Transportation and language access as social determinants of health and food access

Transportation has emerged in the health services literature as an important determinant for healthcare access in a variety of contexts. For instance, in a cross-sectional study that sought to determine significant predictors of chronic illness (age, race, language, gender, insurance, transportation, and food insecurity), transportation was identified as an important social need that was associated with adverse outcomes among patients with a chronic illness diagnosis^{(Reference Byhoff, Guardado and Xiao11)}. Indeed, when transportation programmes have been implemented in conditions where transportation is a significant barrier to care, they have often determined that transportation is associated with improved access to care. A recent prospective study in a cohort of patients enrolled in an randomised controlled trial of hypertension found that housing and transportation displayed higher resistance to change than other social risk factors (food, clothing, healthcare, utilities, debt) and should be prioritised among social determinants for intervention^{(Reference Xu, Goodrich and Moore12)}. For example, for immigrant/ethnic minority populations who travel further to receive culturally competent and in-language care, transportation access is an important determinants of health^{(Reference Russo, Kwon and Tsui13–Reference Yoo, Gee and Takeuchi15)}.

The relationship between transportation and food access is more complex. In a 2009 consensus report to Congress, the USDA has determined that only a small proportion of food-insecure consumers are restricted in their ability to access affordable nutrition because they lack transportation, though this effect is greatly exacerbated in rural environments, where lack of transportation is ‘the most defining characteristic’^{(Reference Ploeg, Breneman and Farrigan16)}. As discussed in the previous section, consumers’ relationship with their food retail environment is greatly complicated by a variety of factors (proximity, work environment, delivery services), meaning that in large metropolitan areas, then, transportation is generally not thought to be an important determinant of food access.

An important question is whether the observed effects in large urban environments are associated with particular ethnic, racial or demographic groups. Yi et al., previously enumerated transportation to be a key conduit for urban immigrant communities to access culturally appropriate foods even in New York City. Yi et al. demonstrate that some immigrant populations—in particular Chinese Americans—display different food procurement patterns than the mainstream population, again similar with healthcare access, prioritising culturally specific grocery and produce items^{(Reference Yi, Russo and Liu17)}. During the ongoing Covid-19 pandemic, researchers have documented the significant increase in food insecurity in the USA. One study found that between March and April 2020, 41 % of previously food-secure households became at risk for food insecurity, and that this increased risk was higher among racial minority populations as well as participants who were living with children and those who reported household incomes of below $100 000^{(Reference Lauren, Silver and Faye18)}.

Morales et al. demonstrated through survey data that Asian and Hispanic households were more likely to face transportation issues when purchasing food, and Black households were more likely to report that they could not afford to buy more food^{(Reference Morales, Morales and Beltran14)}. Indeed, Morales et al. speculate that Asian households who say that they are afraid to leave the home to procure food may face specific barriers such as lower income/education who do not have the knowledge to purchase groceries online, or from fear of leaving home. Furthermore, Asian food-insecure households had higher odds of reporting they did not leave to buy food because of transportation, mobility, or health issues – themes which were reflected in data collected in New York City^{(Reference Ðoàn, Wyatt and Cowen10)}. Morales et al. also note that Hispanic food-insecure households also reported they were afraid or did not want to leave their homes to purchase food.

We posit that disruptions to transportation as observed during the COVID-19 pandemic not only impact access to food but may also have a synergistic effect of impacting well-being for immigrant communities by imparting a feeling of disconnectedness from one’s own communal identity (Fig. 1). Amid increased reports of anti-immigrant and anti-Asian violence, along with subsequent fear and shame felt in immigrant communities, there is a need to bolster programmes that improve social support and public trust. Addressing transportation access for immigrant communities could play a role in this process.

Fig. 1 Transportation as a conduit to preserving ethnic identity and well-being

An important limitation of the studies discussed thus far is that they generally do not include data for particular racial-ethnic groups (e.g. Mexican, Chinese, etc.) nor do they analyse the effect size for non-citizen populations. Asian Americans have been shown to experience transportation barriers and health disparities, but those factors have not been linked to food insecurity, partly due to the lack of availability of disaggregated data and information on citizenship status.

In-language services are also important. A recent integrative review of thirty-three studies found that among the primary barriers to healthcare access for foreign-born individuals, English language proficiency (along with insurance status and citizenship/immigration status) are the drivers of healthcare access for foreign-born populations^{(Reference Adigun, Barroso and Mixer19)}. Disentangling language-based discrimination from other drivers of healthcare access such as citizenship status is especially important, since these determinants are not co-extensive. Yoo et al. show that the association between language discrimination and chronic disease status was stronger for Asian immigrants living in the USA > 10 years compared to recently arrived immigrants^{(Reference Yoo, Gee and Takeuchi15)}. Parker et al. demonstrated that after adjustment of other variables, patient–physician language concordance was associated with improved glycemic control for limited-English language proficiency Latinos with type 2 diabetes^{(Reference Parker, Fernández and Moffet20)}.

Language access acts as a key conduit for food in various contexts. Carney and Krause show through qualitative case studies that language access and immigration status are important determinants of food access for Mexican and Central American migrants in Santa Barbara county^{(Reference Carney and Krause21)}. An in-depth qualitative study of adults living in East Harlem demonstrated that many Spanish- and Chinese-speaking adults’ shopping patterns were dictated by shopping at stores where food was cheapest or where the grocer spoke their language^{(Reference Nieves, Dannefer and Zamula22)}.

Recommendations: policy and community-based interventions

There are many important proposals in the literature to begin to address these challenges, and we describe these efforts below (Table 1).

1. 1. Integrate stable translation services for existing city and municipal food security programs. Many cities and localities have food access programmes that serve significant numbers of non-English speakers. Certain components of the food security system, including school nutrition programmes—which serve as one of the most important bulwarks against child food insecurity—operate with foreign language services. Given that immigrant communities often live unintegrated from well-known food procurement networks, in-language resources on ethnic grocery stores and resources to navigate city and municipal food security programmes can be implemented. Increasing access to existing resources by providing translated materials, language support to enrol in benefits, and in-language recipes are all important developments. Another important responsibility of city and municipal food programmes is to pay attention to fear in immigrant communities due to concerns about public charge and leaving the home. In some cases, a trauma-informed lens will be important to develop tailored solutions for this population.

2. 2. Study transportation as a determinant of health, particularly as an important determinant of food and health for immigrant populations. As described above, access to ethnic food and healthcare options for immigrant populations with low acculturation is an important source of health, well-being and sense of belonging in the USA^{(Reference Morales, Morales and Beltran14)}. Transportation in this way serves both as a linkage to food and also to cultural and ethnic sources of community integration and acculturation. It is therefore imperative to understand patterns of access and the role that transportation (e.g. personal, public, local transit systems) plays for immigrant communities in different geographic locations. Only with this formative knowledge can we then start to formulate solutions for connecting individuals to needed resources whether virtually (i.e. telehealth, online shopping) or through multi-sector partnerships to address community transportation options.

3. 3. Encourage immigrant participation in experimental stipend programs to curb food insecurity. The past few years have seen significant nation-wide experimentation in unconditional stipend programmes to support individuals in and around care. Recent evidence has shown that unconditional stipend programmes led to health-promoting purchases^{(Reference Lily23)}. Since many immigrants are excluded from SNAP, community-engaged approaches will be important to work with these communities.

4. 4. Encourage broader public participation in research efforts. As we have reviewed, there is significant shortcomings with many models of food insecurity, since they rely on a geographical understanding of individuals’ food environment. Furthermore, as Vu et al. argue, the lack of research into the determinants of food insecurity in immigrant and refugee populations have made it difficult to create tailored policy solutions for this population^{(Reference Vu, Raskind and Escoffery24)}. As research efforts are underway to understand and model food security and access in ways that reflect lived realities, investigators and funding bodies can encourage complex systems thinking in food security research. For instance, participatory mapping strategies that include a diverse array of community stakeholders can ensure that diverse needs are met^{(Reference Chebli, Đoàn and Sabounchi25)}. Funding sources can encourage complex systems thinking. Community-based outreach efforts will be important to building trust in research efforts and institutions. Grants such as the USDA Community Food Projects Competitive Grant can foster innovative efforts to involve broader public participation to create tailored interventions for diverse communities.

Table 1 Stakeholders and recommendations for an immigrant-inclusive food security programme

To close, the renewed attention to the importance of nutrition and access to healthy food is heartening. In nations around the world where nutritional inequality is a major public health challenge, these recommendations can help to build trust among various impacted populations and bolster system-wide reform. In this paper, we have focussed on the specific impacts of food insecurity on migrants and refugees– who make up 14 % of the US population, and are a significant portion of the workforce of other nations. We have focussed here on transportation and language access, but further study of other determinants, particularly as they impact populations on an intersectional basis, are needed.