Through HER eyes: barriers and solutions to adopting healthy diets for women and children in Addis Ababa, Ethiopia

Through HER eyes Barriers and solutions to adopting healthy diets for women and children in Addis Ababa, Ethiopia Photo: iStock.com/Andy Wasley AT A GLANCE | 2 | The growing burden of malnutrition in all its forms Ethiopia has made great progress in reducing undernutrition. Yet, challenges remain: • About 2 in 5 children under five are stunted, and 1 in 10 are wasted. • 1 in 5 women of reproductive age (15-49 years) are anaemic. • Overweight and obesity are rising, especially in cities – in Addis Ababa, over 1 in 3 adult women are overweight or obese. These figures highlight the double burden of malnutrition (DBM) the country is facing – with undernutrition and overweight/obesity existing side by side. Aim This study explores how women in urban Ethiopia perceive challenges of eating healthily for themselves and their children, and the solutions they propose. This study is part of a broader project called TAMMIE (TAckling Multiple forms of Malnutrition In Ethiopia amongst women of reproductive age and children under five), which aims to assess the causes of the double burden of malnutrition and develop a roadmap for action to tackle it by characterising current policies/programmes, the stakeholders involved, and intervention priorities. To guide this work, a 4P cycle (Problem, Policies/Programmes, People, and Priority) was employed. This study falls under the Problem domain, which focuses on understanding the drivers of the DBM, specifically poor-quality diets, a common factor contributing to multiple forms of malnutrition. Methods Qualitative participatory photography (Photovoice) was used with women living in deprived or wealthier neighbourhoods of Addis Ababa, the capital city of Ethiopia. This method encourages participants to take and discuss photographs that illustrate a theme or problem they experience. As a participatory and actionoriented approach, it provides a platform for women to express their viewpoints and generates material for advocacy actions. A total of 31 women participated, telling the stories behind their photographs and discussing challenges and solutions to adopting healthy diets during five focus group discussion workshops. | 3 | Results Women from both lower and higher socio-economic groups described the challenges to eating healthily for themselves and their children: • Time constraints, financial and physical inaccessibility, and poor food safety are perceived as major barriers to adopting a healthy diet among women from both lower and higher socioeconomic groups. • Inadequate household infrastructure in economically disadvantaged groups makes healthy meal preparation difficult. • The availability and marketing of unhealthy foods encourage their consumption among wealthier groups. In response to these challenges, women proposed solutions to improve their diets and those of their children: • Women from poorer socioeconomic backgrounds emphasised government-led interventions (job creation, provision of affordable healthy food, improved cooking infrastructure, and gender equality). • Women from wealthier socioeconomic backgrounds highlighted both governmentand society-led measures (childcare support, urban agriculture, and restrictions on unhealthy food advertising). Key Recommendations These findings highlight the need for integrated interventions targeting individual behaviours, food environment, and socio-economic factors to improve diets amongst women and children in urban Ethiopia. Government-led actions could include: • Improving access to affordable, healthy foods • Enhancing household cooking infrastructure • Supporting job creation • Restricting unhealthy food marketing • Implementing legal protections for gender equality • Providing childcare support. Society and community-led actions could include: • Urban agriculture initiatives • Raising awareness around gender equality in caregiving • Strengthening existing communitybased loan schemes. Women’s voices should be central to policy-making, and interventions should consider local realities and the lived experiences of women across different socio-economic groups. | 4 | CONTENTS Background and Objective pg. 5 Method pg. 6 INDIVIDUAL-LEVEL FACTORS Individual food preferences pg.8 Lack of awareness/knowledge about healthy diets pg.12 Low income and employment pg.34 Time constraints pg.14 Poor food safety, water, and hygiene pg.21 FOOD ENVIRONMENT FACTORS Inadequate cooking space pg.24 Physical inaccessibility pg.27 Availability and promotion of unhealthy food pg.29 ECONOMIC FACTORS Financial inaccessibility and high cost of food pg.38 Acknowledgements pg. 47 Contact pg. 48 | 5 | OBJECTIVE This study explored the perceived challenges and proposed solutions for achieving healthy diets among women and their children in urban Ethiopia. This study is part of a broader project called TAMMIE (TAckling Multiple forms of Malnutrition In Ethiopia amongst women of reproductive age and children under five), which aims to assess the causes of the double burden of malnutrition and develop a roadmap for action to tackle it by characterising current policies/programmes, the stakeholders involved, and intervention priorities. BACKGROUND Ethiopia showed remarkable progress in reducing undernutrition but still has one of the highest rates of undernutrition amongst children under five (U5) (e.g. 41% and 11% of children U5 are stunted and wasted, respectively) and women of reproductive age (WRA) (e.g. 20% of WRA are anaemic). This is also coupled with a rising problem of overweight/obesity, particularly amongst urban women (e.g. 36% in Addis Ababa). Given Ethiopia’s double burden of malnutrition, it is important to better understand the factors contributing to malnutrition, particularly unhealthy diets, a key shared driver of multiple forms of malnutrition. | 5 | Photo: iStock.com/hadynyah | 6 | 1. Photovoice is a method used to facilitate the production, discussion, and exhibition of photographs illustrating a theme or problem experienced by a group of individuals. This participatory and action-oriented approach provides a platform for participants to express their viewpoints and generates material for advocacy actions. Qualitative participatory photography (Photovoice)1 was used among women living in deprived or wealthier neighbourhoods of Addis Ababa, capital city of Ethiopia. Women (n=31) told the stories of their photographs and discussed challenges and solutions to adopting healthy diets in focus group discussion (FGD) workshops (n=5). METHOD Study design | 7 | Recruitment and data collection Step 1: Selection of Photovoice participants • Women of reproductive age (18-49y) in the preconception period, pregnant/lactating, or mothers of children under five years of age (not pregnant/ lactating) residing in Addis Ababa • Women representing diverse socio-economic backgrounds Step 2: Recruitment of Photovoice participants • Quota or convenience sampling methods based on key biological and sociodemographic characteristics (i.e. neighbourhood deprivation level and/or household socioeconomic status) • Selection of study sites within targeted neighbourhoods (Gulele and Lemi Kura sub-city) was informed by consultation with the respective administration office (for lower socio-economic groups) • Health extension workers at each health centre facilitated participant recruitment using family folder registrations Step 3: Introductory session • Presentation of study objectives & Photovoice methodology • Basic photography & ethics/safety training • Distribution of smartphones (for lower socio-economic groups) • Informed consent obtained from all participants Step 4: Photography Activity • Women were asked to take photographs to illustrate the barriers to adopting healthy diets for themselves and their children (over a 1 week period) • Women shared their photographs (minimum 2, maximum 4) via WhatsApp with study team members • Study team printed photographs ahead of the workshop Step 5: Workshop (full day) Morning session: identification and prioritisation of key challenges • Women defined what healthy eating means for themselves and their children. • Women sorted the photographs into sub-themes (i.e. challenges) and then discussed the photographs and their meanings collectively. • Women prioritised the challenges by voting for their top four challenges individually. The four highest-scoring challenges were chosen by summing the votes. Afternoon session: identification of solutions to the prioritised challenges Step 6: Data analysis, synthesis, and production of materials for advocacy actions (photography booklet and exhibition) and dissemination to decision-makers | 8 | INDIVIDUAL FOOD PREFERENCES ‘There are vegetables and there is also shiro3 and fish. And the same thing on the next day, rice and shiro are there on both days. My problem here is that my child only eats the shiro and the constraint I am facing through my son is that he only eats the same thing over and over.’ HIGHER SOCIO-ECONOMIC STATUS (SES), PREGNANT, 31Y 2. Individual-level factors include a person’s economic status, overall life situation, thought process, and behavior. Note: in this booklet, photographs depicting aspects of economic status are included in the section on economic factors. 3. Shiro is a traditional Ethiopian stew made from ground legumes (ground chickpea or broad bean) and spices Individual-level factors2 SUMMARY • At the individual level, women from both higher and lower socio-economic (SES) groups identified time constraints as a key challenge, mainly due to unequal division of labour, multitasking, the nature of work and lack of support from other household members. • Women from lower SES highlighted limited awareness of healthy diets as a major factor leading to a monotonous, undiversified diet, even when a variety of foods was available at home. • Women from higher SES emphasized that taste preferences play a central role in determining the foods consumed by themselves and their children. Individual-level factors RESULTS | 9 | ‘The children don’t like the taste of healthy foods. They prefer junk food’ HIGHER SES, MOTHER OF A CHILD UNDER 2 (U2), LACTATING, 35Y ‘I couldn’t quit sugar. It is Cake and Macchiato. Both have sugar in them.’ HIGHER SES, MOTHER OF A CHILD U2, LACTATING, 35Y | 16 | ‘I work at night, I come at 6 am. In the morning, I find my children sleeping. [….] After I go back home, I just sleep without eating anything. When the children wake up, I will cook food that can be done quickly. It can be eggs, it can be injera. I put my children to sleep and go back to work at eight o’clock. [….] I am working overnight six times a month, so think about it. What kind of work can I do after spending a tough night? Our option is, to eat shiro, which is left over from the day. So, my major challenge is time shortage, so I don’t even eat what I have because of time constraints.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 36Y | 17 | ‘This is the challenge I face with transport, when I come home from work, I am already tired and do not have time to prepare healthy foods for my family. […] One of the things that bothers me the most is the transportation problem. Because of this, I do not reach my children in time.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 30Y ‘Mine is a high workload. We have our own company. To take orders, and distribute, I don’t eat breakfast and I may even forget my lunch and just eat dinner. One constraint that I am facing is skipping meals. You go out in the morning, the road is crowded as you know, time flies, you receive orders and you do the distribution. So that will be your day and sometimes there is ups and downs in business. So at that time, you eat fast food.’ HIGHER SES, PRECONCEPTION, 22Y | 18 | ‘I have no one to help me at home and the other thing is my sickness. I like the foods here but I need someone to help me cook the meal and the constraint I am facing is not having someone to help me and lack of time which l e a d s m e t o n o t e a t t h o s e . ’ LOWER SES, PREGNANT, 22Y ‘This tea with bread is obligatory because my siblings and I all go to school, so we use bread with honey or bread with tea to save time; we use it daily.’ LOWER SES, PRECONCEPTION, 20Y ‘I work shifts. If I am in a night shift, I spend the night without proper sleep. When I get back home, I have the responsibility to do household chores. The picture shows potato so I eat it because it i s e a s i e r f o r m e t o c o o k . ’ LOWER SES, PREGNANT, 31Y | 19 | ‘As you can see, he slept before I could change his clothes, meaning it is because I don’t have a helper. I am doing all this alone but if I had a helper, he wouldn’t sleep on the floor without eating his dinner. My constraint is the high workload.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 28Y ‘Our regular meal mainly consists of two varieties, if not it could be one type. Sometimes it could have three or four types. This is because of time shortage when I get home. I am a government employee so when I get back home I do not have enough time to prepare all those varieties. Even for my under five child, I could not prepare three or four varieties. Mostly we eat two varieties. The demands of both work and domestic duties leave little room for me to feed my son properly.’ HIGHER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 39Y | 20 | WOMEN’S PROPOSED SOLUTIONS TO TIME CONSTRAINTS Government to provide sustainable water and electricity supply to all households Government to construct daycare centers Media to promote equal division of labor for men and women at household level Government to create job opportunities that can be done from home, to help with childcare responsibilities Government to subsidise the cost of household appliances Improve working patterns Reduce time spent commuting by improving road infrastructure and transportation services ‘Fast food is the only thing available.I said this because I work in a pharmacy and I go out early and come in late. I don’t have time to think of a b a l a n c e d d i e t . ’ HIGHER SES, PREGNANT, 31Y | 21 | Food environment factors5 POOR FOOD SAFETY, WATER, AND HYGIENE ‘The picture shows a mobile street vendor selling bananas. It is highly exposed to sunlight and dirt. I really appreciate the presence of vegetables and fruits around my home. Those vendors sell their goods by moving from place to place. When I buy from them, most of the fruits will be spoiled and discarded. I also believe that they wash those fruit with dirty water and it is difficult to trust them’ HIGHER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 38Y 5. The food environment is where people interact with the food system for the purpose of acquiring and eating food. SUMMARY At different levels of the food environment, women described various challenges: • At the household level, poor food safety and hygiene, as well as inadequate cooking space, were reported as main contributors to unhealthy eating, particularly amongst women from lower SES backgrounds. • At the neighbourhood and workplace levels, all women highlighted the physical inaccessibility of healthy foods as a key barrier to healthy eating. High availability and promotion of unhealthy foods were perceived as additional challenges, particularly among women from higher SES backgrounds. Food environment factors | 22 | ‘One of the pictures I took shows the act of cleaning vegetables before eating it. If vegetables are not cleaned properly, they might c a u s e d i f f e r e n t i l l n e s s e s . ’ HIGHER SES, PREGNANT, 31Y ‘Right now, we are facing a water supply problem. This jerrycan is mine. They say we get water once a week but it is less often than that. We are not able to do what we want or take a bath and water is essential to keep ourselves clean.’ LOWER SES, PRECONCEPTION,18Y ‘I wanted to buy cabbage but got kale instead and I bought it from the local street market. When I brought it home, it was all dirty so it represents a challenge of bad cleanliness making me not to follow a healthy diet.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 38Y | 23 | WOMEN’S PROPOSED SOLUTIONS TO WATER, FOOD SAFETY, AND HYGIENE ‘It’s lentils. Lentils need time to cook. It has to be washed, picked and even to do that, we get water once a week. So with all this, I only eat lentils once a week.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 28Y Government to provide small shops/shade for street vendors Government to provide sustainable water and electricity supply to all households Government to oversee the safety and hygiene of food sold Government to ensure food vendors have proper licenses | 24 | Food environment factors INADEQUATE COOKING SPACE ‘Rain penetrates the roof when it is winter and the floor has creeks on it and the roof is thick plastic roof. So my cooking space is not comfortable. The one constraint I am facing is finding a place to put my kitchen utensils neatly.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 29Y | 25 | ‘It is the life of many of us, the cookstove is here, there is a bed, we sleep there, we live in a very cramped house. So, it is difficult to cook something balanced in such an unfavorable situation. [...] I don’t cook when my children are sleepy because I am worried that they might be burned.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 36Y ‘I took a picture of the kitchen. The one constraint I am facing is finding a place to put my kitchen utensils neatly. So healthy eating needs a clean kitchen. That is why I took the picture.’ LOWER SES, PRECONCEPTION, 22Y | 32 | ‘The picture shows the advertisement of sweet foods and packed juices. When I pass the road with my children, they easily see the banner and ask me to buy them those cakes and juices. It promotes consumption of unhealthy foods like junk and processed foods.’ HIGHER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 38Y | 33 | ‘As you can see from the photo, the food served by the restaurant is not healthy. I just eat it because I am hungry and it is cheap. Eating my breakfast near my work also allows me to save money on transportation. By saving money from this, I can get better food for my son.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 30Y WOMEN’S PROPOSED SOLUTIONS TO AVAILABILITY AND PROMOTION OF UNHEALTHY FOOD Modify the food served at different gatherings Celebrate events in playgrounds for children to be more active Restrict advertisement of unhealthy foods Add front of pack labeling on junk foods and change the packaging to be less appealing | 34 | Economic factors9 LOW INCOME AND EMPLOYMENT ‘There are mangoes, oranges, and cabbages. But I didn’t buy those because I didn’t have money. So I left those and I bought sweet potatoes and potatoes since those are the only thing I could afford’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 38Y 9. Economic factors relate to household income, employment, food prices, and purchasing power. SUMMARY Economic drivers play a key role in shaping women’s food purchasing and consumption patterns, especially among women from lower SES backgrounds. Factors such as limited job opportunities, low salaries, unemployment, and high cost of living were reported as major barriers to consuming healthy foods. Economic factors | 35 | ‘It’s been a year since I graduated, but I didn’t get a job. I am eating from the money I saved during the COVID-19 outbreak. I don’t have a job at the moment. I buy injera or bread by ten or five birr, if I have it, I will cook firfir or shiro and eat it. I have a financial problem because I don’t have a job’ LOWER SES, PRECONCEPTION, 31Y ‘When I have money, I serve my children pastini with vegetables. But if I don’t have it, I can give them in white. Raising a child is easy if we can afford it.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 31Y | 36 | ‘I eat and feed my children bread and tea for breakfast. We could eat better food than this. They eat porridge with love, but they don’t always get it. But I have a financial problem to prepare that nutritious porridge’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 31Y | 37 | ‘I always feed my child oats and shiro. My problem is, I can’t afford to buy and provide other foods. I am working as a Janitor and my salary is low. [...] Sometimes I work various jobs and when I get money; It could be in three months, it could be in six months, I can buy them egg and bananas.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 31Y ‘I want to increase my income and am willing to work even harder if I can secure a place to sell. To avoid losing this opportunity, I currently work in front of someone’s door.’ LOWER SES, PREGNANT, 39Y | 38 | Economic factors FINANCIAL INACCESSIBILITY AND HIGH COST OF FOOD ‘The lady selling Kolo (roasted barley or pea) in the street. It is a source of income for her and I get kolo at a reasonable price. I have 4 children and they love cakes and the price of one cake goes up to 60 birr (0.5 USD). So I buy kolo from her and give it to them. It is not that they don’t want the cake but it is because I can’t afford it. I think I would rather spend 100 birr (0.84USD) to buy kolo for my 4 children rather than spend 200 birr (1.68USD) on cakes for them.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 39Y | 39 | ‘I may not get bananas when I want to. I may buy them once a week, and oranges are more expensive than the other fruits so I can’t get them every time. Papaya goes bad fast so you can’t buy that often. The other is watermelon. Its weight gets to around 4 kilos and it’s too much for one family and is expensive plus it will be wasted. So it is hard. I can only afford to get bananas. The others are expensive like oranges, papaya goes bad fast so I don’t want to buy it.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 28Y ‘Every Friday when I get extra money, I get some fruit. I love fruit, so I enjoy it with my family.’ LOWER SES, MOTHER OF A CHILD U5, NOT PREGNANT/LACTATING, 25Y | 40 | ‘Since banana is the only thing I could find easily, that is what I buy. The other fruits are expensive so I cannot afford them’ LOWER SES, PREGNANT, 28Y ‘I captured the photo when I went to work in the Menan area (around Addis Ababa University). The government consumer associations are supposed to provide goods with a lower price compared to other merchants. Sunday markets are expected to provide goods at a lower price but I have not seen any price difference with other markets.’ LOWER SES, MOTHER OF A CHILD U2, LACTATING, 29Y | 41 | ‘With the current cost of living, it is mandatory to eat the same foods over and over again, as we can see from the picture. Despite recommendations for a varied and nutrient-rich diet, economic realities often limit my choices. It is difficult to procure diverse foods. Our meals predominantly consist of budget-friendly staples like teff, bread, and lentils which are purchased in bulk to sustain the entire family.’ HIGHER SES, MOTHER OF A CHILD U2, LACTATING, 35Y | 48 | Dr Rebecca Pradeilles (French National Research Institute for Sustainable Development; International Food Policy Research Institute) email: [email protected] Professor Kaleab Baye (Addis Ababa University) email: [email protected] Meron Worku (Addis Ababa University) email: [email protected] CONTACT | 49 | Photo: iStock.com/mustafa6noz