Individual-level drivers of dietary behaviour in adolescents and women through the reproductive life course in urban Ghana: A Photovoice study

Evidence on the individual-level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual-level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13–14 years) and women of reproductive age (15–49 years). Data analysis was both theory- and data-driven to allow for emerging themes. 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), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual-level as well as wider environmental drivers of dietary behaviours. This study was part of a wider project, the Dietary Transitions in Ghana project (datalink: https://dataverse.ird.fr/dataverse/diet_trans_ghana;jsessionid=d8c3c605c1c1bf3125e01476d0f6), conducted in Accra (Greater Accra region) and Ho (Volta region), as we were interested in capturing cities with different levels of urbanization and prevalence of overweight/obesity (as a proxy for nutrition transition). In 2015 (study conception), overweight/obesity prevalence among women of reproductive age (WRA) was 57.3% and 31.1% in Greater Accra and the Volta region, respectively (GSS, 2015). 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 designed to identify a range of factors at the individual, social, physical and macro‐levels that influence dietary behaviours (Story et al., 2008). This paper reports the findings on the individual‐level factors that emerged. The findings on the influence of the physical‐level (accessibility, affordability, convenience, etc.) food environment on dietary behaviours have been previously published (Pradeilles et al., 2021). Photovoice, a community‐based participatory photography method, was used to allow participants to document influences on their dietary behaviours in their daily lives. This method facilitates in‐depth exploration, stimulates reflection and enables discussion among participants and policymakers to foster change in a community (Wang, 1999). While Photovoice has largely been used in high‐income countries (Belon et al., 2016; Díez et al., 2017; Gravina et al., 2020; Heidelberger & Smith, 2016), recent studies have used this method in Africa, to assess factors influencing adolescents’ dietary behaviours in urban Ethiopia (Trubswasser et al., 2020), among women in rural/urban Uganda (Auma et al., 2020) and balancing work and childcare in Kenya (Hani Sadati et al., 2019). The Photovoice methodology was selected as it places the research participant at the centre of the research process, opening up a pathway for dialogue between the researchers and the participants in a way that face‐to‐face interviews or focus group discussions alone do not. Photographs allow access to the participants’ world and can help to break down power dynamics between the researcher and researched, encouraging reflection, recall and discussion (Auma et al., 2021). A list of all deprived neighbourhoods in Accra and Ho from the Accra Poverty Mapping Exercise (CHF International, 2010) and United Nations Human Settlements Programme urban profiling report (UN‐HABITAT, 2009) were used to select two neighbourhoods: James Town (Accra) and Dome (Ho) (see further detail in Supporting Information 1). To ensure diversity, participants were purposively selected using quota sampling based on age/reproductive life course stage, gender, body mass index (BMI), education, occupation, maternal status and socioeconomic status (SES) (Supporting Information 2). A subsample (i.e., a third) of the overall study population was 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 Supporting Information 3 for additional information). Before the project began, initial formal meetings with community leaders were held to explain the study and establish community entry. These meetings encouraged community mobilization and engagement with the study and facilitated data collection. RP led the qualitative fieldwork training for seven Ghanaian research assistants. Fieldwork was conducted by native speakers, who were not members of the targeted communities. Data for the Photovoice study were collected between May and December 2017. The Photovoice interview guide was adapted from the original format proposed by Wang (1999) (Supporting Information 4). Initial community engagement activities revealed that women in these urban areas had busy schedules outside of the home setting, making it difficult to organize group discussions at a time suitable to all participants. Therefore, individual interviews were conducted instead of focus group discussions. The Photovoice interview guide was piloted in Accra (n = 3) and Ho (n = 3) and then amended, accordingly, thus excluding them from the analysis stage. The Photovoice study took place in three stages. The first stage was comprised of an initial home visit, where participants were trained on: (i) the consent process (because they potentially would photograph people); (ii) the Photovoice methodology; (iii) the use of a camera to take photographs; (iv) photography ethics, including the ‘no face or identification details’ protocol to ensure the anonymity of people or places (Supporting Information 5). Participants were asked to take photographs that identify factors driving their dietary behaviours. Specifically, they were asked to take five photographs on the following themes: (i) a place where you eat food and/or drink; (ii) Something that makes eating healthy difficult for you; (iii) something that makes eating healthy easy for you; (iv) something that influences what you eat in your area/neighbourhood; (v) a 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 interview that lasted 45–60 min. Interviews were conducted with participants in their preferred language: Ga (n = 24); Twi (n = 5); English (n = 3) in Accra and Ewe (n = 28); English (n = 3); Twi (n = 1) in Ho, respectively. During the interviews, participants told the ‘stories’ related to their five selected photographs. When data collection was complete, a photography exhibition was held to raise awareness of drivers of unhealthy food and beverage consumption in the targeted communities. Photographs from the data collection stages were used as a tool to facilitate dialogue between study participants, the media and local government officers. The photography exhibition also promoted community dialogue and stakeholder engagement by sharing results with the wider community. In‐depth interviews were transcribed and translated verbatim into English for analysis. All coders, RP/AT/SL, used an agreed‐upon codebook in NVivo version 11 to ensure consistency and accuracy, with blind double coding of 25% of the transcripts (Fonteyn et al., 2008). Interviews were coded using deductive (a priori themes) and inductive (data‐driven codes) schemes, to allow for emerging themes (Supporting Information 6). Existing socioecological models of dietary behaviours and systematic review evidence from Africa (Gissing et al., 2017; Story et al., 2008) were used to identify factors, biological, demographic, cognitions (e.g., knowledge and preferences) and practices (e.g., skills and behaviours), influencing dietary behaviours 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 structure the reporting of our results (Osei‐Kwasi et al., 2021). Data were synthesized by creating a framework matrix with nodes for different themes and subthemes (Gale et al., 2013). Nodes were then broken down into four populations at different stages of the life course: early adolescents, WRA who were neither pregnant nor lactating, pregnant WRA and lactating WRA. Similarities and differences were highlighted between the different stages and the factors influencing dietary behaviour.