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Prevalence of adolescent-reported food insecurity and the determinants including coping strategies living in urban slum communities of Bangladesh during the era of COVID-19: a cross-sectional study

Prevalence of adolescent-reported food insecurity and the determinants including coping... Background As food insecurity (FI) continues to rise worldwide especially in developing countries like Bangladesh, adolescent experience of FI have received minimal attention globally. This study aimed to identify the prevalence of adolescent-reported FI and its association with individual and socio-environmental factors as well as coping strategies amongst a sample of adolescents living in urban slum areas of Bangladesh in the times of the Coronavirus 19 (COVID- 19) pandemic. Methods A descriptive cross sectional study was conducted amongst 326 adolescents (12–18 years) living in the urban slums of Narayanganj, Dhaka from April to May, 2022. Adolescent-reported FI was assessed using a structured questionnaire adopted from Household Food Insecurity Access Scale (HFIAS). Descriptive statistics, Chi-square tests and ordinal logistic regression were used to draw inference. Results Prevalence of adolescent-reported FI was high (46.6% moderate and 29.8% severe). The likelihood of experiencing moderate or severe FI versus no/mild FI were 1.7 times (95% Confidence Interval (CI) [1.1, 2.5]) higher in younger adolescents and 5 times (95% CI [2.3, 12.7]) higher in unemployed youth. Socio-environmental factors determining the economic status of a household such as higher number of family members, only one earning family member, unemployed father, no household assets, food aid received by the family during pandemic and positive COVID-19 infection in family were associated with moderate and severe FI. Coping strategies such as a higher number of food seeking strategies (Adjusted Odds Ratio (AOR) 3.4, 95% CI [1.9, 5.9]), substance use (AOR 6.2, 95% CI [1.2, 31.7]) and stopping school (AOR 3.3, 95% CI [1.9, 5.7]) increased odds for moderate and severe FI. Stratified by drop-out of school status, an association between food seeking strategies and FI remained significant among those school-going, while there was no association among those dropping out of school. *Correspondence: Seo Ah Hong [email protected] Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Yasmin et al. BMC Public Health (2023) 23:2046 Page 2 of 11 Conclusion This study showed that adolescents living in urban slum communities in Bangladesh are at very high risk of FI and resort to harmful coping strategies. Our study highlights the importance of further research in adolescent reported FI and coping strategies in low to middle income countries (LMICs) and create appropriate interventions to lower FI among this group and improve their state of health and wellbeing. Keywords Adolescents, Food insecurity, Coping strategies, Bangladesh, COVID-19 pandemic Background used some strategies to cope with FI, such as selling Food insecurity (FI) is defined by Food and Agricultural drugs, asking for food, stealing and borrowing money/ Organization of United Nations as “a situation that exists food [2, 19], and they may be associated with higher when people lack regular access to adequate amount of chances of dropping out from school [2] and engaging in safe and nutritious food for normal growth and devel- unhealthy behaviors, such as smoking and using drugs opment and an active and healthy life” [1]. During the [20], ultimately contributing to social disadvantage when past decade, there was a steady global rise in the level of transitioning to adulthood [21]. Literature on adolescent- moderate to severe food insecure people, which accounts specific health outcomes provide a strong rationale for for almost 30% of the world’s population, with more research on FI and coping strategies. In particular, a bet- than half of them hailing from Asia and one third from ter understanding of the implemented coping strategies Africa [1]. In addition, the COVID-19 pandemic, along by adolescents suffering from FI in extremely food-inse - with its lingering impact on global economies and the cure environments like the urban slums may be beneficial unrecovered income losses among those most affected in developing appropriate and effective programs. by the pandemic, particularly in low to middle income Since most studies on adolescent FI were assessed countries (LMICs) like Bangladesh, has exacerbated the based on parent’s reports, the estimate based on paren- state of food insecurity and hindered progress towards tal accounts often failed to adequately gauge the adoles- meeting Sustainable Development Goal (SDG) 2 by 2030 cents’ experiences and underestimated FI in adolescents [1]. Many studies on FI in developed [2] and developing [21, 22]. With a dearth of adequate information regarding countries [3, 4] showed that FI is associated with poor self-reported FI experience and coping strategies among health outcomes among all age groups but emphasis has either school-going or working adolescents in LMICs like largely been on the vulnerability of households and young Bangladesh, this study aimed to identify the prevalence children [5–8]. Furthermore, since studies reported that and determinants of FI and their association with imple- parents often protected younger children than older chil- mented coping strategies among adolescents living in dren from the impacts of household FI [9], adolescents urban slums of Narayanganj, Dhaka, Bangladesh and also often face a higher vulnerability to FI. Pre-pandemic, to identify the association between coping strategies and Around 50% of adolescents in developing countries were FI amongst school going and dropout adolescents dur- already suffering from FI [ 10, 11]. ing the era of COVID-19 pandemic. Bangladesh has an Since adolescence is a crucial transitional period urban population of nearly 65  million people and about between childhood and adulthood, it is characterized half of them are slum dwellers [23]. Dhaka Division has by major physical, psychological, and social transitions. been recorded to have the highest number of slum settle- uTh s, FI during this period results in not only food ments and in terms of population density, Narayanganj related health outcomes, such as micronutrients defi - has the greatest proportion of slum households [24]. Pri- ciency and poor health outcomes [5, 12], but also consist oritizing the needs of underprivileged adolescents, allows of anxiety, feeling of distress and deprivation, as well as us to lay the foundation for a healthier, prosperous and adverse changes in family and social interactions [2, 13]. more equitable future. This study can serve as a premise Nonetheless, the adolescent FI has received less atten- for further research and discussion on adolescent FI in tion particularly in LMICs such as Bangladesh. Very little urban slum communities in Bangladesh and other LMICs is known about adolescent FI especially among adoles- because there is minimal awareness regarding this public cents hailing from disadvantaged backgrounds, such as health crisis. urban slum settings, although they are disproportionately affected by a higher burden of health risks since child - Methods hood [12, 14–16]. Study design and participants When individuals are food insecure, they resort to cop- The study, a quantitative cross-sectional study, took place ing strategies which minimize risks to an individual’s from April to May 2022 in urban slums of Narayanganj food and economic resources in times of crisis [17]. Thus, district of Dhaka division via face to face interview using the type of coping strategies used may indicate a sever- structured questionnaire in Bengali language. We pur- ity of FI [18]. Previous research showed that adolescents posively chose Narayanganj, as it has one of the highest Yasmin et al. BMC Public Health (2023) 23:2046 Page 3 of 11 rates of urban population growth in Dhaka division with a structured coping strategy questionnaire was designed most of them residing in urban slums [25]. Narayanganj by the researchers based on literature review with three was the epicenter of the COVID-19 in Bangladesh and coping strategies: (1) food seeking strategies, (2) drop- faced one of the strictest lockdown measures during the ping out of school due to lack of food/money, and (3) pandemic, which severely affected the already struggling substance use. During the past 30 days, when you did not slum dwellers [26]. Adolescents from 12 to 18 years of have enough food or money to buy food, how often the age, either working or school going, were recruited for following seven food-seeking strategies adolescents used this study. Based on Cochran’s formula, the sample size were asked: (i) acquiring food on loan/credit, (ii) visiting was estimated using 95% confidence interval, a precision neighbors/relatives for food, (iii) storing food for self, (iv) of 0.05, and a prevalence of FI as 25% [27], and anticipat- searching for food outside home (v) borrowing money ing 10% response/missing data, the determined sample from others to acquire food, (vi) shoplifting, and (vii) size was 316. A total of 326 adolescents were recruited begging for foods/money [2, 19, 21, 30]. The responses for this study. (‘never’=0, ‘sometimes’=1, and ‘often/always’=2) were Of 27 wards in Narayanganj City Corporation, three scored. A total score was then obtained for each par- wards were selected via random lottery sampling and ticipant by adding up the scores of individual strate- two slums per ward were selected via convenience sam- gies (0 to 14 scores) and categorized into three equal pling. Lists of adolescents and their households from groups using tertiles. Second, whether the adolescent the selected slums were obtained by the researchers has dropped out of school due to lack of food/money to from government and non-governmental organizations save expenses were asked and the response was recorded who were working with households in the slum areas as “yes” or “no”. Lastly, during the past 30 days, three and numbered. Equal number of adolescents per slum questions about ‘how many days did you use the fol- were then selected via random sampling for the survey. lowing substance’ were asked: (i) smoking, (ii) any other Selected adolescents and their households were then smokeless tobacco products (e.g. biri, jarda, tobacco leaf, approached for consent/assent to participate in a face gul, or shisha), and (iii) marijuana (also called ganja or to face survey. If researchers failed to contact/approach weed), adopted from Global School Health Survey [31]. selected participant, another participant was selected The responses in the questionnaire were recorded by randomly to participate for the survey. the number of days in the last 30 days for smoking cig- Prior to undertaking the study, ethical approval was arettes and smokeless tobacco and the number of times obtained from a Mahidol University Ethical Commit- the participant consumed marijuana in the last 30 days. tee (2022/03–054) and Ward Councilors. Pretesting the Due to lower proportion of adolescents reporting their questionnaire was performed on around 5% of the total usage in the last 30 days (6.1% smoking, 0.6% smokeless sample size at none of the selected slums and minimal tobacco, and 9.8% marijuana), the final response of the corrections were required. COVID-19 precautions were participants for analysis was recorded as ‘no’ if the cho- maintained during the survey by both researchers and sen option was 0 times/days, and was recorded as ‘yes’ participants by wearing masks and maintaining social for the rest of the options of use for all 3 substances. The distance. After explanation of study objectives and pro- Chronbach’s alpha for reliability of the coping strategy cess, written informed assent was obtained from the ado- questionnaire was 0.70. Furthermore, the coping strate- lescents along with written consent from the guardian gies, such as food-seeking strategies and the number of with assurance of confidentiality. All data were treated substances used are presented, stratified by drop-out of anonymously using study identification numbers. school status. The individual (age, sex, education level, school enrol - Measures ment and adolescent work status, COVID-19 infection The FI was assessed using the Household Food Insecurity history and coping strategy variables) and socio-environ- Access Scale (HFIAS), which has been validated for use mental factors (number of household earning members, in several LMICs [28, 29]. To measure adolescent FI, we number of younger siblings, father’s work status, house- adopted the HFIAS questions from a previous study in hold status, number of household assets categories, food Pakistan [10]. The Chronbach’s alpha coefficient was used aid received in pandemic, COVID-19 infection history in to assess internal consistency (reliability) of the FI ques- family, household head sex, household head education tion items and the coefficient was 0.82. Four ordinal cat - and number of household members) of the participants egories of FI were developed depending on the obtained were also included in this study. score: 0–1 (no FI), 2–8 (mild FI), 9–16 (moderate FI) and 17–27 (severe FI) [28]. Statistical analysis As current literatures lack standardized question- Data was analyzed using SPSS version 25. All individual naires to identify coping strategies for FI in adolescents, and socio-environmental variables were categorized and Yasmin et al. BMC Public Health (2023) 23:2046 Page 4 of 11 descriptive statistics (frequency, percentage, mean and Results standard deviation) are presented. The four categories of Of a total of 326 adolescents, while 2.2% was food secure, FI variables (no, mild, moderate and severe) were consol- 23.6% reported mild, 46.6% moderate and 29.8% severe idated to make 3 variables for further analyses: no/mild, FI. Majority of participants were females (62.3%), early moderate and severe FI. Chi-square test was used to ana- adolescence (12–14 years, 51.5%) and had some second- lyze association between dependent and independent ary education (50.6%) (Table 1). Regarding the types and variables and significant variables (p < 0.05) were identi- frequencies of the various food seeking coping strate- fied for logistic regression. Ordinal logistic regression gies (Fig.  1), most common coping strategies adopted by was performed to identify the factors associated with adolescents were borrowing money for food (95.1%) and the ordinal response of adolescent FI. Results are shown buying food on loan and credit (88.4%), whereas begging as adjusted odds ratio (AOR) and associated 95% CI (5.8%) and stealing (4%) were the least adopted coping with p < 0.05 considered to be significant. Furthermore, strategies. to measure the association between adolescent FI and Bivariate analysis showed that individual factors coping strategies stratified by drop out of school status, (Table  1) (age, adolescent sex, education level, adoles- Chi-square test was performed separately by drop out of cent work status, and adolescents’ coping strategies, such school status (p < 0.05). as food seeking, drop out of school and number of sub- stances used) and socio-environmental factors (Table  2) (number of households earning members, father’s work- ing status, household status, number of household assets, Table 1 Descriptive statistics for individual factors and their association with food insecurity levels INDIVIDUAL FACTORS All No/mild Moderate Severe (n = 97) P-value (n = 326) (n = 77) (n = 152) n (%) Demographic factors Age of adolescents Early adolescence 168 (51.5) 35 (45.5) 72 (47.4) 61 (62.9) 0.027 (Mean ± SD: 14.5 ± 1.8) (12–14 years) Late adolescence (15–18 158 (48.5) 42 (54.5) 80 (52.6) 36 (37.1) years) Adolescent sex Female 203 (62.3) 39 (50.6) 103 (67.8) 61 (62.9) 0.041 Male 123 (37.7) 38 (49.4) 49 (32.2) 36 (37.1) Education level None/some 161 (49.4) 39 (50.6) 61 (40.1) 61 (62.9) 0.002 primary(1–5) Some secondary (6–12) 165 (50.6) 38 (49.4) 91 (59.9) 36 (37.1) School enrollment Enrolled 286 (87.7) 63 (81.8) 139 (91.4) 84 (86.6) 0.102 Not enrolled 40 (12.3) 14 (18.2) 13 (8.6) 13 (13.4) Adolescent work status Not working 290 (92.6) 64 (81.8) 144 (94.7) 94 (96.9) 0.001 Working 23 (7.4) 14 (18.2) 8 (5.3) 3 (3.1) COVID19 infection No 303 (92.6) 72 (97.4) 145 (95.4) 86 (88.7) 0.126 history Yes 23 (7.1) 5 (6.5) 7 (4.6) 11 (11.3) Coping strategy factors Stopped school due to lack of food/ No 260 (79.8) 67 (87.0) 132 (86.8) 61 (62.9) < 0.001 money Yes 66 (20.2) 10 (13.0) 20 (13.2) 36 (37.1) Food seeking 1st tertile (0–4) 108 (33.1) 35 (45.5) 60 (39.5) 13 (13.4) < 0.001 strategies 2nd tertile (5–6) 138 (42.3) 24 (31.2) 67 (44.1) 47 (48.5) 3rd tertile (6–14) 80 (24.6) 18 (23.3) 25 (16.4) 37 (38.1) Smoking cigarettes last month Yes 20 (6.1) 5 (6.5) 6 (3.9) 9 (9.3) 0.229 No 306 (93.9) 72 (93.5) 146 (96.1) 88 (90.7) Marijuana last month Yes 32 (9.8) 10 (13.0) 13 (8.6) 9 (9.3) 0.554 No 294 (90.2) 67 (87.0) 139 (91.4) 88 (90.7) No.of substance Two or more 7 (2.1) 0 (0.0) 2 (1.3) 5 (5.1) 0.033 used last month At least one 41 (12.6) 15 (19.5) 17 (11.2) 9 (9.3) (Mean ± SD: None 278 (85.3) 62 (80.5) 133 (87.5) 83 (85.6) 0.16 ± 0.409) Abbreviations: SD – Standard deviation Yasmin et al. BMC Public Health (2023) 23:2046 Page 5 of 11 Fig. 1 Food seeking coping strategies among adolescents food aid received in pandemic, COVID-19 infection of CI [1.4, 4.6]) more food insecure that those who did family members, household head sex and education, and not receive food aid during the pandemic. Positive number of household members) were associated with FI COVID-19 infection in family (AOR 4.7, 95% CI [2.0, (p < 0.05). 10.9]) was another significant predictor to adolescent As seen in Table  3, significant predictors (p < 0.05) FI. As seen, adolescents who suffered a higher level for adolescent FI include individual factors such early of FI, have higher likelihood of adopting more cop- adolescents (12–14 years) and adolescents with lower ing strategies. They were 2.6 times (95% CI [1.6, 4.2]) education level (no education/some primary) were 1.7 more likely to be on the second tertile and 3.4 times times (95% CI [1.1, 2.5]) and 1.5 times (95% CI [1.1, (95% CI [1.9, 5.9]) more likely to be on the third tertile 2.3]) more likely to be food insecure compared to older for use of food seeking related coping strategies. They adolescents (15–18 years) and those with some sec- are also 6.2 times (95% CI [1.2, 31.7]) more likely to ondary education respectively. Employed adolescents use two or more substances and 3.3 times (95% CI [1.9, in our study were found to be 5.4 times (95% CI [2.3, 5.7]) more likely to stop school. 12.7]) less likely to suffer from a higher degree of FI. Furthermore, when adolescent coping strategies are Socio-environmental factors such as female house- stratified by status, drop out of school were assessed hold head (AOR 4.7, 95% CI [2.0, 11.4]) and lower (Table  4), a positive association between FI levels and education of household head (AOR 4.2, 95% CI [1.7, food seeking strategies were observed among those 10.6]) were strong predictors of adolescent FI. Other school-going (p < 0.001), while there was no association significant socio-environmental factors that play are among those dropping out of school (p = 0.100). In terms role in determining the adolescent FI in a household of number of substances used the previous month, there includes ≥ 5 family members (AOR 1.7, 95% CI [1.1, were no associations, regardless of drop-out of school 2.9]), only 1 earning family member(AOR 2.6, 95% CI status (p > 0.05). Although, severe FI had a higher per- [1.6, 4.2]), unemployed father (AOR 3.0, 95% CI [1.5, centage of marijuana use the previous month, compared 6.2]) and no household assets (AOR 39.7, 95% CI [13.1, to their counterparts. 120.5]). Adolescents who received some food aid dur- ing the COVID-19 pandemic were 2.6 times (95% Yasmin et al. BMC Public Health (2023) 23:2046 Page 6 of 11 Table 2 Descriptive statistics for socio-environmental factors and their association with 3 levels (no/mild, moderate, severe) of food insecurity SOCIO-ENVIRONMENTAL FACTORS All No/mild (n = 77) Moderate Severe (n = 97) P-value (n = 326) (n = 152) n (%) No. of earning members 1 earning member 230 (70.6) 44 (57.1) 111 (73) 75 (77.3) 0.010 (Mean ± SD: 1.3 ± 0.457) > 1 earning member 96 (29.4) 33 (42.9) 41 (27.0) 22 (22.7) No. of younger siblings None 138 (42.3) 33 (47.0) 63 (41.4) 42 (43.3) 0.957 (Mean ± SD: 0.8 ± 1.0) 1 sibling 130 (39.9) 29 (34.9) 61 (40.1) 40 (41.2) > 1 sibling 58 (17.8) 15 (18.1) 28 (18.4) 15 (15.5) Father work status Working 295 (90.5) 75 (97.4) 138 (90.8) 82 (84.5) 0.016 Not working 31 (9.5) 2 (2.6) 14 (9.2) 15 (15.5) Household status Not self-owned/rented 177 (54.3) 25 (32.5) 88 (57.9) 64 (66.0) < 0.001 Rented 84 (25.8) 22 (28.6) 34 (22.4) 28 (28.9) Self-owned 65 (19.9) 30 (63.8) 30 (19.7) 5 (5.2) No. of household assets No assets 230 (70.6) 31 (40.3) 113 (74.3) 86 (88.7) < 0.001 (savings, jewelry, electronics 1 asset category 67 (20.6) 21 (27.3) 36 (23.7) 10 (10.3) /home appliances, vehicles) >=2 asset categories 29 (8.8) 25 (32.4) 3 (2.0) 1 (1.0) Food aid received in pandemic Some food aid 276 (84.7) 56 (72.7) 132 (86.8) 88 (90.7) 0.003 No food aid 50 (15.3) 21 (27.3) 20 (13.2) 9 (9.3) COVID 19 infection No 301 (92.3) 75 (97.4) 145 (95.4) 81 (83.5) < 0.001 history in family Yes 25 (7.7) 2 (2.6) 7 (4.6) 16 (16.5) Household head sex Female 22 (6.7) 2 (2.6) 8 (5.3) 12 (12.4) 0.023 Male 304 (93.3) 75 (97.4) 144 (94.7) 85 (87.6) Household head No education 242 (74.2) 56 (72.7) 117 (77.0) 69 (71.1) 0.031 education Some primary 60 (18.4) 10 (13.0) 26 (17.1) 24 (24.7) Some secondary 24 (7.4) 11 (14.3) 9 (5.9) 4 (4.1) No. of household < 5 103 (31.6) 33 (42.9) 39 (25.7) 31 (32.0) 0.03 members (Mean ± SD: 5.26 ± 1.525) >=5 223 (68.4) 44 (57.1) 113 (74.3) 66 (68.0) Abbreviations: SD – Standard deviation Discussion in LMICs were therefore at a higher risk of FI during the To our knowledge, this study is the first to report ado - COVID-19 pandemic, attributed to loss of income of the lescent-reported FI and the association with individual low-income families during the global and nationwide and socio-environmental factors and coping strategies in recession in Bangladesh during the pandemic [33]. Insuf- urban slums in Bangladesh during the times of the pan- ficient efforts to deal with this situation, lack of adequate demic. Two-third reported moderate or severe FI and understanding and screening for adolescent FI, have they are more inclined to a wider selection of coping only increased the burden of the situation in the pan- strategies, such as food seeking, substance use and stop- demic [32]. In addition, the recent humanitarian crisis ping school due to lack of food/money. This study showed events and inflation has led to the International Mon - that adolescents from underprivileged households are at etary Fund (IMF) categorizing Bangladesh as one of the very high risk of FI and resort to coping strategies. hunger hotspots [34]. To lessen the impact of the existing The prevalence of adolescent FI in our study was adolescent FI problem, policymakers should prioritize found to be much higher compared to those from previ- battling current inflation and safeguarding the most dis - ous studies in other LMICs. A recent study on FI among advantaged which includes adolescents residing in urban adolescent students from 95 countries using data from slums. the Global School-based School Health Survey (GSHS) Adolescent FI may be an indicator for a wide set of showed that 25.5% aged 11–14 years compared with individual, social, and household challenges that con- 30% aged 15–18 years reported FI [20]. Another from tribute to adolescent health and well-being. Since the low income countries such as Pakistan [10] and South- legal age of employment in Bangladesh is 14 years [35], west Ethiopia [11] was reported to be around 50%. The older adolescents particularly from socially disadvan- high prevalence noted in our study may be due to the taged households can support themselves financially study timing, since our study was conducted during the and also provide for their families. Our study supported COVID-19 pandemic. COVID-19 has exacerbated mal- this by showing that older adolescents and those work- nutrition and FI at a global scale [32]. Adolescents living ing are less food insecure. However, When children are Yasmin et al. BMC Public Health (2023) 23:2046 Page 7 of 11 Table 3 Summary statistics using ordinal logistic regression of adjusted odds ratio (AOR) and 95% Confidence interval (CI) for individual, socio-environmental and coping strategy variables in association with food insecurity Food insecurity (No/mild = 0, Moderate = 1, Severe = 2) AOR (95% CI) p-Value Individual factors Age of adolescents Early adolescence (12–14 years) 1.658 (1.101–2.498) 0.016 Late adolescence (15–18 years) Reference Adolescent sex Male 1.416 (0.924–2.169) 0.110 Female Reference Adolescent education level No education-some primary(1–5) 1.525 (1.011–2.302) 0.044 Some secondary(6–12) Reference Adolescent work status Not working 5.365 (2.265–12.711) < 0.001 Working Reference Socio-environmental factors No. of household members >=5 1.734 (1.043–2.881) 0.034 < 5 Reference Household head sex Female 4.728 (1.958–11.413) 0.001 Male Reference Household head education No education 2.590 (1.146–5.856) 0.022 Some primary 4.232 (1.682–10.646) 0.002 Some secondary Reference No. of household earning members 1 earning member 2.593 (1.594–4.216) < 0.001 > 1 earning member Reference Father work status Not working 2.988 (1.450–6.156) 0.003 Working Reference Household status Neither self-owned nor rented 4.973 (2.843–8.697) < 0.001 Rented 3.402 (1.810–6.396) < 0.001 Self-owned Reference No. of household assets 1 asset 12.799 (4.035–40.596) 0.001 (savings, jewelry, electronics no assets 39.653 (13.047–120.517) 0.001 /home appliances, vehicles) >=2 asset Reference Food aid received in pandemic Some food aid 2.561 (1.425–4.604) 0.002 No food aid Reference History of COVID 19 infection in family Yes 4.697 (2.023–10.903) < 0.001 No Reference Coping strategies Food seeking strategy 3rd tertile (6–14) 3.353 (1.897–5.926) 0.001 2nd tertile (5–6) 2.582 (1.602–4.159) < 0.001 1st tertile (0–4) Reference Stopped school due to lack of food/money Yes 3.300 (1.921–5.669) < 0.001 No Reference No. of substance used last month Two or more 6.186 (1.209–31.642) 0.029 At least one 0.555 (0.297–1.039) 0.066 None Reference Abbreviations: SD – Standard Deviation, AOR – Adjusted Odds Ratio, CI – Confidence Interval compelled to leave school and engage in labor due to further supported by strong associations of adolescent FI economic pressure, they are deprived of the opportu- with socio-economic factors, such as father’s unemploy- nity to acquire skills and capabilities essential to realize ment, low household assets possession, lower number of their full potential, securing stable and well-paying jobs households’ earning members, female led households, and disrupt a cycle of disadvantage and poverty [35]. and household heads with lower education as shown Both dropping out of school and having a lower level in previous researches [8, 9, 11]. Studies in developing of education can therefore increase the likelihood and countries such as Bangladesh have shown that, female- eventually worsen the cycle of adolescent FI. This is also led households are often more vulnerable to experiencing Yasmin et al. BMC Public Health (2023) 23:2046 Page 8 of 11 Table 4 Adolescent coping strategies by status of drop-out of school Drop out of school (no) p-value Drop out of school (yes) p-value No/mild Moderate Severe No/mild Moderate Severe n (%) n (%) n (%) n (%) n (%) n (%) Food seeking < 0.001 0.100 1st tertile (0–4) 31 (46.3) 54 (41.0) 8 (13.1) 4 (40.0) 6 (30.0) 5 (13.9) 2nd tertile (5–6) 22 (32.8) 56 (42.4) 31 (50.8) 2 (20.0) 11 (55.0) 16 (44.4) 3rd tertile (6–14) 14 (20.9) 22 (16.6) 22 (36.1) 4 (40.0) 3 (15.0) 15 (41.7) Smoking cigarettes last month Never 64 (95.5) 128 (97.0) 56 (91.8) 0.282 8 (80.0) 18 (90.0) 32 (89.0) 0.704 Yes 3 (4.5) 4 (3.0) 5 (8.2) 2 (20.0) 2 (10.0) 4 (11.0) Marijuana use last month Never 57 (85.0) 122 (92.4) 58 (95.0) 0.105 10 (100.0) 17 (85.0) 30 (83.3) 0.388 Yes 10 (15.0) 10 (7.6) 3 (5.0) 0 (0.0) 3 (15.0) 6 (16.7) No of substance used last month None 54 (80.6) 118 (89.3) 53 (86.9) 0.295 8 (80.0) 16 (80.0) 30 (83.3) 0.315 At least one 13 (19.4) 14 (10.7) 8 (13.1) 2 (20.0) 2 (10.0) 1 (2.8) Two or more 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (10.0) 5 (13.9) FI [8, 36]. Less employment opportunities were avail- the fact that poorer communities are often more sus- able to households headed by women, and their pay rates ceptible to severe disease once it is contracted and this were lower than those of male led households. In many could have resulted in greater income loss due to work instances, females also bear the burden through assigned disruptions for the adolescent households, thereby wors- social norms regarding the nature of work they can or ening their state of FI [26]. Our study also showed that cannot do as well as domestic and childcare responsibili- although about 85% of slum-dwelling adolescents have ties [8]. Social reform policies should be implemented to ever received food aids in the COVID-19 pandemic ensure more women are included in workforce and close (90% in severe FI, 86.8% in moderate FI and 72.7% in the gender inequality gap. This study found no gender no/mild FI adolescents, prevalence of the overall ado- link to FI. However, Sheikh et al. in his study found ado- lescent FI in our study was still incredibly high. Bangla- lescent boys more prone to it than girls [10]. A study in desh’s social security policies rarely addressed specific Ethiopia suggested higher FI among adolescent girls [11]. adolescent needs and for the enormous population living These conflicting results highlight the need to under - in poverty, the government has been unable to provide stand what is perceived as FI. Findings from a study con- enough aid and social assistance to the vulnerable during ducted in Bangladesh showed that interaction between the pandemic [33]. This shows that in order to be effec - gender norms and structural, social, and economic fac- tive, policies need to be more targeted and designed to tors often predispose female adolescents to poor nutri- address specific needs of vulnerable population. Differ - tional consumption [37]. According to the study, young ent from our study showing a positive association of FI female respondents found satisfaction in offering food with socioeconomic factors, a study done on adolescents first to the males in their households, accepting their in rural Pakistan showed no significant associations [ 10], less significant status and the financial restraints of their and suggested that FI requires a multilevel investigation families, which caused them to habitually consume less of other variables such as social support, food prices, food than their physical needs [37]. This could have likely unforeseen events like medical or other costs, etc. rather resulted in under reporting of FI by adolescent females. than blaming it all on poverty [10]. Therefore understanding of FI can vary depending on While some studies explored coping strategies in ado- the environment and context of the study. Furthermore, lescents, they lack inference based on quantitative anal- the current study showed a higher family size was sub- ysis [19]. In our opinion, our study is the first to have stantially related to adolescent FI. This may be mostly quantitatively analyzed the association between adoles- because in poor families from slums, food expenditure cent FI and three types of coping strategies which are constitutes a large percentage of total household expen- food seeking coping, substance use coping and dropping ditures [3]. Therefore, having bigger families could lead out of school. Our study revealed that severely food inse- to adolescents compromising their dietary needs despite cure adolescents are more likely than their counterparts higher nutritional demands [14]. The positive association to utilize a larger variety of coping methods to deal with with COVID-19 infection in family can be explained by FI, such as a higher number of food-seeking strategies as Yasmin et al. BMC Public Health (2023) 23:2046 Page 9 of 11 well as number of substances used and dropping out of can go in improving their situation, it can help imple- school. Adolescents dropping out of school due to lack of ment policies that are precisely designed to tackle and foods were around 20% and the drop-out rate increases improve FI situation among adolescents. Yet, our results as the severity of FI increases. This may indicate that drop need to be further examined because these mechanisms out of school status can increase the likelihood and in can be situation or context specific. due course, worsen the state of FI and subsequent coping Our study’s advantages include data on adolescents strategies. Interestingly, food seeking strategies used were from urban slum communities with self-reported esti- also different by status of stopping school. While a sig - mates of FI and various levels of determinants since the nificant association between food seeking strategies and literature on adolescent FI is relatively inadequate in FI remained significant among school-going adolescents, LMICs, especially in urban slum areas. Nonetheless, there was no association among adolescents dropping some limitations of the study should be acknowledged. out of school. It may indicate that different from ado - Due to the nature of a cross-sectional study design, a lescents being employed, school-going adolescents are causal relationship cannot be assumed and recall bias still struggling to cope with FI. The government’s safety may be introduced. Additionally, this survey was also net programs in Bangladesh to reduce FI, largely include collected during the monsoon season (beginning May) food transfer programs which are all food-focused [38]. A in Bangladesh when household FI is more likely to be study in Bangladesh showed that cash transfer programs high in comparison to the dry season [41]. This study have been more beneficial in increasing caloric intake only included adolescents and their households who among school age children compared to food transfer could converse with researchers in the standard spoken programs [38]. Another study showed that school feeding Bengali, this could have underestimated the FI. Since programs to improve FI, will not only improve health in slum households were limited in their space and privacy, adolescents but also increase the number of school days constraints to how much privacy could be maintained attended [39]. Therefore, it is highly recommended that between participants and their caregivers could have policy makers modify their current safety net programs introduced response bias to some sensitive questions and incorporate more diversified policies and strategies (e.g. smoking, begging etc.). In addition, although HFIAS that are designed to address the various issues and fac- questionnaire has been used in various studies in Bangla- tors associated with FI. desh [7, 27] and validated for use in other LMICs [28, 29], In lights of substance use, although the study from the it is yet to be linguistically and cross-culturally validated GSHS from 95 countries revealed that FI is associated for use in Bengali language. with a higher odds of substance use, such as smoking, drinking and drugs [20], our study did not show a sig- Conclusion nificant association with neither smoking cigarettes nor Adolescent-reported FI in urban slums of Bangladesh marijuana, but has shown a positive association between was found to be remarkably high. The participants adolescent FI and the number of substances used last shared a wide range of coping strategies to neutral- month. This shows that FI may result in greater experi - ize risks of FI such as food seeking strategies, sub- mentation with tobacco and marijuana use. Adolescents stance use and pause in schooling. Adolescent FI is a often use substances as source of relief from any mental critical aspect of SDG 2, as it highlights the need to stress and anxiety arising from difficult situations in their address hunger, malnutrition, and inadequate access lives with unawareness of the consequences [2, 40] and to nutritious food of adolescents. As seen with this as a sense of belonging with their peers [20]. Our find - study, adolescent FI is influenced by a combination ing is important, as it is crucial to identifying adolescents of individual, social and economic factors. In order to at earliest stage of FI, to prevent worsening of their FI achieve SDG 2, it is important to recognize these fac- state which could lead to detrimental substance abuse tors and address them through comprehensive and among youths from disadvantaged populations who may multi-dimensional approach which involves concerted be at a higher risk of drug abuse and subsequent poor efforts from numerous shareholders such as the gov- health [20]. While there was no association of smoking ernment, private institutions and non-governmental cigarettes and marijuana use with FI, regardless of drop- organizations. Therefore, prioritizing adolescent FI in out of school status, percentages of marijuana use seem developing countries such as Bangladesh can have far higher in severe food insecure group among adolescents reaching implications that touch on education, eco- stopping school. Given the results of this study, interven- nomic development and overall health and wellbe- tions to reduce FI may need to be tailored to coping strat- ing and thus contribute to more productive lives for egies that differ by adolescent age, sex and school-going young people in Bangladesh as well as other develop- status. Since understanding the use of coping strategies ing nations globally. enable us to understand the extent to which individuals Yasmin et al. BMC Public Health (2023) 23:2046 Page 10 of 11 Abbreviations References AOR Adjusted Odds Ratio 1. FAO I, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the CI Confidence Interval World 2022. Repurposing food and agricultural policies to make healthy diets COVID-19 Coronavirus 19 more affordable. Rome, FAO2022. FI Food Insecurity 2. Popkin SJ, Scott MM, Galvez MM. Impossible choices: Teens and food insecu- GSHS Global School-based School Health Survey rity in America. 2016. HFIAS Household Food Insecurity Access Scale 3. Faye O, Baschieri A, Falkingham J, Muindi K. Hunger and food insecu- IMF International Monetary Fund rity in Nairobi’s slums: an assessment using IRT models. J Urb Health. LMIC Low to Middle Income Country 2011;88:235–55. SD Standard deviation 4. Spieker C, Laverty AA, Oyebode O, Collaborative IHS. The prevalence and SDG Sustainable Development Goal socio-demographic associations of household food insecurity in seven slum sites across Nigeria, Kenya, Pakistan, and Bangladesh. A cross-sectional study. Acknowledgements PLoS ONE. 2022;17(12):e0278855. We would like to acknowledge Tahmina Tamanna, MSc, and her team for 5. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health A. ff their support with data collection and review of questionnaire in Bengali. 2015;34(11):1830–9. I would also like to appreciate my professors; Dr Sariyamon Tiriphat, Dr 6. Oronce CIA. In: Miake-Lye IM, Begashaw MM, Booth M, Shrank WH, Shekelle Bang-on Thepthein, Dr Thunwadee Suksaroj and Dr Phudit Tejativaddhana PG, editors. Interventions to address food insecurity among adults in Canada who were part of the research advisory committee, for their support and and the US: a systematic review and meta-analysis. American Medical Asso- encouragement. ciation: JAMA Health Forum; 2021. 7. Ali D, Saha KK, Nguyen PH, Diressie MT, Ruel MT, Menon P, et al. Household Authors’ contributions food insecurity is associated with higher child undernutrition in Bangladesh, Taniya Yasmin and Seo Ah Hong initiated and conceived the project research Ethiopia, and Vietnam, but the effect is not mediated by child dietary diver - including the questionnaire development. Taniya and Seo Ah Hong conceived sity. J Nutr. 2013;143(12):2015–21. the idea of this article. Taniya Yasmin, Taslima Yasmin and Sarah Sultan were 8. Mallick D, Rafi M. 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J Educ Health Promotion. 2013;2(1):27. 16. Krishna A, Oh J, Lee J-k, Lee H-Y, Perkins JM, Heo J, et al. Short-term and long- Ethical approval and informed consent term associations between household wealth and physical growth: a cross- An ethical committee at Mahidol University in Thailand approved the study comparative analysis of children from four low-and middle-income countries. protocol (No.: 2022/03–054). The study was in accordance with relevant Global Health Action. 2015;8(1):26523. institutional guidelines and regulations in accordance with the declaration 17. Snel E, Staring R. Poverty, migration, and coping strategies: an introduction. of Helsinki. All participants provided an written informed assent along with Focaal Eur J Anthropol. 2001;38:7–22. written informed guardian consent prior to survey initiation after explanation 18. Farzana FD, Rahman AS, Sultana S, Raihan MJ, Haque MA, Waid JL, et al. 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Food insecurity in children but Author details not in their mothers is associated with altered activities, school absenteeism, ASEAN Institute for Health Development, Mahidol University, and stunting. J Nutr. 2014;144(10):1619–26. Nakhon Pathom 73170, Thailand 22. Connell CL, Lofton KL, Yadrick K, Rehner TA. Children’s experiences of food Social and Economic Enhancement Program, Mirpur, Pallabi, insecurity can assist in understanding its effect on their well-being. J Nutr. Dhaka 1216, Bangladesh 2005;135(7):1683–90. 23. Hasan MZ, Hasan AMR, Rabbani MG, Selim MA, Mahmood SS. Knowledge, Received: 8 June 2023 / Accepted: 13 October 2023 attitude, and practice of Bangladeshi urban slum dwellers towards COVID-19 transmission-prevention: a cross-sectional study. PLOS Global Public Health. 2022;2(9):e0001017. 24. Guillem Fortuny RG. Richard Marshall. Poor settlements in Bangladesh an assessment of 29 UPPR towns and cities. 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Prevalence of adolescent-reported food insecurity and the determinants including coping strategies living in urban slum communities of Bangladesh during the era of COVID-19: a cross-sectional study

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Abstract

Background As food insecurity (FI) continues to rise worldwide especially in developing countries like Bangladesh, adolescent experience of FI have received minimal attention globally. This study aimed to identify the prevalence of adolescent-reported FI and its association with individual and socio-environmental factors as well as coping strategies amongst a sample of adolescents living in urban slum areas of Bangladesh in the times of the Coronavirus 19 (COVID- 19) pandemic. Methods A descriptive cross sectional study was conducted amongst 326 adolescents (12–18 years) living in the urban slums of Narayanganj, Dhaka from April to May, 2022. Adolescent-reported FI was assessed using a structured questionnaire adopted from Household Food Insecurity Access Scale (HFIAS). Descriptive statistics, Chi-square tests and ordinal logistic regression were used to draw inference. Results Prevalence of adolescent-reported FI was high (46.6% moderate and 29.8% severe). The likelihood of experiencing moderate or severe FI versus no/mild FI were 1.7 times (95% Confidence Interval (CI) [1.1, 2.5]) higher in younger adolescents and 5 times (95% CI [2.3, 12.7]) higher in unemployed youth. Socio-environmental factors determining the economic status of a household such as higher number of family members, only one earning family member, unemployed father, no household assets, food aid received by the family during pandemic and positive COVID-19 infection in family were associated with moderate and severe FI. Coping strategies such as a higher number of food seeking strategies (Adjusted Odds Ratio (AOR) 3.4, 95% CI [1.9, 5.9]), substance use (AOR 6.2, 95% CI [1.2, 31.7]) and stopping school (AOR 3.3, 95% CI [1.9, 5.7]) increased odds for moderate and severe FI. Stratified by drop-out of school status, an association between food seeking strategies and FI remained significant among those school-going, while there was no association among those dropping out of school. *Correspondence: Seo Ah Hong [email protected] Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Yasmin et al. BMC Public Health (2023) 23:2046 Page 2 of 11 Conclusion This study showed that adolescents living in urban slum communities in Bangladesh are at very high risk of FI and resort to harmful coping strategies. Our study highlights the importance of further research in adolescent reported FI and coping strategies in low to middle income countries (LMICs) and create appropriate interventions to lower FI among this group and improve their state of health and wellbeing. Keywords Adolescents, Food insecurity, Coping strategies, Bangladesh, COVID-19 pandemic Background used some strategies to cope with FI, such as selling Food insecurity (FI) is defined by Food and Agricultural drugs, asking for food, stealing and borrowing money/ Organization of United Nations as “a situation that exists food [2, 19], and they may be associated with higher when people lack regular access to adequate amount of chances of dropping out from school [2] and engaging in safe and nutritious food for normal growth and devel- unhealthy behaviors, such as smoking and using drugs opment and an active and healthy life” [1]. During the [20], ultimately contributing to social disadvantage when past decade, there was a steady global rise in the level of transitioning to adulthood [21]. Literature on adolescent- moderate to severe food insecure people, which accounts specific health outcomes provide a strong rationale for for almost 30% of the world’s population, with more research on FI and coping strategies. In particular, a bet- than half of them hailing from Asia and one third from ter understanding of the implemented coping strategies Africa [1]. In addition, the COVID-19 pandemic, along by adolescents suffering from FI in extremely food-inse - with its lingering impact on global economies and the cure environments like the urban slums may be beneficial unrecovered income losses among those most affected in developing appropriate and effective programs. by the pandemic, particularly in low to middle income Since most studies on adolescent FI were assessed countries (LMICs) like Bangladesh, has exacerbated the based on parent’s reports, the estimate based on paren- state of food insecurity and hindered progress towards tal accounts often failed to adequately gauge the adoles- meeting Sustainable Development Goal (SDG) 2 by 2030 cents’ experiences and underestimated FI in adolescents [1]. Many studies on FI in developed [2] and developing [21, 22]. With a dearth of adequate information regarding countries [3, 4] showed that FI is associated with poor self-reported FI experience and coping strategies among health outcomes among all age groups but emphasis has either school-going or working adolescents in LMICs like largely been on the vulnerability of households and young Bangladesh, this study aimed to identify the prevalence children [5–8]. Furthermore, since studies reported that and determinants of FI and their association with imple- parents often protected younger children than older chil- mented coping strategies among adolescents living in dren from the impacts of household FI [9], adolescents urban slums of Narayanganj, Dhaka, Bangladesh and also often face a higher vulnerability to FI. Pre-pandemic, to identify the association between coping strategies and Around 50% of adolescents in developing countries were FI amongst school going and dropout adolescents dur- already suffering from FI [ 10, 11]. ing the era of COVID-19 pandemic. Bangladesh has an Since adolescence is a crucial transitional period urban population of nearly 65  million people and about between childhood and adulthood, it is characterized half of them are slum dwellers [23]. Dhaka Division has by major physical, psychological, and social transitions. been recorded to have the highest number of slum settle- uTh s, FI during this period results in not only food ments and in terms of population density, Narayanganj related health outcomes, such as micronutrients defi - has the greatest proportion of slum households [24]. Pri- ciency and poor health outcomes [5, 12], but also consist oritizing the needs of underprivileged adolescents, allows of anxiety, feeling of distress and deprivation, as well as us to lay the foundation for a healthier, prosperous and adverse changes in family and social interactions [2, 13]. more equitable future. This study can serve as a premise Nonetheless, the adolescent FI has received less atten- for further research and discussion on adolescent FI in tion particularly in LMICs such as Bangladesh. Very little urban slum communities in Bangladesh and other LMICs is known about adolescent FI especially among adoles- because there is minimal awareness regarding this public cents hailing from disadvantaged backgrounds, such as health crisis. urban slum settings, although they are disproportionately affected by a higher burden of health risks since child - Methods hood [12, 14–16]. Study design and participants When individuals are food insecure, they resort to cop- The study, a quantitative cross-sectional study, took place ing strategies which minimize risks to an individual’s from April to May 2022 in urban slums of Narayanganj food and economic resources in times of crisis [17]. Thus, district of Dhaka division via face to face interview using the type of coping strategies used may indicate a sever- structured questionnaire in Bengali language. We pur- ity of FI [18]. Previous research showed that adolescents posively chose Narayanganj, as it has one of the highest Yasmin et al. BMC Public Health (2023) 23:2046 Page 3 of 11 rates of urban population growth in Dhaka division with a structured coping strategy questionnaire was designed most of them residing in urban slums [25]. Narayanganj by the researchers based on literature review with three was the epicenter of the COVID-19 in Bangladesh and coping strategies: (1) food seeking strategies, (2) drop- faced one of the strictest lockdown measures during the ping out of school due to lack of food/money, and (3) pandemic, which severely affected the already struggling substance use. During the past 30 days, when you did not slum dwellers [26]. Adolescents from 12 to 18 years of have enough food or money to buy food, how often the age, either working or school going, were recruited for following seven food-seeking strategies adolescents used this study. Based on Cochran’s formula, the sample size were asked: (i) acquiring food on loan/credit, (ii) visiting was estimated using 95% confidence interval, a precision neighbors/relatives for food, (iii) storing food for self, (iv) of 0.05, and a prevalence of FI as 25% [27], and anticipat- searching for food outside home (v) borrowing money ing 10% response/missing data, the determined sample from others to acquire food, (vi) shoplifting, and (vii) size was 316. A total of 326 adolescents were recruited begging for foods/money [2, 19, 21, 30]. The responses for this study. (‘never’=0, ‘sometimes’=1, and ‘often/always’=2) were Of 27 wards in Narayanganj City Corporation, three scored. A total score was then obtained for each par- wards were selected via random lottery sampling and ticipant by adding up the scores of individual strate- two slums per ward were selected via convenience sam- gies (0 to 14 scores) and categorized into three equal pling. Lists of adolescents and their households from groups using tertiles. Second, whether the adolescent the selected slums were obtained by the researchers has dropped out of school due to lack of food/money to from government and non-governmental organizations save expenses were asked and the response was recorded who were working with households in the slum areas as “yes” or “no”. Lastly, during the past 30 days, three and numbered. Equal number of adolescents per slum questions about ‘how many days did you use the fol- were then selected via random sampling for the survey. lowing substance’ were asked: (i) smoking, (ii) any other Selected adolescents and their households were then smokeless tobacco products (e.g. biri, jarda, tobacco leaf, approached for consent/assent to participate in a face gul, or shisha), and (iii) marijuana (also called ganja or to face survey. If researchers failed to contact/approach weed), adopted from Global School Health Survey [31]. selected participant, another participant was selected The responses in the questionnaire were recorded by randomly to participate for the survey. the number of days in the last 30 days for smoking cig- Prior to undertaking the study, ethical approval was arettes and smokeless tobacco and the number of times obtained from a Mahidol University Ethical Commit- the participant consumed marijuana in the last 30 days. tee (2022/03–054) and Ward Councilors. Pretesting the Due to lower proportion of adolescents reporting their questionnaire was performed on around 5% of the total usage in the last 30 days (6.1% smoking, 0.6% smokeless sample size at none of the selected slums and minimal tobacco, and 9.8% marijuana), the final response of the corrections were required. COVID-19 precautions were participants for analysis was recorded as ‘no’ if the cho- maintained during the survey by both researchers and sen option was 0 times/days, and was recorded as ‘yes’ participants by wearing masks and maintaining social for the rest of the options of use for all 3 substances. The distance. After explanation of study objectives and pro- Chronbach’s alpha for reliability of the coping strategy cess, written informed assent was obtained from the ado- questionnaire was 0.70. Furthermore, the coping strate- lescents along with written consent from the guardian gies, such as food-seeking strategies and the number of with assurance of confidentiality. All data were treated substances used are presented, stratified by drop-out of anonymously using study identification numbers. school status. The individual (age, sex, education level, school enrol - Measures ment and adolescent work status, COVID-19 infection The FI was assessed using the Household Food Insecurity history and coping strategy variables) and socio-environ- Access Scale (HFIAS), which has been validated for use mental factors (number of household earning members, in several LMICs [28, 29]. To measure adolescent FI, we number of younger siblings, father’s work status, house- adopted the HFIAS questions from a previous study in hold status, number of household assets categories, food Pakistan [10]. The Chronbach’s alpha coefficient was used aid received in pandemic, COVID-19 infection history in to assess internal consistency (reliability) of the FI ques- family, household head sex, household head education tion items and the coefficient was 0.82. Four ordinal cat - and number of household members) of the participants egories of FI were developed depending on the obtained were also included in this study. score: 0–1 (no FI), 2–8 (mild FI), 9–16 (moderate FI) and 17–27 (severe FI) [28]. Statistical analysis As current literatures lack standardized question- Data was analyzed using SPSS version 25. All individual naires to identify coping strategies for FI in adolescents, and socio-environmental variables were categorized and Yasmin et al. BMC Public Health (2023) 23:2046 Page 4 of 11 descriptive statistics (frequency, percentage, mean and Results standard deviation) are presented. The four categories of Of a total of 326 adolescents, while 2.2% was food secure, FI variables (no, mild, moderate and severe) were consol- 23.6% reported mild, 46.6% moderate and 29.8% severe idated to make 3 variables for further analyses: no/mild, FI. Majority of participants were females (62.3%), early moderate and severe FI. Chi-square test was used to ana- adolescence (12–14 years, 51.5%) and had some second- lyze association between dependent and independent ary education (50.6%) (Table 1). Regarding the types and variables and significant variables (p < 0.05) were identi- frequencies of the various food seeking coping strate- fied for logistic regression. Ordinal logistic regression gies (Fig.  1), most common coping strategies adopted by was performed to identify the factors associated with adolescents were borrowing money for food (95.1%) and the ordinal response of adolescent FI. Results are shown buying food on loan and credit (88.4%), whereas begging as adjusted odds ratio (AOR) and associated 95% CI (5.8%) and stealing (4%) were the least adopted coping with p < 0.05 considered to be significant. Furthermore, strategies. to measure the association between adolescent FI and Bivariate analysis showed that individual factors coping strategies stratified by drop out of school status, (Table  1) (age, adolescent sex, education level, adoles- Chi-square test was performed separately by drop out of cent work status, and adolescents’ coping strategies, such school status (p < 0.05). as food seeking, drop out of school and number of sub- stances used) and socio-environmental factors (Table  2) (number of households earning members, father’s work- ing status, household status, number of household assets, Table 1 Descriptive statistics for individual factors and their association with food insecurity levels INDIVIDUAL FACTORS All No/mild Moderate Severe (n = 97) P-value (n = 326) (n = 77) (n = 152) n (%) Demographic factors Age of adolescents Early adolescence 168 (51.5) 35 (45.5) 72 (47.4) 61 (62.9) 0.027 (Mean ± SD: 14.5 ± 1.8) (12–14 years) Late adolescence (15–18 158 (48.5) 42 (54.5) 80 (52.6) 36 (37.1) years) Adolescent sex Female 203 (62.3) 39 (50.6) 103 (67.8) 61 (62.9) 0.041 Male 123 (37.7) 38 (49.4) 49 (32.2) 36 (37.1) Education level None/some 161 (49.4) 39 (50.6) 61 (40.1) 61 (62.9) 0.002 primary(1–5) Some secondary (6–12) 165 (50.6) 38 (49.4) 91 (59.9) 36 (37.1) School enrollment Enrolled 286 (87.7) 63 (81.8) 139 (91.4) 84 (86.6) 0.102 Not enrolled 40 (12.3) 14 (18.2) 13 (8.6) 13 (13.4) Adolescent work status Not working 290 (92.6) 64 (81.8) 144 (94.7) 94 (96.9) 0.001 Working 23 (7.4) 14 (18.2) 8 (5.3) 3 (3.1) COVID19 infection No 303 (92.6) 72 (97.4) 145 (95.4) 86 (88.7) 0.126 history Yes 23 (7.1) 5 (6.5) 7 (4.6) 11 (11.3) Coping strategy factors Stopped school due to lack of food/ No 260 (79.8) 67 (87.0) 132 (86.8) 61 (62.9) < 0.001 money Yes 66 (20.2) 10 (13.0) 20 (13.2) 36 (37.1) Food seeking 1st tertile (0–4) 108 (33.1) 35 (45.5) 60 (39.5) 13 (13.4) < 0.001 strategies 2nd tertile (5–6) 138 (42.3) 24 (31.2) 67 (44.1) 47 (48.5) 3rd tertile (6–14) 80 (24.6) 18 (23.3) 25 (16.4) 37 (38.1) Smoking cigarettes last month Yes 20 (6.1) 5 (6.5) 6 (3.9) 9 (9.3) 0.229 No 306 (93.9) 72 (93.5) 146 (96.1) 88 (90.7) Marijuana last month Yes 32 (9.8) 10 (13.0) 13 (8.6) 9 (9.3) 0.554 No 294 (90.2) 67 (87.0) 139 (91.4) 88 (90.7) No.of substance Two or more 7 (2.1) 0 (0.0) 2 (1.3) 5 (5.1) 0.033 used last month At least one 41 (12.6) 15 (19.5) 17 (11.2) 9 (9.3) (Mean ± SD: None 278 (85.3) 62 (80.5) 133 (87.5) 83 (85.6) 0.16 ± 0.409) Abbreviations: SD – Standard deviation Yasmin et al. BMC Public Health (2023) 23:2046 Page 5 of 11 Fig. 1 Food seeking coping strategies among adolescents food aid received in pandemic, COVID-19 infection of CI [1.4, 4.6]) more food insecure that those who did family members, household head sex and education, and not receive food aid during the pandemic. Positive number of household members) were associated with FI COVID-19 infection in family (AOR 4.7, 95% CI [2.0, (p < 0.05). 10.9]) was another significant predictor to adolescent As seen in Table  3, significant predictors (p < 0.05) FI. As seen, adolescents who suffered a higher level for adolescent FI include individual factors such early of FI, have higher likelihood of adopting more cop- adolescents (12–14 years) and adolescents with lower ing strategies. They were 2.6 times (95% CI [1.6, 4.2]) education level (no education/some primary) were 1.7 more likely to be on the second tertile and 3.4 times times (95% CI [1.1, 2.5]) and 1.5 times (95% CI [1.1, (95% CI [1.9, 5.9]) more likely to be on the third tertile 2.3]) more likely to be food insecure compared to older for use of food seeking related coping strategies. They adolescents (15–18 years) and those with some sec- are also 6.2 times (95% CI [1.2, 31.7]) more likely to ondary education respectively. Employed adolescents use two or more substances and 3.3 times (95% CI [1.9, in our study were found to be 5.4 times (95% CI [2.3, 5.7]) more likely to stop school. 12.7]) less likely to suffer from a higher degree of FI. Furthermore, when adolescent coping strategies are Socio-environmental factors such as female house- stratified by status, drop out of school were assessed hold head (AOR 4.7, 95% CI [2.0, 11.4]) and lower (Table  4), a positive association between FI levels and education of household head (AOR 4.2, 95% CI [1.7, food seeking strategies were observed among those 10.6]) were strong predictors of adolescent FI. Other school-going (p < 0.001), while there was no association significant socio-environmental factors that play are among those dropping out of school (p = 0.100). In terms role in determining the adolescent FI in a household of number of substances used the previous month, there includes ≥ 5 family members (AOR 1.7, 95% CI [1.1, were no associations, regardless of drop-out of school 2.9]), only 1 earning family member(AOR 2.6, 95% CI status (p > 0.05). Although, severe FI had a higher per- [1.6, 4.2]), unemployed father (AOR 3.0, 95% CI [1.5, centage of marijuana use the previous month, compared 6.2]) and no household assets (AOR 39.7, 95% CI [13.1, to their counterparts. 120.5]). Adolescents who received some food aid dur- ing the COVID-19 pandemic were 2.6 times (95% Yasmin et al. BMC Public Health (2023) 23:2046 Page 6 of 11 Table 2 Descriptive statistics for socio-environmental factors and their association with 3 levels (no/mild, moderate, severe) of food insecurity SOCIO-ENVIRONMENTAL FACTORS All No/mild (n = 77) Moderate Severe (n = 97) P-value (n = 326) (n = 152) n (%) No. of earning members 1 earning member 230 (70.6) 44 (57.1) 111 (73) 75 (77.3) 0.010 (Mean ± SD: 1.3 ± 0.457) > 1 earning member 96 (29.4) 33 (42.9) 41 (27.0) 22 (22.7) No. of younger siblings None 138 (42.3) 33 (47.0) 63 (41.4) 42 (43.3) 0.957 (Mean ± SD: 0.8 ± 1.0) 1 sibling 130 (39.9) 29 (34.9) 61 (40.1) 40 (41.2) > 1 sibling 58 (17.8) 15 (18.1) 28 (18.4) 15 (15.5) Father work status Working 295 (90.5) 75 (97.4) 138 (90.8) 82 (84.5) 0.016 Not working 31 (9.5) 2 (2.6) 14 (9.2) 15 (15.5) Household status Not self-owned/rented 177 (54.3) 25 (32.5) 88 (57.9) 64 (66.0) < 0.001 Rented 84 (25.8) 22 (28.6) 34 (22.4) 28 (28.9) Self-owned 65 (19.9) 30 (63.8) 30 (19.7) 5 (5.2) No. of household assets No assets 230 (70.6) 31 (40.3) 113 (74.3) 86 (88.7) < 0.001 (savings, jewelry, electronics 1 asset category 67 (20.6) 21 (27.3) 36 (23.7) 10 (10.3) /home appliances, vehicles) >=2 asset categories 29 (8.8) 25 (32.4) 3 (2.0) 1 (1.0) Food aid received in pandemic Some food aid 276 (84.7) 56 (72.7) 132 (86.8) 88 (90.7) 0.003 No food aid 50 (15.3) 21 (27.3) 20 (13.2) 9 (9.3) COVID 19 infection No 301 (92.3) 75 (97.4) 145 (95.4) 81 (83.5) < 0.001 history in family Yes 25 (7.7) 2 (2.6) 7 (4.6) 16 (16.5) Household head sex Female 22 (6.7) 2 (2.6) 8 (5.3) 12 (12.4) 0.023 Male 304 (93.3) 75 (97.4) 144 (94.7) 85 (87.6) Household head No education 242 (74.2) 56 (72.7) 117 (77.0) 69 (71.1) 0.031 education Some primary 60 (18.4) 10 (13.0) 26 (17.1) 24 (24.7) Some secondary 24 (7.4) 11 (14.3) 9 (5.9) 4 (4.1) No. of household < 5 103 (31.6) 33 (42.9) 39 (25.7) 31 (32.0) 0.03 members (Mean ± SD: 5.26 ± 1.525) >=5 223 (68.4) 44 (57.1) 113 (74.3) 66 (68.0) Abbreviations: SD – Standard deviation Discussion in LMICs were therefore at a higher risk of FI during the To our knowledge, this study is the first to report ado - COVID-19 pandemic, attributed to loss of income of the lescent-reported FI and the association with individual low-income families during the global and nationwide and socio-environmental factors and coping strategies in recession in Bangladesh during the pandemic [33]. Insuf- urban slums in Bangladesh during the times of the pan- ficient efforts to deal with this situation, lack of adequate demic. Two-third reported moderate or severe FI and understanding and screening for adolescent FI, have they are more inclined to a wider selection of coping only increased the burden of the situation in the pan- strategies, such as food seeking, substance use and stop- demic [32]. In addition, the recent humanitarian crisis ping school due to lack of food/money. This study showed events and inflation has led to the International Mon - that adolescents from underprivileged households are at etary Fund (IMF) categorizing Bangladesh as one of the very high risk of FI and resort to coping strategies. hunger hotspots [34]. To lessen the impact of the existing The prevalence of adolescent FI in our study was adolescent FI problem, policymakers should prioritize found to be much higher compared to those from previ- battling current inflation and safeguarding the most dis - ous studies in other LMICs. A recent study on FI among advantaged which includes adolescents residing in urban adolescent students from 95 countries using data from slums. the Global School-based School Health Survey (GSHS) Adolescent FI may be an indicator for a wide set of showed that 25.5% aged 11–14 years compared with individual, social, and household challenges that con- 30% aged 15–18 years reported FI [20]. Another from tribute to adolescent health and well-being. Since the low income countries such as Pakistan [10] and South- legal age of employment in Bangladesh is 14 years [35], west Ethiopia [11] was reported to be around 50%. The older adolescents particularly from socially disadvan- high prevalence noted in our study may be due to the taged households can support themselves financially study timing, since our study was conducted during the and also provide for their families. Our study supported COVID-19 pandemic. COVID-19 has exacerbated mal- this by showing that older adolescents and those work- nutrition and FI at a global scale [32]. Adolescents living ing are less food insecure. However, When children are Yasmin et al. BMC Public Health (2023) 23:2046 Page 7 of 11 Table 3 Summary statistics using ordinal logistic regression of adjusted odds ratio (AOR) and 95% Confidence interval (CI) for individual, socio-environmental and coping strategy variables in association with food insecurity Food insecurity (No/mild = 0, Moderate = 1, Severe = 2) AOR (95% CI) p-Value Individual factors Age of adolescents Early adolescence (12–14 years) 1.658 (1.101–2.498) 0.016 Late adolescence (15–18 years) Reference Adolescent sex Male 1.416 (0.924–2.169) 0.110 Female Reference Adolescent education level No education-some primary(1–5) 1.525 (1.011–2.302) 0.044 Some secondary(6–12) Reference Adolescent work status Not working 5.365 (2.265–12.711) < 0.001 Working Reference Socio-environmental factors No. of household members >=5 1.734 (1.043–2.881) 0.034 < 5 Reference Household head sex Female 4.728 (1.958–11.413) 0.001 Male Reference Household head education No education 2.590 (1.146–5.856) 0.022 Some primary 4.232 (1.682–10.646) 0.002 Some secondary Reference No. of household earning members 1 earning member 2.593 (1.594–4.216) < 0.001 > 1 earning member Reference Father work status Not working 2.988 (1.450–6.156) 0.003 Working Reference Household status Neither self-owned nor rented 4.973 (2.843–8.697) < 0.001 Rented 3.402 (1.810–6.396) < 0.001 Self-owned Reference No. of household assets 1 asset 12.799 (4.035–40.596) 0.001 (savings, jewelry, electronics no assets 39.653 (13.047–120.517) 0.001 /home appliances, vehicles) >=2 asset Reference Food aid received in pandemic Some food aid 2.561 (1.425–4.604) 0.002 No food aid Reference History of COVID 19 infection in family Yes 4.697 (2.023–10.903) < 0.001 No Reference Coping strategies Food seeking strategy 3rd tertile (6–14) 3.353 (1.897–5.926) 0.001 2nd tertile (5–6) 2.582 (1.602–4.159) < 0.001 1st tertile (0–4) Reference Stopped school due to lack of food/money Yes 3.300 (1.921–5.669) < 0.001 No Reference No. of substance used last month Two or more 6.186 (1.209–31.642) 0.029 At least one 0.555 (0.297–1.039) 0.066 None Reference Abbreviations: SD – Standard Deviation, AOR – Adjusted Odds Ratio, CI – Confidence Interval compelled to leave school and engage in labor due to further supported by strong associations of adolescent FI economic pressure, they are deprived of the opportu- with socio-economic factors, such as father’s unemploy- nity to acquire skills and capabilities essential to realize ment, low household assets possession, lower number of their full potential, securing stable and well-paying jobs households’ earning members, female led households, and disrupt a cycle of disadvantage and poverty [35]. and household heads with lower education as shown Both dropping out of school and having a lower level in previous researches [8, 9, 11]. Studies in developing of education can therefore increase the likelihood and countries such as Bangladesh have shown that, female- eventually worsen the cycle of adolescent FI. This is also led households are often more vulnerable to experiencing Yasmin et al. BMC Public Health (2023) 23:2046 Page 8 of 11 Table 4 Adolescent coping strategies by status of drop-out of school Drop out of school (no) p-value Drop out of school (yes) p-value No/mild Moderate Severe No/mild Moderate Severe n (%) n (%) n (%) n (%) n (%) n (%) Food seeking < 0.001 0.100 1st tertile (0–4) 31 (46.3) 54 (41.0) 8 (13.1) 4 (40.0) 6 (30.0) 5 (13.9) 2nd tertile (5–6) 22 (32.8) 56 (42.4) 31 (50.8) 2 (20.0) 11 (55.0) 16 (44.4) 3rd tertile (6–14) 14 (20.9) 22 (16.6) 22 (36.1) 4 (40.0) 3 (15.0) 15 (41.7) Smoking cigarettes last month Never 64 (95.5) 128 (97.0) 56 (91.8) 0.282 8 (80.0) 18 (90.0) 32 (89.0) 0.704 Yes 3 (4.5) 4 (3.0) 5 (8.2) 2 (20.0) 2 (10.0) 4 (11.0) Marijuana use last month Never 57 (85.0) 122 (92.4) 58 (95.0) 0.105 10 (100.0) 17 (85.0) 30 (83.3) 0.388 Yes 10 (15.0) 10 (7.6) 3 (5.0) 0 (0.0) 3 (15.0) 6 (16.7) No of substance used last month None 54 (80.6) 118 (89.3) 53 (86.9) 0.295 8 (80.0) 16 (80.0) 30 (83.3) 0.315 At least one 13 (19.4) 14 (10.7) 8 (13.1) 2 (20.0) 2 (10.0) 1 (2.8) Two or more 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (10.0) 5 (13.9) FI [8, 36]. Less employment opportunities were avail- the fact that poorer communities are often more sus- able to households headed by women, and their pay rates ceptible to severe disease once it is contracted and this were lower than those of male led households. In many could have resulted in greater income loss due to work instances, females also bear the burden through assigned disruptions for the adolescent households, thereby wors- social norms regarding the nature of work they can or ening their state of FI [26]. Our study also showed that cannot do as well as domestic and childcare responsibili- although about 85% of slum-dwelling adolescents have ties [8]. Social reform policies should be implemented to ever received food aids in the COVID-19 pandemic ensure more women are included in workforce and close (90% in severe FI, 86.8% in moderate FI and 72.7% in the gender inequality gap. This study found no gender no/mild FI adolescents, prevalence of the overall ado- link to FI. However, Sheikh et al. in his study found ado- lescent FI in our study was still incredibly high. Bangla- lescent boys more prone to it than girls [10]. A study in desh’s social security policies rarely addressed specific Ethiopia suggested higher FI among adolescent girls [11]. adolescent needs and for the enormous population living These conflicting results highlight the need to under - in poverty, the government has been unable to provide stand what is perceived as FI. Findings from a study con- enough aid and social assistance to the vulnerable during ducted in Bangladesh showed that interaction between the pandemic [33]. This shows that in order to be effec - gender norms and structural, social, and economic fac- tive, policies need to be more targeted and designed to tors often predispose female adolescents to poor nutri- address specific needs of vulnerable population. Differ - tional consumption [37]. According to the study, young ent from our study showing a positive association of FI female respondents found satisfaction in offering food with socioeconomic factors, a study done on adolescents first to the males in their households, accepting their in rural Pakistan showed no significant associations [ 10], less significant status and the financial restraints of their and suggested that FI requires a multilevel investigation families, which caused them to habitually consume less of other variables such as social support, food prices, food than their physical needs [37]. This could have likely unforeseen events like medical or other costs, etc. rather resulted in under reporting of FI by adolescent females. than blaming it all on poverty [10]. Therefore understanding of FI can vary depending on While some studies explored coping strategies in ado- the environment and context of the study. Furthermore, lescents, they lack inference based on quantitative anal- the current study showed a higher family size was sub- ysis [19]. In our opinion, our study is the first to have stantially related to adolescent FI. This may be mostly quantitatively analyzed the association between adoles- because in poor families from slums, food expenditure cent FI and three types of coping strategies which are constitutes a large percentage of total household expen- food seeking coping, substance use coping and dropping ditures [3]. Therefore, having bigger families could lead out of school. Our study revealed that severely food inse- to adolescents compromising their dietary needs despite cure adolescents are more likely than their counterparts higher nutritional demands [14]. The positive association to utilize a larger variety of coping methods to deal with with COVID-19 infection in family can be explained by FI, such as a higher number of food-seeking strategies as Yasmin et al. BMC Public Health (2023) 23:2046 Page 9 of 11 well as number of substances used and dropping out of can go in improving their situation, it can help imple- school. Adolescents dropping out of school due to lack of ment policies that are precisely designed to tackle and foods were around 20% and the drop-out rate increases improve FI situation among adolescents. Yet, our results as the severity of FI increases. This may indicate that drop need to be further examined because these mechanisms out of school status can increase the likelihood and in can be situation or context specific. due course, worsen the state of FI and subsequent coping Our study’s advantages include data on adolescents strategies. Interestingly, food seeking strategies used were from urban slum communities with self-reported esti- also different by status of stopping school. While a sig - mates of FI and various levels of determinants since the nificant association between food seeking strategies and literature on adolescent FI is relatively inadequate in FI remained significant among school-going adolescents, LMICs, especially in urban slum areas. Nonetheless, there was no association among adolescents dropping some limitations of the study should be acknowledged. out of school. It may indicate that different from ado - Due to the nature of a cross-sectional study design, a lescents being employed, school-going adolescents are causal relationship cannot be assumed and recall bias still struggling to cope with FI. The government’s safety may be introduced. Additionally, this survey was also net programs in Bangladesh to reduce FI, largely include collected during the monsoon season (beginning May) food transfer programs which are all food-focused [38]. A in Bangladesh when household FI is more likely to be study in Bangladesh showed that cash transfer programs high in comparison to the dry season [41]. This study have been more beneficial in increasing caloric intake only included adolescents and their households who among school age children compared to food transfer could converse with researchers in the standard spoken programs [38]. Another study showed that school feeding Bengali, this could have underestimated the FI. Since programs to improve FI, will not only improve health in slum households were limited in their space and privacy, adolescents but also increase the number of school days constraints to how much privacy could be maintained attended [39]. Therefore, it is highly recommended that between participants and their caregivers could have policy makers modify their current safety net programs introduced response bias to some sensitive questions and incorporate more diversified policies and strategies (e.g. smoking, begging etc.). In addition, although HFIAS that are designed to address the various issues and fac- questionnaire has been used in various studies in Bangla- tors associated with FI. desh [7, 27] and validated for use in other LMICs [28, 29], In lights of substance use, although the study from the it is yet to be linguistically and cross-culturally validated GSHS from 95 countries revealed that FI is associated for use in Bengali language. with a higher odds of substance use, such as smoking, drinking and drugs [20], our study did not show a sig- Conclusion nificant association with neither smoking cigarettes nor Adolescent-reported FI in urban slums of Bangladesh marijuana, but has shown a positive association between was found to be remarkably high. The participants adolescent FI and the number of substances used last shared a wide range of coping strategies to neutral- month. This shows that FI may result in greater experi - ize risks of FI such as food seeking strategies, sub- mentation with tobacco and marijuana use. Adolescents stance use and pause in schooling. Adolescent FI is a often use substances as source of relief from any mental critical aspect of SDG 2, as it highlights the need to stress and anxiety arising from difficult situations in their address hunger, malnutrition, and inadequate access lives with unawareness of the consequences [2, 40] and to nutritious food of adolescents. As seen with this as a sense of belonging with their peers [20]. Our find - study, adolescent FI is influenced by a combination ing is important, as it is crucial to identifying adolescents of individual, social and economic factors. In order to at earliest stage of FI, to prevent worsening of their FI achieve SDG 2, it is important to recognize these fac- state which could lead to detrimental substance abuse tors and address them through comprehensive and among youths from disadvantaged populations who may multi-dimensional approach which involves concerted be at a higher risk of drug abuse and subsequent poor efforts from numerous shareholders such as the gov- health [20]. While there was no association of smoking ernment, private institutions and non-governmental cigarettes and marijuana use with FI, regardless of drop- organizations. Therefore, prioritizing adolescent FI in out of school status, percentages of marijuana use seem developing countries such as Bangladesh can have far higher in severe food insecure group among adolescents reaching implications that touch on education, eco- stopping school. Given the results of this study, interven- nomic development and overall health and wellbe- tions to reduce FI may need to be tailored to coping strat- ing and thus contribute to more productive lives for egies that differ by adolescent age, sex and school-going young people in Bangladesh as well as other develop- status. Since understanding the use of coping strategies ing nations globally. enable us to understand the extent to which individuals Yasmin et al. BMC Public Health (2023) 23:2046 Page 10 of 11 Abbreviations References AOR Adjusted Odds Ratio 1. FAO I, UNICEF, WFP and WHO. The State of Food Security and Nutrition in the CI Confidence Interval World 2022. Repurposing food and agricultural policies to make healthy diets COVID-19 Coronavirus 19 more affordable. Rome, FAO2022. FI Food Insecurity 2. Popkin SJ, Scott MM, Galvez MM. Impossible choices: Teens and food insecu- GSHS Global School-based School Health Survey rity in America. 2016. HFIAS Household Food Insecurity Access Scale 3. Faye O, Baschieri A, Falkingham J, Muindi K. Hunger and food insecu- IMF International Monetary Fund rity in Nairobi’s slums: an assessment using IRT models. J Urb Health. LMIC Low to Middle Income Country 2011;88:235–55. SD Standard deviation 4. Spieker C, Laverty AA, Oyebode O, Collaborative IHS. The prevalence and SDG Sustainable Development Goal socio-demographic associations of household food insecurity in seven slum sites across Nigeria, Kenya, Pakistan, and Bangladesh. A cross-sectional study. Acknowledgements PLoS ONE. 2022;17(12):e0278855. We would like to acknowledge Tahmina Tamanna, MSc, and her team for 5. Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health A. ff their support with data collection and review of questionnaire in Bengali. 2015;34(11):1830–9. I would also like to appreciate my professors; Dr Sariyamon Tiriphat, Dr 6. Oronce CIA. 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Journal

BMC Public Health – Springer Journals

Published: Oct 19, 2023

Keywords: Adolescents; Food insecurity; Coping strategies; Bangladesh; COVID-19 pandemic

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