study group's high proportion of young, single, and highly educated individuals may have contributed to the lower incidence of food insecurity.

Food insecurity constitutes a substantial issue in Türkiye [23]. In some studies conducted within the Turkish population, the prevalence of food insecurity was found to be 24.6% among adults [24] and 21.6% among women of childbearing age, which is lower than the rate found in this study. Additionally, a recent study found that among Syrian refugees living in Istanbul, moderate food insecurity was 19.4% and severe food insecurity was 64.1% [25]. Thirty percent of Syrian refugees living outside camps in the Turkish provinces of Gaziantep, Hatay, Kilis, and Şanlıurfa reported moderate to severe food insecurity [26]. Differences in the results reported in the literature may stem from variations in the sociodemographic characteristics of the samples, settlement location (camp or non-camp), the cost of living in the city they reside in, and the methods used to evaluate food insecurity.

Young age, education level, having a child under 18 years old, the number of children in the family, and the total number of family members are some of the sociodemographic characteristics associated with food insecurity in refugees [6]. In this study, sociodemographic characteristics associated with food insecurity included older age, shorter duration of education, being married, and having more children in the family. Previous studies have shown that low education levels are associated with higher levels of food insecurity, particularly among women [27, 28]. The association of food insecurity with being married and having more children in the family can be explained by the possibility that mothers gave their food to their children, and hence, their food insecurity was exacerbated.

The economic statuses of individuals and households are among the basic determinants of food insecurity. The income collected by refugees affects their food choices and the diversity of their diets, and low levels of income are associated with the consumption of high-calorie and low-cost food and a less diversified diet. This situation is linked to inadequate dietary intake and a high prevalence of food insecurity [29]. In parallel with the relevant literature [30, 31], the results of this study also showed that the food-insecure group had a higher rate of women with income levels below their expense levels.

Food insecurity has been associated with obesity. In this case, which is defined as the food insecurity-obesity paradox, the overconsumption of low-cost, high-calorie, and less nutritious food in connection with low socioeconomic status can result in overweight and obesity [32]. In some studies, it was stated that food insecurity was associated with obesity in women but not in men [33, 34]. The stronger association between food insecurity and obesity in women may be due to the fact that mothers often sacrifice their own food for their children's food security. The association between food insecurity and obesity in women was also highlighted in studies conducted among refugees [35, 36]. Likewise, in this study, it was found that the food-insecure group had significantly higher rates of overweight and obese women, and as the food insecurity scores of the participants increased, their BMI values also increased.

When they experience food insecurity, refugees adopt a variety of coping strategies such as skipping meals, borrowing money to pay for food, and changing eating patterns and food choices [18]. It was stated that refugee women living in South Africa reduced the number of their meals (92.5%), consumed less preferred and cheaper food (90%), and restricted the size of the portions in their meals (83.5%) [20]. Likewise, it was found that Syrian refugees living in Lebanon consumed less preferred/cheaper food and reduced the size of their portions and the number of their meals [37]. In a similar vein, in this study, the most frequently stated strategies by the participants to cope with food insecurity were choosing less preferred and cheaper food, reducing the size of portions, and giving the food to their children. In the comparison between the two groups, the food-insecure group was found to have significantly higher rates of skipping meals and borrowing money to pay for food than the food-secure group.

This study had some limitations. First of all, as this is a cross-sectional study, it provides correlational results rather than reporting a causal inference. Another limitation of the study was that it had a relatively small sample size. The sampling technique used in the study may also have produced a selection bias. Hence, the sample may not represent all Syrian refugee women in Türkiye. Even if this study had certain limitations, it is considered that it will contribute to the development of the relevant literature as it presents data to identify the prevalence and determinants of food insecurity and strategies for coping with food insecurity with specific reference to refugee women in Türkiye, which hosts the largest Syrian refugee population in the world.

Consequently, it was found in this study that food insecurity was prevalent among Syrian refugee women living in Türkiye, and the women in the food-insecure group had a higher mean age, more children in their families, a higher mean BMI value, a higher rate of having income lower than expenses, and shorter durations of education. As the food insecurity levels of the participants increased, their BMI values also increased. The most frequently adopted strategies among the participants to cope with food insecurity were choosing less preferred and cheaper food, reducing the size of portions, and giving the food to their children.

Despite the high educational level of the women, their low employment rate highlights the importance of creating employment opportunities for women. It is believed that an increase in the number of employed women would positively impact food security as well. Additionally, educating individuals on the importance of healthy eating and the selection of nutritious foods can be effective in maintaining body weight. Identifying the determinants of food insecurity in refugee women who are more susceptible to food insecurity is important to understanding the problem and finding a solution. This research will contribute to a better understanding of the factors contributing to food insecurity among refugee women and inform the development of targeted policies, programs, and interventions to address this issue. However, there is a need for studies with larger samples and long-term follow-up to investigate the causes and effects of food insecurity experienced by refugee women.