Received: 23 February 2022 | Revised: 6 July 2022 | Accepted: 11 July 2022
DOI: 10.1111/mcn.13412
OR I G I NA L A R T I C L E
Individual‐level drivers of dietary behaviour in adolescents
and women through the reproductive life course in urban
Ghana: A Photovoice study
Julia Liguori1 | Rebecca Pradeilles2 | Amos Laar3 | Francis Zotor4 |
Akua Tandoh3 | Senam Klomegah4 | Hibbah A. Osei‐Kwasi5 | Agnès Le Port1 |
Nicolas Bricas1 | Richmond Aryeetey3 | Robert Akparibo6 | Paula Griffiths2 |
Michelle Holdsworth1
1UMR MoISA (Montpellier Interdisciplinary
centre on Sustainable Agri‐Food Systems), Abstract
CIRAD, CIHEAM‐IAMM, INRAE, Institut Agro Evidence on the individual‐level drivers of dietary behaviours in deprived urban contexts
Montpellier, IRD, Montpellier, France
2 in Africa is limited. Understanding how to best inform the development and delivery ofCentre for Global Health and Human
Development, School of Sport, Exercise and interventions to promote healthy dietary behaviours is needed. As noncommunicable
Health Sciences, Loughborough University,
diseases account for over 40% of deaths in Ghana, the country has reached an advanced
Loughborough, UK
3Department of Population, Family & stage of nutrition transition. The aim of this study was to identify individual‐level factors
Reproductive Health, School of Public Health, (biological, demographic, cognitive, practices) influencing dietary behaviours among
University of Ghana, Accra, Ghana
adolescent girls and women at different stages of the reproductive life course in urban
4Department of Family and Community
Health, School of Public Health, University of Ghana with the goal of building evidence to improve targeted interventions. Qualitative
Health and Allied Sciences, Ho, Ghana Photovoice interviews (n=64) were conducted in two urban neighbourhoods in Accra
5Department of Geography, University of and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49
Sheffield, Sheffield, UK
6 years). Data analysis was both theory‐ and data‐driven to allow for emerging themes.School of Health and Related Research,
University of Sheffield, Sheffield, UK Thirty‐seven factors, across four domains within the individual‐level, were identified as
having an influence on dietary behaviours: biological (n=5), demographic (n=8),
Correspondence
Michelle Holdsworth, UMR MoISA cognitions (n=13) and practices (n=11). Several factors emerged as facilitators or
(Montpellier Interdisciplinary Centre on barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/
Sustainable Agri‐Food Systems), French
National Research Institute for Sustainable preferences/risk perception (cognitions); and cooking skills/eating at home/time
Development (IRD), 911 av. Agropolis, 34394 constraints (practices) emerging most frequently. Pregnancy/lactating status (biological)
Cedex 5, Montpellier, France.
Email: michelle.holdsworth@ird.fr influenced dietary behaviours mainly through medical advice, awareness and willingness
to eat foods to support foetal/infant growth and development. Many of these factors
Funding information
were intertwined with the wider food environment, especially concerns about the cost of
Agriculture for Nutrition and Health (A4NH);
Bill and Melinda Gates Foundation food and food safety, suggesting that interventions need to account for individual‐level as
well as wider environmental drivers of dietary behaviours.
K E YWORD S
adolescent, behaviours, diet, Ghana, Photovoice, urban, women of childbearing age
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.
Matern Child Nutr. 2022;18:e13412. wileyonlinelibrary.com/journal/mcn | 1 of 16
https://doi.org/10.1111/mcn.13412
2 of 16 | LIGUORI ET AL.
1 | INTRODUCTION
Key messages
Sub‐Saharan Africa is rapidly urbanizing and is experiencing changing
• Time constraints, eating at home, eating out, cooking
dietary behaviours as food habits and food environments become
skills, food preferences and food safety concerns were
increasingly linked to marketization, industrialization and globalized
identified as key factors influencing dietary behaviours at
food supplies (Agyemang et al., 2016; Holdsworth & Landais, 2019;
the individual level in urban Ghana.
Rousham et al., 2020). Changing nutrition landscapes, often referred to
• Ability to eat nutritious, safe food was largely mediated
as the nutrition transition, have shifted the global disease burden from
by income and wealth.
communicable to non‐communicable diseases (NCDs) (Baker et al.,
• Biological factors, such as pregnancy/lactating status
2020). In 2021, estimates indicated that 77% of NCDs were found in
influenced behaviours through medical advice, nutrition
low‐ and middle‐income countries (LMICs) (World Health Organization
knowledge and willingness to promote foetal/infant
[WHO], 2021). Increased prevalence of NCDs in these settings is
development.
further compounded by multiple burdens of malnutrition (micronutrient
• Many individual‐level factors were intertwined with the
deficiencies, undernutrition as well as overweight and obesity), often
wider food environment.
present within the same individual, household or population (Popkin
• Factors influencing dietary behaviour at different levels
et al., 2020). Unhealthy diets, propelled by shifts in food environments
need to be considered together when developing
and dietary changes, are one of the major drivers of this emerging
interventions/policies for healthier diets.
phenomenon. Adolescent girls and women in Africa are more
vulnerable to overweight/obesity than men and adolescent boys (Case
& Menendez, 2009; Kanter & Caballero, 2012; Muthuri et al., 2014),
partly because of the consumption of energy‐dense, nutrient‐poor alongside rapidly changing food environments (Holdsworth & Landais,
foods (Sedibe et al., 2014; Trubswasser et al., 2020). 2019; Turner et al., 2018), interventions targeting adolescent girls and
Ghana is a highly urbanized country (~60% of the population women of reproductive age are needed as they have the potential to
lives in urban areas) (Ghana Statistical Services [GSS], 2021) that promote positive lifelong and intergenerational nutrition outcomes
has reached an advanced stage of the nutrition transition (Norris et al., 2022; Wells et al., 2020) as they progress into different
(Agyemang et al., 2016; Ecker & Fang, 2016). Dietary behaviours stages of the reproductive life course. Ensuring good nutrition among
in urban Ghana have been modified by urbanized lifestyles and all these age groups, coupled with female empowerment, can help
increased preference for imported food (Food and Agriculture improve dietary diversity and overall diet quality in Ghana (FAO, 2021).
Organization [FAO], 2009, 2021), which may contribute to the This study, therefore, aims to identify the individual‐level
increased prevalence of overweight/obesity among women drivers of (un)healthy dietary behaviours of adolescent girls and
(34.4% in 2006 to 39.2% in 2016) and school‐aged and women at different time points during their life course, among
adolescent girls (12.6% in 2006 to 17.5% in 2016) (Global socioeconomically deprived urban neighbourhoods in Ghana.
Nutrition Report, 2021). NCDs account for 43% of total deaths More specifically, the study investigates (i) the individual‐level
in Ghana (WHO, 2018, 2020). In addition, poor health outcomes (biological, demographic, cognitions, practices) drivers of (un)
from diet‐related NCDs (DR‐NCDs) are particularly common healthy food consumption and (ii) whether there are any
among Ghanaian women (Agyei‐Mensah & de‐Graft Aikins, differences in the factors influencing dietary behaviours between
2010; GSS, 2015; Ofori‐Asenso et al., 2016; Ofori‐Asenso women at different stages of life course (i.e., early adolescence,
et al., 2017). Given this nutritional context, identifying factors pregnancy or lactating status).
that drive dietary behaviours is essential, especially as the
Ministry of Health (MoH) of Ghana has placed integrated
interventions to promote healthy diets at the core of its public 2 | METHODS
health policies (MoH, 2012, 2020).
A range of models and frameworks have been developed to 2.1 | Study setting
understand the drivers of food choice and how food environ-
ments can influence individual‐level dietary behaviours (Marijn This study was part of a wider project, the Dietary Transitions in
Stok et al., 2018; Osei‐Kwasi et al., 2021; Story et al., 2008; Ghana project (datalink: https://dataverse.ird.fr/dataverse/diet_trans_
Turner et al., 2018). This paper will contribute to the growing ghana;jsessionid=d8c3c605c1c1bf3125e01476d0f6), conducted in
evidence on the influence of individual‐level factors on dietary Accra (Greater Accra region) and Ho (Volta region), as we were
behaviours in Africa across the different dimensions of the food interested in capturing cities with different levels of urbanization and
environment. Individual‐level factors are important to investigate as prevalence of overweight/obesity (as a proxy for nutrition transition). In
they may influence food consumption through different pathways, such 2015 (study conception), overweight/obesity prevalence among
as self‐efficacy and skills (Story et al., 2008). As adolescent and young women of reproductive age (WRA) was 57.3% and 31.1% in Greater
adult populations increase worldwide (Norris & Richter, 2016), Accra and the Volta region, respectively (GSS, 2015).
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LIGUORI ET AL. | 3 of 16
2.2 | Study design assistants. Fieldwork was conducted by native speakers, who were
not members of the targeted communities.
A qualitative study was conducted among young adolescent girls
(13–14 years) and WRA (15–49 years) living in socioeconomically
disadvantaged neighbourhoods in Accra and Ho. The study was 2.4 | Data collection
designed to identify a range of factors at the individual, social,
physical and macro‐levels that influence dietary behaviours (Story Data for the Photovoice study were collected between May and
et al., 2008). This paper reports the findings on the individual‐level December 2017. The Photovoice interview guide was adapted from
factors that emerged. The findings on the influence of the physical‐ the original format proposed by Wang (1999) (Supporting Informa-
level (accessibility, affordability, convenience, etc.) food environment tion 4). Initial community engagement activities revealed that women
on dietary behaviours have been previously published (Pradeilles in these urban areas had busy schedules outside of the home setting,
et al., 2021). making it difficult to organize group discussions at a time suitable to
Photovoice, a community‐based participatory photography method, all participants. Therefore, individual interviews were conducted
was used to allow participants to document influences on their dietary instead of focus group discussions. The Photovoice interview guide
behaviours in their daily lives. This method facilitates in‐depth was piloted in Accra (n = 3) and Ho (n = 3) and then amended,
exploration, stimulates reflection and enables discussion among partici- accordingly, thus excluding them from the analysis stage.
pants and policymakers to foster change in a community (Wang, 1999). The Photovoice study took place in three stages. The first stage
While Photovoice has largely been used in high‐income countries (Belon was comprised of an initial home visit, where participants were
et al., 2016; Díez et al., 2017; Gravina et al., 2020; Heidelberger & Smith, trained on: (i) the consent process (because they potentially would
2016), recent studies have used this method in Africa, to assess factors photograph people); (ii) the Photovoice methodology; (iii) the use of a
influencing adolescents' dietary behaviours in urban Ethiopia camera to take photographs; (iv) photography ethics, including the
(Trubswasser et al., 2020), among women in rural/urban Uganda (Auma ‘no face or identification details’ protocol to ensure the anonymity of
et al., 2020) and balancing work and childcare in Kenya (Hani Sadati people or places (Supporting Information 5). Participants were asked
et al., 2019). The Photovoice methodology was selected as it places the to take photographs that identify factors driving their dietary
research participant at the centre of the research process, opening up a behaviours. Specifically, they were asked to take five photographs
pathway for dialogue between the researchers and the participants in a on the following themes: (i) a place where you eat food and/or drink;
way that face‐to‐face interviews or focus group discussions alone do not. (ii) Something that makes eating healthy difficult for you; (iii)
Photographs allow access to the participants' world and can help to something that makes eating healthy easy for you; (iv) something
break down power dynamics between the researcher and researched, that influences what you eat in your area/neighbourhood; (v) a
encouraging reflection, recall and discussion (Auma et al., 2021). person that influences your food or drink choices in your area/
neighbourhood. During the second stage, two follow‐up visits were
made to check on progress. The third stage consisted of an in‐depth
2.3 | Sampling interview that lasted 45–60min. Interviews were conducted with
participants in their preferred language: Ga (n = 24); Twi (n = 5);
A list of all deprived neighbourhoods in Accra and Ho from the Accra English (n = 3) in Accra and Ewe (n = 28); English (n = 3); Twi (n = 1) in
Poverty Mapping Exercise (CHF International, 2010) and United Ho, respectively. During the interviews, participants told the ‘stories’
Nations Human Settlements Programme urban profiling report related to their five selected photographs. When data collection was
(UN‐HABITAT, 2009) were used to select two neighbourhoods: complete, a photography exhibition was held to raise awareness of
James Town (Accra) and Dome (Ho) (see further detail in Supporting drivers of unhealthy food and beverage consumption in the targeted
Information 1). To ensure diversity, participants were purposively communities. Photographs from the data collection stages were used
selected using quota sampling based on age/reproductive life course as a tool to facilitate dialogue between study participants, the media
stage, gender, body mass index (BMI), education, occupation, and local government officers. The photography exhibition also
maternal status and socioeconomic status (SES) (Supporting Informa- promoted community dialogue and stakeholder engagement by
tion 2). A subsample (i.e., a third) of the overall study population was sharing results with the wider community.
randomly invited to partake in the Photovoice study, resulting in
32 participants in Accra and Ho (n = 64 total). Recruitment took
place through the communities, schools and health facilities (see 2.5 | Data analysis and synthesis
Supporting Information 3 for additional information).
Before the project began, initial formal meetings with community In‐depth interviews were transcribed and translated verbatim into
leaders were held to explain the study and establish community English for analysis. All coders, RP/AT/SL, used an agreed‐upon
entry. These meetings encouraged community mobilization and codebook in NVivo version 11 to ensure consistency and accuracy,
engagement with the study and facilitated data collection. RP led with blind double coding of 25% of the transcripts (Fonteyn et al.,
the qualitative fieldwork training for seven Ghanaian research 2008). Interviews were coded using deductive (a priori themes) and
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4 of 16 | LIGUORI ET AL.
inductive (data‐driven codes) schemes, to allow for emerging themes of the study sample was 13–49 years, with 75.0% of
(Supporting Information 6). Existing socioecological models of dietary participants aged 15–49 years (Table 1). Overall, 37.5% of
behaviours and systematic review evidence from Africa (Gissing et al., participants were in work, 12.5% in education and 50.0% were
2017; Story et al., 2008) were used to identify factors, biological, not in work/education. Half of the participants were either
demographic, cognitions (e.g., knowledge and preferences) and pregnant or lactating. Almost half (48.4%) had a BMI ≥ 25 kg/m2
practices (e.g., skills and behaviours), influencing dietary behaviours (overweight or obese).
at the individual level. The African Food Environment framework, an
expert validated framework created to help prioritize research and
intervention development in Africa, was also consulted and used to 3.2 | Individual factors influencing dietary
structure the reporting of our results (Osei‐Kwasi et al., 2021). behaviours
Data were synthesized by creating a framework matrix with
nodes for different themes and subthemes (Gale et al., 2013). Nodes Thirty‐eight individual‐level factors were identified to influence
were then broken down into four populations at different stages of dietary behaviour across four domains of biological (5 factors),
the life course: early adolescents, WRA who were neither pregnant demographic (8 factors), cognitions (13 factors) and practices (11
nor lactating, pregnant WRA and lactating WRA. Similarities and factors) (Figure 1). Factors influencing dietary behaviours were similar
differences were highlighted between the different stages and the between early adolescents and WRA, with few marked differences
factors influencing dietary behaviour. across life course stages.
3 | RESULTS 3.2.1 | Biological
3.1 | Sociodemographic characteristics of the Biological factors included age, ethnicity, pregnancy/lactation
study sample status, sex and weight status. Eighteen participants referenced
their pregnancy/lactating status as an influential factor in their
The Photovoice study was conducted with 64 female participants everyday dietary behaviour. Several subfactors used to describe
across the two cities (n = 32 in Accra; n = 32 in Ho). The age range this influence included: medical recommendation, knowledge and
TABLE 1 Sociodemographic characteristics of the sample (based on quota sampling)
Early adolescents WRA (not pregnant/ Pregnant WRA Lactating WRA
Total 13–14 years lactating) 15–49 years 15–49 years 15–49 years
(n = 64) (n = 16) (n = 16) (n = 16) (n = 16)
n % n % n % n % n %
Location
Accra 32 50.0 8 50.0 8 50.0 8 50.0 8 50.0
Ho 32 50.0 8 50.0 8 50.0 8 50.0 8 50.0
Occupation
In work 24 37.5 0 0.0 8 12.5 8 12.5 8 12.5
In education 8 12.5 8 12.5 0 0.0 0 0.0 0 0.0
Not in work or education 32 50.0 8 12.5 8 12.5 8 12.5 8 12.5
Household SESa
Lowest SES 32 50.0 8 50.0 8 50.0 8 50.0 8 50.0
Low to middle SES 32 50.0 8 50.0 8 50.0 8 50.0 8 50.0
BMI
<25 kg/m2 33 51.6 8 50.0 9 56.3 8 50.0 8 50.0
≥25 kg/m2 31 48.4 8 50.0 7 43.7 8 50.0 8 50.0
aHousehold socioeconomic status (SES) was measured using the EquityTool (Chakraborty et al., 2016). SES scores were derived using proxy indicators of
the household environment (ownership of consumer durables; source of drinking water and type of toilet facilities; type of materials used for the floors
and walls; and land ownership). SES quintiles were subsequently derived. Participants were further classified into three groups: lowest SES (first quintile);
low to middle SES (second and third quintiles) and high SES (fourth and fifth quintiles). For this project, only participants in the first and second tertiles,
representing the lowest and low to middle SES, respectively, were selected.
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LIGUORI ET AL. | 5 of 16
F IGURE 1 Individual level factors and domains influencing dietary behaviours among early adolescents and women of reproductive age in
Accra and Ho, Ghana
willingness to eat what is good for the baby's growth—that is, 3.2.2 | Demographics
increased homemade consumption and diversified diet and
willingness to consume foods that increase breast milk production: Income, wealth and employment
‘Because if I don't eat a lot or eat healthy food, they [young children] Demographic factors included income, wealth, employment and house-
will not get the breast milk to feed on and they need to grow well […] hold eating/food security. The majority of WRA reported financial
At first, anything I get, I will eat it. But now, I know that I have to barriers (income and wealth) to consistently accessing food, whether it
feed myself well […] So, I have to eat more vegetable, fruits and was healthy or otherwise: ‘It is all about having enough money’ [Accra, 35
also take blood tonic’ (nutrient supplement often rich in iron, years, low‐middle SES] (Table 2). Fresh fruit, meat and fish were listed as
Vitamin B12 and folic acid) [Ho, 38 years, lactating, nutrient‐rich foods that were desirable, but unaffordable: ‘When I have
low‐middle SES]. good work to do and the money is coming […] I can buy fresh fish, chicken, I
Four participants discussed their weight status and a preference can cook well, buy fruits and eat. But if I don't have work or my work is not
among adolescents and not pregnant/lactating WRA for not being going on well, buying food is difficult. So, having a livelihood/income makes it
overweight. One 13–14‐year‐old participant explained that her classmate easy to eat healthy’ [Ho, 49 years, lowest SES]. When income was
advised her to eat less to lose weight: ‘I was eating a certain food that was reduced, food provision became difficult. One pregnant participant
not good for me and I was growing fat and she [classmate, 16 years] has been described coping strategies, such as eating unripe fruit or selecting food
giving me advice of the food that I have been eating […] she helped me so items with a reduced price.
now I am a little bit slim’ [Accra, 14 years, lowest SES]. However, being too Some adolescents reported going to school and working
thin was considered undesirable and associated with illness. Additional occasionally. Employed participants in Ho and Accra had similar jobs:
influential factors, such as, ethnicity (n=4) was mentioned by each group, ambulatory vendors, market vendors, seamstresses and shift workers
while age (n=1) and sex (n=1) were only discussed by not pregnant/ (i.e., shopkeepers, waitresses). Participants typically bought more
lactating WRA. food and cooked at home when their source of income was reliable.
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6 of 16 | LIGUORI ET AL.
TABLE 2 Demographic drivers of dietary behaviours
Factor Quote Photovoice image
Theme: Income, wealth and employment
Employment ‘If I am working all the time, I will get money
to be able to buy whatever I want to eat
and even eat morning, afternoon and
evening. Or it may even be more than the
three times a day. So it is good that work
all the time’. [Ho, 24 years, lactating,
lowest socioeconomic status (SES)]
Income/Wealth ‘Because of my pregnancy, I cannot work, so
I wait on my husband to send me money
before I will be able to eat. At times too,
my dad supports me and also my in‐laws
support me financially’. [Accra, 19 years,
pregnant, lowest SES]
Theme: Household eating/food security
Household eating ‘These instant noodles that we buy almost
every evening, they add all sort of
artificial spices to it, the sausage and all
those things are not good for our body
but we cannot afford the fish. We have
no choice than to eat the instant noodles
and sausage’. [Accra, 38 years,
lowest SES]
Household food security ‘This is a picture of myself and my friends
eating together. We always eat together
and that determines what I should eat. I
may feel for kenkey and a friend might
feel for banku but once I am eating the
kenkey, they will join in and eat with me.
The same thing happens when they feel
for some kind of food and we all eat
together. This is because we don't have
enough money, so what we have is what
we use to buy food and eat together’.
[Accra, 19 years, lactating, low‐
middle SES]
Some women reported losing their source of livelihood during Household eating/food security
pregnancy, which in turn made eating difficult. Participants associ- Participants aged 15–49 years (not pregnant/lactating) stated a
ated additional sources of revenue with eating enough and eating preference for healthy food but reported prioritizing children's
well. Two pregnant/lactating participants described purchasing dietary needs, as well as school tuition. Among pregnant/lactating
sugar‐sweetened beverages when extra money was available. participants, eight mentioned serving homemade meals for their
Adolescents mentioned purchasing food, often snacks, with their families, although this was challenging as they needed to spend
pocket money. money in advance. Two mothers discussed positive dietary
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LIGUORI ET AL. | 7 of 16
behaviours such as sharing fruits (e.g., pineapple, bananas) with positive changes to their diets (e.g., eating more fish than meat
their children. However, it was widely observed that income, because of ‘high cholesterol’): ‘I could fry like 5 to 7 eggs and it was
affordability, time, convenience and seasonality were barriers to normal for me. But it started having an effect on me. My blood
eating healthy: ‘fruit is good for us but the prices do change pressure shot up and when I was sent to the hospital, the doctor
depending on whether they are in season or not and because of advised me to stop taking eggs and meat […] So, it's what my heart
that we cannot buy fruits at higher prices’ [Accra, 32 years, wants that I eat’ [Accra, 29 years, lactating, lowest SES]. Despite
lactating, low‐middle SES]. some misconceptions, many participants reported accurate
information on nutritious and safe foods.
Health and nutrition knowledge and beliefs were quite similar
3.2.3 | Cognitions across age groups, with specific pregnancy/lactation‐based examples
among those who already had children. Participants who were
Central cognitions factors included health and nutrition knowledge, pregnant described trying to eat food that would: promote foetal/
risk perceptions around food safety, preferences, food character- infant growth, encourage good nutritional status and ease the
istics, hunger, mood and emotions. birthing process. General knowledge of healthy eating during
pregnancy was good, including, diverse nutrient‐rich local foods
Health and nutrition knowledge and dishes to encourage in‐utero development, such as fresh fruits,
Study participants seemed to have a relatively good level of yam, fried chicken, palm nut soup, taro leaf (‘nkontomire’) stew and
health and nutrition knowledge (Table 3). An understanding of garden egg stew (made with white aubergine). Some pregnant/
how to eat well and stay healthy in these communities was lactating participants shared correct knowledge of the protective role
already established in early adolescence. Nutritious diets were of fruit, sources of protein and starchy carbohydrates, in addition to
identified as rich in fruit, vegetables, green leafy vegetables, eggs, some knowledge about the need to avoid sugar, fried instant noodles,
fish and meat. Poor health outcomes were associated with poor salty stock cubes and too much fat. Anaemia during pregnancy was
quality diets by five participants across the different stages of the cited frequently as a concern among pregnant women. Eating
life course. As participants were aware that their health was iron‐rich foods, such as turkey berries (‘kantose’), was frequently
influenced by diet, several referenced dietary changes as a means recommended to them to prevent anaemia. Reduced consumption of
to control prediagnosed health conditions, such as hypertension. sugar and oil during lactation was advised by family, midwives and
Advice from medical professionals led some women to make other health professionals. Some misconceptions, such as eating ‘too
TABLE 3 Cognitions‐related drivers of dietary behaviours
Factor Quote Photovoice image
Knowledge, risk perception and hunger and satiety
Risk perception ‘When I know how a meal was prepared or
the ingredients that were used to prepare
a meal, I find it easy to eat the meal but
when I do not know how the meal was
prepared, I do not find it easy to eat. So, if
food is sold close by where we live and I
know how it is prepared, I find it easy to
eat’. [Accra, 14 years, low‐middle
socioeconomic status (SES)]
Hunger and satiety ‘The truth is that I usually do not like eating
much, I eat very little, so in the mornings,
this is the meal I eat. When I eat this
meal, I do not feel hungry for a long time
during the day. I just drink water’. [Accra,
28 years, low‐ middle SES]
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8 of 16 | LIGUORI ET AL.
much oil as a cause of malaria’ and the nutrient‐rich composition of Preferences
malted beverages, frequently consumed during lactation, were held. In all groups, food preferences were important. Many participants
reported a preference for nutrient‐rich foods such as fish, plantain,
Risk perceptions around food safety fruit and chicken. However, affordability was frequently mentioned
The majority of participants referenced food safety risks, indicating as a barrier. Only three participants referenced eating well‐liked
that there was a lot of anxiety and a good level of knowledge foods that were specifically beneficial to their pregnancy. Stable
surrounding food safety. In addition, some participants discussed income was also linked with personal and family‐related preferences.
the need to limit the consumption of foods and beverages with This was echoed by some younger and older adolescents, who
additives sold in shops, like sugar‐sweetened beverages and stock described eating food available at home and using pocket money to
cubes. Participants deployed mitigation strategies to avoid falling ill buy sweets and other preferred foods.
when risk was perceived. Individual hygiene practices such as hand
washing before meals were common among pregnant/lactating Food characteristics (texture, taste, aroma, food appearance)
participants. Washing utensils after eating and preparing food in Participants described sensory elements as facilitators or barriers to
clean areas were also listed. One 13–14‐year‐old participant eating healthily. When the food had a strange taste, look, smell or
mentioned her ability to positively influence food hygiene within texture, it was considered unappealing. Younger adolescents specifi-
her household: ‘Even [I] cook the family food, so due to this I can cally mentioned texture, smell, appearance and taste as factors
teach my mom how to be hygienic in cooking’ [Accra, 13 years, influencing food selection. Some pregnant/lactating participants had
low‐middle SES]. Four mothers in the sample specifically cited a preference for homemade food because they could take personal
making food for their children at home to avoid unclean food taste preferences into consideration. One woman indicated that
purchases out of the home. some vendors sold food that was: ‘too sweet’ [Accra, 19 years,
Two 13–14‐year‐old participants and one lactating participant pregnant, low‐middle SES]. One 13–14‐year‐old and one 15–49‐
described avoiding risk by eating food prepared in a hygienic way year‐old participant described that some vendors used too much
by someone they know. Some 13–14‐year‐old participants ‘kanwe’ in their cooking (i.e., potassium nitrate, for flavour/thickener).
perceived an increased food safety risk when food was prepared Plain rice and small portions of purchased food were considered
outside of the home, purchased as ‘takeaway’ or leftovers from a bland and participants added meat, eggs or fish to create ‘fine’ meals
group event. Some pregnant/lactating participants (n = 4) men- full of flavour. Food appearance, notably in terms of quantity or
tioned having a preference for cooking/preparing food at home portion size, was frequently mentioned. Another participant men-
because they could make food taste the preferred way and tioned that freshness was a key element to make a meal taste good.
ensure hygiene. The location where participants chose to eat was In the pregnant/lactating group, two participants mentioned that
also driven by risk perception. For example, several participants sewage inside the home or from toilets or manholes out of the home,
preferred eating indoors. Eating outdoors was viewed as made eating difficult and caused loss of appetite.
unhygienic, as it was more difficult to avoid house flies and
illness. However, several participants preferred eating outdoors to Hunger and satiety
avoid inviting ants or other pests inside the room. Eating well was associated with feeling full. Eating a filling meal was
Despite concerns, participants ate outside of the home and preferable for the majority of participants, as a way to stay satiated
often adapted strategies to minimize risk. For example, all longer: ‘foods like plantain and nkontomire stew and garden egg stew
participant groups cited looking for clean environments to sit mixed with groundnuts or turkey berries […] these are foods that are
and eat their meals. Buying hot meals and buying from a well‐ healthy for the body. When I eat these foods, I can go the whole day
known, trusted vendor was a key risk mitigation strategy. Food without eating another meal’ [Accra, 16 years, lowest SES]. WRA
temperature was important; eating food served at a hot preferred heavy meals, regardless of pregnancy/lactating status,
temperature to avoid illness was described. Prior experience while other adolescents preferred lighter meals; both mentioning
with food poisoning (stomach ache, diarrhoea, vomiting) made snacking practices and consuming ‘heavier’ meals at home.
pregnant/lactating participants wary of outside food or unknown Factors in the wider food environment influenced satiety
vendors. Participants avoided ‘buying sickness’ from vendors indirectly, such as food prices, affordability and eating a meal alone
selling food near gutters and unclean environments. However, or without family. In addition, time for work, school and childcare was
despite these strategies, financial barriers sometimes forced often brought up as barriers to satiety. Participants described eating
participants to buy from unclean vendors. With low incomes more food in a group setting while eating alone was often associated
and few alternatives, participants frequently mentioned eating with eating reduced food portions. For example, adolescent
whatever they could, if it was cheap and they were hungry: ‘In my participants reported greater satisfaction when eating at home due
area when you don't have money, some of the things you cannot to the larger portion size. Other participants described needing to
afford, so that will influence you to go in for some maybe cheap food drink something (malted drink or sugar‐sweetened beverage) to
and that will, later on, affect your health’ [Accra, 19 years, low‐ increase their appetite before a meal, with two WRA taking apple
middle SES]. juice and/or eating oranges to stimulate appetite.
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LIGUORI ET AL. | 9 of 16
Mood and emotions time to cook influenced the diets of the entire household. For
Participants explained that stress and feeling unhappy made eating example, participants described buying instant noodles when arriving
well difficult. Examples of stress included: school, work, the workload late/tired from work. Many healthy food and meals, such as cassava
at home and/or unclean food outlets. Being in a calm, relaxed mood soup and plantain‐based meals, were cited as requiring more time and
facilitated eating. The type of food consumed also influenced more financial resources to prepare. Some participants stated that
individuals’ moods, especially when social connections such as eating they did not have enough time to eat what they wanted. As a result,
with family were considered. Several pregnant/lactating participants heavy meals were preferred by many to stay full for longer durations,
and other WRA reported physical cravings for food, including pies, especially when the reduced time to purchase/make/eat meals (i.e.,
bread and iced kenkey (fermented maize dumpling smoothie with school, work and childrearing) were considered. Home‐made food
sugar and milk). Some mentioned selecting or changing where they was sometimes brought to work/school due to time constraints: ‘I
ate to avoid judgment. would pour some of the tom browns in the thermos and then take it to
work […] and [when] I feel hungry I take some’ [Ho, 38 years, lactating,
low‐middle SES].
3.2.4 | Practises Snacking: Among adolescents, long school days from
7:00 AM–4:00 PM were cited as a barrier to healthy eating.
Cooking skills Purchasing snacks during school breaks was frequently cited: ‘During
Participants in all reproductive stages described practices such as the first break, I take in Kalyppo [fruit drink] and biscuit then during the
cooking skills, eating at home or out and time constraints (Table 4). In second break then we eat the canteen food’ [Accra, 14 years, lowest
regard to cooking skills, only one participant (13–14 years) mentioned SES]. Snack foods often included sweet foods, such as chocolate, ice
her ability to cook, with younger participants frequently describing cream, candy, biscuits, yoghurt, sugar‐sweetened beverages and fried
involvement in food preparation or learning cooking skills at home. foods. Three participants linked the frequency of their snacking with
Cooking at home between one and three times per day was their pocket money.
mentioned as a common practice. Many culinary skills were Skipping meals: Among older participants, snacking was an
described, such as cooking over charcoal, frying fish, boiling yams alternative to eating a full meal, as time influenced the quantity and
and grinding cassava/corn/nuts into flour. Among the 15–49‐year‐ timing of meals. Participants tended to skip meals during the day and
old participants, a lack of cooking skills led to unhealthy eating only ate in the morning or at night. Being too busy with work and not
behaviours despite food safety concerns as there were few having time to stop and eat was mentioned by several participants,
alternative solutions available: ‘[…] after that experience, you may especially shift workers. One lactating woman indicated skipping
decide not to buy food there again but because you don't know how to meals as a barrier to eating healthily.
cook at home, you will still go and buy food there again’ [Accra, 19 Speed eating: Participants across age groups described eating
years, low‐middle SES]. quickly, despite their stated preference for eating slowly in a
comfortable location. Time constraints and workload at home/
Eating at home or out employment potentially drove participants to eat fast. Caregivers
Eating food prepared at home was most common. Eating out or and/or employed women felt rushed when eating, with one
getting a takeaway were practised with varied frequencies. Home- participant describing that she had to eat 'fast fast'. Another pregnant
made food was the overall preference, as ingredients, flavour, portion participant indicated that when eating with others, she felt a need to
size and hygiene level could be monitored. Younger adolescents ate eat quickly so that she was able to eat enough: ‘when you are eating
out at school canteens, while adults described eating at work or on with other people, you want to eat quickly and be full before all the food
the way to or from work. Adolescents and WRA reported eating out gets finished. Other times too, when you are eating with someone […]
more often on weekdays and eating more at home on the weekends, they will eat all the meat on the food before you finish eating’ [Accra, 15
influenced by busy school/work schedules and income. Among the years, pregnant, lowest SES].
13–14‐year‐old participants, eating homemade food was thought of
as a positive, enjoyable practise that facilitated healthy eating. One
participant even refused to eat school food. Several participants 4 | DISCUSSION
brought homemade food to work as it was convenient and
affordable. This study explored individual‐level factors influencing dietary
behaviours among adolescent girls and women at different stages
Time constraints of the reproductive lifecycle in urban Ghana. Thirty‐eight factors
Time constraints were an overarching theme. Busy lifestyles meant were identified as having an influence on dietary behaviour across
having little free time, which resulted in not 'eating well'; with four domains within the individual level: biological (5 factors),
unbalanced meals/diets at varied frequencies reported. Some demographic (8 factors), cognitions (14 factors) and practices (11
adolescents described buying food before school due to time factors). The most frequently cited factors were income/wealth
constraints. Among pregnant/lactating WRA, not having enough (demographic); nutrition knowledge/preferences/risk perception
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 of 16 | LIGUORI ET AL.
TABLE 4 Practices‐related drivers of dietary behaviours
Factor Quote Photovoice image
Cooking skills, eating at home/out and time constraints
Cooking skills ‘So this one, I do not find it difficult to cook. When I get
back from school, I just get it done. And always when I
come back from school, they have not cooked so
when I enter the kitchen, I just fetch the gari, add the
oil and water and then eat, I don't eat again till
morning’. [Ho, 13 years, low‐middle socioeconomic
status (SES)]
Cooking skills ‘People should buy the fish fresh and prepare it well as
home and fry it to their taste and they should eat more
fish to be healthy’. [Accra, 16 years, lowest SES]
Cooking skills ‘Most of the time, I like preparing my own food at home
because I know how and where I will prepare it’.
[Accra, 25 years, lactating, lowest SES]
Eating at home ‘Sometimes we eat rice in the afternoon and akple in the
evenings or we pound fufu. We all eat the same thing
all the time. Whatever I cook, we all eat it together.
There is no food that I eat that they don't eat’. [Ho, 27
years, pregnant, low‐middle SES]
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LIGUORI ET AL. | 11 of 16
TABLE 4 (Continued)
Factor Quote Photovoice image
Eating at home ‘So you go and buy outside, you don't know how the
person is, you don't know how they take care of their
place and how they cook. So when you cook in your
own house and eat, it is better than eating outside […]
There is no other place that you can eat without
getting diseases other than the house’. [Ho, 49 years,
lowest SES]
Eating at home ‘[…] Let's say if I have 12 cedis, I can buy onion, tomatoes,
pepper, palm oil and fish and I come home to prepare
my food. […] I always ensure that I cook most often so
that we could have good food to eat in order to avoid
problems like stomach ache, diarrhoea and vomiting.
This is why I prefer cooking at home’. [Accra, 32 years,
lactating, low‐middle SES]
Eating out ‘What makes me buy food from this place is that the
woman is clean, she is neat and the food too tastes
nice that is why I like buying from her. She sells this
food opposite our house’. [Accra, 14 years, low‐
middle SES]
Time constraints ‘I don't eat. Sometimes when I am late to school early in
the morning, instead of buying tom brown and bread, I
go and buy fried yam and chofi [fried turkey tails] and
my friends have been advising me that it is not good,
so I should stop’. [Accra, 14 years, lowest SES]
Skipping meals ‘When I go roaming to sell, I find it difficult eating healthy.
The picture you see is the head‐pan I carry on my head
to sell the Alasa (Africa Star apple). […] When it is like
this, I do not get time to eat because I have to come
home afterwards, do the household chores and then I
start selling soon as I finish the household chores.
When I step out, I may or may not find a decent place
to buy food. Hence it makes healthy eating difficult for
me’. [Accra, 25 years, lactating, lowest SES]
(Continues)
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12 of 16 | LIGUORI ET AL.
TABLE 4 (Continued)
Factor Quote Photovoice image
Skipping meals ‘When you have money, you can eat all the time, morning,
afternoon, evening. But when there is no money, you
can skip it, you can say I won't eat it this morning or I
won't eat this afternoon, I'll wait till evening’. [Ho, 24
years, lactating, lowest SES]
Speed eating ‘[…] So if I get the time, let's say I want to eat fufu in the
afternoon and then I happen to get a little time to eat
the fufu, I will eat it very very fast, because I also have
to go and look at other things. And that is the little
time I have to eat the food, so I have to eat it so fast
that I would be able to finish early and go and do other
things’. [Ho, 22 years, low‐middle SES]
(cognitive); and cooking skills/eating at home/time constraints reduce perceived food safety risks where finances allowed. Contin-
(practices). Dietary behaviours were influenced by similar factors, ued eating out practices, influenced by affordability, preference and
with few marked differences across life course stages. For example, taste and lack of alternatives were observed in a recent systematic
pregnancy/lactating status influenced dietary behaviour through review on food safety concerns in LMICs (Liguori et al., 2022).
medical advice, awareness and willingness to eat foods that promote Actions to improve food safety among food vendors have emerged as
infant/child growth and development. a core concern among participants in several research studies in
Many individual‐level factors, such as the cost of food, Ghana (Boatemaa et al., 2018; FAO, 2016; Pradeilles et al., 2021;
overlapped with the wider social and physical food environments Rheinlander et al., 2008). Individuals' primary concern related to food
(Pradeilles et al., 2021; Wanjohi et al., 2022). This suggests that hygiene is observed in street food practices in LMICs (Akparibo et al.,
interventions need to account for multiple levels and wider drivers 2021; Alimi, 2016; Omari & Frempong, 2016), with concern
of food consumption. This supports findings from previous studies increasing among participants that have experienced prior episodes
in Kenya (Downs et al., 2022) and Ghana (Boatemaa et al., 2018), of food‐borne illness (Adam et al., 2014), which supports the need to
showing the need to target multiple levels of the food environ- implement healthy food environment policies in these cities (Laar
ment to help women negotiate factors such as food safety, et al., 2020). Another qualitative study from the Dietary Transitions in
nutrition, time, cost trade‐offs that prevent them from adopting Ghana project, conducted in the same targeted communities in
healthy diets. Accra and Ho, showed that efforts (i.e., research, one‐off events) to
Despite low levels of education, there appears to be an overall address the issue of unhealthy diets among adolescent girls and
high level of knowledge and awareness of food safety and food women exist but are scarce. These were often implemented within
hygiene and the impact these may have on diets. Food safety was school settings, community health centres, churches or mosques
also observed as a key factor influencing adolescent dietary (Pradeilles et al., 2019).
behaviours in Ethiopia (Trubswasser et al., 2020) and women of Remaining satiated for longer durations was valued as time
reproductive age in Uganda (Yiga et al., 2020). Participants used constraints and the price of eating out of home was challenging. Time
several risk mitigation strategies, such as preparing and consuming constraints emerged as a key factor for eating unbalanced meals and
homemade food and eating in clean environments, to ensure the overall diets. Participants reported being too busy to eat as much or
hygienic preparation of food consumed. Despite food safety as often as they liked, often skipping meals or eating ‘on the go’. In
concerns, participants continued to eat out of home, buying hot addition, adolescents attending school preferred quick meals, such as
meals, eating in cleaner environments and from familiar vendors to snacks. This could lead to increased consumption of energy‐dense,
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LIGUORI ET AL. | 13 of 16
nutrient‐poor foods, which are widely consumed among this group, environments, especially as promoting energy‐dense, nutrient‐rich
without creating a feeling of satiety (Drewnowski & Darmon, 2005). diets in deprived urban settings remains an unresolved challenge.
Among low SES groups, there appears to be an emphasis on
consuming maximum calories, rather than nutritional quality (Darmon AUTHOR CONTRIBUTIONS
& Drewnowski, 2008). A study in the same communities found that Michelle Holdsworth, Amos Laar, Francis Zotor, Hibbah A. Osei‐
time allocated to a meal was usually <30min for the vast majority of Kwasi, Nicolas Bricas, Paula Griffiths, Robert Akparibo, Richmond
study participants (Holdsworth et al., 2020). This finding supports Aryeetey, Rebecca Pradeilles designed the research study and
increased incentives and subsidies targeting local food vendors to contributed to protocol development. Akua Tandoh/Senam
provide healthy foods that are convenient and can be consumed Klomegah contributed to protocol development and led the data
quickly (Holdsworth et al., 2020). collection and translation/transcription of interviews. Akua Tandoh,
This study includes several strengths, namely, the sampling Senam Klomegah and Rebecca Pradeilles coded the data. Julia Liguori
method used to achieve diversity across the life course, application of analysed and synthesised the data with support from Agnès Le Port,
the African Food Environment framework and the use of Photovoice Michelle Holdsworth and Rebecca Pradeilles. Julia Liguori, Rebecca
(i.e., added value over commonly used methods like in‐depth Pradeilles, Michelle Holdsworth and Agnès Le Port wrote the first
interviews and focus group discussions only). Participants were draft of the paper. All authors reviewed the manuscript and approved
asked to tell their stories and to engage with a research topic that the final version.
sought to better understand the current situation within their
community. Using photography allowed participants in low‐income ACKNOWLEDGEMENTS
communities to have an additional means of communication to The authors would like to acknowledge the participants who were
identify, capture and discuss challenges and facilitators to eating involved in this project in Accra and Ho, Ghana. This article was
healthily. While individual Photovoice interviews were conducted in supported by funding from CGIAR Research Program on Agriculture
place of group discussions, participants were able to discuss their for Nutrition and Health (A4NH). The original data set was collected
concerns with a larger audience directly during a community‐based as part of the Drivers of Food Choice (DFC) Competitive grants
photography exhibition (Pradeilles et al., 2021). Nevertheless, as programme, which is funded by the UK Government's Department
participants were only selected from two neighbourhoods in Accra for International Development and the Bill & Melinda Gates
and Ho, additional or differing factors may also be a concern within Foundation and managed by the University of South Carolina, Arnold
urban neighbourhoods and rural areas in Ghana. It is also important School of Public Health, USA.
to consider the potential for limited success when individual‐level
approaches do not account for the wider food environment factors CONFLICT OF INTEREST
that influence the individual level (Allender et al., 2015; Doak et al., The authors declare no conflict of interest.
2006; Mackenbach et al., 2014; Osei‐Kwasi et al., 2020; Story et al.,
2008; Tanentsapf et al., 2011). DATA AVAILABILITY STATEMENT
An open access data repository, DataSuds (part of the Dataverse),
was used to write this article. Metadata and tools for Accra and Ho
5 | CONCLUSION can be accessed here: https://doi.org/10.23708/XSACNA.
In conclusion, investigating the individual‐level factors that influence ETHICS STATEMENT
dietary behaviours through a Photovoice study demonstrated that Ethical approval for the study was received from the Ghana Health
there is a wide diversity of individual‐level factors, such as Service Ethics Review Committee (GHS‐ERC 07/09/2016) and the
affordability, food safety concerns and time constraints, that should University of Liverpool (1434 25/1/2017). The University of
be considered when designing interventions to promote healthy Sheffield Research Ethics Committee and Loughborough University's
eating practices. These factors are linked with the wider food ethics Committee recognized the ethical review processes of the
environment, which reflects the complexity of factors influencing Ghana Health Service Ethical Review Committee and, therefore, did
dietary behaviours. Our findings suggest that the life course stage, not require additional independent ethical review. Written informed
particularly for adolescents and WRA, had less influence on overall consent was obtained from participants aged ≥18 years and consent
diet quality than socioeconomic barriers or food safety concerns. of legal guardians of participants aged 13–17 years. All minors
Hence, interventions should focus on providing the means to achieve (participants aged 13–17 years) provided assent before being
a healthy diet to all adolescents and WRA in deprived urban areas in interviewed. Participants used a photograph release form to request
Ghana. Redesigning fiscal and physical food environment policies consent/assent if a person's face was visible in a photograph.
would help support access to a healthy diet for all. Further Participants granted permission for photograph re‐use in scientific
implementation research is needed to ensure that individual‐level outputs. The ethical committee also granted permission for photo-
factors are considered in interventions and policies that improve food graph re‐use in scientific outputs.
 17408709, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13412 by University of Ghana - Accra, Wiley Online Library on [23/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
14 of 16 | LIGUORI ET AL.
ORCID Darmon, N., & Drewnowski, A. (2008). Does social class predict diet
Julia Liguori http://orcid.org/0000-0001-8847-7169 quality? American Journal of Clinical Nutrition, 87(5), 1107–1117.
https://doi.org/10.1093/ajcn/87.5.1107
Rebecca Pradeilles http://orcid.org/0000-0003-0334-3714
Chakraborty, N. M., Fry, K., Behl, R., & Longfield, K. (2016, Mar). Simplified
Richmond Aryeetey http://orcid.org/0000-0003-4667-592X asset indices to measure wealth and equity in health programs: A
reliability and validity analysis using survey data from 16 Countries
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