What factors are associated with obesity‐related health behaviours among child refugees following resettlement in developed countries? A systematic review and synthesis of qualitative and quantitative evidence

Refugee children are likely to become less active and eat more unhealthily after their resettlement in developed countries. This review aims to identify and synthesize research about factors that influence unhealthy behaviours related to obesity in this population. Six electronic databases were searched systematically to identify studies that sampled refugee children or parents of refugee children aged 2 to 16 years who have resettled in a developed country. Methodological and cultural study quality was assessed and factors associated with obesity‐related health behaviours investigated. Twenty studies fulfilled the inclusion criteria. Five major themes, representing factors influencing health behaviours, were identified from the data synthesis process: Acculturation, Environmental, Socioeconomic, Cognitive, and Family. The analysis revealed that refugee's health behaviours are influenced by several complex factors that are common to immigrant groups but have a greater influence among refugees. The review also revealed parental practices influence the health behaviours of children, especially those aged 2 to 10 years. Research is needed to understand further the role that parents have in influencing health behaviours and weight trajectories of children following resettlement.


Summary
Refugee children are likely to become less active and eat more unhealthily after their resettlement in developed countries. This review aims to identify and synthesize research about factors that influence unhealthy behaviours related to obesity in this population. Six electronic databases were searched systematically to identify studies that sampled refugee children or parents of refugee children aged 2 to 16 years who have resettled in a developed country. Methodological and cultural study quality was assessed and factors associated with obesity-related health behaviours investigated.
Twenty studies fulfilled the inclusion criteria. Five major themes, representing factors influencing health behaviours, were identified from the data synthesis process: Acculturation, Environmental, Socioeconomic, Cognitive, and Family. The analysis revealed that refugee's health behaviours are influenced by several complex factors that are common to immigrant groups but have a greater influence among refugees. The review also revealed parental practices influence the health behaviours of children, especially those aged 2 to 10 years. Research is needed to understand further the role that parents have in influencing health behaviours and weight trajectories of children following resettlement.

K E Y W O R D S
diet, health behaviours, physical activity, refugee parents

| INTRODUCTION
Obesity is an extremely important public health problem facing individuals, communities, and governments. 1 The last decade has seen a marked rise in the prevalence of obesity rates worldwide, with incidence of overweight reaching epidemic proportions 2 and threatening to outnumber global rates of undernutrition. 3,4 The increasing prevalence of global obesity has serious health implications for populations worldwide as it constitutes a major risk for chronic diseases, including type 2 diabetes, cardiovascular disease, hypertension, and stroke, as well as certain forms of cancer. 5 Importantly, although it is more common among adults, a marked rise has also been observed in the incidence of obesity in children. 6 Rising levels of childhood obesity constitutes one of the most serious public health challenges in the modern era. 7 Although this trend has been observed globally, the increase in overweight children and adolescents is especially evident in economically developed countries. 8 There are many negative physical, social-emotional, psychological, and academic effects associated with childhood obesity. Shortterm repercussions include hypertension, dyslipidaemia, orthopaedic problems, and poor quality of life, while longer-term health impacts include cardiovascular disease and diabetes. [9][10][11] Childhood obesity and its associated increased health risks often persists into adulthood. 12,13 Increased childhood obesity has been observed across populations; however, data show a particularly rapid rise in the prevalence of obesity among children in low-educated, low-income families, and among immigrant groups and refugees who have settled in developed countries. 14 This suggests that different or additional factors may be operating for these individuals and a different approach may be required to reduce the risks of obesity.
Forced migration is a life-changing process for refugees. A refugee is defined as any person who is forced to leave their home country due to 'fear of being persecuted for reasons of race, religion … and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country' (P2). 15 As such, refugees can be differentiated from immigrants who leave their home country following planned migration. At least 13 million children live as refugees or asylum seekers outside their home country, most of whom originate from Asia, the Middle East, or Africa. 15,16 Many refugees, especially children, are exposed to considerable health risks on these dangerous and often prolonged journeys, reaching host countries suffering from the effects of undernutrition, infectious disease, and poverty. [17][18][19] Although their health and weight typically improves postresettlement, their health tends to decline in the longer term, possibly as a result of adopting the unhealthy health behaviours that may relate to the culture of the country in which they resettle. 20 The profound alteration of lifestyle, associated with resettlement in developed countries, has numerous attendant challenges for refugees, including adaptation to the local food environment. 21,22 The processes involved in acclimatizing to a new environment can negatively affect the general health of refugees, manifesting in a range of negative outcomes. 22,23 For example, it is argued that the challenges in navigating the obesogenic lifestyle associated with some economically developed societies during resettlement can increase the risk of childhood obesity. 24 Ethnicity and acculturation have been identified as factors that contribute to health inequality and so function as determinants of diet and lifestyle among migrants. A number of studies have focused on the role of acculturation (i.e., the process of adopting the cultural norms and practices of a host society) in studying obesity and the associated health decline of immigrant and refugee populations. 25 Previous studies have demonstrated a connection between acculturation and increased risk of obesity and cardiovascular disease, with suboptimal dietary behaviours mediating this connection. 26 Other studies highlight important ethnic differences in cardiovascular disease risk factors among immigrant populations, which demonstrate the connection between ethnicity/acculturation, diet, and the risk of cardiovascular disease. 27 These findings also suggest that each ethnic group may have a distinct trajectory related to the lifestyle in their country of origin and their level of acculturation in their host country.
This difference between lifestyles in the country of origin and reception may explain why obesity trajectories can be expected to be diverse in refugee children. This is especially important given that obesity rates differ greatly between high-income countries, which may be attributable to differences in diet and levels of physical activity. However, other research reveals the limited extent of acculturation theory to clarify the differences and changes between refugee and immigrants as well as the factors underpinning health inequality among refugee populations. 25 There is evidence that refugee children have poorer health outcomes than other migrant children. Refugees relocating to the United States of America report more adverse physical health outcomes (e.g., heart disease, hypertension, and type 2 diabetes) and become more overweight and have obesity than nonrefugee immigrants. [28][29][30][31] One explanation for this is that refugees experience greater stress prior to (e.g., stress related to armed conflict), during migration (i.e., the actual journey), and after settlement (e.g., insecure and transient accommodation) than migrants. [32][33][34] The trauma and stress associated with the refugee experience increases the risk of chronic disease. [35][36][37] The reasons for this are unclear, but it is likely that the stressors involved in being refugee influence obesity related health behaviours during resettlement. For example, refugee children who have undergone long-term dietary limitation in refugee camps may adopt health behaviours that are associated with obesity development, such as increased consumption of processed and energy-dense foods and corresponding decreased consumption of fish, fruit, and vegetables. 25,38,39 It is important to systematically synthesize the existing literature to obtain a deeper understanding of the complex factors that contribute to unhealthy weight change, specifically among refugee children. 40 To date, there are limited data focusing on the factors associated with behaviour changes and obesity among refugee families after their resettlement. The interaction between ethnicity/acculturation and refugee stress is poorly understood 41,42 ; this may be due to the associated methodological difficulties involved in studying this hard-toreach population. 43,44 The reluctance of refugees to become involved in research, as well as the likelihood that individuals will move after resettlement, make it difficult to obtain necessary sample sizes and to obtain follow up data. Other methodological challenges include the difficulties in ascertaining the legal status of refugees, because most organizations that support minorities tend to group immigrants and refugees into a single category. 40 Moreover, some refugees are worried about revealing their legal status.
Consequently, this review sought to contribute to existing knowledge by obtaining a deeper understanding of the complex factors that influence obesity-related health behaviours in refugee children after their resettlement in developed countries. Specifically, it aimed to identify the factors associated with health behaviours in this population, as well as identifying those areas that would benefit from further research. Insights in this area could provide important information for

| Study selection
The study selection process occurred over several stages: duplicates were removed, then each title and abstract was screened for inclusion by two reviewers (MH) and (SK) with reference to the inclusion criteria. Full texts of promising studies were subsequently reviewed against the inclusion and exclusion criteria by same two reviewers.
Any disagreements were resolved through consultation with a third reviewer. See Figure 1 for a PRISMA diagram depicting the process of selecting studies.

| Assessment of methodological quality
The quality of the quantitative studies was assessed using a qualityappraisal tool that used six methodological questions (rating the sampling methods, response rate, primary/secondary data source, validity/reliability of the measures used, data quality, and the definition of the problem), see Table 3. 47 The methodological quality of qualitative studies was assessed using 10 evaluation criteria of the Joanna Briggs Institute approach. 48 Given the focus on refugee children, who represent several ethnic groups, assessment was also conducted into the 'cultural quality' of each ethnic group in the studies. The cultural quality assessment considers the cultural, social, and linguistic needs of a highly diverse population during the development of the research ideas, designing, conducting research, and exploring the applicability of research findings. 4 Was the validity and reliability of translated questionnaires tested?). 49,50 All studies meeting inclusion criteria were included in this review regardless of their quality because some of the lower-rated papers contributed different insights; however, their findings were treated with caution.

| Data extraction
The results of the literature search were managed using the EndNote reference management software. Data were extracted from the studies using a data extraction tool by one author (MA). For the qualitative studies, all quotes from participants, results, and discussion sections were extracted and uploaded to NVivo11 software.

| Data synthesis
A separate synthesis for qualitative and quantitative studies was conducted, in which thematic synthesis and narrative synthesis were conducted, respectively. The initial synthesis revealed that five themes extracted from all studies were similar; therefore, a narrative synthesis approach using text and tables was employed to compare and combine the results of the thematic and narrative synthesis. 52

| RESULTS
A total of 1,892 papers were identified (see Figure 1). After duplication and title/abstract screening, 63 potentially eligible studies were retrieved for full text screening. Twenty fulfilled the inclusion criteria and were included in the review (see Tables 4-6).

| Methodological quality
Almost all the studies were of moderate to high quality, with only one study rated as low. 25 Two of the quantitative studies received a high score (83.33%) and eight received a satisfactory score (34-66%) (see Table 7). The main quality issue was around the approaches to sampling. This has been considered a common methodological issue among research into refugee populations. 40 Probability sampling was only used to recruit participants in one study, 28 with the remainder utilizing nonprobability sampling. This might be an issue as the sample may not be representative of the whole population, therefore views maybe missed or not explored (e.g., from participants who do not volunteer as they are not confident or not able to articulate their experience clearly). It was notable that the majority of studies explored the associations between the different factors and health behaviours.
Qualitative studies were ranked as higher quality compared with the quantitative studies; studies which employed participatory methods (a recommended approach in researching vulnerable populations) were the highest quality. Almost all of the qualitative studies provided information on the underpinning theoretical framework, the appropriateness of the research design, data analysis, and findings (see Table 8). However, few studies provided information on the impact of the investigator, believability, and evaluation/outcome.
During the cultural quality appraisal, it became clear that the studies were low on some aspects. Although most of the qualitative studies used professional bilingual interpreters, interviewers, and meditators to conduct the interviews and focus groups, only seven of the studies reported comprehensive training (e.g., on cultural and ethical issues, safety considerations, and interview techniques) for the interviewers and interpreters. 25,28,60,69,[72][73][74] Half of the studies did not mention or report in detail the translation process of the questionnaires, measurement tools, or interviews. Only one study used ethnic matching (i.e., the interviewers were from the same background as the study population). 70 Higher cultural quality was more evident for other aspects: for example, the majority offered interviews and questionnaires in both English and the native language of the target population. Providing participants with an option to speak in their own language empowers them to express themselves more accurately and easily, giving a clearer picture of their challenges. This suggests a high level of cultural sensitivity, especially in the qualitative studies. All the studies cooperated with community agencies working with refugees.
Together, the findings suggest an improvement in the consideration of cultural quality to that seen in other relatively conducted recently meta-analyses (e.g. Nazir, 2015). A more detailed discussion of cultural quality of the included studies is provided in Appendix A.

| Synthesis of findings
The data synthesis process attempted to interpret the retrieved material within two parallel frameworks, namely the refugees' ethnicity and specific history of stress. Five major themes were identified to represent the factors influencing changes in health behaviours related to obesity among refugee children. Since the literature on ref- ugee families is primarily focused on three distinct ethnic groups, the identified factors will be presented by ethnicity (see Figure 2): and (5) Family. Quotations corresponding to the themes are shown in Table 9.

| Acculturation
Acculturation (i.e., the cultural and psychological changes that occur as a result of two different cultures coming into contact with each other 64 ) was the focus of nine studies. 65  Qualitative (using semi structured interviews) (n = 15) Hmong refugee, mothers with young children Acculturation • Data is reported separately by ethnicity • The importance of Hmong food culture as it represents their identity, healthful lifestyle and social support.
• Differences between American and Hmong food culture and its impact on nutritional health.
• Different level of acculturation has an influence on the type of food children and their mother consume.
• Children adopted American diet as results of the effect of American lifestyle. Renzaho • The complexity of nutrition messages due to poor literacy levels.
• Contradiction in body size between Africa culture and Australia culture, which considered one of the main themes.
• An abundance of cheap and readily available processed and packaged foods.
• Australian food perceived as being full of harmful chemicals.
Renzaho, Green, Mellor  72 The perspective of some adolescents echoed their parents, declaring that they had 'developed a taste' for unhealthy food as a result of growing up in western culture. 25 However, the relationship between acculturation and health behaviour was not always negative: for example, one quantitative study found that while the levels of acculturation were generally low among Cambodian refugee mothers, more acculturated mothers reported consuming more healthy food choices. 28 The impact of ethnicity was also influenced by the stressful life experiences of refugees, such as the stressful journey to the host country, the challenges inherent to navigating a new culture/society, stresses relating to financial and legal circumstances, and encountering racism and discrimination.
The combination of having a history of stress (from war/armed conflict, and living in refugee camps), the challenges of living in a new culture or society, financial and legal stresses, and racism and discrimination had clear effects on how refugee children interacted with the food environment. One study, of refugee adolescents, explored the association between health behaviours and negative mood from stress attributed to the refugee experience. 60 A significant association was found between negative mood and health behaviours, with those reporting more positive moods also showing healthier behaviours (i.e., reduced consumption of sugary carbonated drinks and higher levels of physical activity).
The above findings suggest that these factors are important for consideration in the development of interventions. This highlights the multidimensional and complex effect of acculturation and ethnicity on the health behaviour of refugees.
The dominant language used in the household and the length of stay in the host country were commonly used as proxy indicators to measure acculturation. 23,66-68 Many sub-Saharan African refugee parents reported that language acted as a barrier to the purchase of healthy food (i.e., the inability to read labels in English) and it also shaped their food shopping patterns, by limiting the foods they recognised or knew how to cook without reading instructions. This subsequently affected their children's diet. 57 An additional study found that children of sub-Saharan African refugee parents with low English competency reported a greater intake of 'soda' and 'snacks' as these were preprepared and obviated the need to read instructions. 71 These children also had a lower intake of fruit and vegetables. This indicated that the children were driving their own diet. 65

Religion
Religion was found to be a major part of the lives, identity, and culture of refugees and highly related to health behaviours. Those with a high degree of religious loyalty were more likely to be refugees who had been forced to leave their home country due to a well-founded fear of religious persecution. Forcible migration to a culture with a different religious belief was a factor influencing the adoption of unhealthy eating patterns and lower levels of physical activity. For example, the food choices of sub-Saharan African refugees who followed Islam were more likely to be affected because of their religion, such as the prohibition of nonhalal meat and the rules of eating as prescribed by The high cost of healthy food was also an element that shaped diet. 59 For example, adolescents revealed that their parents cannot afford to buy healthy food; this was especially profound at the end of the month, when food assistance (e.g. 'food stamps') was not available. Many parents reported this limitation as the main reason for their unhealthy food choices. 71 This issue was also discussed by Rondinelli et al, who found that low socioeconomic status led to increased consumption of ready prepared meals and fast food. 69 Limited economic resources not only led to poor food choices, but also encouraged the development of unhealthy eating patterns. For example, one mother described how she had to cook one type of food and feed it to her children over many days and encouraged her children to drink additional water as a strategy to overcome hunger. 71 Given the above discussion, and in conjunction with the availability and affordability of energy-dense, nutrient-poor foods in western countries, many refugee children experience negative changes to their diet and eating habits. This indicates that economic constraints affect refugee's dietary intake, preventing parents from buying preferred or traditional food when these are expensive. 71 The combination of availability and affordability was shown to have a profound impact on food choices among refugee families. Parents complained about the availability of unhealthy food, but when this food was more affordable than healthy items, the parents chose this food. Many parents reported that fast food was cheap to buy and quick to prepare, encouraging busy parents with limited economic status to take these options for their children. 72,74 In their focus groups, Tiedje et al found that many refugee families reported that eating cheap fast food helped them to stay within a tight budget. 25 Furthermore, some studies linked fast food to social status, in which some parents held the perception that takeaway food is only for rich people, perhaps because they could not afford it in their home countries.

Housing conditions
Rondinelli et al found that many newly arrived refugee families with limited finances are drawn to poor neighbourhoods, where the rent is low and they can be near other people from the same background to help with resettlement. 69 Interviews with parents and health providers working with referees revealed how the limited housing conditions were related to increased sedentary behaviour in children and inhibited refugee parents' ability to prepare and safely store healthy food. 69 Parents expressed concerns about the safety of their neighbourhoods. This inhibited young people from being active as parents tended to keep their children the relative safety of the home.
The unintended consequence was increased sedentariness. 69 This was a common complaint raised by parents in two studies highlighting the importance of neighbourhoods in influencing children's physical activity levels. 58,69 Past food insecurity Increased food consumption after resettlement was strongly associated with refugees' experiences of food shortages in the preresettlement period. 22 'It is very hard to say "no" to a child. . . so it is good to cook lighter.' (Vue et al., 2011, p.202).
'They do not want their children to feel hungry and that is why they get the children the foods that they prefer.' (Patil et al., 2009, p. 352).
• Changes in family structure 'My mom does not cook anymore because she is always at her job.' (Tiedje et al., 2014, p.9).
According to an early study by Renzaho and

Accessibility of unhealthy food
Across almost all studies, the availability of fast food, canned food, processed, and preprepared food was perceived as a factor that influenced an increase in unhealthy dietary intake after resettlement.
Parents in several studies reported significant differences in food availability between their home country and the United States of Anerica, with availability in their originating country being highly dependent on location and season. 69 technology. 59 Many adolescents reported that they spent more time watching TV, on social media, and playing video games than playing outdoors. 29,59 Many refugee children also ate while watching the TV, and some adolescents reported that this was encouraged by their parents. 25 Another example was the effect of household technology that was not available in refugees' home countries such as washing machines, vacuum cleaners, and dishwashers. Young African refugee girls moving to Australia perceived that these technologies constituted a dramatic lifestyle change, as access to such appliances significantly reduced the extensive physical effort previously required to clean their homes. 72 Alongside the availability of electronic entertainment devices and household goods, modern transportation had the potential to exert a negative impact on shaping food choices and levels of physical activity. One qualitative study revealed life in Australia was physically easier with readily available modern public transport than in the refugee's home country, where they needed to walk everywhere. 72 The availability of cars was perceived by adolescent refugees to be one of the factors that negatively impacted on their level of physical activity postresettlement as parents now escorted them by car rather than them walking. 72 Parents also reported a greater reliance on cars and a corresponding reduction in exercise over their previous levels in their home country. 72 This contrasted with the high levels of daily physical activity undertaken by refugees and immigrants from the Horn of Africa who were active for economic reasons like 'farming and harvesting' or because walking was the only source of transport. 65

Cultural perceptions of body size
Almost all of the qualitative studies concentrated on refugee families from Africa. Many of the refugee parents from this region held a cultural preference for large body sizes, which represents wealth and beauty in their culture. 65 Unsurprisingly therefore, parents tended to maintain these cultural beliefs and to promote weight gain among their children. 65 Cultural preferences for larger body size was not only seen among parents from sub-Saharan African cultures, but also among refugee parents from Southeast Asian cultures (e.g., Hmong). As a consequence, parents with this perception encouraged their children to gain weight by using unhealthy feeding practices, such as encouraging them to eat more 58,72 or feeding lots of milk and cheese to young children. 65 It might be that parents, in seeking to reinforce their traditional beliefs, are inadvertently also encouraging the development of negative eating habits among their children; for example, parents reportedly offered their children fast food and even restricted their physical activity, potentially incentivizing weight gain. 58 Some adolescent refugees held similar views to their parents, reporting that their culture viewed a large body size as 'highly valued' and signified 'wealth' and 'success,' with slimness perceived as a sign of sickness and poverty. 74 Parental perceptions of large body size not only influenced dietary intake, but also physical activity levels. In one study, parents, particularly fathers, were reported to restrict involvement in sport activities to promote large body size. Fathers perceived the involvement of their children in school sport activities as a 'waste of time and pointless,' which necessarily influenced physical activity levels. Renzaho et al found that these cultural perceptions were held by the majority of parents, with only a small number of mothers linking large body size to negative health consequences. 58 Typically, these women were single and more highly educated, reflecting the importance of knowledge and education about food. Regarding acculturation, refugee children were generally more integrated into the host culture than their parents, with correspondingly greater exposure to knowledge about food. Therefore, refugee children in particular sub-Saharan African and Southeast Asian were found to possess superior knowledge of food and nutrition than their parents in four out of eight qualitative studies. 25,65,72 While children in some studies developed a taste for fast food, these children also worried about their parents' feeding practices and restriction of physical activity. 25 They reported greater awareness of healthy food and tended to disagree with their parents about body size preferences. 25 These children were usually considered to be highly integrated into the new culture, as a result of high levels of exposure and education.
When asked about their source of knowledge about food, the most common knowledge sources that adolescents reported were school and the media. 70 While the media can play an important role in educating children about food, it can also negatively affect their eating patterns, with TV advertisements regularly encouraging unhealthy food choices.

| Family factors
The family was identified as the main element that had an impact on the health behaviours of children. Family functioning, structure, and parenting style influenced the diet and physical activity of refugee children. A stark difference was found between the perceptions of refugee parents and adolescents regarding their family functioning and communication. 55,77 For example, Cyril et al found that the majority of children perceived their family as functioning more poorly than their parents, and this was strongly positively associated to their BMI. 77 The eating behaviours of children were shown to be strongly influenced by family functioning, through parental dietary practices, food choices, and family meal environment. 77 Parents were found to have greater control over the lifestyles of younger children; however, adolescents in also thought their parents played an influential role in determining their diet and influencing their levels of physical activity. 25,58,72,74 Parenting style Parents were identified as one of the primary sources of information for children about eating habits and food knowledge. The majority of the studies showed that parenting played a significant role in the feeding practices and dietary intake of young children. 70,72 For example, parents from sub-Saharan African countries tended to be restrictive and to exert a high level of control over their child's eating habits.
This was particularly prevalent among newly arrived refugee parents, who were fearful of losing their cultural identity and feared that their children would lose their cultural values, thereby weakening their family attachments. 72 Studies that investigated parenting style found that children perceived their parents to be more authoritative than their parents believed themselves to be and that parents exerted profound influence over the lifestyle behaviours, and dietary intake, of their children. 77 In contrast, some parents reported difficulties controlling their children's diet in the host country, particularly young mothers who reported the challenge of 'saying no' to their children. 70 Moreover, some parents showed concern about their own diet and explained how they had given up traditional or healthy food to ensure that their children ate well. This strong desire of having control over their young children's diet and physical activity was also linked to parental cultural perceptions of body size, or cultural and religious beliefs.

Changes in family structure
After migration, family dynamics experienced dramatic changes, which created familial conflict. These marked changes in the family structure could be particularly challenging for parents from collectivist societies, such as many African nations, where mothers are responsible for house work and raising and feeding the children, while fathers work outside the house. 72 Many refugee mothers described having to work in the host country as being 'stressful' and expressed feelings of 'loss identity.' 65,72 Given the previous factors, changes in family structure may also be highly related to acculturation and low socioeconomic status. Mothers who have to work long hours do not have enough time to prepare healthy meals: Many adolescents expressed how their mothers were too busy to cook for them. A lack of time to prepare meals was found across all the studies. Given competing priorities, the preparation of healthy food was accorded a lower significance than going to work, especially for refugee parents who had a low socioeconomic status. In our findings, acculturation also included the adoption of a more sedentary lifestyle, which affected levels of physical activity. These results corroborate the findings of a recent study, which concluded that young refugees from Nepal, Somalia, and Sudan to the United States of America had fewer opportunities to be physically active than in their home country. This was largely attributed to their cultural perception of physical activity, with individuals needing to make a conscious effort to exercise in developed countries, rather than physical activity being integrated into their daily lives, as was the case in their home countries. 82 The subtheme of religion was shown to exert an impact on health The findings showed that age was a moderating factor. Adolescent refugees tended to voluntarily integrate into the host culture, attempting to fit in through behaviours such as the adoption of culturally more acceptable fast food. In contrast, younger children were highly influenced by their parents. The wider literature supports this finding, showing that acculturation at a young age to high income country like the United States of America is significantly associated with increased consumption of fast food among adolescent immigrants. 85 This may explain the extent to which age-associated differences can affect the impact of acculturation.
One of the main factors affecting refugee children is their environment, which includes changes in weather, living in poor housing conditions, access to modern technology, and living in a new food environment with higher availability of unhealthy, convenient food.
These environmental changes have a noticeable effect on the eating habits and levels of physical activity among refugee children. These findings are consistent with existing research, which has overwhelming negatively associated environmental factors with dietary habits and levels of physical activity among immigrants to high-income countries. [86][87][88] The present study identified that socioeconomic factors had a powerful effect on dietary intake. An interesting finding was the negative association between past food insecurity and the current eating habits of refugee children, as manifested in overeating and consumption of nutritionally dense foods. This change in eating habits was explained as a response to exposure to a food-rich host environment after having lived through food shortages. This matches the outcomes of previous studies, which identified that refugees with experience of food deprivation may adopt unhealthy eating practices, including increased consumption of high-density food. 28,89 Food insecurity is prevalent among refugee families after their resettlement in the host country. 22,23 The experience of economic hardship and lack of social support distinguishes many refugees from other immigrants, making them more vulnerable and at higher risk of developing unhealthy behaviours as a result of enduring these situations.
Refugee parents from sub-Saharan African backgrounds have a cultural perception of preferred body size; specifically, a preference for a larger body shape, which may encourage behaviours that can lead to obesity. Our findings showed that the strong desire of these individuals to maintain their traditional orientation is a determinant that influences the diet and levels of physical activity of their children. The language offered to participants was often culturally sensitive, especially in the qualitative studies, where the option to speak in their own language meant that participants were empowered to express themselves more accurately and easily, giving a clearer picture of their challenges. However, conducting the interviews and focus groups in the native language of the population also created the risk that data might be lost in the translation process, therefore it was important to review the translation process of these studies to determine whether it was sufficiently rigorous. The remaining studies used interpreters.
12 Was validity and reliability of translated questionnaires tested?