UC Davis

Adolescence is a transformative period of physical, cognitive, and social growth and development. Good nutrition during this period is essential for optimal growth and development during adolescence as well as health in adulthood. Nutrition interventions for adolescents have been understudied, but school may be a promising platform for adolescent nutrition interventions (Chapter 1). Further, despite the importance of nutrition during adolescence, globally adolescent diets are poor and malnutrition in all its forms is common. Adolescent food insecurity is also associated with negative health and development outcomes, but parents may be unaware of their child’s experiences due to time spent away from home and adolescents’ increasing independence. In Ghana, adolescents attending junior high schools do not have access to the national school feeding program and therefore must bring food from home or purchase it while at school. Thus, school food environments may influence adolescents’ food purchasing and consumption. It is important to understand how adolescents interact with their food environments when making choices around food. This study explores food insecurity, school food environments, and school food choices among adolescents attending junior high schools in the Cape Coast metropolitan region of Ghana. In Chapter 2, we describe the prevalence of adolescent experiences of food insecurity at home and school and assess parents’ abilities to report on their child’s experiences. We also test whether adolescent food insecurity at home and at school are related to their diet quality. We selected 8 public junior high schools in the Cape Coast area and randomly selected 187 adolescent /parent pairs across the schools. Using the Child Food Insecurity Experiences Scale (CFIES), adolescents and parents reported about adolescent experiences of food insecurity at home and at school. Parents also reported on household food insecurity using the Household Food Insecurity Access Scale (HFIAS). Adolescents reported their diets via the Diet Quality Questionnaire (DQQ) for Ghana, which was used to create Food Group Diversity (FGDS), NCD-protect, NCD- risk, and All-5 scores to describe diet quality. We assessed differences in food insecurity scores using t-tests and agreement between parents and adolescents using Cochrane’s Q and Cohen’s kappa. We used linear and logistic regression to assess the relationship between food insecurity and diet quality indicators, adjusting for covariates. We found food insecurity to be high among adolescents with over half of adolescents reporting several/many food insecurity experiences at school (56.7%) and at home (53.5%), but this was not significantly different between home and school (p=0.239). Parent and adolescent reports of adolescent food insecurity at home did not differ, while reports at school did (30.5% vs. 56.7% p=0.002). Parental report of household food insecurity was significantly worse than adolescents’ self-reports (82.4% vs. 56.7% moderate/severe food insecurity). We also found that adolescent, but not parental, reports of food insecurity at home and at school were negatively associated with diet quality. In Chapter 3, we conducted structured observations of all food vendors within a 0.25-km radius of each of the 8 selected junior high schools. We compared foods sold and hygiene practices by on vs. off campus vendors, by urban vs rural vendors, and by vendors located in communities where the primary livelihood activities were fishing, agriculture, and petty trading. We also assessed the relationship between adolescent diet quality (using the same 4 diet quality indicators as in Chapter 2) and where adolescents primarily obtained food during the school day (bring from home, purchase off-campus, or purchase on-campus). We identified 265 food/beverage vendors across the 8 schools and 25.3% of them were on-school campus vendors. On-campus vendors were less likely to sell branded snacks (19.4% vs. 33.8%, p=0.001) and beverages (17.9% vs. 35.4%, p=0.008) and more likely to sell cooked/prepared dishes (53.7% vs. 31.8%, p=0.001) than off-campus vendors. All vendors practiced an average of 38.8% of applicable food hygiene practices, which did not differ by on- or off- campus location. 59.4% of students most often purchased food on campus, but there were no significant relationships between where students primarily obtained their food and any of the diet quality indicators. Finally, in Chapter 4, we used a qualitative, participatory Photovoice method to understand the factors that influence adolescent food choice and how adolescents interact with their school food environments from their own perspectives. We also elicited adolescents’ ideas for the improvement of their school food environments. We used a sub-sample of 4 of the 8 schools and purposively selected 10 students from each school. Adolescents were provided with digital cameras and weekly photography prompts followed by semi-structured group discussions each week for 5 weeks. Photographs and discussion transcripts were analyzed thematically with input from the adolescents. Adolescents reported factors influencing their food choice at the policy, environmental, inter-personal, and individual levels, mirroring the socioecological model. These factors included school policies (30 coded references), food hygiene and safety (374), food availability (83), relationships with vendors (62), peer influence (36), nutritional value (42), taste (41), satiety (25), appearance (30), and affordability (160). Taken together, the results of this study suggest that food insecurity is common and strongly related to adolescent diet quality, but parents are often not aware of their child’s experiences. Additionally, while managing food insecurity many adolescents purchased food at school and there were differences in foods sold by on- and off campus vendors. When making food choices, adolescents often considered food hygiene and safety and affordability. Thus, school-level interventions are needed to address foods available to adolescents at school. School policies may be a promising avenue to alter food environments for adolescents and influence their food choice, especially if they focus on hygiene and safety and affordability of foods.