nutrients

Article
Persistent Food Insecurity and Material Hardships: A Latent
Class Analysis of Experiences among Venezuelan Refugees
and Migrants in Urban Colombia
Andrea L. Wirtz 1,2, * , Megan Stevenson 1 , José Rafael Guillén 3 , Jennifer Ortiz 3 , Miguel Ángel Barriga Talero 3 ,
Kathleen R. Page 1,2,4 , Jhon Jairo López 3 , Jhon Fredy Ramirez Correa 3 , Damary Martínez Porras 3 ,
Ricardo Luque Núñez 5 , Julián Alfredo Fernández-Niño 6 and Paul B. Spiegel 2

1 Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University
Bloomberg School of Public Health, Baltimore, MD 21205, USA; [email protected] (M.S.);
[email protected] (K.R.P.)
2 Department of International Health, Center for Humanitarian Health, Johns Hopkins University Bloomberg
School of Public Health, Baltimore, MD 21205, USA; [email protected]
3 Red Somos, Bogotá 111321, Colombia; [email protected] (J.R.G.); [email protected] (J.O.);
[email protected] (M.Á.B.T.); [email protected] (J.J.L.);
[email protected] (J.F.R.C.); [email protected] (D.M.P.)
4 Department of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
5 Ministry of Health and Social Protection, Bogotá 110311, Colombia; [email protected]
6 Departamento de Salud Pública, Universidad del Norte, Barranquilla 080003, Colombia;
[email protected]
* Correspondence: [email protected]

Abstract: The causes and conditions of displacement often increase the vulnerability of migrant and
refugee populations to food insecurity, alongside other material hardships. We aimed to examine the
multidimensional aspects and patterns of food insecurity and other material hardships in a cross-
Citation: Wirtz, A.L.; Stevenson, M.; sectional sample of 6221 Venezuelan refugees and migrants in urban Colombia using a latent class
Guillén, J.R.; Ortiz, J.; Barriga Talero, analysis. Using multinomial and logistic regression models, we investigated the demographic and
M.Á.; Page, K.R.; López, J.J.; Ramirez migratory experiences associated with identified classes and how class membership is associated with
Correa, J.F.; Martínez Porras, D.; multiple health outcomes among Venezuelan refugees and migrants, respectively. Approximately
Luque Núñez, R.; et al. Persistent two thirds of the sample was comprised cisgender women, and the participants had a median age of
Food Insecurity and Material 32 years (IQR: 26–41). Four heterogeneous classes of food insecurity and material hardships emerged:
Hardships: A Latent Class Analysis of
Class 1—low food insecurity and material hardship; Class 2—high food insecurity and material
Experiences among Venezuelan
hardship; Class 3—high income hardship with insufficient food intake; and Class 4—income hardship
Refugees and Migrants in Urban
with food affordability challenges. Class 2 reflected the most severe food insecurity and material
Colombia. Nutrients 2024, 16, 1060.
hardships and had the highest class membership; Venezuelans with an irregular migration status
https://doi.org/10.3390/nu16071060
were almost 1.5 times more likely to belong to this class. Food insecurity and material hardship class
Academic Editor: Elliot M. Berry
membership was independently associated with self-rated health, mental health symptoms, and
Received: 28 February 2024 recent violence victimization and marginally associated with infectious disease outcomes (laboratory-
Revised: 28 March 2024 confirmed HIV and/or syphilis infection). Social safety nets, social protection, and other interventions
Accepted: 28 March 2024 that reduce and prevent material hardships and food insecurity among refugees and migrants,
Published: 4 April 2024 alongside the host community, may improve public health, support development, and reduce
healthcare costs. In the long term, regularization and social policies for migrants aimed at enhancing
refugees’ and migrants’ social and economic inclusion may contribute to improving food security in
this population.
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
Keywords: migrant; refugee; food security; material hardship; Colombia; Venezuela; violence;
This article is an open access article
infectious disease
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

Nutrients 2024, 16, 1060. https://doi.org/10.3390/nu16071060 https://www.mdpi.com/journal/nutrients

Nutrients 2024, 16, 1060 2 of 15

1. Introduction
The ongoing displacement of over 7.7 million Venezuelans as of November 2023 out-
side their home country represents one of the largest humanitarian emergencies globally [1].
At the same time, the global population of displaced people is growing rapidly and is
expected to continue to do so, with more persons expected to be displaced by climate-
related factors [2]. While hunger and famine have long been characteristic of crises and
displacements, the impacts of climate change, increasing numbers of displaced people,
and the prioritization of food security as a Sustainable Development Goal bring a renewed
focus on the role of food insecurity in these populations [3–5].
In Venezuela, the ongoing economic and political crisis has resulted in declining food
security, an increasing prevalence of acute malnutrition, rising pediatric hospital admissions
with acute malnutrition, and clinician reports of increasing child deaths attributed to acute
malnutrition in between 2014 and 2019 [6]. In the time since that last report, more recent
studies in the literature have suggested that the infant mortality rate in Venezuela has
continued to climb [7]. The National Survey of Living Conditions in Venezuela (ENCOVI)
estimated that 89% of Venezuelan homes were experiencing food insecurity in 2020, and
this figure declined but remained high at 78% in 2022 [8]. Growing household poverty is
considered a major driver, as the 2015 ENCOVI report estimated that 87% of Venezuelan
households do not earn enough income to buy sufficient food, an increase from the 80%
that was reported in 2014. This same survey estimated that 34% of the population was
recently impoverished, 28% lived in chronic extreme poverty, and 19% were in some form
of poverty that was not classified as extreme, chronic, or recent [9].
Of the more than 7.7 million Venezuelans residing outside their home country as
of November 2023, over 6.54 million are estimated to be residing in the Latin American
and Caribbean region. Sharing its border with Venezuela, Colombia is the most signifi-
cant receiving country in the region, with 2.88 million Venezuelans estimated to reside
in Colombia [1]. Research on the Venezuelan refugees and migrants in other countries
demonstrates ongoing food insecurity after relocation, with estimates varying from 39% to
91% in terms of food insecurity [10–13]. In prior reports, we estimated that only 7.9% of the
Venezuelan refugees and migrants residing in four urban settings of Colombia were food
secure in 2021–2022. The remainder were experiencing low (26.5%) or very low (65.7%) food
security [14]. These reports also demonstrated significant material hardships [14,15]. How-
ever, estimates of food security—the ability of households or individuals to consistently
access safe, culturally acceptable, and nutritious foods [16]—vary by measure. Further,
summative indicators of food security fail to capture unique, heterogenous patterns and
the co-occurrence of other material hardships, which are considered important predictors
of a household or individual’s ability to meet basic needs [17].
This analysis aimed to examine the multidimensional aspects and patterns of food
insecurity and other material hardships, broadly classified as expense hardship, food inse-
curity, and housing hardship [17], among Venezuelan refugees and migrants in Colombia
through a latent class analysis. We further aimed to investigate the demographic and
migratory experiences associated with identified classes. Because food insecurity and
material hardships are recognized social determinants of health [18], we investigated how
class membership is associated with multiple physical and mental health outcomes among
Venezuelan refugees and migrants. Understanding patterns and relationships with these
social determinants of health, food insecurity, and material hardships can inform policies
and health and social protection programs for migrants and refugees in this context and in
similar settings.

2. Materials and Methods

We used data from a cross-sectional survey implemented by Red Somos (Bogotá,
Colombia), Johns Hopkins University (Baltimore, MD, USA), and the Colombian Ministry
of Health and Social Protection (Bogotá, Colombia). The study activities were reviewed and
approved by the Ethical Review Committee at Universidad el Bosque (Bogotá, Colombia)
Nutrients 2024, 16, 1060 3 of 15

and the Institutional Review Board at Johns Hopkins School of Public Health (Baltimore,
MD, USA). The protocol was also reviewed in accordance with the US Center for Disease
Control and Prevention human research protection procedures. Methodological details and
other results have been published previously [14,15,19,20].
Study sample and setting: We used respondent-driven sampling (RDS), a non-probability
chain referral sampling method [21]. RDS is widely used across international settings to
sample populations that lack a sampling frame. Our RDS began with 10 purposively
selected ‘seeds’ from the target population, who participated in all study activities and
were then asked to invite 4 adult Venezuelan peers (recruits) to participate in the study
activities. Eligible and participating recruits were then asked to refer up to four more peer
Venezuelans. This process continued until the target sample size was achieved [19].
The study was conducted in two conurbation sites of the following cities: (1) Bogotá
and Soacha and (2) Barranquilla and Soledad. Candidate participants could be referred
across and participate within any of the selected cities. The cities were chosen for their
population distribution of Venezuelan refugees and migrants, available healthcare and
humanitarian referral options for Venezuelans, and lower presence of Venezuelan refugees
and migrants en route to another country. Data collection was conducted from 30 July 2021
to 5 February 2022 among 6221 participants.
Individuals were eligible to participate if they met the following criteria: aged 18 years
or older, self-reported birth in Venezuela, self-reported migration to Colombia in 2015 or
later, currently lived in a study city, did not report the intention to leave Colombia, and
had a valid recruitment coupon. Enrollment was restricted to one member per immediate
family. Eligible participants underwent initial screening, gave consent, and underwent
literacy screening and data collection in a private study location. Those who consented
completed a survey questionnaire and rapid HIV and syphilis testing with laboratory-
based confirmatory testing. To limit in-person contact during COVID-19, participants
with an appropriate literacy level completed a self-administered electronic questionnaire;
participants with low literacy or those who reported discomfort with technology completed
an interviewer-administered questionnaire.
Survey measures: The survey measures spanned the domains of demographics; migra-
tion status, motivation for migration or displacement, and displacement experience; food
security; health history, including access to healthcare, chronic health conditions, self-rated
health [22], and anxiety and depression, based on the 4-item Patient Health Questionnaire
for Anxiety and Depression (PHQ4) [23]; experiences of violence and discrimination; and
the use of humanitarian services. We included existing survey measures from the region
that had been validated in migrant populations or in the Spanish language when possi-
ble [19]. Current migration status was measured as self-reported regular status, meaning
that the individual had valid, legal, permitted residence in Colombia, or irregular status,
meaning that they had no legal permit to stay in Colombia or that their permit had expired.
A regular migration status provides access to formal employment and access to health
insurance through employment or the subsidized system in Colombia.
Food security was measured using the Spanish translation of the US Department of
Agriculture Food Security Survey 6-item short-form module [24]. This module includes
items measuring the self-reported frequency of the following events over the past 12 months:
purchased food did not last in the household and there were insufficient funds to purchase
more, the participant/other adults in the household did not have money to buy more,
the participant/other adults could not afford to eat balanced meals, the participant/other
adults cut the size of meals or skipped meals because there was not enough money for
food, the participant ate less than they felt they should because there was not enough
money for food, and the participant was hungry but did not eat because there was not
enough money for food. The first two items included Likert scale responses of often true,
sometimes true, and never true, and the last three items were binary yes/no responses.
Participants who reported that they or other adults in the household had cut the size of
their meals or skipped meals in the past 12 months were asked an additional question
Nutrients 2024, 16, 1060 4 of 15

about the frequency at which this occurred. The scores from the individual items were
standardly summed to create the classifications of high or marginal food security, low food
security, and very low food security [24], estimates which we have previously reported for
this study [14,15].
Statistical analysis: Our analysis focused on patterns of food insecurity and material
hardships. For the purposes of the latent class analysis and because the Food Security
Survey 6-item short-form module uses a combination of binary and ordinal measures and
moderate responses such as ‘sometimes true’ were much less frequent, we dichotomized
all categorical food security items, classifying ‘often’ or ‘sometimes true’ to ‘yes, occurred
in past 12 months’ and ‘never true’ to ‘no, did not occur’. The optional item related to
the frequency of cutting/skipping meals was also excluded from the latent class analysis.
The five included binary items had an internal consistency of KR20 = 0.77. Other material
hardship measures included income and housing insecurity. Income was classified as
follows: (1) less than minimum wage (908,526 pesos per month), (2) minimum wage
(908,526 pesos), and (3) above minimum wage (>908,526 pesos). Housing insecurity was a
categorical measure of the number of nights in which the participant had difficulty finding a
safe place to sleep in the past 6 months. For the purposes of this analysis, housing insecurity
was collapsed to none versus one or more unsafe nights in the past 6 months. In total, seven
items spanning food security and material hardships were included as indicators in the
latent class analysis. We did not include an indicator for medical hardship; these typically
focus on access to healthcare when needed and would have reduced our analysis of the
sample to people with predominantly chronic health conditions.
We used a latent class analysis, carried out through a data-driven approach, to identify
underlying patterns or classes using finite mixture modeling [25] to generate classes rep-
resenting different patterns of food insecurity and material hardship experiences among
Venezuelan refugees and migrants in urban Colombia. We determined the optimal number
of classes based on the fit indices (Table 1) and model interpretability [26]. The participants
were then assigned into different classes based on their posterior probabilities of class
membership. We then conducted descriptive analyses to characterize the demographics
and displacement experiences for each class and compare the differences across the classes.

Table 1. Fit indices for potential latent classes (N = 6221).

Number of Akaike Information Bayesian Information

Log Likelihood
Classes Criterion (AIC) Criterion (BIC)
1 −19,650.61 39,317.21 39,371.10
2 −16,776.07 33,586.15 33,700.66
3 −16,550.18 33,152.37 33,327.49
4 −16,452.71 32,975.42 33,211.17

We fit a multivariable multinomial logistic regression model to examine the relation-

ship between participant characteristics and identified latent class membership for food
insecurity and material hardship. Class 1 served as the base category. Independent vari-
ables included items that were conceptually or previously shown to be associated with
food insecurity among refugee and migrant populations. Items that were significantly
associated with predicted class membership (p < 0.05) in the bivariate analyses were tested
for inclusion in the multivariable model; those that were no longer significant after other
variables were added to the model, and those that were colinear with other variables in the
model were omitted from the final multivariable multinomial model for model parsimony.
The final multivariable model was examined for fit using the Hosmer–Lemeshow goodness
of fit test for multinomial models [27].
Finally, we used separate adjusted logistic regression models to determine the relation-
ship between the identified classes and participants’ physical and mental health outcomes,
controlling for site, age, and migration status. The health outcomes included self-rated
health, classified as fair to poor vs. good to excellent [22]; symptoms of anxiety and de-
Nutrients 2024, 16, 1060 5 of 15

pression, classified as normal or mild (PHQ4 score <= 5) vs. moderate or severe (PHQ4
score >= 6) [23]; report of physical, psychological, and/or sexual violence victimization
in the past 12 months [28]; and laboratory-confirmed HIV and/or syphilis infection. All
statistical analyses were conducted using Stata version 17 (College Station, TX, USA).

3. Results
A four-class model appeared to be the optimal class solution (Table 1), based on the
Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) [26]. The four
classes maintained a reasonable size and interpretability, as graphed in Figure 1. The four
classes appeared to represent distinct food insecurity and material hardship experiences
among Venezuelan refugees and migrants in Colombia (N = 6211). Class 1 was represented
by the lowest item response across all food insecurity and material hardship indicators,
relative to other classes, and had the lowest probability of class membership (0.053). Class
2 reflected the highest item response across all food insecurity and material hardship
indicators and had the highest probability of class membership (0.708). Class 3 appeared
to represent high income hardship (probability of income below minimum wage: 0.79)
with insufficient food intake (probability of eating less: 1.0; probability of reducing or
skipping meals: 0.85), though other food insecurity items had probabilities that exceeded
0.60. The probability of class membership for Class 3 was 0.089. Class 4 appeared to
represent income hardship (probability of income below or at minimum wage: 0.66 and
0.25, respectively) and food affordability challenges (probability that food did not last or
could not afford food was 0.94 for both indicators). The probability of class membership for
Class 4 was 0.150. The probability for the unsafe housing item was generally lower, though
it varied by class and was as low as 0.01 in Class 1 and as high as 0.17 in Class 2.
Participant characteristics and class membership: Table 2 displays the sample’s charac-
teristics and associations with posterior probabilities of class membership. The study
participants had a median age of 32 years (IQR: 26–41), with two thirds of the sample
comprising cisgender women. Seventy-one percent reported having an irregular migration
status, though this was more commonly reported among Class 2 members than those in the
other groups. Food insecurity in Venezuela was the most common motivation for migration
to Colombia (52.6%), followed by job insecurity (28.0%), other reasons (12.6%), and to join
family members (6.8%), though food insecurity was more commonly reported among Class
2 members. Overall, more than half (54.1%) of the participants reported that finances were
their most significant challenge in Colombia, followed by food (18.7%), housing (16.9%),
and other challenges (6.9%), and no challenges were reported by 3.3% of the participants.
Participants in Class 2 and 3 were more likely to report that their most significant challenge
was food access, while participants in Class 1 and 4 were more likely to report experiencing
no challenges compared to those with membership in other classes. Almost 20% reported
using humanitarian services while in Colombia, and this was more commonly reported by
members of Class 2 and 3 than those in Class 1 or 4.
 Nutrients 2024, 16, x FOR PEER REVIEW 6 of 16
Nutrients 2024, 16, 1060 6 of 15

1.00 1.00 0.980.960.99 1.00

0.940.94
0.90
0.90 0.85
0.84
0.79
0.80
0.74
0.70
0.70 0.66

0.60
0.60
Probability

0.51
0.50

0.40
0.33
0.29
0.30 0.25
0.24

0.20 0.16 0.17 0.17 0.15

0.14
0.13 0.12
0.08 0.09 0.09
0.10 0.06 0.06
0.04 0.04
0.020.01
0.00
Class 1 Low food insecurity and Class 2 High material hardships and Class 3 High income hardship with Class 4 Income hardship with food
material hardship (class probability: food insecurity (class probability: insufficient food intake (class affordability challenges (class
0.053) 0.708) probability: 0.089) probability: 0.150)
FI1: Food did not last FI2: Could not afford balanced meals FI3: Reduced or cut meals because not enough money

FI4: Ate less that felt they should FI5: Hungry but did not eat because not enough money MH1: One or more nights without safe splace

MH2: Less than min wage (908,526 pesos) MH2: Min wage (908,526 pesos) MH2: Above min wage (>908,526 pesos)

Figure 1. Item response probabilities of food insecurity (FI) and material hardships (MH) among Venezuelan refugees and migrants in Colombia.
Figure 1. Item response probabilities of food insecurity (FI) and material hardships (MH) among
Venezuelan refugees and migrants in Colombia.
Nutrients 2024, 16, 1060 7 of 15

Table 2. Participant characteristics and associations with predicted food insecurity and material hardship class membership among Venezuelans in urban settings of
Colombia (N = 6221).

Predicted Classes
Class 1: Low
Food
Total Sample Insecurity Class 2: High Material Hardships and Food Class 3: High Income Hardship with Class 4: Income Hardship with Food
(N = 6221) and Material Insecurity (n = 4636) Insufficient Food Intake (n = 392) Affordability Challenges (n = 849)
Hardship
(n = 344)
Col Col Col p- Col p- Col p-
n n n aPrR 95%CI n aPrR 95%CI n aPrR 95%CI
% % % Value % Value % Value
Site
Bogotá and Soacha 3102 49.9 229 66.6 2128 45.9 Reference 206 52.6 Reference 539 63.5 Reference
Barranquilla and Soledad 3119 50.1 115 33.4 2508 54.1 2.0 1.5 2.5 0.000 186 47.4 1.6 1.1 2.1 0.005 310 36.5 1.1 0.8 1.5 0.430
Age
18 to 29 2470 39.7 147 42.7 1761 38.0 1.1 0.9 1.5 0.419 153 39.0 1.2 0.8 1.7 0.358 409 48.2 1.6 1.2 2.1 0.004
30 to 39 1978 31.8 84 24.4 1536 33.1 1.6 1.2 2.2 0.001 134 34.2 1.8 1.2 2.6 0.003 224 26.4 1.5 1.1 2.1 0.025
40 and above 1773 28.5 113 32.8 1339 28.9 Reference 105 26.8 Reference 216 25.4 Reference
Gender * (n = 6217)
Man 2124 34.2 162 47.4 1474 31.8 Reference 136 34.8 Reference 352 41.5 Reference
Woman 4046 65.1 178 52.0 3129 67.5 1.5 1.2 1.9 0.001 251 64.2 1.4 1.0 2.0 0.029 488 57.5 1.1 0.9 1.5 0.384
Transgender or Nonbinary 47 0.8 2 0.6 32 0.7 1.6 0.4 6.8 0.531 4 1.0 2.2 0.4 12.3 0.378 9 1.1 1.9 0.4 9.0 0.418
Marital status * (n = 6220)
Never married 2287 36.8 148 43 1657 35.7 Reference 156 39.8 Reference 326 38.4 Reference
Married or cohabitating 2991 48.1 164 47.7 2232 48.2 1.0 0.8 1.3 0.739 188 48 0.9 0.7 1.3 0.736 407 47.9 1.2 0.9 1.5 0.256
Divorced, separated, or
942 15.1 32 9.3 746 16.1 1.9 1.3 2.9 0.002 48 12.2 1.3 0.8 2.2 0.312 116 13.7 1.9 1.2 3.0 0.006
widowed
Number of dependents
4 (3-5) 4 (2-5) 4 (3-5) 1.1 1.0 1.1 0.008 4 (3-5) 1.1 1.0 1.1 0.069 4 (3-5) 1.0 0.9 1.1 0.967
(median, IQR) *
Highest completed education * (n = 6218)
No formal or primary only 1383 22.2 69 20.2 1069 23.1 - - - - 91 23.2 - - - - 154 18.1 - - - -
Secondary 3429 55.1 192 56.1 2524 54.5 - - - - 229 58.4 - - - - 484 57.0 - - - -
Higher or other 1406 22.6 81 23.7 1042 22.5 - - - - 72 18.4 - - - - 211 24.9 - - - -
Employment * (n = 6219)
Formal, full-time, or
749 12 67 19.5 487 10.5 Reference 40 10.2 Reference 155 18.3 Reference
part-time
Unemployed 2283 36.7 88 25.7 1771 38.2 2.1 1.5 3.0 0.000 143 36.5 2.3 1.4 3.8 0.001 281 33.1 1.3 0.9 1.9 0.213
Informal 3028 48.7 176 51.3 2273 49 1.3 0.9 1.7 0.125 197 50.3 1.5 1.0 2.4 0.063 382 45 0.9 0.6 1.3 0.509
Other 159 2.6 12 3.5 104 2.2 1.0 0.5 2.0 0.892 12 3.1 1.5 0.6 3.8 0.354 31 3.7 1.0 0.5 2.1 0.991
Nutrients 2024, 16, 1060 8 of 15

Table 2. Cont.

Predicted Classes
Class 1: Low
Food
Total Sample Insecurity Class 2: High Material Hardships and Food Class 3: High Income Hardship with Class 4: Income Hardship with Food
(N = 6221) and Material Insecurity (n = 4636) Insufficient Food Intake (n = 392) Affordability Challenges (n = 849)
Hardship
(n = 344)
Col Col Col p- Col p- Col p-
n n n aPrR 95%CI n aPrR 95%CI n aPrR 95%CI
% % % Value % Value % Value
Migration Status *
Regular 1779 28.6 124 36.0 1247 26.9 Reference 131 33.4 Reference 277 32.6 Reference
Irregular 4442 71.4 220 64.0 3389 73.1 1.4 1.1 1.7 0.012 261 66.6 1.0 0.8 1.4 0.834 572 67.4 1.1 0.9 1.5 0.418
Motivation for migration *
To join family 422 6.8 43 12.5 276 6.0 Reference 25 6.4 Reference 78 9.2 Reference
Job insecurity 1741 28.0 100 29.1 1293 27.9 2.3 1.5 3.4 0.000 122 31.1 2.3 1.3 4.1 0.004 226 26.6 1.4 0.9 2.2 0.157
Food insecurity 3275 52.6 155 45.1 2519 54.3 2.4 1.7 3.6 0.000 191 48.7 2.0 1.2 3.5 0.011 410 48.3 1.6 1.0 2.4 0.037
Other 783 12.6 46 13.4 548 11.8 2.3 1.4 3.6 0.000 54 13.8 2.3 1.2 4.3 0.011 135 15.9 1.8 1.1 2.9 0.030
Self-reported chronic health condition * (n = 6219)
No 5518 88.7 306 89.0 4076 88.0 - - - - 361 92.1 - - - - 775 91.3 - - - -
Yes 701 11.3 38 11.0 558 12.0 - - - - 31 7.9 - - - - 74 8.7 - - - -
Used humanitarian resources * (n = 6218)
No 5015 80.7 302 87.8 3686 79.5 - - - - 309 78.8 - - - - 718 84.7 - - - -
Yes 1203 19.3 42 12.2 948 20.5 - - - - 83 21.2 - - - - 130 15.3 - - - -
Most significant challenge in Colombia (n = 6218) *
Finances 3366 54.1 193 56.1 2528 54.6 - - - - 197 50.3 - - - - 448 52.8 - - - -
Housing 1048 16.9 56 16.3 798 17.2 - - - - 61 15.6 - - - - 133 15.7 - - - -
Food 1165 18.7 21 6.1 946 20.4 - - - - 77 19.6 - - - - 121 14.3 - - - -
Other 432 6.9 40 11.6 257 5.5 - - - - 39 9.9 - - - - 96 11.3 - - - -
No challenges 207 3.3 34 9.9 105 2.3 - - - - 18 4.6 - - - - 50 5.9 - - - -
Notes: Col %: column percentages; aPrR: adjusted prevalence ratio from multivariable multinomial regression model with Class 1 as base category; 95%CI: 95% confidence interval;
* differences associated with class membership in bivariate analysis based on p < 0.05; - indicates that no aPrR and corresponding statistics calculated were omitted from the multivariable
model due to collinearity or a lack of significance once other items were included in the model. The number of analytic samples for the multivariable model was 6105 (98% of full sample)
due to this study being a complete case analysis.
Nutrients 2024, 16, 1060 9 of 15

Corresponding adjusted prevalence ratios (aPrRs) from the multivariable multinomial

regression model are also displayed on Table 2. Most characteristics were associated with
class membership in the bivariate analyses. Education, chronic health condition, and the
use of humanitarian resources were no longer associated with class membership after the
inclusion of other variables and were omitted from the multivariable model for parsimony.
Associations with Class 2 membership: Residents of Barranquilla or Soledad (refer-
ence: Bogotá or Soacha; aPrR: 2.0, 95%CI: 1.5–2.5); participants aged 30 to 39 (reference:
>=40 years; aPrR: 1.6, 95%CI: 1.2–2.2); cisgender women (reference: cisgender men; PrR
1.5, 95%CI: 1.2–1.9); participants with increasing numbers of dependents (aPrR: 1.1; 95%CI:
1.0–1.1); participants who were divorced, separated, or widowed (reference: never married;
aPrR: 1.9, 95%CI: 1.3–2.9); participants who were unemployed (reference: full or part-time
employment in formal sector; aPrR: 2.1; 95%CI: 1.5–3.0); and participants who had an
irregular migration status (reference: regular; aPrR 1.4, 95%CI: 1.1–1.7) or who reported
migration due to job insecurity (reference: to join family; aPrR: 2.3, 95%CI: 1.5–3.4), food
insecurity (reference: to join family; aPrR: 2.4, 95%CI: 1.7–3.6), or other reasons (reference:
to join family; aPrR: 2.3, 95%CI: 1.4–3.6) were independently associated with Class 2, which
contained those with high material hardships and food insecurity.
Associations with Class 3 membership: Residents of Barranquilla or Soledad (refer-
ence: Bogotá or Soacha; aPrR: 1.6, 95%CI: 1.1–2.1); participants aged 30 to 39 (reference:
>=40 years; aPrR: 1.8, 95%CI: 1.2–2.6); cisgender women (reference: cisgender men; aPrR:
1.4, 95%CI: 1.0–2.0); participants who were unemployed (reference: full or part-time employ-
ment in formal sector; aPrR: 2.3; 95%CI: 1.4–3.8); and participants who reported migration
due to job insecurity (reference: to join family; aPrR: 2.3, 95%CI: 1.3–4.1), food insecurity
(reference: to join family; aPrR: 2.0, 95%CI: 1.2–3.5), or other reasons (reference: to join
family; aPrR: 2.3, 95%CI: 1.2–4.3) were independently more likely to be associated with
Class 3, which contained those with high income hardship and insufficient food intake.
Associations with Class 4 membership: Participants who were aged 18 to 29 years (ref-
erence: >=40 years; aPrR: 1.6, 95%CI: 1.2–2.1) or 30 to 39 years (aPrR: 1.5, 95%CI: 1.1–2.1);
divorced, separated, or widowed (reference: never married; aPrR: 1.9, 95%CI: 1.2–3.0); or
who reported migration due to food insecurity (reference: to join family; aPrR: 1.6, 95%CI:
1.0–2.4) or other reasons (reference: to join family; aPrR: 1.8, 95%CI: 1.1–2.9) were indepen-
dently more likely to be assigned to Class 4, which contained those with income hardship
and food affordability challenges. Migration status was not associated with membership in
Class 3 or Class 4.
Associations between class membership and select health outcomes: Table 3 displays the rela-
tionship between class membership and health indicators, including good to excellent self-
rated health, self-reported symptoms of anxiety and depression, and laboratory-confirmed
syphilis and/or HIV infection. Participants with membership in Classes 2, 3, and 4 were
30–60% less likely to report good to excellent health compared to those with membership
in Class 1—low food insecurity and material hardship. Conversely, participants with
predicted membership in these three classes had 1.8 to 4.9 times the odds of self-reported
symptoms of anxiety or depression. Class 2, containing those with low food insecurity and
material hardship, had the most elevated odds of anxiety and depression symptomatology,
with an adjusted odds ratio of 4.9 (95%CI: 3.1–7.6), compared to those in Class 1. There was
no significant association between predicted class membership and laboratory-confirmed
HIV and/or syphilis infection, though there was some evidence to suggest a marginal
association (direction of effect and p < 0.10) between Class 2 and 4 compared to those with
predicted membership in Class 1. Finally, class membership was associated with recent
(past 12 months) physical, sexual, and/or psychological violence victimization. The odds
of recent violence victimization among the Class 2 members were five times that of the
Class 1 members (aOR: 5.2, 95%CI: 2.1–12.8).
Nutrients 2024, 16, 1060 10 of 15

Table 3. Relationship between food insecurity and material hardship class membership and key
health indicators among Venezuelan migrants and refugees in urban Colombia.

Physical, Sexual, or
Good to Excellent Self-Reported Symptoms of Laboratory-Confirmed
Psychological Violence in
Self-Rated Health Anxiety or Depression HIV or Syphilis Infection
Past 12 Months
(n = 4750, 76.4%) (n = 1373, 22.1%) (n = 378, 6.1%)
(n = 327; 5.3%)
p- p- p- p-
Predicted Classes aOR 95%CI aOR 95%CI aOR 95%CI aOR 95%CI:
Value Value Value Value
Class 1: Low food
insecurity and Reference Reference Reference Reference
material hardship
Class 2: High
p<
material hardships 0.4 0.3 0.6 0.000 4.9 3.1 7.6 0.000 1.6 0.9 2.9 0.085 5.2 2.1 12.8
0.001
and food insecurity
Class 3: High
income hardship
0.5 0.3 0.7 0.000 3.7 2.2 6.1 0.000 1.5 0.7 3.0 0.256 3.4 1.3 9.5 0.017
with insufficient
food intake
Class 4: Income
hardship with food
0.7 0.5 0.9 0.023 1.8 1.1 3.0 0.020 1.8 1.0 3.3 0.069 2.3 0.9 6.0 0.093
affordability
challenges
Notes: aOR: adjusted odds ratio calculated from multivariable logistic regression models. Each model was also
adjusted for site, age, and migration status. 95%CI: 95% confidence interval.

4. Discussion
Drawing on data from more than 6200 Venezuelan refugees and migrants from urban
settings of Colombia, we previously estimated that 92% of Venezuelans were experiencing
low (26.5%) or very low (65.7%) food security and material hardships in 2021–2022 [14,15].
While not directly comparable due to methodological differences, a study conducted
by the World Food Programme in 2022 reported that 26% and 4% of the Colombian
population were moderately food insecure and severely food insecure, respectively [29].
In this analysis, we identified four latent classes of food insecurity and material hardships:
Class 1—low food insecurity and material hardship; Class 2—high food insecurity and
material hardship; Class 3—high income hardship with insufficient food intake; and Class
4—income hardship with food affordability challenges. Simply put, Class 1 reflected the
lowest forms of food insecurity and material hardships, while Class 2 reflected the most
severe food insecurity and material hardships, and these two classes had the smallest
and largest class memberships, respectively. Other investigators, through research with
non-displaced populations, have proposed that measures of material hardships reflect
different time horizons and economic conditions [17]. Specifically, they argue that food
insecurity reflects small, short-term variations in resources, expense hardship reflects
compounding short-term economic shocks, and housing insecurity reflects long-term
economic constraints [17]. Thus, while food insecurity was common, it is perhaps a positive
sign that we observed unsafe housing to have the lowest response probability of any
material hardship measure across all latent classes. These findings may also reflect resilience
through social relationships among refugees and migrants that support safe housing.
Paradoxically, consistent with prior qualitative research [20], food and job insecurity
were the most common motivators for migration to Colombia, yet food insecurity and
related material hardships persisted despite the duration of time for which one resided in
Colombia. Further, these motivators were consistently associated with membership in all
three classes with elevated food insecurity and material hardships (Classes 2 through 4).
Nevertheless, it is important to consider that the material conditions of refugees and mi-
grants change over time, and it is often expected that those migrants who manage to
regularize and achieve economic integration will see an improvement in their situation.
Despite the fact that we measured length of stay and migration status among the partici-
pants, the cross-sectional nature of this study does not allow us measure heterogeneous
changes in food insecurity and material hardships over time. Other research has shown
Nutrients 2024, 16, 1060 11 of 15

mixed results in which some health outcomes have improved while others have worsened
for migrants and refugees in this setting [13]; thus, further research is needed to inform
how to support migrants and refugees as they become established in host settings and able
to regularize their status.
Legal protection in a host setting is critical to the realization of human rights, health
protection, and social advancement for refugees and migrants in host settings and is equally
relevant in this context [30]. Venezuelan refugees and migrants with an irregular migration
status, which comprised over 70% of the population at the time, were independently more
likely to have greater levels of food insecurity and material hardships (i.e., Class 2). This
is likely explained by a lack of access to formal employment and other benefits afforded
to those with a regular status through visas, citizenship, or other permits allowing them
to stay. The findings regarding a lack of difference between the Class 3 and 4 members in
terms of migration status are also noteworthy and suggest that, although a regularized
status may protect against the most severe forms of food insecurity and material hardships
(i.e., Class 2), Venezuelan migrants and refugees of any migration status continue to
experience some patterns of food insecurity and material hardships (i.e., Classes 3 and 4).
This is an important consideration in light of the Colombian government’s decision to
establish the 10-year Temporary Protection Statute for Venezuelans (ETPV) [31]. The ETPV
would benefit Venezuelans with an irregular status and is potentially the most significant
structural intervention for this group in that it grants access to formal employment, health
insurance, and other benefits once an individual has received their permit. The ETPV
was established in 2021, and by December 2023, 1.86 million Venezuelans had completed
all steps and received their Temporary Protection Permits [32]. Inferring from our study
findings, the ETPV may help to reduce the most severe forms of food insecurity and
material hardships, but additional social support and safety nets may be needed fully
reduce food insecurity and material hardships among Venezuelan refugees and migrants.
All of the above serves as evidence that the health of migrants in general and food security
are particularly dependent on migration policy in the medium and long term [33]. While
specific programs to identify and address food insecurity among migrants need to be
further developed, especially for irregular migrants, it is equally important to strengthen
policies including regularization, as well as the social and economic inclusion of migrants.
These efforts indeed impact the social determinants of food insecurity and malnutrition.
Other characteristics, such as age, gender, city of residence, and employment sta-
tus were associated with class membership and consistent with findings on Venezuelan
refugees and migrants in other countries, as well as research on Colombian
citizens [10,11,29]. Cisgender women were more likely than cisgender men to experi-
ence almost all classes of food insecurity and material hardships. While other research
has suggested that heightened food insecurity among women may be explained by sepa-
ration from one’s spouse and/or gender norms related to work and parenting [5,34], the
association in our analysis persisted even after controlling for marital status, number of
dependents, and employment status. The number of dependents was also independently
associated with the highest levels of food insecurity and material hardships (i.e., Class
2 membership), likely reflecting the challenge of supporting and providing nutrition for
more family members and suggesting greater social protection needs for large households.
Finally, we found a consistently higher probability of membership in all food insecurity
and material hardships (i.e., Classes 2 through 4) among Venezuelans who resided in
Barranquilla or Soledad relative to those who resided in Bogotá or Soacha. Barranquilla
and Soledad are known to have a lower cost of living compared to Bogotá and Soacha and,
therefore, may attract Venezuelans who have greater socioeconomic vulnerabilities but
may also have more limited economic opportunities. Nonetheless, this finding underscores
the need to ensure that humanitarian services and other benefits are universally accessible
across settings where refugees and migrants reside.
Food insecurity and material hardship class membership was associated with self-
rated health, mental health symptoms, and recent violence victimization and marginally
Nutrients 2024, 16, 1060 12 of 15

associated with infectious disease outcomes (laboratory-confirmed HIV and/or syphilis

infection). There appeared to be a dose–response relationship in which membership in
Class 2 (high material hardships and food insecurity) had the lowest odds of good to excel-
lent self-rated health and had the highest odds of anxiety or depressive symptomatology,
as well as recent violence victimization. These findings are consistent with global research
that has demonstrated the direct links between food insecurity and material hardships with
mental health, as well as indirect relationships with mental and physical health through
malnutrition and delayed medical care [34–36]. Similarly, household food insecurity and
material hardships have been associated with increased household stress that may trigger
violent behavior, while survivors experiencing food insecurity and material hardships
may not have the means to access safer housing or to escape abusive relationships, thus
increasing the risk of violence victimization [37–39]. Ultimately, food insecurity has been
independently associated with emergency medical visits, hospitalizations, and increased
hospital expenditures [40]. National estimates suggest that at least 30% of the Colombian
population also experienced food insecurity in 2023 [29]; thus, interventions that reduce and
prevent material hardships and food insecurity among refugees and migrants, alongside
the host community, may improve public health and reduce medical expenditures.
The findings should be considered in light of this study’s limitations. First, the cross-
sectional study design limits temporal inferences. Furthermore, food insecurity and health
events share common causes related to motivations for migration [41]. Therefore, these
correlations should be interpreted as indicative of existing patterns but not interpreted
as causal. These findings reflect the mixed migratory flows from Venezuela, in which
some refugees and migrants primarily move for economic reasons, while others do so
mainly for health-related reasons. Because we used a latent class analysis to examine the
multidimensionality of food insecurity and material hardships, our estimates should not
be interpreted as population estimates; population estimates of food insecurity and income
have been previously reported [14,15]. Our design does not allow for the evaluation of the
longitudinal patterns of changes in social determinants over time, though we recognize that
heterogeneity within and across individuals occurs over time. This is relevant for future re-
search, given the dynamic nature of migrants’ social conditions, especially considering that
many of them regularize their status and substantially improve their material conditions
over time through the economic and social inclusion that many achieve.
Finally, we do not know the impact that the COVID-19 pandemic and associated
social distancing measures had on these findings. Global food insecurity increased during
the pandemic [5], and Venezuelan refugees and migrants who participated in formative
research reported loss of income and housing and indicated that others had returned
to Venezuela early during the pandemic [20]. However, as a constantly changing social
situation, there are no estimates of the numbers of Venezuelans affected, nor are there
estimates of the numbers who returned to Venezuela. If housing and income loss during
the pandemic were high, then it is possible that our findings regarding food insecurity and
material hardships, may be more elevated than they would have been before the COVID-19
pandemic. Conversely, we may underestimate food insecurity and material hardship if
some Venezuelans experienced worse conditions in Colombia and subsequently returned
to Venezuela during the pandemic. Nonetheless, we do not believe that the pandemic
affected the latent classes and relationships observed in this analysis.

5. Conclusions
Heterogeneous patterns of food insecurity and material hardships exist among Venezue-
lan migrants and refugees in Colombia. These are both causes of external migration and are
persistent challenges faced by Venezuelan refugees and migrants in Colombia, as well as
other host countries [10,11]. However, Venezuelans with an irregular migration status were
more likely to experience the most severe patterns of food insecurity and material hardships.
Regularization through the ETPV and other legal pathways may reduce severe concomitant
patterns of food insecurity, unsafe housing, and economic vulnerabilities, though our data
Nutrients 2024, 16, 1060 13 of 15

suggest that some food insecurity and material hardships may persist even for migrants
and refugees with a regular status. Social safety nets, social protection programs, and
other interventions that reduce and prevent material hardships and food insecurity among
refugees and migrants, alongside the host community, may improve public health, support
development, and reduce healthcare costs. In the long term, strengthening immigration
policies—including regularization and social policies for migrants aimed at enhancing their
social and economic inclusion—could significantly contribute to improving food security
for migrants within this population.

Author Contributions: A.L.W., J.R.G., M.S., K.R.P., R.L.N. and P.B.S. designed the study protocol
and used the data collection instruments. J.R.G. and M.Á.B.T. led the study’s implementation; J.O.,
J.J.L., D.M.P. and J.F.R.C. oversaw data collection at the study sites and the laboratory procedures.
R.L.N. and J.A.F.-N. contributed expertise in public health policy. A.L.W. oversaw the overall
study, with coordination by M.S., A.L.W., M.S. and J.R.G., who had access to and verified the data.
A.L.W. conducted the statistical analysis, wrote the first draft of the manuscript, and was responsible
for the decision to submit for publication. Data were available to all authors. All authors were
responsible for the decision to submit the manuscript, and all authors reviewed and approved
the manuscript for publication. All authors have read and agreed to the published version of
the manuscript.
Funding: This work was supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)
through the Centers for Disease Control and Prevention (CDC) under the terms of Cooperative
Agreement number NU2GGH002000-03-01. The contents of this manuscript are solely the respon-
sibility of the authors and do not necessarily represent the official views of PEPFAR, the CDC, or
the Department of Health and Human Services. This research has been facilitated by the infras-
tructure and resources provided by the Johns Hopkins University Center for AIDS Research, an
NIH funded program (1P30AI094189), which is supported by the following NIH Co-Funding and
Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK,
NIMHD. The content is solely the responsibility of the authors and does not necessarily represent the
official views of the NIH.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Ethics Review Committee at the Universidad El Bosque
in Bogotá, Colombia (No. 022-2020, 6 November 2020) and the Institutional Review Board at Johns
Hopkins School of Public Health, USA (IRB00011598, 19 August 2020).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available upon request due to privacy and ethical reasons.
Acknowledgments: Gratitude is extended to the thousands of Venezuelan migrants and refugees who
participated in this study. This report would not have been possible without their participation and
shared experiences. The study was implemented by a dedicated and compassionate team led by Red
Somos, including Cindy Quijano, Alejandra Vela, Yessenia Moreno, Francisco Rigual, Marlon Stwar
Sierra, Luis Pérez, Edwin Ferney Ramos, Edenys Rangel, Karen Marivi Vera, Valentina Calderón
Giraldo, Daniel Felipe Durán Mongua, Stefanie Perdomo Martín, Paula Rincón Giraldo, Heriberto
Mejía, Luder Fuentes, Jesús Javier Sandoval, Indira Fuentes, Leives Jiménez, Esther María Beltrán,
Rocío Pérez, Mayra de la Cruz, Byron Gutiérrez, Oladys Bolaño, Xiomara Barrios, José Amaris Povea,
Nayrimi Andreina Valbuena Castillo, Rowel Vera, José Gregorio Nieves, Hendriel Briceño, Omany
Fereira, and Jesús Adelvi Rojas. We acknowledge with gratitude the support of colleagues at the US
Centers for Disease Control and Prevention, Dante Bugli, Eva Leidman, Kevin Clarke, Sagarika Das,
and Abu Abdul-Quader; Johns Hopkins University, James Case, Kristin Bevilacqua, Sarah Arciniegas,
and Wilson Gomez; and the United Nations High Commissioner for Refugees in Colombia, Federico
Duarte, and Saskia Loochkartt.
Conflicts of Interest: The authors declare no conflict of interest.
Nutrients 2024, 16, 1060 14 of 15

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