Department of Population, Family and Reproductive Health
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Item Urban physical food environments drive dietary behaviours in Ghana and Kenya: A photovoice study(Health and Place, 2021) Pradeilles, R.; Laar, A.; Irache, A.; et al.We identified factors in the physical food environment that influence dietary behaviours among low-income dwellers in three African cities (Nairobi, Accra, Ho). We used Photovoice with 142 males/females (≥13 years). In the neighbourhood environment, poor hygiene, environmental sanitation, food contamination and adulteration were key concerns. Economic access was perceived as a major barrier to accessing nutritionally safe and healthy foods. Home gardening supplemented household nutritional needs, particularly in Nairobi. Policies to enhance food safety in neighbourhood environments are required. Home gardening, food pricing policies and social protection schemes could reduce financial barriers to safe and healthy diets.Item Nutritional quality and diversity in Ghana’s school feeding programme: a mixed-methods exploration through caterer interviews in the Greater Accra Region(BMC Nutrition, 2024) Liguori, J.; Amevinya, G.S.; Holdsworth, M.; Savy, M.; Laar, A.Background The Ghana School Feeding Programme (GSFP) provides public primary school pupils with a free daily meal. Each meal is expected to follow set menus, providing 30% of children’s’ (6-12 years) energy requirements. This study assessed the nutritional quality and diversity of planned and provided GSFP meals, engaging school caterers to identify how meal quality in the Greater Accra Region could be enhanced. Methods A cross-sectional mixed methods study design was used. Multistage sampling was used to select 129 schools implementing the GSFP in six districts of the Greater Accra Region. GSFP district menus were collected as well as a one-week school caterer recall of provided school meals. The meal served on the day of data collection was recorded and photographed. Nutritional quality was evaluated based on nutrient profling methods: energy density (low<125kcal/100g; medium 125-225kcal/100g; high>225kcal/100g) and nutrient density (low<5%; medium 5-10%; high>10%). Meal diversity was assessed by a simple count composed of 5 food groups: cereals, pulses/nuts/ seeds, animal-source, vegetables and fruits. Caterers’ views on programme facilitators and barriers were also explored. Results Planned menus included 14-20 weekly options, composed of eight minimally processed traditional dishes. All meals, except white rice, had a high nutrient density/100g. Energy density was varied (low, n=2; medium, n=2; high, n=4). Meals included only 2/5 or 3/5 food groups, mainly starchy staples, pulses/nuts/seeds, and sometimes vegetables. Fruit was never reported. About half of caterers (51.1%) reported deviating from the planned menus: 11.7% served alternative meals, with some including animal-sourced food (17.0%), and 39.4% repeated meals pro vided during the week, often based on starchy staples, infuencing overall nutritional quality. Most caterers reported food item cost and lack of food purchase guidelines as barriers to providing school meals, while food safety training and guidelines for food preparation were facilitators. Conclusions While school meals are composed of minimally processed, nutrient dense, local foods, there are nota ble gaps in meal diversity and compliance, as refected in provided meals. Caterer compliance to planned menus var ied greatly, refecting recent food price infation. Upwardly adjusting the current meal allocation of 1.2 cedis (0.22USD) per child per day could enhance access to more afordable, nutritious and diverse foods in school mealsItem Providing Measurement, Evaluation, Accountability, and Leadership Support (MEALS) for Non-communicable Diseases Prevention in Ghana: Project Implementation Protocol(Frontiers in Nutrition, 2021) Laar, A.; Aryeetey, R.; Kelly, B.; et al.Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS). Methods: The protocol for this observational study draws substantially from the INFORMAS’ Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve the food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools. Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates the feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting. Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle-income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of the food environments of children.Item Nutritional quality and diversity in Ghana’s school feeding programme: a mixed-methods exploration through caterer interviews in the Greater Accra Region(BMC Nutrition, 2024) Liguori, J.; Amevinya, G.S.; Holdsworth, M.; Savy, M.; Laar, A.Background The Ghana School Feeding Programme (GSFP) provides public primary school pupils with a free daily meal. Each meal is expected to follow set menus, providing 30% of children’s’ (6-12 years) energy requirements. This study assessed the nutritional quality and diversity of planned and provided GSFP meals, engaging school caterers to identify how meal quality in the Greater Accra Region could be enhanced. Methods A cross-sectional mixed methods study design was used. Multistage sampling was used to select 129 schools implementing the GSFP in six districts of the Greater Accra Region. GSFP district menus were collected as well as a one-week school caterer recall of provided school meals. The meal served on the day of data collection was recorded and photographed. Nutritional quality was evaluated based on nutrient profiling methods: energy density (low<125kcal/100g; medium 125-225kcal/100g; high>225kcal/100g) and nutrient density (low<5%; medium 5-10%; high>10%). Meal diversity was assessed by a simple count composed of 5 food groups: cereals, pulses/nuts/ seeds, animal-source, vegetables and fruits. Caterers’ views on programme facilitators and barriers were also explored. Results Planned menus included 14-20 weekly options, composed of eight minimally processed traditional dishes. All meals, except white rice, had a high nutrient density/100g. Energy density was varied (low, n=2; medium, n=2; high, n=4). Meals included only 2/5 or 3/5 food groups, mainly starchy staples, pulses/nuts/seeds, and sometimes vegetables. Fruit was never reported. About half of caterers (51.1%) reported deviating from the planned menus: 11.7% served alternative meals, with some including animal-sourced food (17.0%), and 39.4% repeated meals provided during the week, often based on starchy staples, influencing overall nutritional quality. Most caterers reported food item cost and lack of food purchase guidelines as barriers to providing school meals, while food safety training and guidelines for food preparation were facilitators. Conclusions While school meals are composed of minimally processed, nutrient dense, local foods, there are nota ble gaps in meal diversity and compliance, as reflected in provided meals. Caterer compliance to planned menus varied greatly, reflecting recent food price inflation. Upwardly adjusting the current meal allocation of 1.2 cedis (0.22USD) per child per day could enhance access to more affordable, nutritious and diverse foods in school meals.Item How do publicly procured school meals programmes in sub-Saharan Africa improve nutritional outcomes for children and adolescents: a mixed-methods systematic review(Public Health Nutrition, 2024) Liguori, J.; Osei-Kwasi, H. A.; Savy, M.; Nanema, S.; Laar, A.; Holdsworth, M.Objective: This review aimed to (i) synthesise evidence of the impact of publicly procured school meals programmes on nutritional outcomes of children/ adolescents (5–18 years) in sub-Saharan Africa and (ii) identify challenges and facilitators to implementing effective school meals programmes. Design: Mixed-methods systematic review (n 7 databases). Nutritional outcomes assessed were anthropometrics (underweight, stunting, wasting, overweight/ obesity), micronutrient deficiencies, food consumed and food environment. Qualitative findings were coded using a nine-step school food system framework: production of food, wholesale and trading, transportation and storage, processing and distribution, food preparation, distribution to students, student stakeholders, community involvement and infrastructure support. Setting: Sub-Saharan Africa. Participants: Children/adolescents (5–18 years), parents, school personnel and government officials. Results: Thirty-three studies (twenty-six qualitative, seven quantitative) from nine sub-Saharan African countries were included. Six studies found a positive impact of publicly procured school meals programmes on nutritional outcomes (wasting (n 1), stunting (n 3), underweight (n 1), vitamin A intake (n 1) and dietary diversity (n 1)). Fifty-three implementation challenges were identified, particularly during food preparation (e.g. training, payment), distribution to students (e.g. meal quantity/quality/diversity, utensils) and infrastructure support (e.g. funding, monitoring, coordination). Implementation facilitators were identified (n 37) across processing and distribution (e.g. programme coordination), student stakeholders (e.g. food preferences, reduced stigma) and community involvement (e.g. engagement, positive perceptions). Included policy recommendations targeted wholesale and trading, food preparation, student stakeholders and infrastructure support in nine, fifteen and twenty-five studies, respectively. Conclusions: As many challenges remain, strengthening implementation (and therefore the nutritional impact) of school meals programmes in sub-Saharan Africa requires bold commitment and improved coordination at multiple levels of governance.Item Addressing the marketing and availability of unhealthy food and beverages in and around selected schools in Ghana: a community readiness appraisal(BMJ Open, 2023) Tandoh, A.; Laar, A.; Pradeilles, R.; et al.Objective This study assessed stakeholder readiness to address unhealthy food and beverage marketing and availability in/around Public Basic Schools (for children 4–15 years) in Greater Accra Region, the highly urbanized the administrative capital of Ghana. Design The community readiness model was used to conduct in-depth mixed methods interviews with stakeholders. Using predefined anchored rating statements, quantitative readiness scores ranging from 1 to 9 were generated. Thematic qualitative analysis was undertaken to understand barriers and facilitators that could influence the implementation of interventions. Setting Greater Accra Region, Ghana. Participants 18 key informants from various schools/ education/citizen sectors, which together represented the ‘school community’ of Greater Accra Region. Results The mean readiness scores indicated that the ‘school community’ was at the ‘preplanning’ stage of readiness (4.44±0.98) to address the marketing and availability of unhealthy food and beverages in and around schools. The mean readiness score for ‘leadership’ was the highest of all dimensions (5.36±1.60), corresponding to the ‘preparation’ stage. The lowest scores were found for ‘community knowledge of efforts’ (3.19±2.45) and ‘resources for efforts’ (3.64±0.87), both of which were at a ‘vague awareness’ stage. Conclusions The ‘school community’ recognized that the marketing and availability of unhealthy food and beverages was a problem. Additionally, the current leadership was actively supportive of continuing/improving efforts that create healthier children’s food environments. However, actions that aim to increase the ‘school community’s’ knowledge of existing interventions and securing resources to sustain those interventions are needed before introducing readiness-appropriate strategies.Item The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa(PLoS ONE, 2021) Osei-Kwasi, H.A.; Laar, A.; Aryeetey, R.; et al.This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro-environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.Item Implementation of healthy food environment policies to prevent nutrition related non-communicable diseases in Ghana: National experts’ assessment of government action(Food Policy, 2020) Laar, A.; Aryeetey, R.; Barnes, A.; et al.Nutrition-related non-communicable diseases (NR-NCDs) are a global health problem, increasingly recognized as driven by unhealthy food environments. Yet little is known about government action to implement food en environment-relevant policies, particularly in low- and lower-middle-income countries. This study assessed government action, implementation gaps, and priorities to improve the food environment in Ghana. Using the Healthy Food-Environment Policy Index (Food-EPI), a panel comprising government and independent experts (n = 19) rated government action to improve the healthiness of the food environment in Ghana against international best practices and according to steps within a policy cycle. Forty-three good practice indicators of food environment policy and infrastructure support were used, with ratings informed by systematically collected evidence of action validated by government officials. Following the rating exercise, the expert panel proposed and prioritized actions for government implementation. Three-quarters of all good practice indicators were rated at ‘low’/‘very little’ implementation. Restricting the marketing of breast milk substitutes was the only indicator rated “very high”. Of ten policy actions prioritized for implementation, restricting unhealthy food marketing in children’s settings and the media was ranked the highest priority. Providing sufficient funds for nationally relevant research on nutrition and NCDs was the highest priority infrastructure-support action. Other priority infrastructure-support actions related to leadership, monitoring, and evaluation. This study identified gaps in Ghana’s implementation of internationally-recommended policies to promote healthy food environments. National stakeholders recommended actions, which will require legislation and leadership. The findings provide a baseline for measuring government progress towards implementing effective policies to prevent NR-NCDs.Item Community perceptions on the factors in the social food environment that influence dietary behaviour in cities of Kenya and Ghana: A Photovoice study(Public Health Nutrition, 2022) Wanjohi, M.N.; Laar, A.; Aryeteey, R.; et al.Objective To explore communities’ perspectives on the factors in the social food environment that influence dietary behaviours in African cities. Design A qualitative study using participatory photography (Photovoice). Participants took and discussed photographs representing factors in the social food environment that influence their dietary behaviours. Follow-up in-depth interviews allowed participants to tell the ‘stories’ of their photographs. Thematic analysis was conducted, using data-driven and theory-driven (based on the socio-ecological model) approaches. Setting Three low-income areas of Nairobi (n=48) in Kenya, and Accra (n=62) and Ho (n=32) in Ghana. Participants Adolescents and adults, male and female aged ≥13 years. Results The ‘people’ who were the most commonly reported as influencers of dietary behaviours within the social food environment included family members, friends, health workers and food vendors. They mainly influenced food purchase, preparation and consumption, through 1) considerations for family members’ food preferences, 2) considerations for family members’ health and nutrition needs, 3) social support by family and friends, 4) provision of nutritional advice and modelling food behaviour by parents and health professionals, 5) food vendors’ services and social qualities. Conclusions The family presents an opportunity for promoting healthy dietary behaviours between family members. Peer groups could be harnessed to promote healthy dietary behaviours among adolescents and youth. Empowering food vendors to provide healthier and safer food options could enhance healthier food sourcing, purchasing and consumption in African low-income urban communities.Item How do food safety concerns affect consumer behaviors and diets in low and middle-income countries? A systematic review(Global Food Security, 2021) Liguori, J.; Laar, A.; Trübswasser, U.; et al.Both food safety and dietary behaviors are major contributors to the global burden of disease, especially in rapidly urbanising environments. The impact that food safety concerns have on dietary behaviors in low- and middle-income countries (LMICs) is insufficiently documented. Therefore, we examined whether food safety concerns influence consumer behaviors and diets in LMICs. A systematic review identified 46 relevant studies from 20 LMICs for inclusion. A socio-ecological food environment framework was used to map food safety factors that influence consumer behaviors (food acquisition/purchase, eating out of home, food preparation/storage) and diets (consumption of nutrient-rich or poor foods). Several studies (n = 11) reported that despite food safety concerns, consumers could not always ensure that they consumed safe food; barriers were affordability, accessibilityand appeal. Key concerns included fear of pesticides and fertilizers, hygiene in and around food outlets, unhygienic vendor practices and household storage and preparation methods. These concerns may reduce consumption of animal-sourced food and fresh fruit and vegetables; and increase consumption of starchy staples and processed packaged foods. Policies such as upgrading urban market infrastructure to enhance food safety are accompanied by nutrition and hygiene education could lead to increased accessibility, affordability and appeal of safe, nutrient-rich foods. Thus, reducing the appeal of packaged/processed food as a means to mitigate food safety risk; thereby contributing to preventing foodborne disease and multiple forms of malnutrition.