Appetite 168 (2022) 105748

Contents lists available at ScienceDirect

Appetite
journal homepage: www.elsevier.com/locate/appet

Drivers of food choice among women living in informal settlements in

Nairobi, Kenya
Shauna M. Downs a, b, *, Elizabeth L. Fox c, Alexandra Zivkovic a, Theodora Mavros d,
Minna Sabbahi a, Emily V. Merchant b, d, Vincent Mutuku e, Kedeen Okumu-Camerra a,
Simon Kimenju f
a
Department of Urban-Global Public Health, School of Public Health, Rutgers University, NJ, USA
b
Center for Agricultural Food Ecosystems, The New Jersey Institute for Food, Nutrition, and Health, Rutgers University, NJ, USA
c
Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
d
School of Environmental and Biological Sciences, Rutgers University, NJ, USA
e
G-thamini Youth Group, Nairobi, Kenya
f
Kula Vyema Centre of Food Economics, Nairobi, Kenya

A R T I C L E I N F O A B S T R A C T

Keywords: Suboptimal diets drive the multiple burdens of malnutrition among women living in informal settlements.
Food choice Women’s food choices have important implications for their health, as well as that of their families. The purpose
Food environment of this study was to examine how food choice decisions might differ across different age groups of women living
Food preferences
in informal settlements in Nairobi, Kenya. Using in-depth interviews which incorporated a free-listing task, we
determined the factors influencing food choice decisions in women in two informal settlements, Kibera and
Mukuru. Among women in all age groups, we found income and food price to be the most salient factors
influencing food choice decisions. Differences across age groups regarding food choice considerations included
individual preference and quality being more salient factors amongst younger women while household prefer­
ences were more salient among older women. Women also reported making trade-offs between food affordability
and other factors including time and nutrition, which led to sub-optimal diets. Our findings suggest that in­
terventions in these settings may need to be tailored to specific age groups. Additionally, interventions may need
to target both individual factors and the external food environment to help women overcome the trade-offs they
often find themselves making in food choice decisions.

1. Introduction while the prevalence of overweight/obesity among women was 43.4%

and expected to rise (Ettarh et al., 2013). Suboptimal diets drive the
Kenya is one of the most rapidly urbanizing countries globally and, multiple burdens of malnutrition in these settings (Afshin et al., 2019).
like many low- and middle-income countries (LMICs), over half of urban Women and children residing in informal settlements tend to have poor
dwellers live in informal settlements (i.e., slums), with some estimates as dietary quality and diversity (Wanyama, Gödecke, & Qaim, 2019). Ce­
high as 80% of urban dwellers in Kenya (Metcalfe, Pavanello, & Mishra, reals and vegetables are consumed regularly, and other nutritious food
2011; Amendah, Buigut, & Mohamed, 2014). Inhabitants of informal groups are consumed less frequently (Wanyama et al., 2019).
settlements are among the groups at highest risk of multiple forms of Diets are influenced by the interaction between individual factors (e.
malnutrition, often experiencing undernutrition and overweight/­ g., income, preferences, skills, etc.) and the external food environments
obesity within the same household (Abuya, Ciera, & Kimani-Murage, that consumers interface with. The external food environment “en­
2012; Ayah et al., 2013; Ettarh, Van de Vijver, Oti, & Kyobutungi, compasses the availability, affordability, convenience, promotion and
2013; Kimani-Murage et al., 2015, Kimani-Murage, Schofield, Wekesah, quality, and sustainability of foods and beverages in wild, cultivated,
et al., 2014, Tzioumis & Adair, 2014). In Kibera, an informal settlement and built spaces that are influenced by the socio-cultural and political
in Nairobi, stunting in children <5 years was 47% (Olack et al., 2011), environment and ecosystems within which they are embedded” (Downs,

* Corresponding author. Department of Urban-Global Public Health Rutgers School of Public Health, One Riverfront Plaza, Suite 1020, Newark, NJ, 07102, USA.
E-mail address: sd1081@sph.rutgers.edu (S.M. Downs).

https://doi.org/10.1016/j.appet.2021.105748
Received 1 July 2021; Received in revised form 6 October 2021; Accepted 8 October 2021
Available online 9 October 2021
0195-6663/© 2021 Elsevier Ltd. All rights reserved.
S.M. Downs et al. Appetite 168 (2022) 105748

Ahmed, Fanzo, & Herforth, 2020, p. 5). External food environments in 2. Methods
LMICs are rapidly evolving, particularly in urban settings (Downs et al.,
2020; Turner et al., 2018). Urban food environments are increasingly As part of an ethnographic study, we conducted in-depth interviews,
associated with heightened availability of inexpensive, energy-dense, including a free listing task (Pelto & Armar-Klemesu, 2014; Weller &
nutrient-poor foods driving overweight/obesity and diet-related non-­ Romney, 1988), to identify key factors that women considered when
communicable disease (NCDs) worldwide (Hawkes, Harris, & Gillespie, making decisions about which foods to purchase and consume in the
2017, pp. 34–41; HLPE, 2017; Popkin, Adair, & Ng, 2012; Popkin & Kibera and Mukuru informal settlements in Nairobi.
Gordon-Larsen, 2004). For example, small packages of affordable,
ultra-processed foods, such as sweet biscuits and cookies, are widely sold 2.1. Study setting
by kiosks, roadside stalls, and street vendors for as little as 5 Kenyan
shillings ($0.05 USD) (Euromonitor International, 2017). Although food Kibera and Mukuru are two of the largest informal settlements in
environment changes have been documented in urban LMIC settings Nairobi. Kibera was the first informal settlement established in Nairobi
(Downs, Ahmed, Warne, Fanzo, & Loucks, n.d.), little is known about (1910), while Mukuru was more recently established (1980) (Wanjiru &
how individual factors interact with the changes in urban food envi­ Matsubara, 2017). These settlements are characterized by inadequate
ronments to influence food choice decisions and dietary practices in access to safe water, few sanitation facilities, poor structural quality of
these settings (Downs & Demmler, 2020; Turner et al., 2020). housing, overcrowding, and insecure land tenure. The people living
Women’s food choice decisions are particularly important to within these settings often engage in informal labor, have high levels of
examine, given their roles and responsibilities as critical decision- food insecurity, and consume poor-quality diets (Wanyama et al., 2019).
makers in the context of food environments (Twyman, Talsma, Togka,
Ferraboschi, & Brouwer, 2020). Women are often the ones ensuring that 2.2. Study participants
their nutritional needs, in addition to those of their family are met
(Madzorera & Fawzi, 2020). They balance the trade-offs associated with With the assistance of our local community partners in Kibera and
food choice decisions for themselves and their families and are key Mukuru, we purposively selected 20 women 18 years or older from each
decision-makers regarding household food procurement and prepara­ settlement to participate in the study (total n = 40 participants). We
tion, including in rapidly changing urban food environments (Twyman based our sample size on the number of people needed for free-listing
et al., 2020). Many food choice considerations are well-documented in analyses (Weller & Romney, 1988), and the number we estimated that
existing literature (e.g., health, affordability) (Furst, Connors, Bisogni, we would need in each sub-group (10–15 individuals) to reach theo­
Sobal, & Falk, 1996; Sobal & Bisogni, 2009). However, less is known retical saturation within each subgroup (Fugard & Potts, 2015).
about how and why women prioritize different considerations over We recruited women in three age groups: women 18–24 years;
others when deciding which foods to purchase and consume for them­ women 25–34 years; and women 35 years and older. We focused
selves and their families. In order to address the multiple burdens of exclusively on women given that they are a key population for in­
malnutrition in the face of changing food environments, it is essential to terventions targeting nutrition and food choice, their role in food pro­
understand how women make decisions about their food choices. Un­ curement and preparation in households, and our expectations for
derstanding what drives women’s decision-making can help inform the varied experiences across different age groups. Given that this study was
development of interventions aimed at individual factors and the food focused on adult women, we did not include adolescent girls under the
environments they interface with to reduce the burden of malnutrition age of 18 years. We divided participants in age groups that reflected
for women and their families. differences in fertility rates and population dynamics (Opiyo, 2003;
However, women are not a homogenous group (Fox, Davis, Downs, National Bureau of Statistics-Kenya and ICF International, 2015).
Schultink, & Fanzo, 2018). For example, one way in which women The study participants were selected to capture a diversity in age
exhibit diversity is by age group. Life transitions and events across the range, geographical location of their households within the settlements,
life course influence nutrition decisions (Devine, 2005; Fox & Timmer, and education levels. To recruit women, our local partners identified
2020; Herman et al., 2014). It is important to consider women’s women through their existing networks and reached out to them to
changing roles and responsibilities over time (e.g., childbearing, care­ ascertain their interest in participating in the study. Members of the
giving, schooling, working, etc.). In high-income settings, life course research team then described the study to the participants and obtained
events have been used to assess low-income mothers’ experiences written informed consent. Ethical approval was obtained from the
feeding their families (Agrawal, Farrell, Wethington, & Devine, 2019; Rutgers University Institutional Review Board and the Amref Health
McClain, Dickin, & Dollahite, 2019). Few studies exist to examine how Africa Ethics and Scientific Review Committee in Kenya. We provided
food choice considerations evolve over the life course for adults more participants with 200 Kenyan shillings (~$1.85 USD) to thank them for
generally in LMICs, and the extent to which the experiences of adults participating in the study.
(and specifically, adult women) are shared. Different approaches may be
needed to support women at different life stages given varied drivers 2.3. Data collection
impacting their decision-making, including in rapidly changing food
environments (i.e., the availability, affordability, convenience, promo­ All interviews were conducted in person in March 2019. The in­
tion and quality, and sustainability of foods and beverages in the spaces terviews were conducted in English and/or Swahili, depending on the
that consumers interface with (Downs et al., 2020)) (Fox et al., 2018). preference of the participant. Members of the research team (SMD, MS,
As such, this study aimed to examine the considerations (including EM) conducted the interviews with the assistance of local translators.
both individual factors and elements of the food environment) that in­ The interviews took an average of 35–40 min to complete. As part of the
fluence food choice decision-making among women living in two interviews, we asked the women a series of open-ended questions about
informal settlements in Nairobi, Kenya, with special consideration for their eating patterns, how they perceived their culture to influence food
how women’s context shapes their food choice decisions. We specifically choice, the considerations they make when deciding what foods to
looked at differences based on age and hypothesized that the key con­ include in their diet, how their diet has shifted over time, how they
siderations influencing women’s food choice would differ across age define healthy eating, and where they get information about foods they
groups despite living in comparable settings and engaging with similar should eat. We audio-recorded all interviews and recorded notes during
food environment contexts. the interviews to facilitate data analysis.
In addition to the open-ended questions, the interview guide also
included a free-listing activity. Free listing is a tool used in focused

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S.M. Downs et al. Appetite 168 (2022) 105748

ethnographic studies to systematically identify items in a “cultural items in each groups’ list corresponded to the salience of those items in
domain” (Borgatti & Halgin, 2013). A cultural domain is a set of words other age groups). A correlation matrix was developed based on estab­
and concepts, at the same level of contrast, that describes a subject lished methods for cross comparisons using free-listing (Thompson &
matter of interest (Weller & Romney, 1988), and is typically shared Juan, 2006). We used chi-squared tests to compare the
across members of a cultural group. In our case, we were interested in socio-demographic characteristics of participants based on age group.
exploring the domain of drivers of food choice among women across the All quantitative analyses were conducted using SPSS (version 27, 2020),
life course in informal, urban settlements in Kenya. We used the tech­ and a p-value of <0.05 was considered statistically significant.
nique to ascertain a list of factors that individuals considered when
deciding what foods to acquire, purchase, and consume. This technique 3. Results
has been previously used to elicit factors that influence breastfeeding
practices as well as food choices in other settings (Fox et al., 2017). We We interviewed 11 women aged 18–24 years, 12 women aged 25–34
asked participants, “What are all of the things that you and others you years, and 15 women 35 years and older. The age group that included
know consider when choosing what foods to eat and buy?” Women women 35 and older contained five women in each of the following age
provided an initial list of considerations, and we probed for additional brackets: 35–44; 45–49; and 50 and over. While this age group repre­
considerations. We recorded the order of the items participants listed on sents a wide age range, the items listed and experiences described by
the interview guide. We also asked participants to describe the meaning these women were similar. We found significant differences in de­
of each consideration and how they thought that consideration influ­ mographic characteristics across the age groups including by the loca­
enced food decisions. tion of residence, marital status, and employment status (Table 1).
Overall, younger women (18–24 years) were more likely to reside in
2.4. Data analysis Mukuru, be single and be unemployed compared to women 25 years and
older.
We used a combination of qualitative and quantitative data analysis
for this study. All interview data were analyzed qualitatively, while the
free-listing exercise data were analyzed quantitatively. 3.1. Overview of dietary patterns
All audio-recordings from the interviews were transcribed verbatim;
the transcripts included interview content in English and Swahili, Overall, women described their diets as consisting mainly of staple
including the translators’ translations, which allowed us to verify their foods such as ugali and rice. Kale was the most commonly consumed
accuracy. Transcripts were subsequently open coded by two members of vegetable. Chapati, mandazi (fried dough), beans, and fish were also
the research team (AZ and TM) and organized based on the constructs reportedly consumed frequently. When asked how their diets have
included in the socio-ecological model of the food environment which changed over time, women reported several changes including
includes: diets, individual factors (e.g., preferences, health, knowledge, consuming less meat and less variety of foods, less frequently consuming
time, etc.), food environments (wild, cultivated and built), sectors of foods that require longer cooking times, and eating more non-traditional
influence (e.g., labor, media, agriculture, etc.), socio-cultural and po­ foods such as spaghetti and pizza. Women who were 35 years or older
litical environment (e.g., culture, conflict, national income, etc.) and more often reported changes in their diets over time. In many cases,
ecosystems (e.g., climate, topography, etc.) (Downs et al., 2020). The these changes were driven by migration from rural to urban areas,
qualitative data from the interviews was used to contextualize the data including the influence of location on food quality and affordability. As
from the free-listing exercise. one interviewee said: “You cannot eat the same way, as you were a child.
In order to analyze the free-listing results, we compiled all consid­
erations following free-listing analysis procedures (Weller & Romney, Table 1
1988). Using the content from the interview transcripts to understand The socio-demographic characteristics of participants from Mukuru and Kibera.
participants’ meaning of the cited items, we consolidated the terms used Sociodemographic variable 18-24* 25-34 35 and p-
in the participants’ respective lists such that common ideas and mean­ (n = (n = over§ (n value
11) 12) = 15) n
ings were represented by the same terminology (Supplementary Mate­
n (%) n (%) (%)
rial, Table S1). We removed any duplicates from a given woman’s list
and used the first mention for the analysis. We used Free List Analysis Location of Kibera 1 (9) 6 (50) 12 (80) .002*
Residence Mukuru 10 6 (50) 3 (20)
under R Environment using Shiny (FLARES) version 1.0 (FLARES, 2017) (91)
to determine data saturation by identifying the point at which an Marital Status Married 1 (9) 8 (67) 6 (40) .020*
additional participant added no new items to the list, and item salience Separated 0 (0) 0 (0) 2 (13)
by using Smith’s Salience (S) Index to account for both the frequency Single 10 2 (17) 4 (27)
(91)
and rank order of items mentioned across participants. The Smith’s S
Widow 0 (0) 1 (8) 3 (20)
Index is a technical construct used to analyze free-listing data, which Missing 0 (0) 0 (0) 1 (7)
produces scores ranging from 0.0 to 1.0 (Borgatti & Halgin, 2013), Highest level of Primary school 3 (27) 5 (42) 9 (60) .364
where numbers closer to 1.0 have higher salience, meaning that they education Secondary 5 (45) 3 (25) 3 (20)
were mentioned first on every participants’ list, and where numbers completed school
Diploma 1 (9) 3 (25) 3 (20)
closer to 0.0 had lower salience, meaning that they were not mentioned College 2 (18) 1 (8) 0 (0)
often and were mentioned towards the end of each participants’ lists Employment Employed by an 1 (9) 4 (33) 4 (27) .018*
(Sutrop, 2001). status organization
We identified the most salient items in the free lists by examining a Self-employed 4 (36) 7 (58) 10 (67)
Unemployed 6 (55) 1 (8) 0 (0)
scree plot of the items ordered from greatest to least salience and
Missing 0 (0) 0 (0) 1 (7)
determining the “elbow” of the plot for all the age groups (Borgatti & Head of Yes 4 (36) 3 (25) 11 (73) .054
Halgin, 2013). We examined the correlation between the most salient household No 6 (55) 9 (75) 4 (27)
items of the free lists of the different age groups (women 18–24 years; Missing 1 (9) 0 (0) 0 (0)
women 25–34 years; and women 35 years and older). Based on this * p-value <0.05 using chi-squared tests.
approach, we compared the most salient items for each age group to the §
Five women were included in each of the following age groups: 35–44; 45–49;
salience scores of those same items for other age groups using Pearson’s and 50 and over.
correlation coefficients (i.e., to determine whether the most salient Please note 2 participants did not provide their ages.

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S.M. Downs et al. Appetite 168 (2022) 105748

You know when I was a child, I used to eat everything, nothing affected me, I older compared to those 25–34 years. Younger women (ages 18–24)
ate anything edible that I got but you find now I have to choose what to eat. In reported food safety concerns related to the hygiene of the food envi­
the rural areas, things like vegetables are not expensive as buying things in ronment (e.g., where the food is being handled and sold, the appearance
Nairobi.” (Interviewee 13, Kibera, 49 years). of the person handling food) whereas the predominant concern related
to hygiene in women ages 25–34 was chemical contamination in foods
(although concern about chemicals in food appeared across age groups).
3.2. Drivers of food choice: free listing
Individual preferences (e.g., tastes, cravings, favorite foods) were
more salient to women in the younger age group (18–24 years)
Participants identified 19 considerations that influenced the foods
compared to the other age group categories, and household preferences
they purchased and consumed (Table 2). On average, each participant
(e.g., children and family’s preferences) were more salient in women 35
listed 3.6 considerations (range: 2–7 considerations), and 8 participants
years and older compared to the other age group categories. The simi­
were needed to reach saturation (i.e., no new items were added to the
larities and differences are elaborated in more detail by the qualitative
list by additional participants). The cut off for the most salient items
interviews reported below.
across participant age groups, based on the scree plot, was 8 items.
Table 3 depicts the correlation between the free lists of women from
Overall, income and food price (i.e., food affordability) consider­
different age groups. Overall, the correlations between the free lists of
ations were the most salient factors influencing food choices across
women 25–34 years and 35 years and over were the strongest. There was
women in all age groups (Table 2). Although there was overlap in food
no significant correlation in the most salient items in the free lists of
choice considerations across age groups, there were also differences
women 18–24 years with the items listed by women in the older age
(Table 2; Fig. 1). For instance, although health was a consideration
groups, though the items listed by women 18–24 years were correlated
shared by all participant groups, nutrition was more often mentioned as
with the most salient messages of women 25–35 years.
a consideration among women 25 and older compared to those 18–24
years, and food safety (e.g., hygiene, chemicals, pesticides, cleanliness)
was more often mentioned among women 18–24 years and 35 years and

Table 2
The considerations influencing food purchasing and consumption based on free listing.

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S.M. Downs et al. Appetite 168 (2022) 105748

Fig. 1. Venn diagram of the most salient food choice considerations made by women based on age group.
Note: we included the top eight considerations for each age group in the Venn diagram.

vegetables such as kale and cabbage were relatively cheaper than other
Table 3
foods, whereas African Indigenous Vegetables (AIVs), meat, and chicken
The correlation of salience for the food choice considerations by age group.
were relatively expensive. Many women noted that they could not
Women’s Women 18–24 Women 25–34 Women 35 years and purchase the foods they would like due to their high cost. The value of
age group years’ salient years’ salient older’s salient
food was viewed in terms of the quantity that could be purchased for a
considerations considerations considerations
given price and was a more salient factor influencing food choices
18–24 1.00 .732* .604
among younger women (18–24 years). Women explained that they were
years
25–34 .604 1.00 .924**
constrained by their income but wanted to ensure that they had food to
years feed themselves and, when applicable, their families; thus, their ability
35 years .457 .930** 1.00 to purchase a large amount of food for a low price was important. As one
and older woman from Mukuru said: “Yeah, you find that vegetables are expensive. I
*p < 0.05, **p < 0.01 using Pearson’s Correlation Coefficient tests. come from a family, like we are six in our family, so I have to consider if I buy
Note: we included the top eight considerations for each age group in the cor­ these vegetables, will they be enough for all of us” (Interviewee 20, 26
relation matrix. years).
Women 25 years and older also mentioned the affordability of re­
3.3. Food affordability sources such as water and cooking fuel as factors influencing their food
choice. In addition, the lack of physical space to cook affected their
Among all age groups of women, the most salient consideration when ability to prepare certain foods. In some cases, this reduced the ability to
making food choices was affordability, the combined considerations of cook more nutritious foods (e.g., beans, AIVs, etc.). As one interviewee
income and food price. Women described having to make trade-offs in stated: “You may want to cook turtle beans but you don’t have enough money
terms of the nutrition and health aspects, quality, safety, and variety of to cook it so you will be forced to eat rice because it’s cheap to cook because to
foods purchased and consumed, and the relative affordability of foods. cook turtle beans I need charcoal and I may lack the money to get them”
Moreover, their ability to purchase the foods they preferred was limited (Interviewee 17, Kibera, 53 years).
due to economic constraints. Many of the women we interviewed
worked in the informal labor sector, and their food choices were pri­ 3.4. Variety
marily driven by their purchasing power. As one young woman from
Mukuru said: The variety of foods purchased and consumed was an important
“It depends on income for that day, so if you have cash you go purchase, if consideration made by women, particularly those 25 years and older.
you do not have [cash], then you have no choice … you cannot select Given their economic constraints, women were often not able to
what type of food to eat so it will depend on what you earn per day, you consume the varied diet that they desired. Women reported getting
can take anything maybe rice, ugali or chapatti, sometimes you just skip “bored” and “no longer feel[ing] like eating” the foods they commonly
meals, that is how it is” (Interviewee 33, 21 years). consumed. Women also reported stigma and shame associated with not
eating a varied diet. As one woman stated:
In order to overcome their income constraints, the women inter­
viewed indicated that they would purchase cheaper food, smaller “… at your home you take like let’s say for example, ugali with cabbage
quantities, or purchase more expensive foods less frequently or not at all. maybe it didn’t have tomatoes so it was white, you can imagine how that
Income, food price, and perceived value of food were intricately tastes. So someone comes and say we had rice with meat, then you are like
linked. Women indicated that staple foods (e.g., rice, ugali) and some what’s this person telling me, then at the end of the day you feel bad. Then
the following night you still have to take the same meal, and then you will

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S.M. Downs et al. Appetite 168 (2022) 105748

be imagining that person on the next doorstep is taking a different meal, a due to economic constraints. As one woman said: “We need to have a
whole good one then you are like I cannot take this, so you have to go to balanced diet but we do not have that … we just eat so that you can continue
sleep that way without eating” (Interviewee 33, Mukuru, 21 years). with life” (Interviewee 10, Kibera, 37 years).
Many of the women also described having stomach ulcers. The
Some women (across the three age groups) described making time­
women who were suffering from stomach ulcers indicated that they had
tables that outlined which foods they would consume for different meals
been advised by health professionals to avoid acidic foods in order to
each day of the week. These timetables helped to ensure a variety of
improve their health. In particular, they were told to avoid leafy greens
foods were consumed while maintaining relatively low food costs.
and red meat and to consume a balanced diet. As one woman explained,
“I suffer from ulcers so I cannot eat acidic foods. So I just eat the foods with
3.5. Food safety and quality not much acid. Like now for greens, like kales you cannot eat today,
tomorrow, and the day after because of acid.” (Interviewee 27, Kibera, 55
Food safety and quality were both important factors that influenced years).
food choice among the women. Food safety was often described in the
context of hygiene and the perceived use of chemicals. Food quality was 3.7. Individual and household preferences
often described in terms of the freshness and appearance of the food.
While perceived quality (i.e., freshness, appearance) was an important Among women aged 18–24 years, personal food preferences were a
consideration for women 18–34 years, it was not mentioned as a factor key consideration while among women 35 years and over household
influencing food choices among women 35 years and older. Given the food preferences were an important consideration. This contrasts with
economic constraints of the women included in our study, many had to the key considerations of women 25–34 years, where neither personal
weigh trade-offs between food affordability (and the resources needed to nor household preferences were prominent salient factors influencing
prepare it) and its quality. As one woman stated: “… vegetables are dirty, food choice. Overall, women indicated a preference for ugali, kale, rice,
when cars pass by; they splash mud on vegetables, now you cannot avoid meat, chapati, fish, mangoes, and oranges. While some women reported
them, so you go purchase them. Then you go and wash, and then that in­ a preference for AIVs, others did not. Women aged 25–34 years and 35
creases the expense because washing them, you’ll have to fetch water and that years and older spoke of the influence that their children have over the
water you’ll have to pay for it …” (Interviewee 33, Mukuru, 21 years). foods they purchase and prepare. One 55-year-old woman said: “maybe
Moreover, multiple participants referenced a community belief related today I bought flour, tomorrow I have to convince him to eat that food
to vegetables being grown in Kibera “with sewage water.” because he has been asking me ‘mum I want to eat this’ ‘mum I want to eat
In addition to the quality concerns related to hygiene, women indi­ this’ so I change for him. When I get money, I change and buy him something
cated that the number of chemicals in the foods they consume had like rice or spaghetti” (Interviewee 27, Kibera). Women indicated wanting
increased over time. They described chemicals in processed foods as well to expose their children to traditional foods but described their children
as in the context of the way food is grown (e.g., pesticides) and reared (e. as not always being receptive to them. As one woman said: “We have the
g., hormones, antibiotics). Traditional foods were considered to be safer jute mellow (murenda), Bacella alba (nderema), pumpkin leaves (malenge)
and more health promoting given the perceived lower quantities of they are sweet vegetables, but you find that they don’t like … even when I am
chemicals. As one woman said: “My grandmother was telling me about eating they are not eating, they don’t like them” (Interviewee 13, Kibera, 49
those foods. She was telling me don’t like these foods from the white people years).
just eat your food like cowpeas leaves and maize without husks, eat them they While the majority of women mentioned preferences for foods that
are healthy and strong compared to these added chemicals” (Interviewee 34, have traditionally been consumed in Kenya, a growing preference to­
Mukuru, 21 years). Another woman, talking about the way food is wards spaghetti, pilau, and pizza were also mentioned. As one inter­
grown, said: “I saw how a lot of diseases are caused by the herbicides in our viewee from Mukuru said: “[My mother], in her tradition, they use
plants, in the past people did not fall sick as much, because that food didn’t vegetables a lot. So I am like ‘mother, I want to eat pizza’ and she is like ‘you
have herbicides” (Interviewee 11, Kibera, 67 years). The belief that there eat it but … consequences’” (Interviewee 19, 24 years). In general, women
were chemicals in non-traditional food appeared across all age groups reported having the cooking skills necessary to prepare the foods that
but was most prevalent among women in the 25–34 years age group they preferred to consume. However, some women reported a desire to
compared to the other age groups. learn how to cook pilau and to bake cakes.

3.6. Nutrition and health 3.8. Availability and access

Women 35 years and older were more likely than the relatively Both availability and access to foods, which were influenced by up­
younger women to identify nutrition and health as important food stream food systems drivers such as climate and conflict, were important
choice considerations. While health was described in terms of the considerations for women when making decisions about which foods to
absence or presence of disease, nutrition was described in terms of a purchase and consume. Seasonality and climate variability impacted
balanced diet to “build your body” (Interviewee 23, Mukuru 42 years) both the availability and accessibility of foods, which subsequently
and “protect … from getting some diseases” (Interviewee 24, Mukuru, 44 affected their affordability. More specifically, during droughts, some
years). foods were not available in the markets, whereas during the rainy sea­
Many women had knowledge related to what constituted a balanced son, there was a greater variety of vegetables. As one interviewee said:
diet, including the importance of different macro- and micro-nutrients. “like when the season is good, you can purchase twenty shillings traditional
As one woman said: “Healthy diet, you balance the diet. You have the vegetables for lower cash, but when there is drought, you cannot really eat for
proteins, vegetables, carbohydrates and fruits there” (Interviewee 32, twenty shillings with your family” (Interviewee 29, Kibera, 37 years). In
Kibera, 26 years). They commonly reported doctors, television, word of addition to the influence of climate on food access, interviewees
mouth from friends and other community members, and the hospital as mentioned that conflict influenced women’s ability to safely walk
the sources of their nutrition and health knowledge. One woman said: “A around within the informal settlements which decreased their mobility
certain doctor who used to pass by was telling us … They said that you should and thereby, their food access.
not keep eating meat, there was a woman who was suffering from cancer so
they were telling us about it, health workers were doing that” (Interviewee 3.9. Time
28, Kibera, 44 years). Despite the desire to consume a healthy and
balanced diet, many women indicated that they were unable to do so Time was another important consideration that influenced women’s

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decisions regarding which foods to purchase and consume. Women aged decisions in two informal settlements in Nairobi, Kenya. Food afford­
25–34 years were the most likely to mention time as an important ability was the most salient consideration for women across all age
consideration for food choice. Time was described both in terms of how groups examined. Other important considerations included variety, food
long it took to access food from markets as well as food preparation. In safety and quality, nutrition and health, individual and household
many cases, women needed to weigh the trade-offs between the time preferences, availability and access, time and perishability. Women
needed to acquire or prepare food and the time they needed to work: often reported weighing trade-offs between food affordability and other
“Maybe something you want to cook takes longer time and you do not have important considerations such as nutrition, quality, and time. In many
that time. You have to cook and rush to hustle, so you just find something that cases, these trade-offs led to suboptimal diets. These findings suggest
will take shorter time” (Interviewee 21, Mukuru, 24 years). Traditional that overcoming these issues (e.g., finding ways to make certain foods,
dishes (e.g., githeri) were described as taking anywhere from “one and a like vegetables, more affordable), is key to improving diets among
half hours or 2 h” (Interviewee 16, Kibera, 35 years) to as much as “6 h” women and their families living in informal settlements in Kenya and
(Interviewee 37, Mukuru, 31 years) to prepare. These foods also require beyond.
more cooking fuel, which added to their cost. Given the time and the cost
of cooking fuel associated with preparing specific foods, women re­
4.1. Food choice considerations differ across age groups
ported purchasing prepared these foods from food vendors rather than
cooking them.
While there were many similarities among the key considerations
Another aspect of time relates to food access and the sources of food.
that women made across different age groups, there were also important
“Because you find it is a long distance, so you want the vegetables you want to
differences that have implications for public health interventions. In­
buy, but due to time, maybe you cannot be able to go there. So it forces you to
dividual preferences as well as quality were more salient considerations
buy on the roadside” (Interviewee 23, Mukuru, 42 years). Given that the
among younger women. This contrasted with the most salient consid­
roadside vendors often sell foods at a higher price than the wet markets
erations among relatively older women, where household preferences
that are a further distance from the women’s households, this led to a
were key considerations influencing food choice. The findings among
trade-off between the time it would take to access the market and the
relatively older women were similar to those found among women in
price of the food that would be acquired from it.
India, where household preferences of husbands and children were
especially influential in food choice decision making (Bailey, 2016).
3.10. Perishability
Women in our study described children as being less receptive to the
consumption of nutritious traditional foods. Moreover, the ‘pester
Perishability, both in the context of the distance from market to
power’ of children, which has been documented in other settings
household as well as storage within the household, was a consideration
(Bailey, 2016; Downs, Glass, Linn, & Fanzo, 2018), has the potential to
for some women, particularly those 25 years and older, when deciding
move diets further away from nutrient-rich foods. Given the differences
which foods to purchase and consume: “For example, you can buy, let us
in the most salient considerations influencing food choice among
say fruits like watermelon, and you are staying far, when you have reached
women of different ages, there is a need to tailor public health in­
[your home], it has already perished” (Interviewee 37, Mukuru, 31 years).
terventions to the life course stages. For example, behavior change
In terms of storage within the household, foods such as fish and some
communication strategies delivered as part of a package of interventions
fruit could not be stored for long due to their short shelf life and a lack of
might target individual diets for children and younger women and
cold storage. This, in addition to the limited income of the women, led
children’s diets among relatively older women. This will become
them to purchase foods for daily consumption rather than purchasing
increasingly important as the appeal for energy-dense foods of low
larger quantities of food and storing them. While purchasing food in
nutritional quality continues to increase in these settings.
smaller units is more affordable in the short term, the price for a given
unit is often higher than if purchased in larger amounts. In addition to
the storage and income constraints related to purchasing food in larger 4.2. Food affordability is the main driver of food choice
quantities, transportation also becomes a barrier. As one woman said:
“Maybe you want to buy like, a food that you inspire to eat maybe for one While in high-income countries, taste is often the primary consid­
week and maybe you cannot carry it. You need to hire a motorbike (boda­ eration that people make when deciding which foods to purchase and
boda), or you cannot afford so you will just have to buy what is enough for consume (Furst et al., 1996; Sobal & Bisogni, 2009), we found that food
that day and then you will go the other day” (Interviewee 36, Mukuru, 29 affordability was by far the most salient consideration made by women
years). living in urban informal settlements. Food affordability superseded all
other considerations, including taste preferences. The dominance of this
3.11. Culture and tradition consideration is perhaps unsurprising given that previous research
conducted in Kibera found that over 85% of residents were food insecure
While culture and tradition were not widely reported as a key (Kimani-Murage, Schofield, Wekesah, et al., 2014). In other countries,
consideration when making decisions about which foods to purchase or affordability was also described as a key consideration related to food
consume, we probed about culture in our interviews. Moreover, two choice, particularly among low-income populations (Palmer, Kno­
women 35 years and older included it as part of the free-listing exercise. blauch, Winham, Hiller, & Shelley, 2020; Machín, Giménez, Curutchet,
In the interviews, most women reported that they valued teaching their Martínez, & Ares, 2016). Similar to our findings, a study examining the
children about preparing and consuming traditional foods: “Because food choices of women in Malawi found that they would purchase a
teaching about traditional food will keep the culture because once we do not smaller quantity or a different food (e.g., fish rather than meat) if the
teach them about the culture it is gone” (Interviewee 34, Mukuru, 21 food price was prohibitive (Flax, Thakwalakwa, Jaacks, Phuka, &
years). Some women noted changes when describing their diet while Schnefke, 2019). We also found that women would purchase less variety
living in an urban area compared to their diet as children living in a rural of foods due to affordability, which has important implications for
area. overall dietary quality. Given that previous research has found house­
hold income to be one of the main factors explaining dietary patterns in
4. Discussion urban settlements in Kenya (Wanyama et al., 2019), identifying ways to
increase income-generating opportunities in these settings is critical.
This study examined the considerations made by women across Alongside income generation, lower costs for nutritious foods through
different age groups when making food purchasing and consumption improvements in production, distribution, etc. are needed.

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4.3. Balancing trade-offs in food choices 4.4. The need to improve basic living conditions to improve diets

Overall, women were aware of the need to consume a diverse and In addition to nutrition considerations, many women indicated that
balanced diet, and their nutrition beliefs largely aligned with global health was an important consideration when making food purchasing
dietary recommendations. However, they were often unable to make and consumption decisions. While nutrition was defined in the context
food purchasing and consumption decisions based on their nutrition and of a balanced diet that would keep women and their families well, health
health-related beliefs due to their limited income. This led them to was described in the context of existing or potential future disease. In
consume a monotonous diet that they felt did not meet their nutritional particular, many women described having stomach ulcers which led
needs. While a lack of knowledge is often described as a key factor them to consume fewer leafy greens, based on the advice they had
influencing diet quality (Darmon & Drewnowski, 2008), our findings received from health professionals. Given that animal-source foods tend
suggest that women were knowledgeable yet did not have the means to to be prohibitively expensive for many women, leafy greens are an
purchase and consume the foods they aspired to eat. Overcoming the important source of key nutrients in their diets (Raneri, Padulosi, Mel­
financial barriers to acting upon existing nutrition knowledge will be drum, & King, 2019; Natesh, Abbey, & Asiedu, 2017). While kale was
critical given the context of rapidly evolving food environments that described by our study participants as being high in acid and exacer­
women living in informal settlements interface with. While cash trans­ bating ulcer symptoms, it has been used in traditional medicine to cure
fers aimed at increasing purchasing power among women would be gastric ulcers and is considered to be basic rather than acidic (Šamec,
beneficial, they should be delivered as part of a package of interventions Urlić, & Salopek-Sondi, 2018). Epidemiological studies have found the
that simultaneously target the food environment as well as more up­ prevalence of stomach ulcers to be high in informal settlements in Kenya
stream drivers influencing the availability, affordability, acceptability, (M’itonga et al., 2015; Dinda & Kimang’a, 2016). Interventions aimed at
and appeal of nutritious foods (Hawkes, Fox, Downs, Fanzo, & Neve, addressing the root cause of the high prevalence of stomach ulcers in
2020). This could include strengthening supply chains for fruits and these communities, such as poor sanitation and access to safe water, is
vegetables by creating food hubs in the informal settlements, strength­ critical to improving diets and overall health. Alongside prevention,
ening food safety regulations and increasing testing of foods being sold increased access to affordable treatment is also needed.
in the settlements, subsidies for cooking fuel, etc.
We found that women often had to weigh trade-offs between the time 5. Limitations
it would take to walk to markets with lower food prices or prepare
traditional nutritious foods and their need to generate income. These While there were several strengths to our study, there were also
time-related trade-offs, which have been observed in other countries limitations. One limitation of our study was our lack of information
(Bailey, 2016; Palmer et al., 2020), were also influenced by food regarding household composition and whether or not our participants
affordability and the resources needed for food preparation. For were parents or guardians of children under five. However, the goal of
example, foods such as beans that require longer cooking times would our study was to understand women’s food choices, and participants in
result in higher costs associated with the use of cooking fuel. Women our study provided this information when it was relevant to their food
also indicated that the time, and associated costs, to obtain water choices. Moreover, they discussed their household roles and relation­
influenced food acquisition. For this reason, women indicated pur­ ships throughout the interview. Another limitation of our study is that it
chasing foods that would take longer times to cook from street vendors. was conducted at a single time point. Future work could examine the
While street vendors play an important role in terms of convenience, and drivers of food choice across seasons.
many foods sold are traditional foods that are relatively healthy (e.g.,
githeri which is beans and maize), there are often drawbacks in terms of 6. Conclusions
the quality of ingredients used (e.g., oils) as well as food safety risks
(Alimi, 2016; Salamandane, Silva, Brito, & Malfeito-Ferreira, 2021; Food affordability was the primary factor influencing the purchase
Gupta, Downs, Ghosh-Jerath, Lock, & Singh, 2016). This suggests that and consumption of foods among women living in two informal settle­
food supply interventions, including the processing of such foods to ments in Nairobi. There was a significant amount of overlap in the food
reduce the time burden in preparing them (Aseete, Katungi, choice considerations of women across different age groups; however,
Bonabana-Wabbi, Birachi, & Ugen, 2018), could be valuable contribu­ there were also noteworthy differences. Interventions targeting both
tions to improving healthy diets. individual factors such as income and perceptions related to the food
Our study, along with many others conducted in LMICs (Downs et al., environment (e.g., food safety) need to be combined with those that
2018; Wertheim-Heck & Raneri, 2019), have found food safety and target the elements of the external food environment (e.g., food prices).
quality to be an important consideration when people make decisions We anticipate that a package of interventions tailored to age-group is
about which foods to purchase and consume. While several qualitative needed to ensure that women and their families can consume a diverse,
studies have now identified perceived food safety and quality as nutritious diet. Future research should involve working with these
important drivers of food choice, there are limited data that objectively communities to design a complementary set of interventions aimed at
assess it. In Vietnam, while consumers had food safety concerns related improving diets and nutrition that are tailored to their needs and con­
to foods purchased from wet markets, the actual public health risk was ducting rigorous evaluations of their impact and implementation.
deemed to be low with little evidence from food-safety and
bio-contaminant analysis to support the belief that foods were unsafe Author contributions
(Raneri & Wertheim-Heck, 2019). In Kenya, we found concerns related
to the hygiene of food and food vendors themselves as well as the SMD and ELF conceived of the study. SMD and AZ drafted the first
perception of high quantities of chemicals and contaminants in the foods draft of the manuscript, with significant input from ELF. SMD, AZ, TM
sold within the settlements. However, in the absence of objective data and KOC conducted the data analysis and SMD, MS, EM and VM con­
that measure these aspects of food safety, the associated threat remains ducted data collection. All authors contributed to the writing of the final
unclear (Kutto et al., 2011; Njuguna et al., 2019). This is problematic manuscript.
given that many of the foods that women expressed a safety concern for
are nutrient-rich foods (e.g., kale, beans, chicken, milk). While recent Data access
data is sparse, a previous study found higher bacterial contamination of
kale sold in wet markets and supermarkets as compared to those directly Access to qualitative data codes from this study can be obtained by
sourced from farms (Kutto et al., 2011). contacting the corresponding author.

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Ethics statement Ettarh, R., Van de Vijver, S., Oti, S., & Kyobutungi, C. (2013). Overweight, obesity, and
perception of body image among slum residents in Nairobi, Kenya, 2008–2009.
Preventing Chronic Disease, 10. https://doi.org/10.5888/pcd10.130198
Ethical approval was obtained from the Rutgers University Institu­ Euromonitor International. (2017). Sweet Biscuits: Snack bars and fruit snacks in Kenya.
tional Review Board and the Amref Health Africa Ethics and Scientific Euromonitor International.
Review Committee in Kenya. Flares. (2017). Version 1.0. .
Flax, V., Thakwalakwa, C., Jaacks, L., Phuka, J., & Schnefke, C. (2019). Food purchasing
decisions in overweight mother-child dyads in Malawi (FS01-05-19). Current
Declaration of competing interest Developments in Nutrition, 3(Supplement_1). https://doi.org/10.1093/cdn/nzz028.
fs01-05-19
Fox, E. L., Davis, C., Downs, S. M., Schultink, W., & Fanzo, J. (2018). Who is the woman
None. in women’s nutrition? A narrative review of evidence and actions to support
women’s nutrition throughout life. Current Developments in Nutrition, 3(1). https://
doi.org/10.1093/cdn/nzy076
Acknowledgements Fox, E. L., Pelto, G. H., Rasmussen, K. M., Debrosse, M. G., Rouzier, V. A., Pape, J. W.,
et al. (2017). Who knows what: An exploration of the infant feeding message
The authors would like to thank the study participants for sharing environment and intracultural differences in Port-au-Prince, Haiti. Maternal and
Child Nutrition, 14(2), 1740–8709. https://doi.org/10.1111/mcn.12537
their experiences. We thank the staff of the Mirror of Hope community- Fox, E. L., & Timmer, A. (2020). Children’s and adolescents’ characteristics and
based organization in Kibera and the G-thamini Youth Group in Mukuru interactions with the food system. Global Food Security, 27, 100419. https://doi.org/
for their assistance with this research. This study was funded by a pilot 10.1016/j.gfs.2020.100419
Fugard, A. J. B., & Potts, H. W. W. (2015). Supporting thinking on sample sizes for
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