Krystal Rampalli, MPH, Rebecca Pradeilles, Ph.D., and Akua Tandoh, MSc discuss food safety as a driver of food choice in urban Ghana.

Food environments are transforming worldwide in the context of nutrition transition (Popkin, 1994). Consumers can expect to face several decisions about what to eat, when, where, why, and how to prepare their meals along with competing time and resource constraints and changing food environments. The drivers of food choice are complex in both high-income (HICs) and low- and middle-income countries (LMICs). Rising incomes, improved globalization of supply chains, higher numbers of women working outside the home, and an increased penetration of multinational corporations have brought a wide array of new food and beverage options to many corners of the globe (Stuckler, et al., 2012).

Consumption of pre-packaged convenience foods (commonly known as processed or ultra-processed) as well as foods prepared outside the household (such as fast food or street food) have become increasingly popular in both high-income countries (HICs) and LMICs in response to time constraints for food acquisition and preparation that many households face between their jobs and general family management (Jabs and Devine, 2006; Celnik, et al., 2012; Omari and Frempong, 2016). Most convenience foods contain high quantities of added sugars, sodium, and saturated fats and are generally palatable to the common consumer (Moss, 2013). Though it varies widely, some types of processed foods are lower in cost than their fresh or unprocessed counterparts, making them more appealing to some consumers. Lastly, consumption of Westernized processed food products, such as Coca-Cola® soft drinks or McDonald’s® French fries, are considered a status symbol among younger populations in some LMICs (Maxfield, Patil, and Cunningham, 2016).

Grace (2015) describes how unlike in HICs, LMIC “food systems are heterogenous and fragmented with large numbers of actors, many small-scale actors, large informal sectors, and relatively little organization”. Despite most LMICs witnessing an explosion of supermarkets, shopping malls, and sit-down restaurants in wealthier areas, informal food outlets (often called “street foods”) are still a cornerstone of urban daily life (Steyn, et al., 2013). The popularity of street food and ready-prepared food in LMICs present unique contextual challenges.

Informal food outlets pose several health concerns, particularly related to food safety. Even though the true burden of foodborne illnesses worldwide is unknown, it is believed that LMICs have the highest burden (Grace, 2015). The reasons for this claim make intuitive sense; many LMICs have high prevalence of diarrheal diseases, have reduced access to clean water for washing hands, food, and utensils, and human or animal waste are used in the cultivation of horticulture products (Fletcher, et al., 2013; Grace, et al., 2010; Grace, 2015). In addition to these structural and environmental factors, some scholarship in food safety suggests that a lack of education for both food preparers and the common person about safe food handling techniques may also be a major contributor to foodborne disease outbreaks in LMICs (Grace, 2017).

Recent studies have shown that despite the various challenges in quantifying foodborne diseases and maintaining a safe food system in many LMICs, people by and large do consider food safety when making food choices (Grace, 2015). For example, in Vietnam, when foodborne illnesses traced to pork were reported by the popular media, many Vietnamese consumers either stopped consuming pork entirely, substituted chicken for pork in meals, or went to food outlets they considered cleaner and safer than their normal repertoire (Grace, 2015; Lapar and Toan, 2010). In Kenya, fears about contracting Rift Valley fever led to consumers demanding butcher certificates and the overall demand for red meat reduced, while the consumption of poultry rose (Grace, 2015; Rich and Wanyoike, 2010). Understanding consumers perspectives on food safety in their neighborhoods can provide important insight into targets for policy or program interventions.

In urban Ghana, one of our Drivers of Food Choice (DFC) projects (‘Dietary Transitions in Ghanaian cities’) has been utilizing an exciting, visual photography method called Photovoice. Last year, the team used Photovoice to explore the social and physical factors that drive food choices in adolescent girls and women of reproductive age in two Ghanaian Cities (James Town in Accra and Ho Dome in Ho) – with the aim of identifying context-specific interventions to tackle the rising burden of obesity and nutrition-related noncommunicable diseases (NR-NCDs).

In that process, they identified food safety as key in driving women’s food choices – particularly as a barrier to eating healthily. Factors identified include, food hygiene, food adulteration and contamination and environmental sanitation, i.e. cleanliness of food outlets/home surroundings. These food safety concerns need to be addressed within the physical food environment, in order to improve dietary behaviors in adolescent girls and women. In a recent review, the Food and Agriculture Organization of the United Nations (FAO), found that contamination and adulteration levels of food were very high in street food outlets in Ghana, and poor hygiene practices were often adopted, increasing the risk of developing foodborne diseases (FAO, 2016).

It is evident from the findings in James Town and Ho Dome that when making decisions about what to eat, avoiding immediate infection related to poor food safety practices is a primary concern to many people in urban Ghana. The prevention of NR-NCDs, like heart disease and type 2 diabetes are seen as secondary to remaining healthy in the short term.

Through their photographs, women captured how concerned they are with food hygiene and environmental sanitation, either in the home or neighborhood environment, and how these influence what they eat. Most women believed that food cooked outside the house was not prepared in a hygienic way, and thus not safe, promoting the transmission of infectious foodborne diseases.

Issues of food hygiene mentioned by women included cleanliness of food vendors (including hand washing practices and wearing of gloves and/or hair nets); food preparation methods (cleaning the food products before cooking them or using clean water to prepare meals); and covering the food to avoid contamination once it has been cooked and is ready to be sold.

“She covers her food with clean materials to prevent flies. Also, when she is not selling, she tries to always clean the surrounding and the utensils. Because of that I always like to buy food at her shop so I don’t get stomach problems.”
(Adult female, low to middle SES, Accra)

Women also identified a great number of unhygienic places/outlets in their communities or surrounding their homes. Women were well aware of the risks of cooking/eating under unsanitary conditions, and stated it was best to avoid eating from dirty places/outlets to avoid getting sick and therefore seeking medical care, which is not affordable for the majority of women living in the poor communities selected for the study.

 “Some food vendors keep rubbish around where they sell… Others also sell close to gutters and I will not entreat anyone to buy from such food joints. I will not feel comfortable myself buying food at such places.” 
(Adolescent girl, lowest SES, Accra).

“It shows a gutter. This place is in the house and it is dirty. Whenever I see it I don’t feel like eating… when I have cooked and say I go and fetch water, and I see it, I am unable to eat. If that place is not very neat, eating becomes very difficult for me.” 

(Adult female, low to middle SES, Ho) 

“…the place is not neat and for me even if the people here cook and offer me some of the food to eat, I will not eat it…. if you cook in a place like this and sell, I will not buy food from you to eat… there are dirty rags on the ground and the place is littered with plastic rubbers…” 
(Adult female, lowest SES, Accra)

Finally, women also raised the issue of food adulteration, which they believed was common practice in their neighborhood. They identified different forms of adulteration of foods including the use of so called “white” stock cubes and other condiments/additives to change and enhance the flavor and appearance of meals; the use of polythene bags to sell food and selling food items that are out of date or in bad condition. “There is this white …[stock]… smaller in size like rice and it is very poisonous. If you have a spoilt and smelly fish and you apply this white …[stock]… on it, it will make the fish taste nice again and people use it to cook which is not good. Also some people use rotten tomatoes to prepare the food… Some of the food sellers use white polythene bag to sell the food and it is not good because that rubber can cause sickness.” (Adult female, low to middle SES, Accra) 

“These instant noodles that we buy almost every evening they add all sort of artificial spices to it, the sausage and all those things are not    good for our body but we cannot afford the fish. We have no choice than to eat the instant noodles and sausage.”

 (Adult female, lowest SES, Accra) 

Currently, Ghana has several pieces of legislation on food safety to ensure effective adequate and effective standards of food to protect human health and consumers’ interest but many of these laws are poorly implemented. The legislation for regulating street food vendors needs attention. Other researchers in Ghana have shown that food vendors have satisfactory knowledge of food safety issues, but this does not necessarily translate into good practice. Priority actions must focus on educating food vendors and people in communities on good  hygiene practices such as hand-washing, safer food handling and food preparation methods, keeping the cooking surroundings cleaner as well as enforcement of policy regulations must occur, in order to protect women and the wider community against unsafe practices, and transmission of communicable foodborne diseases and to allow the community to feel safe in consuming healthier food options such as uncooked sliced fruits and vegetables. Until the public feels that their food is safe in the short term, they will not worry about eating a nutritionally poor diet that could lead to NR-NCDs in the long term.


This research has been funded by the Drivers of Food Choice (DFC) Competitive Grants Programs, which is funded by the UK Government’s Department for International Development and the Bill & Melinda Gates Foundation, and managed by the University of South Carolina, Arnold School of Public Health, USA.

The “Dietary Transitions in Ghanaian Cities” project is being delivered by the Universities of Sheffield, Loughborough, Liverpool, Ghana, Health and Allied Sciences and the CIRAD-Agricultural Research for Development in France. More details of the project can be found on our project website: would like to thank the women in Ho and Accra who generously gave their time to tell this story of how food safety influences their daily food choices in their communities.


Krystal Rampalli, MPH, is a Ph.D. student in Health Promotion, Education, and Behavior at the University of South Carolina’s Arnold School of Public Health. She is a Research Assistant for the Drivers of Food Choice Competitive Grants Program. 

Rebecca Pradeilles, PhD, is a Research Fellow in Global Public Health Nutrition at the University of Sheffield’s School of Health and Related Research. She is a team member on the Drivers of Food Choice project in Ghana. 

Akua Tandoh, MSc, is a Principal Research Assistant at the University of Ghana’s School of Public Health. She is a team member on the Drivers of Food Choice project in Ghana.


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