Building forward better—An exploration of nutrition practices, food choice, and coping behaviors among Kenyan adolescents during COVID-19: Experiences and program implications

This implementation research study sought to examine the impact of the COVID-19 pandemic on adolescent nutrition practices and related behaviors in Nairobi and Uasin Gishu Counties, Kenya. Eight focus group discussions (FGDs) were conducted with adolescents 10–19 years of age, in-depth interviews with 10 health facility providers, and a combination of FGDs (n-4) and key informant interviews with government stakeholder and implementing partners (n = 9). During the pandemic, adolescents tended to avoid commonly consumed junk foods, in favor of “immune boosting, protective” foods. Widespread unemployment and reductions in parental income rendered some food items such as meat, eggs, and fruits unaffordable for families of adolescents. Adolescents relayed experiences of skipping meals and reducing the amount and variety of foods consumed. Adolescents also described employing strategies such as working in the informal sector and selling personal items to support families financially, in response to rising food insecurity. School closures mandated during the pandemic likely contributed to reductions in overall physical activity. To improve the diets of adolescents, programs should build on the healthy mindset brought on by the pandemic, while strengthening, targeting, and improving access to social protection measures and agricultural initiatives for vulnerable families with adolescents to cushion them from rising food insecurity as an effect of COVID-19. Building practical adolescent life skills to encourage healthy nutrition actions will also be key to building forward from the COVID-19 pandemic in Kenya. Consensus from key government, partner organization, and academic stakeholders in the country, through various national technical working groups (i.e., MIYCN Technical Working Group, Research Technical Working Group; Ministry of Health, Kenya), was garnered to determine criteria for study site selection. Criteria for study site inclusion were as follows: (1) counties with the highest COVID‐19 burden based on MOH data on COVID‐19 infections/cases; (2) one urban and one rural county; (3) one county which experienced at least one government lockdown versus. one county that did not experience a lockdown during the course of COVID‐19 pandemic; and (4) counties which included persons of low socioeconomic status who resided in informal settlements were selected in consultation with the government officials, and Ministry of Health country data. Ultimately, Nairobi and Uasin Gishu counties had the highest burden of COVID‐19 cases in Kenya (Ministry of Health (MoH), Kenya, 2021) and met study criteria for selection. In Nairobi County, urban Embakasi East and Kibra subcounties are comprised of informal settlements in the country. Kibra subcounty had the third highest number of COVID‐19 infections in the county, which was notable. In Uasin Gishu County, rural Ainabkoi, and Turbo subcounties, accounted for almost half of the COVID‐19 infections within a county which had not experienced a mandated COVID‐19 lockdown. Fieldwork occurred between August and September 2021, and country caseloads of COVID‐19, per available Ministry of Health data were 36,479 and 10,331 for August and September, respectively (Ministry of Health – Republic of Kenya, 2022). Data collection for adolescents was part of a larger implementation research study collecting qualitative information from pregnant and lactating women on dietary intake, access, and use of health services, while also examining perspectives from health workers, community health volunteers, and food vendors on effects on the health and food systems (Ahoya et al., 2022). While study participants were part of this larger implementation research study, adolescent boys and girls were selected as an independent sample via opportunistic purposeful sampling (Patton, 1990). Data were largely collected in‐person with adolescents, with some virtual data collection for stakeholders, due to the COVID‐19 pandemic. Inclusion criteria for study participation included adolescent boys and girls 10–19 years of age, residents of study sites for at least a 3‐year period, and nonpregnant and/or non‐lactating individuals (i.e., adolescent girls only). Within each study site, local community health volunteers associated with the nearest health facility offering maternal, newborn, and child health services supported the identification of adolescents for study enrollment. In‐depth interviews (IDIs) with facility health workers and key informant interviews (KIIs) and small focus group discussions (FGDs) with key stakeholders (i.e., national and county government officials and key focal points from implementing partner organizations) explored topics such as integration of adolescent nutrition into health services, adolescent food choice and consumption, related adolescent behaviors in response to food insecurity and school closures, and physical activity during the COVID‐19 pandemic. FGDs with adolescents explored the following topics: effect of the pandemic on beliefs and perceptions of foods, decisions around food choice, school attendance, physical activity, and coping strategies during the pandemic. Eight face‐to‐face FGDs were conducted with 54 adolescents, 10–19 years of age, and IDIs with 10 facility health workers (i.e., 6 in‐person and 4 virtual). Virtual data collection, using the Zoom platform, was used for all 18 stakeholders, which was comprised of national and county government officials and implementing partners (except 2 in‐person FGDs, see Table 1). Four small FGDs were carried out with nine county/subcounty stakeholders working on maternal, adolescent, infant, and young child nutrition (MAIYCN) programs, KIIs with national‐level government nutrition officials (n = 4), and KIIs with government officials and implementing partners working in adolescent programming at national and subnational levels (i.e., county and subcounty) (n = 5). COVID‐19 precautions were also followed during face‐to‐face data collection—including donning of face masks during interviews and FGDs, use of hand sanitizers and handwashing with water and soap, as available, and social distancing of 3 m between interviewer and study participant(s). Characteristics of study participants, by methodology and study site, Nairobi and Uasin Gishu Counties Local ethical approval was obtained from the Institutional Ethics Review Committee of Masinde Muliro University of Science and Technology, Kenya, and country‐based research license was obtained from National Commission for Science Technology and Innovation. Verbal informed consent was obtained from study participants. Trained interviewers audio recorded all IDIs and FGDs, which were translated and transcribed verbatim from Swahili into English. The quality of transcriptions was checked for accuracy and completeness against the audio recordings by the Kenyan research team members, alongside local trained transcribers. The researchers (JK, CG, BA , and LR) conducted a preliminary review of the data by reading a subset of the transcripts to create an initial codebook that included major themes and subthemes that emerged from the data. The researchers (JK, CG, BA, and LR) then coded a subset of the transcripts and discussed, and a consensus was reached among research team members regarding any discrepancies in coding. The codebook was further refined and used for coding (see Supplementary File S1). Once coding was complete, researchers looked independently at a subset of transcripts for verification of the themes in the codebook and to confirm any additional emerging concepts. Transcripts were further reviewed and triangulated with corresponding field data collection forms. All transcripts were coded using Dedoose online software. Each subtheme was then summarized, and illustrative quotes were selected (see Table 2). Summary of dominant themes by study participant group, Nairobi (NC) and Uasin Gishu (UGC) Counties R3: “In the morning, black tea with mandazis in case its available. If it’s not, we take it with leftovers from the previous night. Lunch is uncertain. We may or may not eat. Then supper, we take whatever is available and life continues.” R4: “In the morning, we take tea with bread then skip lunch and wait for supper to take ugali with kale mixed with avocado….and then wait for the following day [to eat].” R6: “In the morning, we usually wake up to take tea with 2 mandazis. Then lunch, it’s by chance. We may or may not eat. Then supper, we take what’s available… although mostly it’s served in low quantity to be enough for my small siblings and I.” R7: “Whatever is there is what we take, whether it’s in low or high quantity.”—Adolescent FGD Nairobi County “You see, as before, we [would] wake up around 6 a.m… You see, we would run up to around 8 a.m. But with corona… I don’t remember that last day I did that.”—Adolescent FGD Nairobi County “Boys here love playing football, but now getting an opportunity to play isn’t easy – not unless you play it at your home compound with a few of your friends. But before corona, we could go to play at the community ground. But now since the pandemic, we no longer play there because of restrictions on social gatherings.”—Adolescent FGD Nairobi County “[My parents] lost their jobs, and they were forced to wash clothes for households to get [money].”—Adolescent FGD, Nairobi County “Let me use myself as an example… I sold like my phone, I sold some of my shoes, my trouser … because during that time my parent had nothing completely, he had even come to stay home… so when I sold those things I bought vegetables, sugar, tea leaves… and I told her not to panic because we don’t have… the little that we get is what we will eat.”—Adolescent FGD, Uasin Gishu County