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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
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Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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The Impact of Food Insecurity on the Health of Colombian Refugees in Ecuador

Michele G. Shedlin*, Carlos U. Decena, Hugo Noboa, Oscar Betancourt, Stacia B. Birdsall, Kaitlyn M. Smith

College of Nursing, New York University, New York, USA

Abstract: This paper illustrates the salience of the specific factors challenging the food security of a refugee population and the effects on their health and wellbeing. Data presented are part of an NIH/NIDA study that explored the health implications of the forced migration of Colombian refugees in Ecuador. The two-year investigation utilized a qualitative approach and methods including in-depth interviews with refugees (n=96), focus groups (n=5) and interviews with key informants (n=21), permitting the triangulation of data sources and methods. Ethnographic observations and media analysis of the refugee situation were carried out as well. Data were analyzed using Atlas.ti software. Food insecurity emerged as a primary factor affecting all aspects of refugee life, the result of a complex interplay of socio-political forces such as discrimination and high rates of unemployment. The results of the study suggest the need to develop grounded, informed, and situation-specific guidelines to address the burgeoning epidemic of food insecurity in Ecuador and among refugee communities.

Keywords: Colombian refugees, food insecurity, health, discrimination, Ecuador

Citation: Michele G. Shedlin, Carlos U. Decena, Hugo Noboa, Oscar Betancourt, Stacia B. Birdsall, Kaitlyn M. Smith, The Impact of Food Insecurity on the Health of Colombian Refugees in Ecuador. Journal of Food Security, 4 (2). 42-51. January 2016. doi:10.12691/jfs-4-2-3

1. Introduction

Food security is defined by the WHO as existing “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life” [66]. Conversely, groups that experience food insecurity consume insufficient and/or poor quality food, and may engage in socially undesirable activities to obtain food. Food insecurity (FI) is a major cause of poor nutritional status in populations globally [15]. Serious short- and long-term health implications [18] include poor physical, mental, and social health [62]. FI can be chronic and persistent, generally caused by extreme poverty, or acute, which is transitory and often triggered by violent conflict or forced migration [27].

Refugees are particularly vulnerable to FI [14,18,23,51,52,57], and the consequences of food insecurity often make the resettlement process more difficult [18]. It is important to understand the factors influencing forced migration and the development and prevalence of post-migratory FI among refugees. Although 75% of refugees worldwide relocate to neighboring, lower mid-income, non-OECD countries with ‘similar ethnic, social, and cultural characteristics’ [21,26,59], the existing literature has largely focused on refugees resettled in food-rich OECD nations such as Australia, the UK, and US [16,18,20,34,43,44,46,49]. While acculturation variables such as English competency, time since resettlement, and adaptation to new shopping environments and budgeting practices are often cited as barriers to food security in these contexts [14,23,24,51], refugees resettling in resource-poor countries likely face different barriers. The literature addressing this phenomenon in these countries is limited in scope, with the majority only briefly mentioning FI when discussing the benefits and burdens endured by host communities [1,8,36,64]. This represents a significant gap in the literature.

This paper illustrates the context-specific factors challenging the food security of a refugee population and the effects on their health and wellbeing. The data presented were collected as part of an NIH/NIDA R21 study, completed in 2012, which explored the health implications of forced migration on Colombian refugees in Ecuador. The study addressed the need for a more complete understanding of the migration process and the vulnerabilities of refugees as they cross international borders, especially the understudied borders of South America. The study aims reflected the urgent need for research on specific health risks of populations in transition and how the nature and extent of disruption in their lives and environment affect voluntary and involuntary risk behaviors. Although not the primary focus of this study, food insecurity emerged as a major theme, impacting every aspect of daily life for refugees, including their struggles for safety and the health of their families. We present the context and data relating to food insecurity, as well as the salient factors of structural violence that interact with it including sending country drug-related violence, forced migration, and receiving-country stigma and discrimination.

Although FI among non-refugee populations in Latin America has been reliably measured using the Latin American and Caribbean Household Food Security Scale (ELCSA) [4,41,47], only limited data are available on the experience of FI among refugees in the region. Thus an exploratory, qualitative approach was used to elicit the ‘rich detail about important elements of the household experience’ often missed by quantitative scales [10]. Our study data add to a better understanding of the impact of forced migration on FI, and specifically identify factors that prevent the integration of Colombian refugees in Ecuador. The voices of the refugees themselves provide a deeper understanding of the nuances of FI in this population, and have relevance for food insecurity in migrant and refugee populations globally.

1.1. The Colombian Refugee Situation

Violent conflict between rival right-wing paramilitary groups and left-wing guerilla forces has been intensifying in Colombia since the 1970s [29], and has led to the internal and international displacement of over 10 percent of the Colombian population [30]. Military factions involved in Colombia’s illegal drug trade, such as the Revolutionary Armed Forces of Colombia (FARC) and the National Liberation Army of Colombia (ELN), are known to target innocent civilians and engage in kidnapping, assassination, and extortion in the countryside [5]. Fearing for their lives, Colombian individuals and families are forced to flee to neighboring countries, often leaving behind relatives and personal possessions [59,61]. The number of refugees leaving Colombia each year has increased significantly over the past decade [59]. By 2012, 374,000 people had left Colombia, ranking it 8th in the world among source countries of refugees [59]

In Latin America, no country receives more refugees than Ecuador, where 98 percent of the refugees are Colombian citizens fleeing violence in their home country [60]. It is estimated that more than 1,000 Colombian refugees enter Ecuador each month [60], and in 2012, the United Nations High Council on Refugees estimated that Ecuador was home to 123,000 refugees, of which only 54,600 were registered [59]. With little social or economic capital, these refugees are often unprepared to deal with the traumatic consequences of resettlement. They arrive in Ecuador lacking any valuable assets and are met with few employment opportunities, low wages, and limited social support, all of which compromise their food security [5]. In Ecuador, where more than 19 percent of the urban population suffers from chronic malnutrition [67], refugees are at even greater risk for food insecurity and its consequences [5]. In addition, refugees face discrimination, violence, inadequate health care and housing insecurity, all contributing to their health vulnerability [53]. The exacerbated vulnerability to FI facing refugees is the product of a unique interaction of variables [63] often characteristic of forced migration.

2. Study Approach and Methods

The major objective of this research was to collect descriptive data on the characteristics of recent refugees from the Colombian drug wars living in Ecuador, and the contextual and behavioral factors placing them at risk for substance abuse and sexually transmitted infections, including HIV. However, because the in-country collaborating agencies were concerned about the sensitivities associated with these topics, the bi-national research team expanded the focus to include general health-related issues into which the more sensitive topics were embedded. Modifications included the addition of the topic of food insecurity.

Grounded theory served as the rationale for methodological decisions regarding the qualitative approach and methods, and the emphasis on multiple perspectives [56]. Our two-year study involved in-depth interviews and focus groups. Inclusion criteria for refugee participants included: adult men and women 18 years of age or older; born in Colombia; minimum residency in Ecuador of three years; and migration due to violence and concerns for physical or emotional safety. Semi-structured individual interviews were conducted with 96 refugees. The refugee interviews utilized a questionnaire with open and closed-ended questions. This questionnaire was developed in Spanish by the international, interdisciplinary team of researchers and pre tested by the implementing NGO. Five focus groups (total n=41) were facilitated by the Principal Investigator or NGO investigators. These sessions took place with various sectors of the population: sex workers; drug users; male refugees; female refugees; and key informants. Interviews with key informants (n=21) contributed to the triangulation of data sources and methods. The key informant interview guides and the focus group moderator guide were developed to provide additional depth and detail to the survey data and to obtain additional perspectives from knowledgeable gatekeepers and refugees respectively. In addition, in-country researchers carried out ethnographic observations and a review of printed media coverage of the refugee situation during the period of data collection. The ethnographic component of the study provided important information on the context of health challenges for the refugee population. Observation guides were used to obtain some degree of comparability of observations in the community by NGO investigators. Thus four (4) separate instruments were developed for this study in order to better obtain multiple perspectives on the key research questions.

All data collection was carried out in Spanish and analyzed in Spanish using Atlas.ti.

3. Ethics

The Institutional Review Boards (IRBs) of the University of Texas at El Paso (where the study was originally funded), New York University (where the study was transferred) and the Universidad Central de Ecuador approved the study. Informed Consent documents were written in Spanish, modified in-country and adjusted to ensure compliance with all regulations of the IRBs of the US and Ecuadorian universities involved. This protocol conforms to the stipulations within the Helsinki Declaration. Basic demographic information about participants was collected to inform an overall participant profile, but identifying personal information was not collected and no individual names were used. Numbers and codes were used to identify each tape and transcript.

4. Results

4.1. Refugees’ Environment

Multiple waves of migration to Quito over the last forty years have created a distribution of settlements in several sectors of the city. Most of these sectors are of modest economic condition, densely populated with working class residents and internal migrants from the countryside. Ethnographic observation confirmed that overcrowding and substandard construction was common, with dirt-floored one or two-roomed cinderblock structures often housing a dozen refugees. Notably, study observations also found that all of the areas studied had a wide variety of fresh foods available in municipal markets, government warehouses, and grocery stores, indicating that food insecurity in the study population did not stem from a lack of availability of food.

4.2. Disrupted Social Support Networks

Many refugees who fled Colombia because of paramilitary violence experienced the disruption of their social networks as they came alone without friends or family. Often they had no time to coordinate travel with other people leaving Colombia and were unable to find them once they arrived in Ecuador. All members of a family were not always able to leave together. Sending a mother with her children to escape an attack, or sending the man of the household first to find work and shelter, meant that refugees had to survive on their own for extended periods of time.

In reflecting on their displacement, many participants noted new obstacles that confronted them in Ecuador and shared how difficult resettlement was without the help of family and friends. One man described that it was much more difficult to survive in Ecuador than in Colombia because he was alone as never before:

Once I ate breakfast and did not eat until lunch the next day. And here it is more difficult because if you don’t have money to buy food, you don’t eat because you are alone, while in Colombia if you don’t have [food], you go to your brother, your uncle, your grandmother, and they feed you.

Similarly, a 30-year-old mother came alone to Quito with her two children, leaving their father and her parents behind in Colombia for one year commented:

Well, my kids sometimes, sometimes did not eat enough, many times I went without eating…because I didn’t have money, I didn’t have a stable job, I didn’t have access. Well, it’s different when you’re home [in Colombia], you go to your mom, even though you disguise it, ‘Hi mom, how’re you doing this morning?’ And then they offer you lunch, [you can go to] your sister, [or] a friend. Here it’s not like that, or it could be that we don’t have family here and we don’t have a close friend with whom you can pretend you don’t know anything at lunchtime, and help wash the dishes so they feed you; there wasn’t a way, so we endured [the hunger].

4.3. Economic Instability

Participants cited economic instability and lack of employment opportunities as the most significant impediments to accessing sufficient quantities of nutritious food. The majority of respondents reported surviving on limited incomes with little to no outside financial support. They often described living in poverty with their families and reported being forced to compromise on basic needs, most often limiting their food intake. Given the circumstances under which many were forced to flee Colombia, participants typically left most, if not all, valuable assets behind, and had few resources to rely upon during their initial displacement.

Many refugees were involved in informal economic activity such as the selling of CDs, clothing, and food and beverages, along with domestic work for women and construction work for men. The use of survival sex was another salient finding of the interviews. Many women reported having resorted to sex work as the only means of income. In fact, sex work was seen as one of the few stable jobs available to female refugees. As one of the women explained, “There are women who engage in prostitution so their children don’t go hungry, and their husbands have to accept this because neither is working.”

When employment opportunities were available, participants described them as short-term, informal, and unstable. Some participants who were able to find work reported discriminatory and abusive practices. It was not uncommon to complete a job and have the employer refuse to pay or pay less than the agreed-upon amount. Workers had little recourse, as employers could threaten to report undocumented refugees to Ecuadorian authorities. More commonly, the refugees interviewed described discrimination from potential employers. A common complaint was, “Here we can’t find work, nobody wants to give us work because we are Colombian.”

4.4. Discrimination

Discrimination was described as a fundamental issue affecting refugees. Study participants consistently reported experiencing stigma and discrimination in all aspects of their lives in Ecuador, including in jobs, schools, clinics, and social venues. Colombians, they said, were seen as a threat to Ecuadorian society. As a result, they experienced threats, verbal abuse, and violence, especially when seeking charitable assistance. One participant noted, for example, that his health was directly affected because of discrimination:

…a woman was giving me breakfast, but not anymore, and I wanted to see if I could go to the large supermarket to see if they would give me something but people always say bad things to me and I have to put up with it.

Another participant described facing both hunger and unkindness:

Sometimes I look purple when I wake up. I have gone three days without eating. I beg people but they tell me to work.

It is not surprising that when asked about the greatest needs of Colombian refugees in Ecuador, one participant stated, “food and good treatment.”

4.5. Inadequate Government and Charitable Assistance

The conditions of displacement were compounded by differential access to state assistance and international aid to supplement refugees’ access to work and income. Participants also reported few resources of governmental and charitable support, such as vouchers, for accessing food. Interestingly, food security was rarely a concern for Colombians prior to migration. Even amidst violence, many described governmental support and greater access to food in Colombia. One participant described the following:

When I was displaced, I went to Bogota and I received coupons for the supermarket from the international community [agency] and I was able to get everything [I needed]…dairy, fruits and everything, and outside of this they helped me get fresh vegetables and then my conditions were better.

4.6. Food Donations and Health Concerns

Without a steady income, participants reported having to rely on food donations from charitable sources. However, taking advantage of foods that were donated was seen as risky, since they were said to often be expired. Participants cited food borne illness as one of the major health problems facing them, blaming expired food donations. Multiple respondents specifically linked expired food donations to conditions within refugee shelters with outbreaks of illness among children and adults. As one respondent explained, “In the shelter they were sick a lot because the donations that come in are expired foods, preserved foods…the children had diarrhea and became pale.” Participants also linked what they perceived as a high prevalence of intestinal parasites among children to their consumption of contaminated fruits and vegetables.

The questionable safety of food donations was thought to exacerbate the effects of already nutritionally poor diets. The incidence of food borne illness stemming from these donations by governmental and non-profit agencies was so troubling, one participant reported bringing it to the attention of authorities stating, “The prosecutor’s office knows about this.” As a strategy to stay healthy, many refugees, especially those with children, reported thoroughly washing and cooking any fruits and vegetables they received. Others stated that they did not accept donated fruits and vegetables because they appeared rotten.

4.7. The Centrality of Food Insecurity

Displacement posed numerous threats to the health and wellbeing of this population. Though having faced extreme violence and tragedy in Colombia, some participants said that life in Ecuador was worse for them. As one woman described:

In Colombia you were well. Here we are in terrible conditions, both [for] food, and where one lives, sleeping on the ground, many things, because imagine, to pay rent you have to eat less; it’s very difficult.

Food insecurity was a nearly universal health concern. Access to stable and healthy food sources was reported to be one of the most urgent and unmet needs among study participants, often superseding discrimination, social isolation, and job security. Food was a consistent source of preoccupation for many. As one participant noted, “Always, every day, I start my day worried, because I am always thinking about food, I always wake up with a pain in my stomach.” One participant described hunger as a sickness that plagued the refugee population, saying that he viewed fellow Colombians as “dying of hunger.” It was not uncommon for participants to arrive at the interviews having not eaten for several days. They reported regularly experiencing hunger while resettling in Ecuador, and for many, dietary inadequacies persisted well beyond initial displacement. One mother reported being in Ecuador for six years before eating a consistent and regular diet, “Well actually, actually the lack [of food] for the children, I said hunger, they never endured hunger, but I could not feed them well for 6 years, not until I could stabilize myself.”

4.8. Rationing

Rationing was the most common strategy reported for coping with food insecurity. Most often this entailed adults eating less in order to provide sufficient food for their children. Participants largely described this method of rationing as a strategy to ensure sufficient childhood growth and development. However, many respondents suggested a deeper underlying context for this decision—ensuring that children had enough to eat, even if it meant the adults themselves went hungry, was seen as a mechanism by which children were protected from the hardships being faced. Women were seen as more likely to control how food was distributed among household members. One mother stated, “I have forgone eating several times in order to feed my children, so that they can wake up with a full stomach, because they don’t know that we are going through difficult times.”

However, participants often stated that every member of their family experienced the ramifications of food insecurity; “there wasn’t enough for anybody,” as one of them stated. Despite efforts to ration, the effects of food shortages trickled down to the youngest members of the refugee households. In these instances, it was common to skip or delay meals in order to make up for household food insufficiency. Since many participants lacked a steady income, rationing strategies were particularly used to cope with food insecurity during periods of unemployment.

4.9. Limited Food Choices

Along with rationing, participants also described eating only a limited range of foods, especially in the initial months of resettlement, which many refugees found to be extremely difficult. As one participant relayed:

I have a friend in Carapungo and he told me that things were hard the first few days. Because they did not give him work or anything, he had to sleep in cardboard boxes with his wife and daughter. He didn’t sleep, didn’t eat, didn’t have money.

One woman who reported significant weight loss in her entire family during this period described how they only ate rice for the first four or five months after arriving in Ecuador. Also during this time, refugees commonly reported only having access to rice, bread, or lentils, and never fruit, vegetables, or meat.

Lack of employment was also seen to have an important role in limiting the range of foods that Colombian refugees could access:

We are five people, and food is a problem. The other day [we had] lentils, and I couldn’t buy eggs because my husband doesn’t have a stable job.

The lack of reliable employment and steady income forced household heads to make choices among competing needs, such as food, shelter, and health care. Participants commonly described having enough income only to pay their rent, with little left over to feed their families.

The small portion of household income participants had allocated to food was reported to be used to purchase inexpensive, nutritionally devoid foods. Although respondents described the importance of fruits and vegetables in a healthy diet, they found them to be cost-prohibitive. One participant, responding to questions about variety in their diet stated:

It’s very little, and this relates to buying it, and sometimes we have so few earnings. Then you have to make enough for the rent, and then there is no opportunity left to buy small things, because the truth is that I am aware that fruits and vegetables are very good for better eating but I can’t [afford them].

Many interviewees described having to subsist on rice and oatmeal for weeks at a time, rarely having traditional Colombian meals. Colombian foods were seen as either too expensive or largely unavailable in Ecuador.

4.10. Food-Related Health Beliefs and Concerns

Study participants were asked to describe what they did in their daily lives to maintain good health. While a small number of the respondents identified getting adequate rest and controlling anxiety as healthy practices, the overwhelming majority cited an adequate diet as the most essential component of physical wellbeing. Respondents used adjectives such as “basic” and “fundamental” to describe the relationship between nutrition and health. They affirmed that the consumption of nutritious foods was a means of maintaining health and preventing disease for all segments of the population. The refugees interviewed associated a well-balanced diet with improved immune health, longevity, higher energy levels, childhood growth and development, and overall physical wellbeing. Others made a connection between adequate nutrition and physical and mental wellbeing. “The basic thing for a person is food,” one participant noted, “it is fundamental to good physical and emotional health.”

Participants also demonstrated an understanding of the role certain foods and nutrients play in maintaining a healthy diet. One participant stated, for example, “Proteins are a source of strength.” Certain foods were believed to have healing and protective powers as well. As one participant explained, “Above all, soup fortifies and protects against illness.”

Underlying the association between nutrition and health was the assumption that food contributes to general wellbeing when it is both plentiful and nutritious. This, unfortunately, was rarely the case for most of the interviewees. Conversely, they frequently saw food insufficiency as contributing to the etiology of disease. As one participant noted, “When someone isn’t eating well, bodily defenses are reduced.” Participants saw malnutrition as leaving them weak and increasingly vulnerable to illness and poorer health, especially among children. Many refugees we interviewed associated poor performances at work or in school with hunger and malnutrition.

4.11. Impact on Children

Despite the willingness of parents to go hungry so their children could eat, children of Colombian refugees in Ecuador were extremely vulnerable to the negative consequences of food insecurity. Parents frequently reported that their entire households, including their children, were forced to go days without food. One respondent reported a four-month period in which he could not adequately provide his children with food, resulting in his daughter's malnourishment.

The health effects of malnutrition were perceived as being far more severe in children. The impact of food insufficiency on child health was not simply a function of parental perceptions. Children frequently complained of headaches, abdominal pain, nausea, and fatigue to their parents, and many parents stated that their pediatrician told them that their children’s symptoms were a consequence of malnutrition. One of the most obvious signs of nutritional deficiencies at medical check-ups was their children’s weight. Parents described visits to the pediatrician during which they were told their infant or toddler was dramatically underweight for their age. One parent stated, “The last time I took the child for a check-up, they told me he should be 24 (kg) and he is 18 kg.”

Parents interviewed also described profound changes in the demeanor of their children, which they primarily attributed to insufficient food. One parent noted the increased physical and mental suffering of her daughter due to hunger and her diagnosis of anemia:

My daughter didn’t have this, she didn’t suffer from anything. Now she suffers a great deal, her bones hurt, she suffers from headaches, she is pale and weak. I will say, she suffers from nutrition, because a person can’t live like this.

Another mother lamented that her sons were “not active like they were before [they moved from Colombia]: their hair, their nails, their skin, their spirit, they are so thin.” Parents of school-aged children believed that malnutrition contributed to their children’s lower level of academic achievement in Ecuador. Respondents associated skipped meals, unhealthy foods, and periods of hunger with poor performance in school and lower self-esteem among children.

4.12. Health Consequences

Food insecurity also negatively affected the self-assessed health status of the adult study participants. When asked to rate their health, they often reported poorer overall health as a result of limited food. They explained that the increased susceptibility to illness was the result of compromised immunity stemming from malnutrition. They also described the negative sequelae of malnutrition in terms of specific medical diagnoses or somatic manifestations. Most commonly reported medical diagnoses were gastritis, anemia, and tension headache. They also complained of fatigue, chronic body ache, sporadic fever, and generalized weakness, for which they routinely sought medical advice. One participant said, “I feel, as I have told you, like it is a grand weakness, and because of this I got such fevers and headaches, it is the result of hunger I think.” They also reported a perception of poor control over cardio-metabolic diseases as a result of a poorly balanced diet. “Because of the economic situation you need to eat a lot of oatmeal, in the streets, for example, the thing they give us most is oatmeal, then it bloats you and your cholesterol and sugar go up.” Participants also reported that chronic diseases had become worse as a result of limitations on food. Additionally, participants who experienced hunger and malnutrition were more likely to feel they needed medical attention. Perceptions of enhanced disease susceptibility and a deteriorating physical condition seemed to reflect a broader sense of not having control over their health.

The toll of displacement and food insufficiency was quantified in terms of perceived weight loss. Reports of weight loss ranged anywhere from 10 to 30 pounds and often occurred rapidly over a period of weeks. Some simply stated they had noticed their clothes were becoming too big. Precipitous drops in body weight were noted by several participants, while others focused their comments on establishing a connection between lack of food and fatigue and their mood. “I feel tired,” said one participant, “I don’t feel like working or doing anything with high spirits. I think [lack of food] influences this.”

4.13. Mental Health

The refugees interviewed described numerous threats to their mental health stemming from displacement. Among these were: the traumatic nature of their displacement and violence in their sending-communities; discrimination and prejudice towards Colombian refugees; substance abuse; sexual violence; and most commonly, concern over their basic survival, which included access to food. Refugees reported feelings of sadness, stress, and worry, driven by concern over where their next meal would come from. They often used the terms ‘depressed,’ ‘exhausted,’ or ‘helpless,’ and described feeling more susceptible to depression as a consequence of FI.

One respondent stated, “[I feel] stress and sadness, I spend a lot of time thinking about the things that I don’t have, and who I am going to ask for money for food.” They commonly reported sleep disturbances and a sense of decreased morale as a result of their circumstances. One respondent stated, “Psychologically most everything is bad, I have low morale, physically also because I have to endure hunger and everything.”

For many, FI was a manifestation of the social position refugees in Ecuador occupy, and reinforced their sense of powerlessness. It was a constant reminder of the lack of social support, the prejudicial attitudes of others, and the oppressive reality of displacement. Food insecurity was associated with negative feelings of anger, resentment, and weakness, all of which reflected the emotional instability among respondents.

5. Discussion

Consistent with the literature on other refugee populations [2,19], the results of this study indicate that the Colombian refugee community in Ecuador is vulnerable to severe and persistent FI. Additionally, the health risks and sequelae described by our respondents find echo in other food insecure populations globally. Among refugees resettled in developing world nations, food insecurity has been found to be associated outcomes ranging from decreased resilience [55] and poor mental health [37] to decreased antiretroviral adherence [42] . However, the particular circumstances in which FI develops, along with the demographics and sociocultural norms that influence the community’s perception of and response to the experience, provide a lens through which to interpret the detailed accounts of the men and women interviewed. They also foster a more complete understanding of the complexity of the experience of FI, which can assist in the development of targeted aid and policy.

The context of forced migration varies among refugee populations and can be an important factor in the challenges of resettlement. The presence of family and social support is critical to the health and wellbeing of refugees [35,54]. However, Colombians fleeing violence often migrate alone and arrive in Ecuador without a support network. As many respondents described, this lack of social support makes it harder to cope with and recover from the acute post-migratory food insecurity often characteristic of initial resettlement. This is an aspect of the FI experience unique to displaced populations. The single most important predictor of being able to recoup the losses incurred during displacement is ‘belonging to a spatially bound community or geo-political entity,’ as belonging is essential to accessing basic needs [32]. Unlike most developing host countries, Ecuador does not place refugees in camps [65]. This leaves Colombian refugees on their own to seek assistance or file for benefits upon arrival. The enactment of a new refugee decree (no. 1182) in 2012, required asylum requests to be made within 15 days of arrival in Ecuador [60]. As a result, the number of applicants achieving asylum status drastically declined [60], from 45% in 2009 to 13% in 2012 [61]. Without documentation and legal working papers, 70% of refugees are forced to rely on low-wage irregular and short-term employment [68].

Another key element of the context of forced migration is the proximity of the receiving country, Ecuador, to the four decades of violent conflict in Colombia. This complex geopolitical situation influences the factors associated with the persistence of FI. Pre-existing animosities existing between cultural or ethnic groups may exacerbate tensions and discrimination when these populations are forced to coexist due to a refugee situation [21]. The familiarity of the Ecuadorian host communities with the longstanding violence in Colombia has significant implications for host-refugee relations and refugee integration. This familiarity also gives specificity and grounded nuances to discrimination in how Ecuadorians perceive and interact with Colombian refugees. The literature on the effects of refugee resettlement in neighboring countries sparse; however studies from Tanzania, a nation that since its independence has hosted refugees from a dozen nearby African countries [9], highlight both potential adverse effects on receiving communities [3,40] and the experience of significant discrimination for refugees [38].

Food insecurity is located within a continuum of structural violence, beginning with sending country drug-related violence from which individuals and families flee, into an economically stressed receiving environment where fears of drugs and violence, as well as competition for scarce resources, shape the discrimination faced by those forcibly displaced. Such discrimination appears to be a major factor in the transition from the acute food insecurity faced by refugees in the initial resettlement period, to the chronic food insecurity described by our respondents, all of who have resided in Ecuador for at least 3 years. This discrimination affects options and opportunities for the refugees, especially employment, and thus the economic stability needed for addressing the basic needs of housing and food. With little money and no support system, refugees must often resort to negative coping and adaptive strategies. These findings are consistent with those in other refugee populations demonstrating that post-resettlement traumas and stressors may continue to negatively affect the lives of refugees even after they have escaped violence and trauma in their home countries [33,31].

Women can be most vulnerable to the negative coping mechanisms and risk behaviors of food insecurity. They are often in control of the food distribution in their homes, and female respondents described rationing as maternal shielding to protect their children from the harsh realities of the circumstances. Similar patterns of household food allocation have been found in other refugee populations [45]. These coping strategies represent an immediate response to FI, which tend to indicate a worsening of conditions [13,39].

The qualitative approach employed in this study provided insight into the perceptions of this refugee population, which shape their behaviors [46]. The ways in which our respondents adapted long-term food procurement practices, such as resorting to troubling methods to earn a living, can serve as indicators of vulnerability and food insecurity [39,50]. The composition of the displaced Colombian population in Ecuador is significant as nearly 50 percent of registered refugees are females, many of whom are young heads of household [7,58]. Among Colombian women in Ecuador, sex work was seen as socially unacceptable, but often necessary for survival. This is not uncommon, as indicated by Hamelin and colleagues [25], whose results suggested that eventually, the search for food takes precedence over previously held values of socially or culturally acceptable ways to provide for one’s family.

6. Conclusion

In Ecuador, discrimination and exclusion weigh heavily on refugees, impeding their integration into the host community and their ability to establish sustainable livelihoods, all of which contribute to FI and health vulnerability. The stigma and discrimination faced by refugees was the most salient finding of this study, impacting all aspects of their daily lives despite the efforts of Ecuadorian governmental agencies and refugee-serving NGOs to support these populations. Discrimination experienced by refugee groups in host communities is a predictor of social exclusion, which in itself has significant implications for poor health outcomes [11]. It is important to appreciate that one consequence of the experience of discrimination is a refugee’s inability to afford a balanced diet and that humanitarian efforts to provide nutritional provisions could benefit from stricter controls to ensure that the donated foods meet standards of nutrition, hygiene, and safety.

It is often incorrectly assumed that refugees crossing international borders in search of safety successfully resettle with dignity in the host community [32]. National and local governments, responsible for ensuring food security for vulnerable populations, including displaced populations and refugees, need policies directed at assuring that these populations achieve sustainable work, fair pay, and the elimination of discrimination [17]. Hidrobo et al. [28] compared the varying efficacies of different forms of short-term assistance such as cash, food, and vouchers to Colombian refugees who had been in Ecuador for 6 months. However, the chronic food insecurity affecting this population calls for a more sustainable solution to address the specific factors that influence its persistence. Despite the best intentions of the Ecuadorian government, work that specifically engages Ecuadorian society is also clearly needed to achieve their desire to support the refugee population. Public campaigns to help sensitize the Ecuadorian population about the refugees might go a long way towards reducing quotidian expressions of stigma and discrimination.

The majority of Colombians living in Ecuador intend to settle there permanently, with less than 7% wishing to return to their country of origin [58]. Therefore, there is an urgent need to understand and address the health implications for long-term refugees. In order to do so, the risk factors that contribute to health vulnerability, such as those associated with chronic food insecurity, must be well understood [48].

The data in this study support an increase in ongoing efforts to educate Ecuadorians and Colombians about each other’s circumstances and the need for efforts to diffuse tensions and increase understanding in a difficult situation for all involved. Promoting the inclusion of refugees via economic participation and reducing discrimination can have benefits for both the displaced and host populations [12]. For example, it may help reduce food insecurity prevalence in general, which may limit the future healthcare costs needed to treat long-term health consequences of poor nutrition within these populations [52]. Although refugees are often presented as burdens on developing host countries, they can be social agents [22] with positive economic impacts [6] in developing countries as they are in developed countries. Consideration should be paid to the knowledge brought to light by previous studies, such as Whitaker [64] in Tanzania, which noted that benefits and burdens can be unequally distributed across a host community, with wealthier, empowered members reaping benefits of a stimulated economy and affordable labor, and poorer members facing resource and job competition.

The experience of seeking safety in a neighboring nation is shared among many refugee populations. As illustrated by our respondents, the proximity of the sending and receiving countries is significant in conflict-driven migration. Our findings offer an opportunity to better appreciate challenges to food security for populations resettling in neighboring, economically unstable nations in the Global South. As similar patterns of forced population movements between neighboring countries unfortunately increase around the world, the findings discussed in this article will have resonance beyond the specific conditions and contexts negotiated by this refugee group.

7. Limitations

Caution is necessary when interpreting the results of this study. Participants recruited for this study collaborated with us through outreach carried out by peers and trusted sources. The convenience sample is not representative of all Colombian refugees in Ecuador since participants were recruited only in urban Quito, and the sample size does not permit generalization. Data obtained also do not capture the perspectives of refugees not connected with the partner advocates and providers in Ecuador. Finally, the perspectives shared by the women and men in this study need to be situated in the larger context of how the Ecuadorian government and society have grappled with a complicated humanitarian issue despite the economic limitations of their country and the additional demands on scarce resources with the continuing increase of the refugee population.

Acknowledgements

This research was funded by the NIH National Institute on Drug Abuse (NIDA), (5R21DA024706). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDA or the National Institutes of Health. We are grateful to the US and Ecuadorian organizations and governmental and non-governmental institutions that contributed to the development and implementation of this research. We especially thank Michelle Baez and Sebastián Betancourt of the Fundación Salud, Ambiente y Desarrollo and Juan Villalobos and Paola Moreno of the ServicioJesuita a Refugiados y Migrantes in Quito for their key roles as in-country co-investigators. We also recognize Ruth Álvarez and Omar Ocoro for their valuable assistance with the interviews and ethnographic observations. We acknowledge the contributions of Mary Margaret Weigel and Rodrigo Armijos who suggested the importance of this inquiry and participated as co-investigators during the initial stage of research. We also acknowledge Tina Sadarangani for her work on an earlier draft and Chris Hilliard for his tireless assistance in the preparation of the manuscript. Special thanks are due to Peter Hartsock, our NIDA Project Officer, who understands not only research, but also the commitment necessary to address inequities and inform change. And to the Colombian study participants who represented their displaced community of people needing international protection, we are sincerely grateful for their generosity in sharing their time and lives with us.

Conflict of Interest

None.

References

[1]   | Alix-Garcia, J. and Saah, D. (2010) ‘The Effect of Refugee Inflows on Host Communities’. World Bank Economic Review 24(1), 148-170.
[2]   | Abdollahi, M., Abdollahi, Z., Sheikholeslam, R., Kalantari, N., Kavehi, Z., & Neyestani, T. R. (2015). High occurrence of food insecurity among urban Afghan refugees in Pakdasht, Iran 2008: a cross-sectional study. Ecology of Food and Nutrition, 54(3), 187-199.
[3]   | Anderson, S.A. (1990) ‘Core Indicators of Nutritional Status for Difficult-to-Sample Populations’. The Journal of Nutrition 120(Suppl.), 1559-1600.
[4]   | Baez, J. E. (2011). Civil wars beyond their borders: The human capital and health consequences of hosting refugees. Journal of Development Economics, 96, 391-408.
[5]   | Bermudez, O.L., Palma De Fulladolsa, P., Deman, H., and Melgar-Quinonez, H. (2010) ‘Food Insecurity is Prevalent in Rural Communities of El Salvador, Guatemala, Honduras and Nicaragua’. The FASEB Journal 24(104.7).
[6]   | Bilsborrow, R.E. and CEPAR. (2006) The Living Conditions of Refugees, Asylumseekers, and Other Colombians in Ecuador: Millennium Development Indicators and Coping Behaviour. NIDI: The Netherlands.
[7]   | Brees, I. (2010) ‘Burden or Boon: The Impact of Burmese Refugees on Thailand’. The Whitehead Journal of Diplomacy and International Relations: 35-47.
[8]   | Capurro, M. (2014) ‘The Dilemma that Faces Some Female Colombian Refugees: Telling the Human Story’. UNHCR: Esmeraldas, Ecuador. Available at: http://www.unhcr.org/53738c839.html (Accessed: 21 February 2015).
[9]   | Chambers, R. (1986) ‘Hidden Losers? The Impact of Rural Refugees on Poorer Hosts’. International Migration Review 20(2), 245-263.
[10]   | Chaulia, S. S. (2003). Politics of Refugee Hosting in Tanzania: From Open Door to Unsustainability, Insecurity and Receding Receptivity, The [article]. Journal of Refugee Studies, (2), 147.
[11]   | Coates, J., Frongillo, E.A., Rogers, B.L., Webb, P., Wilde, P.E., and Houser, R. (2006) ‘Commonalities in the Experience of Household Food Insecurity across Cultures: What Are Measures Missing?’. The Journal of Nutrition 136(Suppl.), 1438S-1448S.
[12]   | Correa-Velez, I., Gifford, S.M., and Barnett, A.G. (2010) ‘Longing to Belong: Social Inclusion and Wellbeing Among Youth with Refugee Backgrounds in the First Three Years in Melbourne, Australia’. Social Science & Medicine 71(8), 1399-1408.
[13]   | Correa-Velez, I., Spaaij, R., and C, S. (2012) ‘‘We Are Not Here to Claim Better Services Than Any Other’: Social Exclusion among Men from Refugee Backgrounds in Urban and Regional Australia’. Journal of Refugee Studies 26(2), 163-186.
[14]   | Davies, S. (1993) ‘Are Coping Strategies a Cop Out? IDS Bulletin 24(4), 60-72.
[15]   | De Vriese, M. (2006) ‘Refugee Livelihoods: A Review of the Evidence’. Evaluation and Policy Analysis Unit. UNHCR: Geneva.
[16]   | Dharod, J.M., Croom, J.E., and Sady, C.G. (2013) ‘Food Insecurity: Its Relationship to Dietary Intake and Body Weight among Somali Refugee Women in the United States’. Journal of Nutrition Education and Behavior 45(1), 47-53.
[17]   | FAO, IFAD, and WFP. (2013) The State of Food Insecurity in the World 2013. The Multiple Dimensions of Food Security. Rome, FAO.
[18]   | Foley, W., Ward, P., Carter, P., Coveney, J., Tsourtos, G., and Taylor, A. (2010) ‘An Ecological Analysis of Factors Associated with Food Insecurity in South Australia, 2002-7’. Public Health Nutrition 13(2), 215-221.
[19]   | Food and Agriculture Organization Of The United Nations (FAO). (1996) Rome Declaration on World Food Security and World Food Summit Plan of Action. FAO: Rome.
[20]   | Gallegos, D., Ellies, P., and Wright, J. (2008) ‘Still There’s No Food! Food Insecurity in a Refugee Population in Perth, Western Australia’. Nutrition & Dietetics 65: 78-83.
[21]   | Ghattas, H., Sassine, A. J., Seyfert, K., Nord, M., & Sahyoun, N. R. (2015). Prevalence and Correlates of Food Insecurity among Palestinian Refugees in Lebanon: Data from a Household Survey. PLoS ONE, 10(6).
[22]   | Gillam, L., and Clapham, M. (2009) ‘The Relationship Between Food Insecurity and Practical Food Issues amongst a Sample of Refugees in Edinburgh’. Journal of Human Nutrition and Dietetics 22(3), 258-259.
[23]   | Gomez, M.P. and Christensen, A. (2011) World Development Report 2011: The Impacts of Refugees on Neighboring Countries: A Development Challenge. World Bank: Washington, DC.
[24]   | Grabska, K. (2006) ‘Marginalization in Urban Spaces of the Global South: Urban Refugees in Cairo’. Journal of Refugee Studies 19(3), 287-307.
[25]   | Hacket, M., Zubieta, A.C., Hernandez, K., and Melgar-Quinonez, H. (2007) ‘Food Insecurity and Household Food Supplies in Rural Ecuador’. Archivos Latinoamericanos de Nutrición 57(1), 10-7.
[26]   | Hadley, C., and Sellen, D. (2006) ‘Food Security and Child Hunger among Recently Resettled Liberian Refugees and Asylum Seekers: A Pilot Study’. The Journal of Immigrant and Minority Health 8(4), 369-375.
[27]   | Hadley, C., Zodhiates, A., and Sellen, D.W. (2007) ‘Acculturation, Economics and Food Insecurity among Refugees Resettled in the USA: A Case Study of West African Refugees’. Public Health Nutrition 10(4), 405-412.
[28]   | Hamelin, A., Habicht, J., and Beaudry, M. (1999) ‘Food Insecurity: Consequences for the Household and Broader Social Implications’. Journal of Nutrition 129(2), 525S-528S.
[29]   | Hatton, T.J., and Williamson, J.G. (2003) ‘Demographics and Economic Pressure on Emigration out of Africa’. Scandinavian Journal of Economics 105(3), 465-486.
[30]   | Hendrix, C.S., and Brinkman, H. (2013) ‘Food Insecurity and Conflict Dynamics: Causal Linkages and Complex Feedbacks’. Stability: International Journal of Security and Development 2(2:26), 1-18.
[31]   | Hidrobo, M., Hoddinott, J., Peterman, A., Margolies, A., and Moreria, V. (2012) Cash, Food, or Vouchers? Evidence from a Randomized Experiment in Northern Ecuador. Discussion Paper 01234. Washington, DC: International Food Policy Research Institute.
[32]   | Ibánez, A.M., and Vélez, C.E. (2008) ‘Civil Conflict and Forced Migration: The Micro Determinants and Welfare Losses of Displacement in Colombia’. World Development (36)4: 659-676.
[33]   | Ibánez, A.M., and Moya, A. (2010) ‘Vulnerability of Victims of Civil Conflicts: Empirical Evidence for the Displaced Population in Colombia’. World Development 38(4), 667-663.
[34]   | Idemudia, E. S., Williams, J. K., & Wyatt, G. E. (2013). Migration challenges among Zimbabwean refugees before, during and post arrival in South Africa. Journal of Injury and Violence Research, 5(1), 17-27.
[35]   | Kibreab, G. (2003) ‘Displacement, Host Governments’ Policies, and Constrainsts on the Cosntruction of Sustainable Livelihoods’. International Social Science Journal 55(175), 57-67.
[36]   | Kim, I. (2015). Beyond Trauma: Post-resettlement Factors and Mental Health Outcomes Among Latino and Asian Refugees in the United States. Journal of Immigrant and Minority Health / Center for Minority Public Health.
[37]   | Kiptiness, C. and Dharod, J. (2011) ‘Bhutanese Refugees in the US: Their Dietary Habits and Food Shopping Practices Upon Resettlement’. Journal of Hunger and Environmental Nutrition 6(1), 1-11.
[38]   | Lamkaddem, M., Essink-Bot, M.-L., Devillé, W., Gerritsen, A., & Stronks, K. (2015). Health changes of refugees from Afghanistan, Iran and Somalia: the role of residence status and experienced living difficulties in the resettlement process. European Journal of Public Health, 25(6), 917-922.
[39]   | Lavik, N.J., Hauff, E., Skrondal, A., and Solberg, O. (1996) ‘Mental Disorder among Refugees and the Impact of Persecution and Exile: Some Findings from an Out-Patient Population’. British Journal of Psychiatry 169(6), 726-732.

[40]  
Mabiso, A., Maystadt, J., Vandercasteelan, J., and Hirvonen, K. (2014) ‘Refugees, Food Security, and Resilience in Host Communities: Transitioning from Humanitarian Assistance to Development in Protracted Refugee Situations’. 2020 Resilience Conference Paper 2: Building Resilience for Food & Nutrition Security, May 15-17, 2014, Addis Ababa, Ethiopia. International Food Policy Research Institute: Washington, D.C.

[41]   | Maharaj, V., Tomita, A., Thela, L., Mhlongo, M., & Burns, J. K. (2016). Food Insecurity and Risk of Depression Among Refugees and Immigrants in South Africa. Journal of Immigrant and Minority Health / Center for Minority Public Health.
[42]   | Mann, G. (2012). On Being Despised: Growing up a Congolese Refugee in Dar es Salaam. In J. Boyden & M. Bourdillon (Eds.), Childhood Poverty (pp. 185-199). Palgrave Macmillan UK. Retrieved from http://link.springer.com/chapter/10.1057/9780230362796_12.
[43]   | Maxwell, D. (1996) ‘Measuring Food Insecurity: The Frequency and Severity of “Coping Strategies”’. Food Policy 21(3), 291-303.
[44]   | Maystadt, J.-F., & Verwimp, P. (2014). Winners and Losers among a Refugee-Hosting Population. Economic Development & Cultural Change, 62(4), 769-809.
[45]   | Melgar-Quinonez, H.R., Zubieta, A.C., Mknelly, B., Nteziyaremye, A., Gerardo, M.F., and Dunford, C.J. (2006) ‘Household Food Insecurity and Food Expenditure in Bolivia, Burkina Faso, and the Philippines’. The Journal of Nutrition 136(5), 1431S-1437S.
[46]   | Melgar-Quinonez, H., Alvarez Uribe, M.C., Paras, P., and Pérez-Escamilla, R. (2010) ‘Assessing Differences in the Psychometric Characteristics of the Latin American and Caribbean Food Security Scale in Colombia and Mexico’. The FASEB Journal 24(104.8).

[47]  
Mendelsohn, J. B., Rhodes, T., Spiegel, P., Schilperoord, M., Burton, J. W., Balasundaram, S., … Ross, D. A. (2014). Bounded agency in humanitarian settings: A qualitative study of adherence to antiretroviral therapy among refugees situated in Kenya and Malaysia. Social Science & Medicine, 120, 387-395.

[48]   | Patil, C.L., Hadley, C., and Nahayo, P.D. (2009) ‘Unpacking Dietary Acculturation among New Americans: Results from Formative Research with American Refugees’. The Journal of Immigrant and Minority Health 11(5), 342-358.
[49]   | Patil, C.L., Mcgown, M., Nahayo, P.D., and Hadley, C. (2010) ‘Forced Migration: Complexities in Food and Health for Refugees Resettled in the United States’. NAPA Bulletin 34: 141-160.
[50]   | Paul, A., Doocy, S., Tappis, H., & Funna Evelyn, S. (2014). Preventing malnutrition in post-conflict, food insecure settings: a case study from South Sudan. PLoS Currents, 6.
[51]   | Pelletier, D.L., Olson, C.M., and Frongillo, E.A. (2012) ‘Food Insecurity, Hunger, and Undernutrition’. In Erdman Jr., J.W., Macdonald, I.A., and Zeisel, S.H. (eds) Present Knowledge in Nutrition, Tenth Edition. Iowa, USA: John Wiley & Sons, pp. 1165-1181.

[52]  
Pérez-Escamilla, R., Segall-Corréa, A.M., Kurdian Maranha, L., Sampaio Md. Mde. F., Marín-León, L., and Panogasso, G. (2004) ‘An Adapted Version of the U.S. Department of Agriculture Food Insecurity Module is a Valid Tool for Assessing Household Food Insecurity in Campinas, Brazil’. The Journal of Nutrition 134(8), 1923-8.

[53]  
Pérez-Escamilla, R., Melgar-Quinonez, H.R., Nord, M., Alvarez, M.C., and Segall-Corréa, A.M. (2007) ‘The Latin American and Caribbean Food Security Scale (Escala Latinoamericana y Caribeña de Seguridad Alimentaria (ELCSA)), Proceedings of the 1st Latin American Conference on Household Food Security Measurement’. Perspectivas en Nutrición Humana (supplement), 117-134.

[54]   | Peterman, J.N., Wilde, P.E., Silka, L., Bermudez, O.I, and Rogers, B.L. (2013) ‘Food Insecurity Among Cambodian Refugee Women Two Decades Post Resettlement’. Journal of Immigrant and Minority Health 15(2), 372-380.
[55]   | Piwowarczyk, L., Keane, T.M., and Lincoln, A. (2008) ‘Hunger: The Silent Epidemic among Asylum Seekers and Resettled Refugees’. International Migration 46(1), 59-77.
[56]   | Radimer, K.L., Olson, C.M., Greene, J.C., Campbell, C.C., and Habicht, JP. (1992) ‘Understanding Hunger and Developing Indicators to Assess It in Women and Children’. The Journal of Nutrition Education and Behavior 24(1), 36S-45S.
[57]   | Sellen, D.W., and Tedstone, A. (2000) ‘Nutritional Needs of Refugee Children in the UK’. Journal of the Royal Society of Medicine 93: 360-364.
[58]   | Sellen, D.W., Tedstone, A.E., and Frize, J. (2002) ‘Food Insecurity among Refugee Families in East London: Results of a Pilot Assessment’. Public Health Nutrition 5(5), 637-644.
[59]   | Shedlin, M.G., Decena, C.U., Noboa, H., and Betancourt, Ó. (2014) ‘Sending-Country Violence and Receiving-Country Discrimination: Effects on the Health of Colombian Refugees in Ecuador’. Journal of Immigrant and Minority Health 16(1), 119-124.
[60]   | Simich, L., Beiser, M., & Mawani, F. N. (2003). Social Support and the Significance of Shared Experience in Refugee Migration and Resettlement. Western Journal of Nursing Research, 25(7), 872-891.
[61]   | Siriwardhana, C., Abas, M., Siribaddana, S., Sumathipala, A., & Stewart, R. (2015). Dynamics of resilience in forced migration: a 1-year follow-up study of longitudinal associations with mental health in a conflict-affected, ethnic Muslim population. BMJ Open, 5(2).
[62]   | Strauss, A. and Corbin, J. (1994) ‘Grounded Theory Methodology: An Overview’. In Denzin, N.K. and Lincoln, Y.S. (eds) Handbook of Qualitative Research. London: Thousand Oaks: Sage, pp. 273-285.
[63]   | Tusiime, H.A., Renard, R., and Smets, L. (2013) ‘Food Aid and Household Food Security in a Conflict Situation: Empirical Evidence from Northern Uganda’. Food Policy 43: 14-22.
[64]   | UNHCR (UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES). (2012a) Ecuador: 2012 Global Report. UNHCR: Geneva.
[65]   | UNHCR (United Nations High Commissioner for Refugees). (2012b) Statistical Yearbook 2012. UNHCR: Geneva.
[66]   | UNHCR (UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES). (2013) UNHCR Global Appeal 2014-2015 – Ecuador. UNHCR: Geneva.
[67]   | UNHCR, Joint Idp Profiling Service (JIPS), and Feinstein International Center, Tufts University (FIC). (2014) Urban Profiles of the Colombian Population in Quito: Refugees, Asylum Seekers, and Other Migrants, Main Results and Recommendations. UNHCR: Geneva.
[68]   | Vozoris, N., and Tarasuk, V. (2003) ‘Household Food Insufficiency is Associated with Poorer Health’. Journal of Nutrition 133: 120-126.
[69]   | Webb, P., and Harinarayan, A. (1999) ‘A Measure of Uncertainty: The Nature of Vulnerability and Its Relationship to Malnutrition’. Disasters 23(4), 292-305.
[70]   | Whitaker, B.E. (2002) ‘Refugees in Western Tanzania: The Distribution of Burdens and Benefits among Local Hosts’. Journal of Refugee Studies 15(4), 339-358.
[71]   | Women’s Refugee Commission. (2006) Caught in the Crossfire: Displaced Colombians at Risk of Trafficking. Available at: http://www.refworld.org/pdfid/48aa82ea0.pdf (Accessed 22 February 2015).
[72]   | WORLD HEALTH ORGANIZATION (WHO). (2016) Food Security. Available at: http://www.who.int/trade/glossary/story028/en/.
[73]   | World Health Organization (WHO). (2013) Ecuador: Country Cooperation Strategy at a Glance. Available at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ecu_en.pdf (Accessed: 27 March 2015).

[74]  
WFP. (2014) Terms of Reference End of Term Operations Evaluation: Ecuador – PRRO – 200275 – Assistance to Refugees and Persons Affected by the Conflict in Colombia (2011-2014). WFP Office of Evaluation: Evaluation Quality Assurance System. Available at: http://documents.wfp.org/stellent/groups/public/documents/tor/wfp269209.pdf (Accessed 9 March 2015).