Sub-Saharan Africa has persistently high rates of fetal growth retardation, pre-term birth, low birth weight, underweight and child stunting but also rapidly increasing rates of overweight and obesity^{(Reference Bain, Awah and Geraldine1–Reference Steyn and Mchiza3)}. The region is faced with a ‘double burden’ of malnutrition, where undernutrition in infancy and early childhood is followed by enduring micronutrient deficiencies and overnutrition in later childhood⁽⁴⁾. The 2019 Lancet series on Double Burden of Malnutrition suggested that this is due to changes in the global food system making less nutritious food cheaper and more accessible than nutritious food^{(Reference Popkin, Corvalan and Grummer-Strawn5)}. The risk of the double burden of malnutrition is now impacting people with low incomes and in rural areas, not just wealthier urban households. The Lancet series suggested that lifecourse interventions are needed to address malnutrition by optimising diet quality and implementing double-duty interventions by simultaneously tackling both under- and overnutrition^{(Reference Hawkes, Ruel and Salm6)}. The ‘first 1000 days’ concept emphasises the importance of nutritional investment from conception to the child’s second birthday to improve long-term population health^{(Reference Black, Victora and Walker7,Reference Bhutta, Das and Rizvi8)} .

This double burden, combined with food insecurity, is a feature of transitioning societies across Africa. Over half of sub-Saharan Africans live in extreme poverty, subsisting on less than US$1·90 per day, limiting their ability to purchase food⁽⁹⁾. Availability and access to higher quality food are further limited by lack of transport infrastructure⁽¹⁰⁾, and increasingly unpredictable climate has resulted in low harvest yields further reducing food availability^{(Reference Rayco-Solon, Fulford and Prentice11–Reference Mendenhall and Singer14)}.

Over the past 20 years, there has been rapid economic transition in Africa, including a shift from a subsistence to a more modern, industrialised economy, with accompanying urbanisation^{(Reference Popkin15)}. Economic transition has not only reduced levels of wasting and stunting but has also reduced physical activity. At the same time, industrialisation and urbanisation have resulted in a change away from traditional food systems and methods of food production. Traditional African diets, which include higher proportions of fruit and vegetables, have been found to be healthier than those in some high-income countries, but this is only the case if food access is secure^{(Reference Imamura, Micha and Khatibzadeh16)}. More often, the move towards modern food systems supports increased availability and reduced costs of high fat, sugar and salt foods, lowering dietary quality^{(Reference Agyepong, Sewankambo and Binagwaho19)}. The recent nutrition transition in Africa has seen communities moving from reliance on traditional foods towards more modern or mixed (traditional and modern) diets⁽¹⁷⁾, involving increased consumption of processed foods^{(Reference Popkin, Corvalan and Grummer-Strawn5)}, higher energy intakes and prevalence of overweight and obesity^{(Reference Steyn and Mchiza3)}. Nutritional transition is therefore accompanied by an epidemiological transition in that there is a parallel shift away from a burden of infectious disease towards chronic conditions^{(Reference Popkin, Corvalan and Grummer-Strawn5,Reference Barrett, Kuzawa and McDade18)} . Africa’s economic growth and societal changes also bring opportunities to address these health challenges^{(Reference Agyepong, Sewankambo and Binagwaho19)}. Further, the transitioning roles of women reduces obligations to marry, increases opportunities for employment and ‘personal liberation…being perceived as a free woman’^{(Reference Coquery-Vidrovitch20)}, which may offer women the chance to have more control over their family’s health and nutrition status. Women’s economic and political empowerment has long been linked to better health and well-being of their families^{(Reference Van den Bold, Quisumbing and Gillespie21)}, issues which are discussed in another paper in this special issue^{(Reference Compaoré, Ouedraogo and Boua22)}.

Implementing supportive double-duty nutritional interventions to simultaneously tackle both under- and overnutrition requires engagement of the target population along with policymakers across multiple sectors and the frontline operators. Such actions will need to be delivered through health services, social safety nets, educational settings, and agriculture, food systems and environments^{(4,Reference Black, Victora and Walker7)} . Double-duty interventions are discussed in another paper in this special issue^{(Reference Erzse, Goldstein and Norris23)}. Research suggests these interventions should be accompanied by a shift from a ‘top-down’ to a combined integrated ‘bottom-up and top-down’ approach that encourages collaboration between diverse stakeholders and creates shared value to reflect the nutritional needs of communities^{(Reference Huang, Cawley and Ashe24)}.

This study is focused on maternal and child nutrition in three settings at varying stages of economic transition. Although quantitative data can tell us how transitions lead to a double burden of malnutrition, they do not explain why or how national transitions affect individuals and local communities. Qualitative research can do this by providing an approach through which to engage with, explore and document people’s experiences and concerns. In the context of inequalities, qualitative research is valuable as a multicultural, gendered process, which can bridge local communities’ lived experience to history, politics and decolonisation^{(Reference Denzin and Lincoln25)}. The focus of previous qualitative studies on nutrition in sub-Saharan Africa included communities’ belief on and practices with foods. Two qualitative synthesises of data from participatory interviews and focus groups on maternal and child health in sub-Saharan Africa reported that many communities spoke of foods that were ‘forbidden’ for pregnant women as they were believed to increase the risk of birth complications and death^{(Reference Sumankuuro, Crockett and Wang26)}. Strong beliefs in the healing power of foods were also identified, although there was little agreement on which foods had which powers^{(Reference Raman, Nicholls and Ritchie27)}. Previous qualitative studies have described beliefs and practices concerning food and nutrition in sub-Saharan Africa, but have not explored communities’ understandings of causes of and solutions to poor maternal and child nutrition. Objectives of the study reported here were therefore to explore communities’ perceptions of factors affecting maternal and child nutrition in three transitioning sub-Saharan African sites and to collect ideas for context-specific solutions to maternal and child nutrition problems^{(Reference Compaoré, Ouedraogo and Boua22,Reference Erzse, Goldstein and Norris23,Reference Debpuur, Nonterah and Chatio28)} .

Results

Thirty focus groups were conducted, eleven in Nanoro, ten in Navrongo and nine in Soweto, involving 237 participants whose characteristics are presented in Table 1.

Table 1 Characteristics of focus group discussion participants by country

We identified two major themes underlying participants’ experiences on and concerns with maternal and child nutrition in their settings: (i) stage of the country’s transition (epidemiological, nutritional and economic) and (ii) proposed solutions (household, community and structural). Data under each theme are presented below as a series of sub-themes, supported by quotes from each site, gender and age group. Theme one is represented in Fig. 1 that explains what the communities perceived to be influencing maternal and child nutrition. Participants described problems of under and overweight in mothers and children in their sites, the extent of which appeared to depend on the stage of economic, epidemiological and nutritional transition of their countries. Participants in all three sites described economic constraints that influenced the way they were either able to produce or purchase food. For farming communities, climate change was seen to be having profound impacts on the way they could feed themselves. Communities suggested solutions to these problems which are described in Table 2.

Fig. 1 What did communities perceive to have influenced maternal and child nutrition in three sites in sub-Saharan Africa? Thematic map

Table 2 Proposed solutions by community members across all three sites, operating at three ecological levels: household, community and structural

Transitions

Discussions with participants suggested that different stages of epidemiological, nutritional and economic transition in each of the study settings influenced the communities’ disease status, access to nutritious food and economic constraints, ultimately impacting upon maternal and child nutrition and health. Findings from the discussions are presented to reflect these ongoing transitions and the differing economic conditions between countries.

Epidemiological transition

Participants spoke of different disease states, which appeared to be influenced by the stage of epidemiological transition of their site. People in Nanoro and Navrongo spoke of infectious diseases affecting community health, whereas in Soweto, the coexistence of infectious and non-communicable diseases was discussed.

In Nanoro, the least transitioned setting, the focus of health concerns was infectious diseases; particularly, malaria were prevalent and believed to be caused by environmental factors.

‘Here in Nazoanga, children suffer from malaria and malnutrition’ FGD03_Men_18–55yr_Nanoro, Burkina Faso

‘It is mosquitoes, dirty waters, the dust and the wind.’ FGD01_Women_18–25 yr_Nanoro, Burkina Faso

Similarly, communities in Navrongo reported infectious disease as an issue; however, community members reflected on how their understanding of disease has evolved over time so that they now take effective preventive actions. In this way, the community felt they had become more active agents in managing their own health.

‘In the past, after fetching water… some women soak clothes in water for days without washing them, and mosquitoes can easily breed in them for them to get malaria …. Now the women wash their clothes and put everything in order, they cover their items with nets, ….so the things of the past have changed.’ FGD03_Women_26–39 yrs_Navrongo, Ghana

Discussions in Soweto, the most urbanised of the settings, revealed the coexistence of communicable and non-communicable disease in the community, including mental health problems.

‘A lot of people where I live are sick, some have HIV and then most of the youth and elderly have diabetes, and some have cancer.’ FGD02_Women_26–40 yrs_Soweto, South Africa

‘Depression, it’s there, it does exist among women but people don’t understand what it is exactly.’ FGD01_Women_26–40 yrs_Soweto, South Africa

Nutritional transition

Regardless of whether their main concerns were about communicable or non-communicable diseases, participants in all sites made the connection between disease and nutrition. They recognised that eating well improves health for adults and children and prevents both types of disease.

‘Good nutrition is the one that gives you good health.’ FGD01_Women_18–25 yrs_Nanoro Burkina Faso

‘Good nutrition gives blood and also protects you from diseases…The white people have a saying that, “an empty sack cannot stand upright”. When you wake up from bed, and the stomach is empty, you are weak, you cannot stand up to work. So it opens the mind, it also gives blood, it also makes you strong. It is in the body fighting against diseases.’ FGD03_Women_26–39 yrs_Navrongo, Ghana

‘In order for them to be healthy you need to give them healthy food, give them veggies, get him accustomed to eating veggies, eating fruits, we need to pull them away from eating junk because at the end of the day … it makes kids obese, it makes kids not think properly’ FGD01_Women_26–40 yrs_Soweto, South Africa

Participants spoke of the ways that food availability and access to food had changed in recent times. They described how farmers in settings with more traditional food systems including Nanoro and Navrongo were struggling to grow enough nutritious food to feed their families. They believed this to be, at least in part, caused by changing weather patterns. By contrast, the urban community in Soweto reported increasing reliance on processed takeaway foods instead of home-cooked meals and diminishing cultivable land for agricultural production. This is both a feature of transition to a more modern food system which had moved away from agricultural production and increasing urbanisation in South Africa.

In Nanoro, participants described how seasonal fluctuations affected food security and how they had to travel long distances and required transport to buy nutritious foods.

‘The season was good but last year it hadn’t rained enough and we had bad harvest…. One year is not enough to solve one bad year’s harvest.’ FGD03_Men_18–55 yr_Nanoro, Burkina Faso

‘Here we do not have vegetables. We must go and buy some in Wamzaala (6 km) to sell. Times before we went by bike to Nanoro (21 km) to buy the vegetables.’ FGD02_Women_35–55 Nanoro, Burkina Faso

In Navrongo, it was reported that water insecurity led to insufficient fresh produce and the community had to eat dried vegetables. They associated this with poor nutrition and health.

‘There is no water for us to water our gardens. We harvest the fresh vegetables and dry them. These dried vegetables, they don’t have nutrients for the body’ FGD06_Women_40–50 yrs_Navrongo, Ghana

Additionally, communities in Navrongo reported that health workers advise pregnant women to eat healthy food but these foods were not available; they did not grow in this area and were too expensive to buy.

‘Whenever we go to the hospital, they tell us to eat these foods because they are good. Because we don’t have them is why we eat our local foods like the kapuno, TZ, and the vegetables and rice.’ FGD03_Women_26–39 yrs_Navrongo, Ghana

More of the conversation with participants from Navrongo and Nanoro was focused on issues with generating sufficient food for their families rather than on the provision of good quality, diverse diets. This was less the case in Soweto, where much of the concern was with the poor quality of the food available locally in the shops and sold by street vendors. It was perceived to be more convenient and cheaper to purchase and consume widely available junk food than to prepare fresh food; this was a recent phenomenon.

‘Food these days is wrong, wrong, wrong; you know back then, there used to be kota (bunny chow) we’d get it from school but it was scarce, but now at every corner there are those chips for R5 (US$0·27)…’ FGD08_Women_40+yrs_Soweto, South Africa

Economic constraints

All communities described problems of poverty and lack of employment opportunity that limited access to nutritious foods for mothers and children and so affected their health. Different causes of poverty were discussed, including poor agricultural yield and lack of employment, which lead to having little food and no money to live on.

Participants described poverty as the main constraint to quality nutrition and health. They said poverty dictated their lives, and that they had developed coping mechanisms in order to survive.

‘Poverty is the first disease.’ FGD03_Men_18–55 yrs_Nanoro, Burkina Faso

Men in Navrongo described how they attempted to escape poverty by migrating to the cities and leaving their families behind.

‘When the dry season comes about most of us especially we the young people, we run to Kumasi and stay looking for your daily bread alone, while the woman and the child are at home not having food to eat.’ FGD09_men_35–50 yrs_Navrongo, Ghana

Similarly, in Soweto, people described poverty leading to involvement in crime and substance abuse as a means to escape from a hopeless situation.

‘It’s poverty. There are many who are unemployed and that leads to involvement in crime, and drugs such as Nyaope’ FGD09_men_18+yrs_Soweto, South Africa

In Soweto, drinking was an issue for both genders. Alcohol was an instrument to help respondents’ troubles with additional consequences for the health and well-being of their children.

‘They do that because of their problems, there’s no woman that wants to be an alcoholic when they have kids’ FGD01_Women_26–40 yrs_Soweto, South Africa

Unemployment and underemployment were prevalent contributing factors to poverty in all settings. For those who did work, livelihoods depended on whether the setting was rural or urban and the stage of transition from a more traditional to modern food system. In the rural communities, farming was described as becoming less productive; seasonal fluctuations believed to be caused by climate change were reducing the quantity and quality of foods available to mothers and children in those communities.

In Navrongo, the main source of income is subsistence farming and communities expressed challenges of yielding nutritious crops.

‘… there is no money for us to farm, and also the farming is not progressing well. The land is not nutrient dense because of this, the micronutrient in the produce would not be sufficient’ FGD08_men_24–34 yrs_Navrongo, Ghana

In Soweto, women reported that they put themselves at risk in order to provide for their children.

‘… I can’t find a job, I go taking my CV but they don’t call me back, so what do I do, I come with that mentality that because of I’m a woman, I can use my body to make money. I go to town and prostitute myself so I can buy food for my kids.’ FGD01_Women_26–40 yrs_Soweto, South Africa

In Nanoro, women who had employment spoke of having to work long hours in markets whilst pregnant or with their child.

‘We have to wake up early in the morning to go buy articles we are selling, if you are pregnant with a young child how are you going to manage?’ FGD02_Women_35–55 yrs_Nanoro, Burkina Faso

Solutions

Community members, despite feeling disempowered, had suggestions for improving maternal and child nutrition and wanted to be part of the solutions. Their solutions are presented below as they apply to the household, the community and societal structures.

To address their frustration that they had so little control over theirs and their children’s diets, women asked for financial support to establish businesses to generate their own income. They felt that having their own income would increase the opportunities for them and their children to have healthier lives.

‘The last rainy season, some of us got supported with 20 000 cfa (US$33·19) to improve their business… some women wanted to implement activities to generate income.’ FGD02_Women_35–55 yrs_Nanoro, Burkina Faso

‘We want jobs. If you have a job and you have food with money. You and your children are healthy even without your husband. Because you have your profession, you wouldn’t mind him. You have peace of mind.’ FGD05_Women_40–50 yrs_Navrongo, Ghana

‘Helping mothers to get an income. Especially mothers because they are the ones that go all out to ensure that children are fed.’ FGD02_Women_26–40 yrs_Soweto, South Africa

Participants in all sites suggested solutions based on community empowerment, including investment in gardening and local agriculture, support from health workers with food preparation, and establishing community member support groups.

‘What we can add is we want health care workers who will sensitise people to good nutritional practices, hygiene, cleanliness. To give advice to people, give them solutions.’ FGD03_Men_18_55yrs_Nanoro, Burkina Faso

‘We have a large valley here so that let’s say four or five us go and do gardens there and plant - whether it is cassava, plantain or orange trees. In three to four years’ time, when we go there we will get food for a pregnant woman to eat to be strong’ FGD07_men_18+yrs_Navrongo, Ghana

‘So helping… support groups, we need to talk to each other, because we’re basically fighting on our own as women…’ FGD04_Women_18–25 yrs_Soweto_South Africa

Participants asked that governments provide context-specific solutions to increase the availability of healthier foods. The people in Nanoro wanted a reduction in food prices, communities in Navrongo sought the construction of dams, and people in Soweto wanted healthy food packages and social grants, increased availability of healthy food and regulation over the availability of unhealthy foods.

‘They (the government) won’t give us the food for free. They are going to reduce the price and we are going to give our contribution. … Instead of paying 20 000 cfa (US$33·19) for one bag maybe two bags can be 20000cfa.’ FGD02_Women_35–55 yrs_Nanoro, Burkina Faso

‘If the government can create a dam here … they will get fresh vegetables. Because the rains are seasonal, we dig boreholes, in order to help us farm. Now we are there waiting for the next year’s rains to farm…’ FGD10_men_18+yrs_Navrongo, Ghana

‘I would start a feeding scheme … getting their social grants; they [mothers] need to come back with a little package of at least healthy food… a health pack for the child’ FGD09_men_18+yrs_Soweto, South Africa