A participatory food environment study on healthy diets in Southern and Eastern Zambia

The food environment plays an important role in shaping diets, yet evidence in Zambia is limited. Traditional fermented foods such as mabisi, a Zambian traditional fermented milk, are beneficial and recommended as part of a healthy diet in the Zambian food-based dietary guidelines. Using components of Photovoice, this study explored factors influencing the consumption of healthy diets in the urban and rural food environments of two Zambian districts, Choma and Chipata, which differ in mabisi consumption. Fifty-seven participants shared their perspectives, revealing that despite the differences in mabisi consumption, the two food environments were very similar. The food environment in both districts largely depended on agriculture for the participants' diets and income. Rural participants depended on farming and gathering wild fruits and vegetables, while the urban participants had greater access to less nutrient-dense foods. Food safety and poor hygiene conditions were major concerns for most participants, particularly in urban Chipata where foods were sold on the streets uncovered and near garbage and/or sewer lines. As a result, packaged ultra-processed foods were perceived to be safer and healthier than less processed foods sold in the market. The findings reveal a paradox: although informal markets are vital sources of fresh and healthy food, they are viewed as unhygienic and risky, driving consumers toward ultra-processed foods perceived as safer. Even mabisi, which was generally considered a healthy food, was often perceived as unsafe because it was sold in dirty containers. Interventions must focus on improving hygiene and safety in informal markets, enhancing consumer awareness about the risks of ultra-processed foods, and ensuring that safe, nutritious foods are both accessible and affordable, especially for low-income populations in both urban and rural settings.