Abstract
Refugee-specific nutrition and cooking curricula addressing dietary acculturation barriers to food security are limited. A cooking curriculum was culturally adapted for Burundian and Congolese refugees to address their unique dietary acculturation experiences. A four-phase curriculum adaptation process (information gathering [literature review, researcher informed, and formative interviews; n = 18], preliminary adaptation design [data incorporation and steering committee; n = 5], pilot testing [n = 10 youth/adult dyads], and refinement) was applied to the existing evidence-based iCook 4-H curriculum using a five-strategy (peripheral, evidential, linguistic, constituent-involving, and sociocultural) cultural adaptation framework. A multiphase, two-cycle coding analytic process was completed within NVivo 12, followed by direct content analysis. Seventeen adaptations were made to the iCook curriculum, derived from varying combinations of four data sources (literature review, researcher informed, priority population, and steering committee), applying all five cultural adaptation strategies. A majority of the curriculum adaptations were derived from two or more data sources (71%) and were categorized within multiple adaptation strategies (88%). This study provided a community-based cultural adaptation process that could be used with various populations to address unique barriers and facilitators to food security. This innovative model addresses cultural needs while simultaneously aiming to improve health habits of refugee communities.
Increasing numbers of people are fleeing their homes to escape persecution, oppression, war, or violence all over the globe (United Nations High Commissioner for Refugees [UNHCR], 2018a). When these refugees cannot safely return to their home countries, they resettle in other countries, including the United States (UNHCR, 2018b). Although the United States is typically considered as a nation with plentiful food resources, refugees resettled in the United States have consistently reported low food security rates when compared to national averages of nonrefugee populations (Anderson et al., 2014; Coleman-Jensen et al., 2019; Dharod et al., 2011; Dharod et al., 2013; Hadley et al., 2007; Hadley et al., 2010; Hadley & Sellen, 2006; Nunnery et al., 2015; Peterman et al., 2013). This means they do not have stable access to nutritious, safe foods to support a healthful life (Coleman-Jensen et al., 2019).
According to the U.S. Department of Agriculture, approximately 11.1% (14.3 million) of households in the United States reported low food security in 2018 (Coleman-Jensen et al., 2019). Although there are no national surveillance data focused on the food security status of refugees living in the United States, several smaller studies have explored this topic. Compared to the prevalence in the general population (11.1%), refugees resettled in the United States have reported low food security at much higher rates, ranging from 24% to 85% (Anderson et al., 2014; Coleman-Jensen et al., 2019; Dharod et al., 2011, 2013; Hadley et al., 2007; Hadley et al., 2010; Hadley & Sellen, 2006; Nunnery et al., 2015; Peterman et al., 2013). Although rates varied among different refugee groups, 53% to 85% of the sub-Saharan African refugee households in these studies reported low food security (Dharod et al., 2011, 2013; Hadley et al., 2007; Hadley et al., 2010; Hadley & Sellen, 2006; Nunnery et al., 2015). Based on these rates, sub-Saharan African refugees appear more at risk for low food security compared to other refugee groups and the general U.S. population.
Based on qualitative studies, dietary acculturation issues are barriers to achieving food security among refugee populations resettled in the United States (Hadley et al., 2007; Hadley et al., 2010; Hadley & Sellen, 2006). Dietary acculturation is the process in which refugees adopt food choices, preparation habits, and consumption patterns reflecting their new residence (Himmelgreen et al., 2005). Refugees resettled in the United States from diverse parts of the world have reported dietary acculturation barriers including cooking (limited American food knowledge), shopping (unfamiliar foods and English barriers), accessing (difficulties with transportation), and affording (inadequate economic resources) healthful foods (Anderson et al., 2014; Dharod et al., 2013; Hadley et al., 2010; Hadley & Sellen, 2006; McElrone et al., 2019; Patil et al., 2009).
Burundian and Congolese refugees, the priority sub-Saharan African refugee communities in this study, experience some similar barriers upon resettlement in the United States, such as limited financial resources, low literacy rates, low English proficiency, and limited jobs skills (Cultural Orientation Resource Center, 2007; UNHCR, 2019). These circumstances make it difficult for both Burundian and Congolese refugees to transition to life in the United States, including obtaining and maintaining a food-secure home. In addition to the dietary acculturation barriers noted among various refugee groups, Burundian and Congolese refugees reported other barriers to food security, including difficulty using U.S. currency, limited orientation services, limited culturally appropriate food and land access, and overreliance on and miscomprehension of the U.S. Department of Agriculture nutrition assistance programs and policies (McElrone et al., 2019).
Refugee-specific nutrition curricula addressing dietary acculturation barriers to food security are limited (Cottrell, 2006). The Healthy Eating flip chart was developed by the U.S. Committee for Refugees and Immigrants to address refugee nutrition, healthy eating patterns, and physical activity, but it is often offered without accompanying programming, greatly limiting access for low-literacy refugee populations (Cottrell, 2006). Additionally, while this printed resource is available in multiple languages and intended for a broad refugee audience, few culturally reflective images of African refugees are used, and it is not tailored for sub-Saharan African refugees. Moreover, although similarities in dietary acculturation barriers to food security have been noted among Burundian and Congolese refugees and other refugee groups, some findings varied, reflecting the need for targeted curricula and interventions to adequately address the unique needs of the refugee community of interest (McElrone et al., 2019).
To help fill the gap, this study was designed to adapt an existing, evidence-based cooking curriculum to address food security and the unique dietary acculturation of Burundian and Congolese refugee families living near a midsized city in the Southeastern region of the United States. This multiphase curriculum adaptation process was informed by previous research with the priority population (McElrone et al., 2019) as part of a larger community-based research study (White et al., 2019).
Method
Evidence-Based Curriculum
The existing cooking curriculum, iCook 4-H, was an eight-session, evidence-based, family intervention promoting cooking, eating, and playing together, in which youth and adults were involved in the educational process (Franzen-Castle et al., 2019). The curriculum provided an appropriate foundation to address refugee dietary acculturation barriers to food security such as shopping, cooking, accessing, and acquiring healthful foods in the United States. The curriculum was developed for low–socioeconomic status families and included low-cost ingredients and recipes suitable for low-income refugee families. Additionally, the iCook 4-H curriculum was grounded in the social cognitive theory (Bandura, 1986), which has been successfully used in previous refugee health interventions (El Harake et al., 2018). The social cognitive theory components such as behavioral capability, self-efficacy, and observational learning were used in the curriculum to dynamically share and gain knowledge and skills in a reciprocal manner between facilitators, adults, and youth (Bandura, 1986). Moreover, as a potential avenue for effective refugee nutrition programming (Patil et al., 2009), the iCook 4-H model involved youth-adult dyads and served as a vehicle to reach the primary population of the intervention, sub-Saharan African refugee families, through the incorporation of youth. This dyad model promoted the communal transfer of traditional and postresettlement shopping and cooking knowledge and skills between youth and adults (Patil et al., 2009). Additionally, the iCook 4-H curriculum was designed for a group setting. This group setting was used to strengthen existing social network support and build new ones, which is a facilitator to food security among refugee families (McElrone et al., 2019). As an evidence-based, theory-driven curriculum, iCook 4-H provided a foundation to target dietary acculturation barriers and facilitators to food security within an appropriate sociocultural context for the sub-Saharan African refugee families in the study.
Cultural Adaptation Framework
The cultural adaptation framework was based on the common strategies for enhancing cultural appropriateness in health promotion programs identified by Kreuter et al. (2003). These five strategies, defined in Table 1, including peripheral, evidential, linguistic, constituent-involving, and sociocultural adaptations were used to address dietary acculturation barriers and facilitators to food security through a targeted program for Burundian and Congolese refugee families. The five strategies, used in curriculum adaptations among other cultural groups as a guide to modify materials and intervention processes, assured that various cultural considerations of the priority population were addressed and incorporated into the adapted curriculum (Bender et al., 2014; Kreuter et al., 2003; Resnicow et al., 1999). The five strategies were applied throughout all four phases of the curriculum adaptation process.
Definitions of Cultural Adaptation Strategies Used to Address Barriers and Facilitators to Food Security
Note. From Kreuter et al. (2003).
Data Collection
A four-phase curriculum adaptation process, adapted from the Barrera and Castro heuristic model (2006), was applied to the existing iCook 4-H curriculum. The four phases included (1) information gathering from multiple data sources, (2) preliminary adaptation design based on the identified dietary acculturation barriers and facilitators to food security, (3) preliminary adaptation pilot testing, and (4) adaptation refinement. An overview of the curriculum adaptation process, including the phases and associated components, is depicted in Figure 1.
Overview of the Curriculum Adaptation Process
Phase I: Information Gathering
Literature Review
In the first phase of the curriculum adaptation, the research team conducted a database literature search and review to identify dietary acculturation barriers and facilitators to food security among refugees resettled in the United States. The following databases were searched for relevant refereed research articles: Anthropology Plus, CINAHL, ERIC, Google Scholar, PubMed, Scopus, and Web of Science. Keywords included refugee, sub-Saharan African/sub-Saharan Africa, Burundian/Burundi, Congolese/Congo, dietary acculturation, acculturation, food security, food insecurity, cultural adaptation, nutrition/dietary/physical activity/health/cooking intervention. First, the research team completed a review of abstracts to identify relevant articles. Then, full-text articles were examined and those fitting the aims of the literature review were retained and relevant data were extracted. The existing literature informed adaptations such as content additions, program planning, implementation, and evaluation.
Researcher Informed
Additionally, researcher-informed knowledge of cultural practices and language skills (Swahili), gained from over 2 years of residence in a rural, sub-Saharan African village in East Africa provided foundational information to improve engagement and communication with the priority population (Bernard, 2011). To build rapport with the local Burundian and Congolese refugee community, the lead researcher taught English as a Second Language classes for 20 months at a local refugee program prior to and throughout the research study (Lincoln & Guba, 1985). This prolonged engagement led to relationship building and identification of key stakeholders, community leaders, and local refugee families that participated in various phases of the larger community-based research study as paid translators/interpreters, steering committee members, or research participants (Lincoln & Guba, 1985).
Formative Research
Next, formative research was conducted through semistructured interviews with a criterion-specific sample (n = 18) of Burundian and Congolese refugee women to identify their unique dietary acculturation barriers and facilitators to food security (McElrone et al., 2019). Participants who were female, 18 years of age or older, of self-reported refugee status, a native of a Sub-Saharan African country, and living near the city of interest were invited to participate. The detailed methods and findings from this study are reported elsewhere (McElrone et al., 2019).
Phase II: Preliminary Adaptation Design
Data Incorporation
In the second phase, the data gathered in Phase I were incorporated into the existing iCook 4-H curriculum. This was aided by a multilingual member of the priority population (Bernard, 2011).
Steering Committee
Next, a criterion-specific sample (n = 5) was recruited by email, phone calls, and word of mouth through local refugee programs using network then snowball sampling methods (Bernard, 2011; Dharod et al., 2011; Hadley et al., 2007; Hadley & Sellen 2006). Individuals meeting the following inclusion criteria were invited to participate: 18 years of age or older, and a member for one of the following categories: academic researcher, Extension agent/specialist, 4-H professionals, priority population representative, and/or key community stakeholders, living near the city of interest. The recruited steering committee members were all fluent in English and consisted of an academic researcher (independent of the research team), an Extension agent, key community stakeholders, and a representative from the priority population. All participants gave written informed consent and were given $20 gift card incentives for their feedback on each session.
Over 8 consecutive weeks, the steering committee members provided feedback on the curriculum, focusing on one session per week. Based on availability, committee members provided weekly feedback either at face-to-face meetings or through email. The eight, 1-hour long face-to-face meetings were scheduled and held at the convenience and preferred location of the majority of the steering committee members (often after existing refugee programming), and were documented through extensive field notes (Bernard, 2011; Creswell & Creswell, 2018; Lincoln & Guba, 1985). Committee members were asked to review the curriculum using an evaluation tool developed for use in this study based on Kreuter et al.’s (2003) five strategies for enhancing cultural appropriateness in health programs. The evaluation tool included a series of open-ended questions, depicted in Table 2, to explore the relevance of the peripheral, evidential, linguistic, constituent, and sociocultural adaptations. Members were asked to provide feedback and recommendations on each topic and activity in the session to improve cultural appropriateness of the curriculum for the priority Burundian and Congolese refugee families (Kreuter et al., 2003).
Questions Included in the Curriculum Adaptation Evaluation Tool Provided to Steering Committee Members
Phases III and IV: Preliminary Adaptation Tests and Refinement
After completion of Phases I and II, the adapted curriculum was pilot tested in the priority population (McElrone et al., 2020). Dyads (n = 10) included a youth who was 8 to 12 years of age and an adult who was 18 years of age or older, with self-reported refugee status, a native of sub-Saharan African country, and the self-reported primary meal preparer in the family. Participant feedback, qualitative data regarding what they liked/did not like in the session, was collected through process evaluations at the end of every session and was iteratively incorporated into subsequent sessions as part of the adaptation refinement. Last, participant feedback was collected at the end of intervention eliciting the feasibility and acceptability of the adapted curriculum. Detailed pilot implementation methods, evaluation, and results are reported elsewhere (McElrone et al., 2020).
Data Analysis
Researchers used a multiphase analysis process to identify and organize the major curriculum adaptations, their data sources, and cultural adaptation strategies applied throughout the curriculum adaptation process (Krippendorff, 2018; Saldaña, 2016). In the first phase, data were transcribed and uploaded to NVivo (Version 12; QSR International Pty Ltd., 2018) for storage and organization. Next, the research team developed a priori codes (data sources and cultural adaptation strategies), data-driven codes (curriculum adaptations), and a codebook, which was iteratively revised as needed (Saldaña, 2016). This codebook was used to guide coding, document code definitions, and systematically organize codes into major categories (Krippendorff, 2018).
In the second phase of analysis, first cycle attribute coding was manually applied to transcripts by a trained, single coder to log the data source (literature, researcher informed, priority population or steering committee; Saldaña, 2016). Next, first-cycle descriptive coding was applied to provide an inventory of the curriculum adaptations. In the third phase of analysis, the same coder completed second-cycle pattern coding to the same transcripts to identify the appropriate cultural adaptation strategy (peripheral, evidential, linguistic, constituent or sociocultural; Saldaña, 2016). Codes were organized, categorized, and assembled into hierarchical maps and matrices for direct content analysis (Krippendorff, 2018). In cases of discrepancy between data sources (differing curriculum adaptation recommendations), member checking with the priority community (n = 3) was used to limit analysis bias (Krippendorff, 2018).
Institutional Review Board
The study was approved by the University of Tennessee Institutional Review Board, and written consent was obtained from all participants.
Results
Seventeen major categories of curriculum adaptations resulted from the cultural adaptation process as described in Table 3. The curriculum adaptations were derived from four data sources (literature review, researcher informed, the priority population, and steering committee), in varying combinations, and from different adaptation phases, as depicted on the far left of Table 3. As shown on the far right, all five cultural adaptation strategies were applied in the various curriculum adaptations. A majority of the curriculum adaptations were derived from two or more data sources (71%) and were categorized within multiple adaptation strategies (88%). The specific curriculum adaptation descriptions are detailed in Table 3.
Phase, Data Source, Curriculum Adaptation, Descriptions of Change, and Adaptation Strategies Applied in the Cultural Adaptation Process of Existing Curriculum
Note. Curriculum adaptation process phase: I = Phase I: Information Gathering, II = Phase II: Preliminary Adaptation Design, III = Phase III: Preliminary Adaptation Tests, IV = Phase IV: Adaptation Refinement. Data source: • literature review, ■ researcher informed, ▲ priority population, ◆ steering committee. Adaptation strategy: P = peripheral, E = evidential, L = linguistic, C = constituent-involving, S = sociocultural.
The original iCook 4-H curriculum included many topics and activities identified as barriers to food security among the priority population related to shopping and cooking healthful foods in the United States (McElrone et al., 2019). New topics/activities (Table 3) were added to address additional barriers to food security among the priority population not addressed in the existing curriculum. Moreover, parts of both the existing and adapted curriculum provided follow-up to many topics initially presented in orientation services, such as use of stoves/ovens (limited training was a noted barrier to food security; McElrone et al., 2019).
Discussion
Conducting a cultural adaptation of the iCook 4-H curriculum, Pika Pamoja was created and tailored for Burundian and Congolese refugee families, using the theory-driven (Bandura, 1986), evidence-based design of the original curriculum (Franzen-Castle et al., 2019). Existing iCook 4-H components (group setting and dyad model) reflected relevant sociocultural values (McElrone et al., 2019) and promoted the transfer of knowledge and skills between youth and adults aiming to foster food security (Patil et al., 2009). Additionally, since the original iCook 4-H curriculum already addressed some relevant dietary acculturation barriers and facilitators to food security, it was easy to incorporate supplemental activities to target the unique needs of the Burundian and Congolese refugee families.
A majority of the curriculum adaptations were derived from agreement in the four sources of data; however, there was one notable disagreement during the cultural adaptation process. The steering committee felt the recipes should be altered to include more culturally relevant ingredients; however, data from the literature review and formative research indicated a need and desire to address unfamiliarity of nontraditional foods, cooking methods, and equipment in the United States through the use of American recipes (Hadley et al., 2010; Hadley & Sellen, 2006; McElrone et al., 2019). When the priority population was consulted on the discrepancy, they echoed the formative research findings resulting in the retention of the original American recipes. Not only does this discrepancy support the need for multiple data sources and data collection methods in curriculum adaptation processes, but it also speaks to the need to assess each specific population for their preferred curriculum content throughout the cultural adaptation process. The importance of consulting with the priority population is evident. In the future, the desires of the priority population must be addressed when considering adaptations of recipes with culturally relevant foods.
Acculturation, dietary and otherwise, is a complex and dynamic process with various negative health impacts associated with the opposing spectrum sides among refugees. Researchers have shown refugees reporting low acculturation, often closer to resettlement, have lower rates of food security (Hadley et al., 2007); however, refugees reporting high acculturation, often associated with increased time in the United States, have higher risk of diet-related diseases (Franzen & Smith, 2009) than their respective counterparts. This juxtaposition provides a unique opportunity to culturally adapt curriculum for refugees to address dietary acculturation barriers and facilitators aiming to improve food security while simultaneously providing nutrition education to mitigate diet-related diseases in the future. The adapted program included supplemental activities to address the unique experiences of the priority population to promote food security, while the original iCook 4-H curriculum provided family nutrition education to promote healthy, long-term diet and physical activity behaviors (Franzen-Castle et al., 2019; White et al., 2019). The Pika Pamoja curriculum directly addresses various barriers to food security among the priority population (e.g., with nontraditional foods, using U.S. currency, transportation to food outlets, and accessing nutrition assistance programs). Mastery of these topics and skills is a means for refugee families to improve their household food security status.
Although the cultural adaptation process and resulting curriculum adaptations were targeted for Burundian and Congolese refugee families, the procedures detailed here can be adopted with other refugee or marginalized communities. This community-based cultural adaptation process goes beyond surface structure adaptations (visual and auditory elements) and leads to more comprehensive and deep structural adaptations (core cultural values, norms, and stressors) to improve intervention acceptability (Resnicow et al., 1999).
Limitations
The steering committee meetings were originally designed as face-to-face, group sessions to increase communication among and between committee members and researchers. However, due to time constraints and varying schedules, some committee members opted to provide feedback electronically. Although this design modification ensured committee member participation in the study, this limited the interpretation of feedback and recommendations. Moreover, the number of participants from the priority population involved in this study were limited due to budget and other resource constraints. To increase the number engaged from the priority community, individual participation was limited to only one phase of the study.
Various methods were used to mitigate and decrease analysis biases. Triangulation of curriculum adaptations through various data collection methods and multiple data sources improved the accuracy of findings (Creswell & Creswell, 2018). Additionally, member checking with the priority population was used in cases of discrepancy between data sources (Saldaña, 2016). Although prolonged engagement is often time-intensive, persistent observation and contact with the priority population before, during, and after the study increased credibility (Lincoln & Guba, 1985). Last, the cultural adaptation described here was highly tailored to Burundian and Congolese refugee families. As with all tailored approaches, to meet the needs of other refugee groups, individual tailoring of iCook 4-H is necessary.
Implications for Practice and Research
Refugee populations in the United States consistently live with low food security often related to dietary acculturation issues (i.e., cooking, shopping for, accessing, and affording healthful foods). Culturally and linguistically appropriate interventions are needed to address their unique dietary acculturation and food security experiences. This study provided a community-based cultural adaptation process that could be adopted with various refugee populations to address dietary acculturation barriers and facilitators to food security. This model is an innovative way of addressing the cultural needs of refugee populations while aiming to improve their health habits.
Footnotes
Authors’ Note:
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects/patients were approved by the Institutional Review Board for Protection of Human Subjects at the University of Tennessee. Written informed consent was obtained from all participants. Funding was provided by Agriculture and Food Research Initiative Grant No. 2012-68001-19605 from the U.S. Department of Agriculture National Institute of Food and Agriculture, Childhood Obesity Prevention: Integrated Research, Education, and Extension to Prevent Childhood Obesity, A2101 and respective State Agriculture Experiment Stations.
