Research Brief Acculturation and Food Insecurity Among Puerto Ricans Living in Boston D1X XKaipeng Wang, D2X XPhD1; D3X XYoosun Chu, D4X XPhD2; D5X XAdolfo G. Cuevas, D6X XPhD3; n, D12X XPhD5 D7X XRobert G. Hasson III, D8X XMSW2; D9X XKatherine L. Tucker, D10X XPhD4; D1X XLuis M. Falco ABSTRACT Objective: To examine the associations among acculturation, food environment, and food insecurity among Puerto Ricans in Boston. Methods: The researchers used data from the second wave of the Boston Puerto Rican Health Study. The sample included 719 Puerto Rican adults in Boston. The researchers used logistic regression to examine the associations between psychological and language acculturation and food insecurity. Results: Individuals with medium psychological acculturation were more likely to be food insecure than were those with low or high psychological acculturation (P = .01). The association between language acculturation and food insecurity differed by distance of residence from primary shopping location (P = .02). Conclusions and Implications: This study extends the understanding of acculturation and food insecurity by investigating the impact of psychological and language acculturation. The findings highlight biculturalism, indicated by medium psychological acculturation, as a risk factor for food insecurity. People with low language acculturation who live far from food shopping locations had the highest prevalence of food insecurity. Key Words: acculturation, food insecurity, Latino, Puerto Ricans (J Nutr Educ Behav. 2018;50:829 835.) Accepted May 29, 2018.
TAGEDH1INTRODUCTIONTAGEDN Food insecurity is defined as “a household-level economic and social condition of limited or uncertain access to adequate food.”1 Food insecurity is prevalent among Latinos.2 The prevalence of food insecurity has been reported to be highest among Puerto Ricans (25.4%) relative to other Hispanic groups such as Cubans (12.1%) or Mexican Americans (20.8%).2 Puerto Rican individuals are particularly susceptible to adverse health and health-related outcomes resulting from food
insecurity; research suggested that food insecurity is associated with poor health care access, type 2 diabetes,3 and poor glycemic control over time.4 Research also indicated that food insecurity is associated with subsequent cognitive decline among Puerto Ricans.5,6 There has been much scholarly attention to the relationship between acculturation and food insecurity among Latino/Latina populations in the US. Acculturation is defined as a “multidimensional process consisting of the confluence among heritage-cultural and receiving-cultural practices,
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School of Social Work, Texas State University, San Marcos, TX School of Social Work, Boston College, Boston, MA 3 Department of Community Health, Tufts University, Medford, MA 4 Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Lowell, MA 5 College of Fine Arts, Humanities and Social Sciences, University of Massachusetts, Lowell, Lowell, MA Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Kaipeng Wang, PhD, School of Social Work, Texas State University, 601 University Dr, San Marcos, TX 78666; Phone: (512) 245-2592; Fax: (512) 245-8097; E-mail:
[email protected] Ó 2018 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2018.05.020 2
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values, and identifications.”7 Drawing data from the National Health and Nutrition Examination Survey, studies8 10 found that food insecurity was associated with lower acculturation, as indicated by speaking only Spanish among the Latino/Latina population. However, results appeared to be more complicated for Puerto Ricans than for other Latino/Latina populations. Dhokarh and associates11 found that among Puerto Ricans, food insecurity was positively associated with speaking only Spanish, yet negatively associated with attending Hispanic cultural events. The complexity of the results conveys important implications that acculturation should be examined in different domains in relation to food insecurity. Although studies employed language use and attendance to cultural events as proxies for acculturation, few examined the underlying mechanisms that explain these associations. More research is needed to better understand the unique associations between acculturation and food insecurity among Puerto Ricans. In addition, to the authors’ knowledge, whether the association between acculturation and food insecurity
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varies by food environment remains unexplored. Access to food sources (in the form of shopping location) and the quality of available food can be critical to food security, particularly for an aging population. Therefore, the research questions for this study were: (1) Are language acculturation and psychological acculturation associated with food insecurity among Puerto Ricans in the greater Boston area? (2) Do the associations between these acculturation domains and food insecurity depend on the distance of residence from the primary food shopping location?
TAGEDH1METHODSTAGEDN Data were drawn from the second wave of the Boston Puerto Rican Health Study.12 The sample for this analysis included 719 self-identified Puerto Rican adults who resided in
the Boston metropolitan area. Participants were surveyed through doorto-door enumeration and community approaches.12 Participants were given the option to complete the survey in either English or Spanish. Because this study used publicly available data, which were deidentified, the Texas State University Institutional Review Board reviewed the study and decided that it was exempt from review. Food insecurity was measured using the US Department of Agriculture 10-item, 3-stage survey with screeners.13 Because the food insecurity scale was calculated based on measures with dichotomous choices, Kuder Richardson Formula-2014 was used to assess internal consistency reliability. The Kuder Richardson Formula-20 coefficient of this scale for the study sample was 0.98, indicating high internal reliability for the
Table 1. Characteristics of Puerto Rican Participants in Boston Metropolitan Area (n = 719) Variables Food insecure
Mean (SD) or % 17.4%
Language acculturation Low
33.1%
Medium High Psychological acculturation Low Medium High Living far from primary food shopping location Availability of nutritious food in neighborhood Low High Education No schooling or less than fifth grade
35.1% 31.9% 45.5% 30.5% 24.1% 41.0% 33.9% 66.1% 22.7%
Grades 5 8 Grades 9 12
26.7% 36.2%
Some college or bachelor’s degree At least some graduate school
12.9% 1.5%
Age Woman
63.1 (7.5) 71.9%
Income Living with spouse
$19,200 ($45,200) 25.4%
study sample. Consistent with the US Department of Agriculture food security module,13 food insecurity was defined as having a food security raw score between 3 and 10, and food secure as having a food security raw score between 0 and 2. Food insecure was coded as 1 and food secure as 0. Measures of the food environment include proximity of the home address to the primary food shopping location and the availability of nutritious food in the neighborhood. Participants were asked, How far from your home is the place [or group of places] where your household does most of its food shopping? Responses were recoded into a binary variable, using half a mile or 12 blocks as the cutoff for walking distance, indicating whether the primary grocery shopping location was far. A 10-item scale with the respondent’s assessment of the availability of nutritious food in the neighborhood was adapted from a food environment survey using 5point Likert scales (Cronbach a = .96).15 The raw score was converted into a binary variable indicating low availability (1 to <4) or high availability (4 5) because its distribution is skewed to the left. Psychological acculturation was measured with the 10-item Psychological Acculturation Scale (PAS), which was developed to assess an individual’s sense of psychological attachment to and belonging within the Anglo American or Latino culture.16 This scale also demonstrated high interitem consistency for the study sample (Cronbach a = .95). To address the nonlinear relationship between food insecurity and psychological acculturation and emphasize the unique characteristics of bicultural participants, the PAS score was categorized into 3 levels: low (PAS = 10), medium (10 < PAS 21), and high (21 < PAS 43). The minimum PAS score (10) was chosen as the first cutoff point because it was reported by almost half of the participants. The researchers chose 21 as the second cutoff point because it was closest to the median among those who did not report 10 for the PAS score. Language acculturation was adapted from the Bidimensional Acculturation Scale for Hispanics17
Journal of Nutrition Education and Behavior Volume 50, Number 8, 2018 and constructed based on 7 questions on language use with media, work, friends, neighbors, and family12 The language acculturation measure shows high internal consistency reliability for the study sample (Cronbach a = .94). The language acculturation score (LAS) was also segmented into 3 tertiles: low (LAS = 0), medium (0 < LAS 25), and high (25 < LAS 96). Descriptive statistics were used to summarize the characteristics of the sample (Table 1). Logistic regression was used to determine associations among food insecurity, psychological acculturation, language acculturation, and food environment. Covariates include gender, age, marital status, income, and education. First, 1 model was estimated to show the overall effect of acculturation and food environment on food insecurity after controlling for covariates using odds ratios (ORs) and their 95% confidence intervals (CIs), as shown in Table 2. Based on the main effect model, interaction terms between language acculturation and living far
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from the primary food shopping location, between psychological acculturation and living far from the primary food shopping location, between language acculturation and the availability of nutritious food, and between psychological acculturation and the availability of nutritious food were respectively added for models 1 4 in Table 3. All statistical analyses were conducted using Stata (version 15, Stata SE, Stata Corp., College Station, TX, 2017).
TAGEDH1RESULTSTAGEDN About 1 in 5 participants (17.4%) reported being food insecure (Table 1). Close to half of respondents (45.5%) were classified as having a low level of psychological acculturation. About 24.1% reported high acculturation and 30.5% reported medium acculturation. A total of 41.0% of participants lived far (>0.5 mile or 12 blocks away) from their primary food shopping location whereas two thirds of participants reported high availability
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of nutritious food in their neighborhood. Participants with medium psychological acculturation were more likely to experience food insecurity than were those with low psychological acculturation (OR = 1.96; P = .01) (Table 2). However, there was no significant difference in food insecurity between participants with low and high psychological acculturation. In general, language acculturation did not seem to have a significant main effect on food insecurity. Those who lived far from their primary food shopping location were more likely to be food insecure (OR = 1.61; P = .04). Those who reported a high availability of nutritious food in their neighborhood were less likely to be food insecure (OR = 0.36; P < .001). Age was negatively associated with food insecurity (OR = 0.97; P = .03). Table 3 shows 4 models, each incorporating an interaction term between an acculturation variable and a food environment variable. Only the interaction between medium language
Table 2. Logistic Regression Estimating Overall Effect of Acculturation and Food Environment on Food Insecurity (n = 719) 95% Confidence Interval
P
1.32 1.17
0.74 2.35 0.56 2.44
.35 .68
Psychological acculturation (reference: low) Medium
1.96*
1.15 3.35
.01
High Living far from primary food shopping location
1.63 1.61*
0.80 3.29 1.03 2.51
.18 .04
High availability of nutritious food in neighborhood Education (No schooling or less than fifth)
0.36**
0.24 0.56
< .001
Grades 5 9 Grades 9 12
0.98 0.84
0.54 1.78 0.46 1.53
.95 .57
Some college or bachelor’s degree At least some graduate school
0.72 0.50
0.32 1.60 0.06 4.59
.41 .54
Age, y Woman
0.97* 1.66
0.94 1.00 1.00 2.75
.03 .05
Income Living with spouse
1.00 1.19
1.00 1.00 0.72 1.96
.28 .49
Constant
1.28
0.15 11.07
.83
Variables Language acculturation (reference: low) Medium High
*P < .05, **P < .001.
Odds Ratio
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Table 3. Logistic Regression Estimating Moderation Effect of Food Environment Between Acculturation and Food Insecurity (n = 719)
Variables Language acculturation (reference: low) Medium High
Model 1 Odds Ratio (95% CI)
Model 2 Odds Ratio (95% CI)
Model 3 Odds Ratio (95% CI)
Model 4 Odds Ratio (95% CI) 1.33 (0.74 2.36) 1.18 (0.56 2.46)
2.73* (1.16 6.43) 1.68 (0.61 4.64)
1.28 (0.72 2.28) 1.15 (0.55 2.40)
0.87 (0.41 1.86) 1.09 (0.46 2.59)
1.92* (1.13 3.28)
3.03** (1.39 6.62)
1.93* (1.13 3.30) 2.12* (1.04 4.35)
High Living far from primary food shopping location
1.62 (0.80 3.29) 3.38** (1.40 8.15)
1.93 (0.77 4.84) 2.39* (1.13 5.06)
1.63 (0.80 3.29) 1.91 (0.77 4.73) 1.62* (1.03 2.53) 1.62* (1.04 2.55)
High availability of nutritious food in neighborhood Medium language acculturation £ living far from primary food shopping location
0.37*** (0.24 0.57) 0.37*** (0.24 0.57) 0.24**(0.10 0.58) 0.42* (0.20 0.90)
Psychological acculturation (reference: low) Medium
0.28* (0.10 0.81)
High language acculturation £ living far 0.53 (0.17 1.62) from primary food shopping location Medium psychological acculturation £ living far from primary food shopping location High psychological acculturation £ living far from primary food shopping location Medium language acculturation £ high availability of nutritious food in neighborhood
0.47 (0.17 1.25)
0.71 (0.24 2.13) 2.35 (0.82 6.71)
High language acculturation £ high availability of nutritious food in neighborhood Medium psychological acculturation £ high availability of nutritious food in neighborhood
1.14 (0.37 3.52) 0.86 (0.32 2.32)
High psychological acculturation £ high availability of nutritious food in neighborhood
0.73 (0.24 2.19)
CI indicates confidence interval. Notes: *P < .05, **P < .01, ***P < .001. All odds ratios and their 95% CIs were estimated after adjusting for all of the covariates.
acculturation and primary food location was significant (OR = 0.28; P = .02) (model 1, Table 3), which indicated that for participants with medium language acculturation, the odds of experiencing food insecurity was less likely if they lived far from the primary food shopping location. Based on model 1, the probabilities of food insecurity and their 95% CIs by language acculturation and the distance of residence from the primary food shopping location were estimated after controlling for all covariates to
illustrate the interaction effect further. The adjusted probabilities shown in Table 4 were calculated when the values for continuous covariates were equal to the mean and the values for categorical covariates were equal to the reference categories. In general, those with low language acculturation and living far from the primary food shopping location had the highest probability of food insecurity (Probability = 0.23) (Table 4). Those with low language acculturation and living close to the primary
food shopping location had the lowest probability of food insecurity (Probability = 0.09) (Table 4). Living far from the primary shopping location was a risk factor for food insecurity for those with low or high language acculturation, but interestingly, not for those with medium language acculturation. The Figure further illustrates the associations among living far from the primary shopping location, language acculturation, and probability of being food insecure.
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Table 4. Adjusted Probability of Food Insecurity by Language Acculturation and Distance of Residence From Primary Food Shopping Location Based on Model 1 Group Low acculturation, <0.5 mile from primary food shopping location
Probability 0.09
95% Confidence Interval 0.03 0.15
Low acculturation, 0.5 mile from primary food shopping location Medium acculturation, <0.5 mile from primary food shopping location
0.23 0.20
0.14 0.33 0.13 0.27
Medium acculturation, 0.5 mile from primary food shopping location High acculturation, <0.5 mile from primary food shopping location
0.19 0.14
0.13 0.25 0.07 0.21
High acculturation, 0.5 mile from primary food shopping location
0.21
0.13 0.30
Note: Probabilities and their 95% confidence intervals were estimated when age and income were equal to the sample mean and all other covariates were equal to the values of reference categories.
TAGEDH1DISCUSSIONTAGEDN Food security is a well-established social determinant of health for Puerto Ricans. Whereas acculturation has been shown to have an important role in health,18 little is known about its influence on food insecurity. In the authors’ opinion, the current study went beyond proxy measures of acculturation and specifically investigated the association between 2 acculturation domains, psychological and language acculturation, and food insecurity. Participants with medium psychological acculturation, compared with those with low psychological acculturation, were more likely to be food insecure. Although the main effect of language acculturation on food insecurity was not significant, the association between language acculturation and food insecurity significantly differed by the distance of the residence from the primary food shopping location. Among those who lived far from their primary food shopping location, those with low language acculturation had the highest prevalence of food insecurity. However, among participants who lived close to their primary food shopping location, those with low language acculturation had the lowest prevalence of food insecurity. The current study suggests that Puerto Ricans who had an equal attachment to Puerto Rican and US culture may have experienced a social context and social capital that rendered them more food insecure
compared with those who had a closer attachment to Puerto Rican culture. Social capital refers to the resources found in one’s community that are accessed or transferred through social ties.19 Despite being able to navigate both worlds because of language, Puerto Ricans with medium psychological acculturation may have weak ties within both cultural communities or lack the membership in these respective cultural social networks to obtain tangible resources, which exposes them to poor food security. Previous studies found a positive association between acculturation and social capital.21 However, to the authors’ knowledge, little is known about how those in the middle of the acculturation spectrum navigate social capital in their communities. Among participants who lived close to the food shopping location, individuals who spoke both English and Spanish had higher food insecurity than did those who spoke only Spanish. Although this was initially counterintuitive, the social capital literature suggested that social capital is influenced by social networks and relationships that accommodate and facilitate the exchange of material goods and services.19 21 The latter includes the ability to mobilize resources (financial, emotional, or practical ones, such as access to a car) to fulfill needs. This study had several limitations. Using cross-sectional data limits the researchers’ ability to determine causal relationships between acculturation and food insecurity.
Furthermore, using self-reported data may have introduced bias that was not verifiable. In addition, the sample for this study may have differed from Puerto Ricans living in other communities. More research is needed to generalize the findings.
TAGEDH1IMPLICATIONS FOR RESEARCH AND PRACTICETAGEDN The findings of this study convey implications of preference toward Puerto Rican culture as a protective factor against food insecurity. Filling this research gap is a critical step for developing and innovating community-based interventions that are culturally sensitive to address food insecurity and health disparities among this population. Based on the results, further research and evaluation may consider the relevance of Puerto Rican culture when addressing food insecurity and related health issues among Puerto Ricans with distinct levels of acculturation. In addition, community-based interventions need to recognize the interactive influence of both acculturation and local food environment on food insecurity among this population. Nutrition intervention for Puerto Ricans attached to both US continental and Puerto Rican culture may develop strategies to address their food insecurity by helping them enhance and use social support from both communities. Further research regarding the influence of social capital on food security among
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Figure. Adjusted probability of food insecurity by language acculturation and distance of residence from primary food shopping location. Puerto Ricans is needed to enhance the understanding of the association between acculturation and food security.
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directions in research. Annu Rev Public Health. 2016;37:219-236. 19. Kawachi I, Berkman LF. Social ties and mental health. J Urban Health. 2001; 78:458-467. 20. Valencia-Garcia D, Simoni JM, Alegr{ıa M, Takeuchi DT. Social capital,
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