Determinants associated with low dietary diversity among migrants to Morocco: a cross sectional study

Low dietary diversity (LDD) is prevalent among vulnerable populations, posing a morbidity risk. Few studies have been conducted on the dietary diversity of migrants. The objectives of this study are to determine the prevalence of LDD among migrants in Morocco and the risk factors associated with it. In the Oriental region, we conducted a cross-sectional study with migrants between November and December 2021. The sampling method used was convenience sampling. A face-to-face, structured questionnaire was used to collect sociodemographic, behavioral, and clinical data. We calculated a dietary diversity score based on a 24-h food recall and assessed food intake. The risk factors associated with LDD were identified using multivariate logistic regression. A total of 445 migrants was enrolled. The prevalence of LDD was 31.7%. Risk factors associated with LDD were: being homeless (adjusted Odds Ratio (AOR) of 6.32; CI% [3.55–11.25]), a lack of social support (AOR of 2.30; CI% [1.33–03.98]), and low monthly income (AOR of 8.21; CI% [3.39–19.85]). Public policies must focus on social and environmental determinants. Nutrition training programs should be set up for the migrant population.


Determinants associated with low dietary diversity among migrants to Morocco: a cross sectional study
Firdaous Essayagh 1,6 , Meriem Essayagh 2,6 , Abdellah Lambaki 3* , Ahmed Anouar Naji 1 , Sanah Essayagh 4,6 & Touria Essayagh 5 Low dietary diversity (LDD) is prevalent among vulnerable populations, posing a morbidity risk.Few studies have been conducted on the dietary diversity of migrants.The objectives of this study are to determine the prevalence of LDD among migrants in Morocco and the risk factors associated with it.In the Oriental region, we conducted a cross-sectional study with migrants between November and December 2021.The sampling method used was convenience sampling.A face-to-face, structured questionnaire was used to collect sociodemographic, behavioral, and clinical data.We calculated a dietary diversity score based on a 24-h food recall and assessed food intake.The risk factors associated with LDD were identified using multivariate logistic regression.A total of 445 migrants was enrolled.The prevalence of LDD was 31.7%.Risk factors associated with LDD were: being homeless (adjusted Odds Ratio (AOR) of 6.32; CI% [ Ending hunger and achieving food security and adequate nutrition are part of the Sustainable Development Goals 1 .Access to adequate, safe, nutritious, and diverse food is a basic human right for everyone, regardless of gender, race, religion, or political beliefs 2 .Wars, conflicts, intra-community violence, and repression continue to undermine the ability of people to maintain their day-to-day livelihoods and generate large numbers of asylum seekers and refugees.In 2020, worldwide, 281 million international migrants were registered, including four million asylum seekers and 33.8 million refugees 3,4 .Human mobility aggravates the food and nutritional vulnerability and leads to food insecurity.In 2019, two billion people worldwide lacked regular access to safe, nutritious, and sufficient food 5 .
Vulnerable populations such as migrants may be exposed to insufficient dietary diversity and inadequate nutrition.However, the literature reports that a diversified diet would improve survival, prevent malnutrition and reduce diseases such as diabetes, depression, asthma, metabolic syndrome and osteoporosis 6 .This dietary diversity determines diet quality and nutritional adequacy because no single food can meet an individual's nutritional needs 7 .
Studies on the migrant population in Morocco have shown various nutrition-related issues.Overweight and obesity are prevalent in 39.2% of the population 8 , as are respiratory tract infections (13%) and gastrointestinal illnesses (9%) 9 .
Since implementing a new migrant policy characterized by respect for the human rights of people on the move in 2013, Morocco became not only a transit country to Europe but also a host country for people from Syria and West and Central Africa, with 86,000 migrants in 2014 4 .To date, research has identified the determinants of dietary diversity among adolescents, pregnant and lactating women, and children under the age of five, but no epidemiological study in Morocco has investigated dietary diversity among undocumented migrants, asylum seekers, and refugees [10][11][12][13] .
Taking an interest in dietary diversity among the migrant population would make it possible to maintain or even improve their state of health, which would have a long-term positive influence on the socio-economic OPEN 1 Université Sidi Mohamed Ben Abdellah, Laboratoire droit privé et enjeux de développement, Faculté des sciences juridiques, économiques et sociales, Fès, Morocco. 2 Office national de sécurité sanitaire des produits alimentaires, Oriental, Morocco. 3 Université de Lomé, Faculté des sciences de la santé, Lomé, Togo. 4 Hassan First University of Settat, Faculté des sciences et techniques, Laboratoire agroalimentaire et santé, Settat, Morocco. 5 Hassan First University of Settat, Institut supérieur des sciences de la santé, Laboratoire sciences et technologies de la santé, Settat, Morocco. 6These authors contributed equally: Firdaous Essayagh, Meriem Essayagh and Sanah Essayagh.* email: lambakiabdellah@gmail.com

Population and sample size
In this study, a migrant was defined as any person of foreign origin, without legal status in Morocco, regardless of their date of entry into the country and the duration of their stay, or even settlement.Migrants were classified into three categories: (i) Undocumented migrants i.e. those who do not have a valid Moroccan residence permit; (ii) Asylum seekers, defined as anyone seeking safety from persecution or harm in a country other than their own and awaiting a response on their application for refugee status; and (iii) Refugees, defined as anyone who is recognized by the host country as unable or unwilling to return to their country of origin due to a well-founded fear of persecution on account of their race, religion, nationality, membership in a social group, or political opinions 4 .
The minimum size of our sample was estimated at 384 migrants.For the calculation of the sample size, we used the following formula: n = , with an estimated prevalence of low dietary diversity (p) of 50%, a confidence interval (z) of 95%, and a margin of error (e) of 5% (Epi-Info version 7).

Data source
The trained investigators discussed the objective of the study with potential participants who were present in the selected organizations during the days of the survey and invited them to participate in it.Following a brief conversation with potential participants, those who satisfied the inclusion criteria and gave their agreement were invited to a face-to-face interview.Data collection took place in a closed room in the organization to ensure confidentiality and anonymity.The survey was done throughout the week, including Saturdays and Sundays, to reduce healthy workers bias.A structured, standardized anonymous questionnaire was administered by investigators during a face-to-face interview with the participant to collect data in relation to socio-economic, demographic, behavioral, and clinical characteristics.The questionnaire was administered in Arabic, French, or English which corresponds to the main languages spoken by migrants in Morocco.Investigators were trained in data collection to limit measurement bias.No remuneration was awarded to participants to limit selection bias.

Variables
The socio-economic and demographic characteristics collected were: sex (female or male), age in years, marital status (being single or having partnered), educational level (illiterate, elementary, middle school, high school, and college), native country (Eastern Mediterranean Region, Sub-Saharan Africa), housing type (homeless or apartment), number of persons per house (≥ 10, between five and nine and more than five), occupation (no, yes), monthly income ($) (≤ 150 or more than 150), health insurance (no or yes), length of stay in Morocco in years (< 5 or ≥ 5), legal status (undocumented migrant, asylum seeker, and refugee), and number of countries crossed (≥ 3 or < 3).
Dietary diversity score is a qualitative measure of food consumption that reflects the nutritional adequacy of the diet for the individual.It describes how much a person consumes diverse groups of food 17 .This study adopted the Food and Agriculture Organization of the United Nations Dietary Diversity Score Measurement Questionnaire 17 .Food data was collected using the recall method based on a list of twenty-four categories of foods eaten in the last 24 hours 17 .These foods have been grouped into nine groups: (1) cereals; (2) white roots and tubers; (3) vegetables (including vitamin A-rich tubers, dark green leafy vegetables, and other vegetables); (4) fruits; (6) eggs; (7) fish and seafood; (8) legumes, nuts, and seeds; and (9) milk and milk products.For mixed dish consumption, we asked participants to name the list of ingredients included in the dish, and we recorded them separately in the food list.If one or more food groups were not mentioned by the participants after the recall, they were asked if they had consumed one or more foods from these groups in case they had forgotten.We noted the value of "1" when the food of a group was consumed and the value of "0" otherwise.Dietary diversity scores were calculated by counting the number of food groups participants consumed over a 24-h period.The individual dietary diversity score ranged from 0 to 9. As there are no established limits indicating the number of food groups at which dietary diversity is considered adequate or inadequate, we have based our consensus on the value of four.A participant was classified as having low dietary diversity when they consumed four or fewer food groups from the nine food groups in the past 24 h.Above four, the participant was classified as having adequate dietary diversity.
Symptoms of anxiety and depression were assessed using the Hospital Anxiety and Depression scale.On this scale, the participant stated how he or she felt over the past two weeks.The Anxiety sub-scale consists of seven items: (i) I am tense or irritable; (ii) I am afraid that something bad will happen to me; (iii) I worry; (iv) I can sit quietly doing nothing and feel relaxed; (v) I am afraid and my stomach is knotted; (vi) I am on the move and can't stop; and (vii) I have sudden feelings of panic.Each of these items was given a score ranging from 0 to 3, with "0" signifying no symptoms and "3" indicating the most severe symptoms.The sub-scale for anxiety varied from 0 to 21.A score of 11 or above was considered to indicate elevated levels of anxiety symptoms 18 .
The Depression sub-scale consists of seven items: This sub-scale includes seven items: (i) I continue to enjoy the same things I used to; (ii) I laugh easily and see the bright side of things; (iii) I'm in a good mood; (iv) I feel like I'm idle; (v) I'm no longer bothered by how I look; and (vi) I look forward to doing certain activities.(vii) I appreciate both good books and good radio or television shows.Each of these items received a score ranging from 0 to 3. The sub-score for total depression varied from 0 to 21, with a "0" indicating no symptoms and a "3" indicating the most severe symptoms.A score of 11 or above was considered to indicate elevated levels of depression symptoms 18 .
Physical activity was measured according to Global Physical Activity Questionnaire (GPAQ) 19 .Physical activity deemed unsatisfactory if it occurred less than five times per week and for less than 30 min per day [19][20][21][22] .Social support was notified when the participant reported receiving support from close friends or organizations 23 .

Statistical methods
Epi Info version 7.2.0.1 was used to enter and analyze data.All tests were two-sided and statistical significance was set at a p-value less than 0.05.During the descriptive analysis, the categorical variables were expressed in number and percentage, and the continuous variables were expressed in mean and standard deviation.The proportions of categorical variables were compared using the chi-square test or Fisher's exact test, where applicable.Continuous variables were compared using the analysis of variance test.We included in the multiple logistic regression any variables with a p-value < 0.05 in the bivariate analysis.Multivariate logistic regression was used to identify risk factors associated with low dietary diversity, providing odds ratios (ORs) and adjusted ORs with 95% Confidence Intervals (CIs).

Ethics approval and informed consent to participate
The study adhered to the Helsinki Declaration.Potential participants were informed of the objectives of study and procedure.All subjects who took part in the study signed an informed written statement of consent.The study protocol was reviewed and approved by the ethical review board of the faculty of medicine and pharmacy in Rabat, Morocco (#34/21).

Meal frequency and clinical characteristics
Table 2 summarizes meal frequency and clinical characteristics among migrants.A total of 211 (47.4%) participants consumed at most two meals per day, 178 (40.0%) had symptoms of depression, 44 (9.9%) had unsatisfactory physical activity, and 177 (39.8%) were overweight or obese.

Dietary diversity
The overall prevalence of low dietary diversity (LDD) among migrants was 31.7%, while the overall prevalence of adequate dietary diversity was 68.3%.

Multivariate analysis
After adjusting for the other variables, three variables were identified as risk factors associated with low dietary diversity: (i) homeless were 6.32 (95% CI [3.55-11.25])more likely to have low dietary diversity than migrants with house; (ii) migrants without social support were 2.30 (95% CI [1.33-03.98])more likely to have low dietary Table 1.Socio-economic and demographic characteristics among migrants, Morocco, 2021.sd standard deviation.† A partnered means to be married or to be in concubine.‡ Being single means to be single or divorced or widower.*House means living in house or apartment or reception center.For categorical variables, the Pearson chi-2 test estimated the association between the depending variable and the independent variables when the conditions were valid.For the continuous variables, we used a comparison test of two means; p-value was considered significant when it was less than 0.05.4).

Discussion
To our knowledge, this survey is the first in Morocco to measure the prevalence of low dietary diversity among undocumented migrants, asylum seekers, and refugees.This prevalence is 31.7%.When we compared the prevalence of our study to that of Algeria, a neighboring country with the same socio-economic characteristics as Morocco, we found that in Algeria, in 2014, for 355 migrants, the prevalence of low dietary diversity was 60.0% 24 .
In our study, being homeless was a risk factor associated with low dietary diversity.This could be explained by the unfavorable environmental conditions marked by the absence of an adequate place for the preparation of food, the lack of hygiene measures, and the lack of storage spaces, which would limit the preparation of meals and lead to low dietary diversity.The lack of social support could lead migrants to obtain cheaper food, and lower quality food, and have a monotonous and undiversified diet.In our study, a lack of social support was associated with low dietary diversity.
In the current work, the low income of the migrant population was associated with low dietary diversity.The same finding was reported in a study from Kenya in 2018 25 .Indeed, the global economic and financial crisis, poor buying power, and rising food costs would encourage individuals to avoid purchasing particular food products 26 .Poverty would also be at the origin of the adoption of a monotonous diet, of the adoption of a strategy based on staggering meal times and consuming little food, and the consumption of processed foods rich in saturated fats, salt, and sugar.Vulnerable populations, including migrants, would turn to less diversified, less expensive foods, which certainly fill the stomach but are less nutritious, which weakens their immune systems, makes them more exposed to diseases, and reduces their productivity 26 .
Ghattas et al. report in a study of 639 Iraqi migrants a low consumption of milk and dairy products, fruits, meat, and fish, and a high dependence on cereals and fats 27 .These results are consistent with the results of our study.This could be explained by the fact that milk and dairy products, fruits, meat, and fish have relatively high prices compared to cereals, and oils and are therefore the first foods to be reduced in case of financial difficulties www.nature.com/scientificreports/encountered by migrants in host countries.It might also possibly be because these items require cool storage to prevent deterioration, which is unlikely to be available to homeless people or those on limited budgets.

Limitations
Our study had certain limitations, notably its cross-sectional design.Certainly, it is quick, simple, and low-cost; nevertheless, it presents difficulties in confirming the causal association between exposure and low dietary diversity when assessed simultaneously.Other limitations were noted: the food variety score was obtained qualitatively, without quantification of foods consumed in each food group; the social desirability bias in response to monthly income and behavioral characteristics was also reflected during data collection, despite the promise of anonymity and the use of community actors; and the scarcity of studies relating to dietary diversity among the migrant population has made discussion difficult.

Conclusion
In the literature, there is a dearth of epidemiological studies on diet among migrants.Our study was able to meet its objectives, which were to determine the prevalence of low dietary diversity among migrants and the risk factors associated with it.
Undocumented migrants, asylum seekers, and refugees are a vulnerable group with limited dietary options.Low dietary diversity was associated with risk factors such as homelessness, lack of social support, and low monthly income.
Following these findings, nutrition training programs should be developed and implemented to improve migrants' nutritional and dietary knowledge and to broaden the variety of foods and food groups available to ensure nutritional adequacy.Nutrition training might be a good strategy if the migrant population's financial and living conditions improve at the same time.Similar studies should be conducted in various regions of Morocco to ensure that the findings are generalizable.

Table 2 .
Meal frequency and clinical features of the migrants, Morocco, 2021.For categorical variables, the Pearson chi-2 test estimated the association between the depending variable and the independent variables when the conditions were valid; p-value was considered significant when it was less than 0.05.

Table 4 .
Multivariate analysis (odds ratio, p-value) of risk factors of low dietary diversity among migrants, Morocco, 2021.COR Crude Odds Ratio; AOR Adjusted Odds Ratio; CI Confidence Interval.The denominator is the reference group.