Women’s Perception of and Readiness To Adopt a Sustainable Healthy Diet: A Cross-Sectional Survey in Enugu City, Nigeria


 Background: Perceived benefit of and readiness to adopt sustainable healthy diets (SHDs) is under-investigated in low-resource countries. We assessed women’s perceived benefit of and readiness to adopt SHDs and their associated factors in Enugu Metropolis, Nigeria. Methods: A household cross-sectional survey of childbearing women (n = 450) was conducted in January and February 2021 using a questionnaire assessing food choice motives, perceived benefit, and readiness to adopt SHDs. Readiness to adopt SHDs was grouped into pre-contemplation and contemplation (PC/C), preparation and relapse (P/R), and action and maintenance (A/M). Results: About 79% and 60% of women have high perception and adopted SHDs respectively. Perceived benefit of SHD was associated with younger age (β = -0.20, ρ < 0.05), low education (β = -0.19, ρ < 0.05), and poor wealth quintile (β = -0.57, ρ < 0.001). PC/C was predicted by low perceived benefit (OR = 10.07, 95% CI: 4.78-21.22, ρ < 0.001), low education (OR = 2.51, 95% CI: 1.25-5.04, ρ = 0.010), and taste (OR = 3.96, 95% CI: 1.61-9.75, ρ = 0.003). PR was predicted by low perceived benefit (OR = 3.92, 95% CI: 1.99-7.73, ρ < 0.001), low education (OR = 1.82, 95% CI: 1.00-3.29, ρ = 0.049). A/M was related to younger age (OR = 0.48, 95% CI: 0.27-0.84, ρ = 0.010, PR), and health (OR = 0.14, 95% CI: 0.06-0.36, ρ < 0.001, PC/C) and (OR = 0.17, 95% CI: 0.08-0.35, ρ < 0.001, P/R). Conclusions: Adoption of SHDs need to improve in Enugu, Nigeria. We identified the factors that should inform dietary guidelines and campaigns to increase women's adoption of SHDs.


Introduction
Achieving a sustainable healthy diet is a growing global concern given the contributions of food choices and consumption behaviours to human and planetary health and implications for achieving the Sustainable Development Goals (SDGs) [1][2][3][4]. Sustainable diets are dietary patterns that promote all dimensions of individuals' health; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable [5]. It aims to achieve optimal growth and development of all individuals and support functioning and physical, mental, and social wellbeing at all life stages for present and future generations. Also, it prevents all forms of malnutrition (including undernutrition, micronutrient de ciency, overweight, and obesity), reduce the risk of diet-related non-communicable diseases (NCDs), and supports the preservation of biodiversity and planetary health [5].
Transitioning towards sustainable healthy diets requires substantial population-level changes in food consumption practices. These dietary shifts entail shifting consumption away from animal-based foods and towards more plant-based foods such as fruits, vegetables, nuts, seeds, and whole grains; limiting consumption of highly processed foods and beverages [1,5,6]; and balancing nutrient requirements, food costs, and cultural acceptance against environmental impact and other social needs [1,5,7].
Unsustainable and unhealthy diets contribute signi cantly to the risk of NCDs [8,9]. In low-and middle-income countries, urbanization and increasing prosperity have led to a dietary shift termed nutrition transition in which people consume diets high in calories, hydrogenated fats, sugars, and animal products and low in bre [10,11]. Highly processed foods that contain high levels of salt, sugar, and fat lead to increasing rates of various chronic diseases, including obesity, diabetes, heart disease, and stroke [12]. Diet-related NCDs are the top risk factors for deaths and disability-adjusted life-years (DALYs) lost globally [13]. In contrast, adherence to a plant-based dietary pattern reduces the risk of diabetes [14,15]. Moreover, adopting a sustainable healthy diet could avert 10.8-11.6 million deaths per year, resulting in 19-24% of total deaths among adults [1].
The environmental impact of unsustainable and unhealthy diets is also high. Global food systems emit 20-35 per cent of global greenhouse gas (GHG) emissions, occupying about 40 per cent of the Earth's ice-free land area, resulting in terrestrial and aquatic nutrient pollution and biodiversity loss [16]. Overall, the production of animal-based foods has a several-fold higher environmental impact than plant-based foods [17][18][19][20]. In the United Kingdom, replacing 50% of meat and dairy products in the diet with fruits, vegetables, and cereals resulted in a 19% decrease in GHG emissions [21]. Also, diets that eliminate red meat have a lower global warming potential [22]. Avoiding air-freighted foods, choosing organic over conventional produce, and reducing meat consumption have high environmental bene ts [23,24]. Nonetheless, consumer awareness of the environmental impact of meat production and willingness to change meat consumption is low [25,26].
Nigeria is one of the few sub-Saharan African countries to develop food-based dietary guidelines (FBDGs) [27]. FBDGs are a set of simple advisory statements that guide consumers on healthy eating patterns, types of food or food groups, or nutrients needed to promote better nutrition and address diet-related health conditions in a country [28]. Notwithstanding Nigeria's FBDGs since 2006, most urban households do not have adequate dietary diversity [29]. Nigeria is experiencing a double burden of malnutrition [30]. About 37%, 7%, 22%, and 2% of Nigerian children aged 6-59 months are stunted, wasted, underweight, and overweight [31]. Also, 12% of women aged 15-49 are thin, while 28% are overweight or obese [31]. Malnutrition was the leading risk factor for death and disability from non-communicable diseases (NCDs) between 2009 and 2019 in Nigeria [32]. The mortality from NCDs increased from 24% in 2014 to 29% in 2018 [33,34]. In response to these unacceptable indices, Nigeria's food and nutrition policy aims to attain optimal nutritional status for all Nigerians by addressing the double burden of undernutrition and overweight/obesity [30].
A signi cant knowledge gap exists about social and economic aspects of sustainable healthy diets, the drivers of diet, and how scienti c information on health and sustainability in uence perception and actual practices of consumers [52,53]. The environmental impact and socio-cultural aspects of diet are considered less frequently in national dietary guidelines [4]. In Nigeria, no study has examined the readiness of consumers to adopt sustainable healthy diets.
Therefore, this study assessed the perceived bene t of sustainable healthy diets (SHDs), readiness to adopt SHDs, and their associated factors among childbearing women in Enugu State, Nigeria. The ndings can inform appropriate policies and strategies to facilitate transitioning to sustainable healthy diets[6].

Study setting
The study took place in Enugu metropolis, Enugu State, Nigeria. Enugu metropolis is the capital city of Enugu State and comprises three local government areas (LGAs): Enugu East, Enugu North, and Enugu South LGAs. Whereas Enugu North is composed of an entirely urban population, Enugu East and Enugu North have a mix of urban and rural areas. Enugu East, Enugu North, and Enugu South LGAs comprise 808, 565, and 451 enumeration areas (EAs). In 2020, the estimated population of Enugu metropolis was 1.2m people. The publicly owned health facilities in the metropolis include one teaching hospital, three general hospitals, and a network of primary health care facilities.

Research design
The study adopted a cross-sectional survey design using an interviewer-administered questionnaire.

Study population and sampling strategy
Childbearing women aged 18 to 49 years living in the Enugu metropolis constituted our study population. We chose childbearing women for this study because mothers make the decisions regarding food and meals in families in Nigeria. A sample size of 344 women was calculated using a single population proportion formula, assuming 70.1% prevalence for dietary diversity among women in Enugu [31], 95% con dence limit, 5% margin of error, and 10% nonresponse rate. We, however, sampled 450 eligible childbearing using a multi-stage sampling strategy with proportionate size weights. The rst stage was to select 20, 14, and 11 enumeration areas from Enugu East, Enugu North, and Enugu South LGAs correspondingly using systematic random sampling. In the second stage, we selected ten households from each enumeration area by systematic sampling. One eligible woman per household was interviewed, totalling 450 respondents.

Data collection
Data were collected in January 2021 using an interviewer-administered questionnaire. The questionnaire had four sections. Section A covered consumer perception of sustainable dietary habits. We adapted nine questions assessing consumer perception of sustainable healthy diets in a previous study [39].
Women's perceived bene ts of sustainable healthy diets were measured using a 5-point Likert scale from 'very small bene t' to 'very large bene t'. In this study, the scale content validity index is 0.95, while its reliability in our sample is 0.755. Section B of the questionnaire measured readiness to adopt sustainable health diets using one question with six response options based on the stages of change construct of the Transtheoretical Model of behaviour change [54]. The response options included: 'I am not interested in doing this at the moment' (precontemplation), 'I am thinking about this but I need more information' (contemplation), 'I would like to do this but there are things stopping me' (planning), 'I have started to do this some of the time' (action), 'I am doing this con dently most of the time' (maintenance), and 'I am not currently doing this but have done in the past' (relapse).
Section C focused on food choice motives. Childbearing women selected their three most signi cant food-choice motivations from a provided list (health, cost, religion, taste, environmental sustainability, availability, and animal welfare). Section D covered socioeconomic and demographic information. We measured socioeconomic status using Nigeria's equity tool [55]. Information about age, education level, marital status, and whether participants had children living at home were also collected. Data was collected using an open data kit (ODK) collect (version 1.29.2). Five research assistants, trained to use ODK collect, administered the questionnaire. The interviewers evaluated how the women answered each question and scored the response. The questionnaire was pretested and modi ed before actual data collection.

Data analysis
Data were analyzed using SPSS (version 20, IBM, New York, USA). Descriptive statistics were used to summarise the characteristics of respondents, perceived bene t, and food choice motives. The median value of the perceived bene t of sustainable healthy diets was used to dichotomise women into two categories 'low perceived bene t' and 'high perceived bene t'. Also, we reclassi ed the six stages of change into three categories: pre-contemplation and contemplation (PC/C), preparation and relapse (P/R), action and maintenance (A/M). These three stages re ect groups of individuals who are not interested or may need further information (PC/C), those that experience other barriers (P/R), and those who are already taking action (A/M). ANOVA and t-test were used to test the differences in means perceived bene t of SHD by women's sociodemographic characteristics. We identi ed determinants of the perceived bene t of SHD using a Generalised linear model. Differences in the proportion of women at different stages of adoption were tested using the Chi-square test. Multinomial regression analysis was used to predict women's stage of change for sustainable healthy diets based on perceived bene t, demographic characteristics, and reported food-choice motives. The odds ratio (OR) represents the likelihood of childbearing women being in the PC/C or P/R stages of change compared to the reference, A/M stage of change. Statistical signi cance was set at alpha 0.05 level.

Ethical consideration
The Health Research Ethics Committee of Enugu State Ministry of Health, Enugu, Nigeria, approved this study. We obtained written, informed consent from all respondents.

Results
Basic characteristics of the respondents The response rate was 100%. All responses were also complete and included in the analysis. Over 50% of the respondents were in the 25-34 age group (Table  1). Almost 68% of respondents were married, about 60% had tertiary education, and 64% lived with children. Nearly 83% of respondents were in the rich quintiles.
Women's food choice motives Health, cost, availability, and taste were the most reported food choice motives among childbearing women ( Figure 1).

Perceived bene ts of sustainable healthy diets
Overall, 79% of women perceived a sustainable healthy diet as a high bene t ( Table 2). 'Consume seasonal fruits and vegetables' and 'reduce consumption of air-freighted goods' were perceived to have the highest (84%) and lowest bene ts (54%), respectively.
Factors associated with perceived bene t of sustainable health diets As shown in Table 3, the overall perceived bene t of sustainable healthy diets differed signi cantly by age (ρ = 0.005), education (ρ < 0.001), and socioeconomic status (ρ < 0.001). In all, but two sustainable healthy diets (fruits and vegetables, and sustainable sh), the perceived bene t of sustainable healthy diets differed signi cantly by education and socioeconomic status. Except for avoiding food with an excessive package, limiting red and processed meat, and eating sustainable sh, all other sustainable healthy diets signi cantly differed with age.
Predictors of perceived bene ts of sustainable healthy diets Being poor, age <35 years, and low education signi cantly predicted the low perceived bene t of sustainable healthy diets (Table 4).
Factors associated with adoption of sustainable healthy diets About 19%, 21%, and 60% of women are pre-contemplation and contemplation (PC/C); preparation and relapse (P/R); and action and maintenance (A/M) correspondingly. Adoption of SHDs signi cantly differed in some socio-demographic factors except in 'marital status' and 'leaving with a child at home'. Also, the adoption of sustainable healthy diets differed signi cantly by food choice motives except for the environment ( Table 5). As women transit from PC/C through P/R to A/M, the proportion of women with the perceived high bene t of sustainable healthy diets signi cantly increases (ρ < 0.001) ( Table 5).

Predictors of adoption of sustainable healthy diets
Health predicted women's likelihood of being in the A/M stage of change for sustainable healthy diets compared to PC/C (OR = 0.14, ρ < 0.001), and P/R (OR = 0.17, ρ < 0.001) stages of change (Table 6). Low perceived bene t of sustainable healthy diets predicted being in the PC/C (OR = 10.07, ρ < 0.001) and P/R (OR = 3.92, ρ < 0.001) stages of change, correspondingly. Taste, as a food choice motive, was signi cantly associated with being in the PC/C stage of change (OR = 3.96, ρ = 0.003). While low education was associated with being in the PC/C stage (OR = 2.51, ρ = 0.010) and P/R stage (OR = 1.82, ρ = 0.049) compared to A/M stage. Age <35 years predicted the likelihood of women being in the A/M stage compared to P/R (OR = 0.48, ρ = 0.010) stage of change.

Discussion
This study has examined women's perceived importance of and readiness to adopt sustainable healthy diets and the factors associated with perceived bene ts and adoption of sustainable healthy diets (SHDs) in a Nigerian urban city. The ndings revealed that most women considered SHDs of high bene t, but adoption was moderate. Perceived bene t, food motives (health and taste), and socio-demographic factors (age and education) predicted the adoption of SHDs. This evidence provides pointers to strategies to facilitate transitioning to sustainable healthy diets.
Our nding of the high perceived bene t of SHDs among childbearing women is consistent with the evidence of previous studies [23, 37-39, 45, 56]. This nding might re ect an increasing awareness of diet-related NCDs, health consciousness and high nutrition value of SHDs, and renewed interest in traditional foods among Nigerians [57]. Nevertheless, our sample differs from previous existing evidence in some ways. For instance, while 'consuming seasonal fruits and vegetables' conferred the highest bene t in our study, 'avoiding air-freighted goods' conferred the highest bene t in a previous study [39]. Also, our ndings that 'limiting red and processed meat' and 'reduce consumption of air-freighted goods' offered the lowest bene ts contrast results from a previous study in which 'prioritise plant protein' and 'choose organic produce' were perceived to confer the smallest bene ts [39]. These variations in the perceived bene ts of sustainable healthy diets are context-speci c and should inform strategies intended to improve the adoption of SHDs among women.
Despite the high perceived bene t of SHDs among women in our sample, adoption is moderately high, which aligns with ndings from Europe [45], but differs from the evidence of low willingness to adopt SHDs [25,40,41]. Consistent with the Transtheoretical Model of behaviour change[54], we found that adoption of SHDs increased with its perceived bene t. This nding aligns with the results of previous studies [39,45,50,58]. In this study, women with low perceived bene ts were about ten and four times more likely to be in the PC/C and P/R stage of change correspondingly. Generally, as women transit from PC/C through P/R to A/M, the proportion of women with low perceived bene t declines, while the proportion of women with high bene t increases. Yet, the women's high perceived bene t did not always translate to A/M as some women with high perception were in the PC/C and P/R stages. Therefore, interventions to improve the adoption of SHDs must target two sub-populations -women with low perceived bene t and those with high perceived bene t who are in PC/C and P/R.
Health predicted the likelihood of women being in the A/M stage of change for all sustainable healthy diets, thus, con rming our hypothesis that health would predict readiness to adopt SHDs. Health concerns increased women's adoption of sustainable healthy diets as was found in prior studies [39,45,46]. This nding is not surprising because, in this sample, health was the foremost food choice motive, implying that health and nutrition bene ts of foods take precedence over all other motivations for food choice. Evidence indicates that health as a food choice motive positively correlates with better adherence to healthy nutritional guidelines [48]. While health was also the leading food choice motive in the United Kingdom and Tanzania, it was the fourth-ranked motivation for food choice in Europe [39,45,58]. In European settings where health is not a foremost food choice motive, people believe that they already eat a healthy diet and therefore do not consider SHDs would provide bene ts over and above their existing dietary behaviour. Health consciousness resulting from increasing NCDs may have in uenced consumers to adopt SHDs[57, 58].
Our nding that women reporting taste as a food choice motive were more likely to be in the PC/C stage con rmed our hypothesis that taste would predict low readiness to adopt SHDs. These ndings are similar to the results of previous studies where concern for taste was associated with less healthy dietary habits [44,45]. Conversely, a previous study found that taste in uenced the adoption of plant-based proteins but no other SHDs [39]. As argued elsewhere [45], the assumption that other food choice motives would be considered before taste when selecting sustainable healthy diets may have adversely in uenced the readiness to adopt SHDs. In our sample, reporting taste as the fourth important motivation for food choice supports this assumption.
We hypothesized that increased age would have a high perceived bene t and more likely to adopt SHDs. However, while increased age was associated with higher perceived bene ts, it did not translate to the adoption of SHDs. Our nding that younger women were more likely to be in the A/M stage contrasts evidence of a prior study in which younger consumers were more likely to be PC/C stage for SHDs [39]. Our ndings are surprising from three perspectives. First, in a traditional food system, people prefer locally produced foods, legumes, seasonal vegetables, and fruits to animal source foods and highly processed foods [3]. However, young women in Nigeria tend to eat few traditional foods and prefer imported and western goods, perceived as appealing and healthy [59].
Secondly, young women tend to be vulnerable to media in uences that promote air-freighted foods [59]. Thirdly, consumption of sugary foods decreased with age among Nigerian women [31]. One possible explanation of our nding is the large proportion of younger women in our sample who reported health concerns as a food choice motive. Given that attitudes relate to individuals and others and the intention to act is personalised [45], it might also be that younger women are more proactive than older women in translating their perceived bene t into action. There is a need to target older women with behaviour change communication interventions.
This study's ndings con rmed our hypothesis that high education was associated with high perceived bene ts and high readiness to adopt SHDs. Existing evidence suggests that high education predicts the adoption of SHDs [42,48,51]. Although socioeconomic status was not a signi cant predictor of readiness to adopt SHDs in this study, differences in education might re ect income disparities in urban Nigeria. Women in low-income urban households have lower educational quali cations, poorer intake of micronutrients, and less diversi ed diets than high-income urban households in Nigeria [29]. Education increases the opportunities for employment, which improves nancial access to diverse, sustainable healthy diets [29,59]. Targeting information campaigns on maternal nutrition and health knowledge towards women with a lower level of education might improve their adoption of SHDs.
This study contributes to existing scholarship by providing evidence of perceived bene t and motivation to adopt sustainable healthy diets in Nigeria. This evidence can inform the adaptation of FBDGs to improve women's access to SHDs in urban areas of South-East Nigeria. These notwithstanding, social desirability bias might limit the study. Women in this study may have projected a socially desirable image of food choice motives and dietary behaviours. The use of an interviewer-administered questionnaire reduced the chances of response biases. Secondly, the perceived bene t of SHDs may not have adequately captured environmental bene ts. In this study, environmental concern was the fth important motivation for food choice. Evidence elsewhere suggests that the impact of food on the environment is poorly understood, and consumers have not yet internalised environmental sustainability [51]. Therefore, the interpretation of the environmental effects of food in Nigeria constitutes an area for future studies. Equally, it would be a helpful addition to exploring the adoption of sustainable dietary behaviour from a qualitative perspective.

Conclusions
This study has highlighted the gap between perceived bene t and readiness to adopt sustainable healthy diets and the factors associated with the adoption of SHDs in a South-Eastern Nigerian City. High perceived bene t does not always translate to the adoption of SHDs. Health concern, taste, younger age, and high formal education are critical determinants of readiness to adopt SHDs and might be considered in interventions to accelerate the transition to sustainable healthy diets.         Figure 1