In many low- and middle-income countries (LMICs) worldwide, populations face a triple burden of malnutrition: under-nutrition, micronutrient deficiencies, and over-nutrition. Promoting healthy eating habits can reduce the prevalence of non-communicable diseases and improve overall health outcomes while helping to address socioeconomic inequalities.
Recognizing this, the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) developed a series of broad food-based dietary guidelines (FBDGs) in 1995. FAO aimed to encourage and support countries to adapt the FBDGs to their unique local contexts. Since then, over 100 countries have established national FBDGs, including ten African countries.
Developing And Testing Food-Based Dietary Guidelines In Tanzania
A national nutrition study conducted in Tanzania found notable improvements in diet and nutrition between 2014 and 2018. However, researchers estimated that over 2.7 million Tanzanian children under five years old faced stunted growth, over 7% of women of reproductive age were underweight, and over 31% of women of reproductive age were overweight. With this in mind, FAO appointed a research team to test proposed FBDG messages and images in Tanzania.
The Digital Medic team collaborated with researchers at Stellenbosch University and the Tanzania Food and Nutrition Centre’s FBDG Technical Working Group to develop and field-test FBDGs for dissemination in Zanzibar and Mainland Tanzania. Community insights and feedback directly influenced the development of contextually and culturally relevant text, illustrations, and formats. Our team co-wrote an open-access paper about this work, published via MDPI in 2022.
We spoke with Digital Medic Research Analyst Nophiwe Job and Illustrator Shân Fischer to get a behind-the-scenes perspective on their experience developing the FBDGs to meet the needs and preferences of communities in Tanzania.
"Interventions, regardless of how well-intentioned they are, will fail if they fail to recognise context."
Nophiwe Job, Research Analyst at Digital Medic
1. Let’s start with a big-picture question: why is it so important to localize health guidelines for specific audiences, particularly when the information relates to diet and nutrition?
Nophiwe Job: We relate to food in a social manner, not a scientific manner. We rarely eat to get nutrients – meal times are social and cultural events of life. When we think of roast chicken, we rarely think of the iron or niacin in the chicken, we think of the loved one who had prepared it the last time we ate it and the scene of the moment. Guidelines for food need to be localised because they need to speak to the way we consume food in everyday life. They need to speak about the foods we have locally and how we can better consume them to get all the nutrients we need for good health and long life.
2. Can you describe how Digital Medic first became involved in this project, and what specific areas of the research and design our team was tasked with?
Shân Fischer: We had previously worked with Associate Professor Lisanne du Plessis of Stellenbosch University on illustrating a set of paediatric food-based dietary guidelines for South Africa. Mercy Chikoko, a Nutrition Officer at the FAO saw our illustrations and contacted Digital Medic to see if we could work on this project. Together with Stellenbosch University we consulted on the initial field-testing of the FBDGs in Tanzania and later facilitated the development of the full set of FBDGs. We made a great team because Digital Medic has experience in creating engaging visuals that communicate health information effectively, and Stellenbosch University had experience in field-testing FBDGs.
3. The paper states that the Tanzanian FBDG Technical Working Group (TWG) first narrowed down the FBDGs to 12 themes most relevant to the local context. These themes were then handed to the research team to develop the preliminary messages. Can you discuss the process of drafting these? How involved was our team, and what were some considerations we needed to keep in mind?
NJ: The TWG is made up of experts with experience in various scientific fields of agriculture, health, nutrition, and maternal and child health. They are knowledgeable about the current health and nutrition needs of Tanzania. They were tasked with clarifying all the nutrition needs of the country and deciding which areas the guidelines should cover. They came up with 12 areas that need to be addressed in an understandable way.
Our team included Professor Du Plessis, who had experience in developing these guidelines for South Africa. She advised the TWG on how to conduct field-testing and we lent our experience in translating scientific statements into simple language. This allowed the TWG to think about its own context and choose language and methods that would be acceptable to the Tanzanian public.
SF: During this process, our team emphasized the importance of the visuals and the need for these to be field-tested as well as the text. I think this only became clear to everyone once the first round of field testing was completed. The TWG was surprised by how positively people responded to colourful relatable images, especially in areas where literacy rates were low.
4. Can you share some behind the scenes about the initial design process? How much research went into deciding on the best format, e.g. the mix of images and illustrations?
NJ: Beautiful, warm, and sunny Zanzibari days come to mind when thinking of the prep days. The DM team was in Tanzania for a few days before consultations began with the Tanzanian team. We walked around the cities of Dar es Salaam and Zanzibar Island collecting fruit and veg that we had no access to in South Africa to create a photo library that would be used to create visuals. Another key consideration was how the country intended to use the guidelines. Were they going to be printed as pamphlets? Were they going to be used as posters? Were they going to be used in digital formats?
SF: As with the South African paediatric FBDGs, we used a mixture of illustration and photographs. This method was originally chosen because focus groups responded better to clear photographic representations of food rather than illustrated ones. They found these to be more recognizable and relatable. So yes, we needed some time before the meetings began to just focus on the photography.
We arrived in Zanzibar a few days early and Nophiwe and I headed to the markets and beaches. We bought a wide variety of fruits and vegetables and photographed them all individually, using a lightbox late into the night. I needed to make sure the photographs were very clear and descriptive, should these FBDGs be printed as lower-quality posters or handouts. We went to fish markets and street stalls and bought everything that was popular and eaten regularly and photographed it all, to build quite an extensive library of Tanzania and Zanzibar foods and drinks.
I took a lot of reference photos for myself as well, for illustrating purposes. The architecture, the people (with permission), nature, the way of life, the details are very important when you’re trying to accurately and respectfully represent a culture visually.
5. What were some considerations going into the field-testing stage? Can you explain the criteria for choosing participants? Why were women chosen as the study population?
NJ: After discussion with the TWG, it was decided that women were ideal for testing these guidelines. In Tanzania, women are largely responsible for food preparation for households and the care of children. They were the perfect group to critique the guidelines on their cultural relevance and practicality. We knew that they would be able to tell us exactly how the language and images need to be in order to influence other community members to prepare more nutritious meals for their families.
6. Did our team have any presence in the focus group discussions? If so, what was that experience like, and did you walk away with any specific insights?
NJ: We did not have a presence in the focus group discussions, but we were responsible for training the facilitators on how to conduct the discussions. That included discussing the role of a facilitator and a fun role-play activity demonstrating how to facilitate focus group discussions in the community.
SF: We didn’t want our presence to influence any discussions. We also tried to coach the focus group facilitator to encourage open discussion and not have one person in the group be the spokesperson.
7. Let’s walk through a couple of specific examples. Can you discuss the differences between the original and revised images and elaborate on why and how these changes were made?
SF: For the first set of images, the feedback was mostly about how certain sports were represented. These are culturally very gender-based. In my artwork, I try to break stereotypes as often as possible, but we also need to be sensitive to the local context. So the boys were shown playing soccer and the girls and grandmother were skipping rope. The women of working age were shown doing just that – working.
The clean water image went through quite a lot of changes. I started simple, depicting what currently happens in the country. However, a plastic bottle-free image was requested, as Tanzania is making some fantastic changes to its policies regarding single-use plastics. The image also needed to represent clean and safe water, so I added a system of water purification as well as a greater sense of community. These changes made for a much more impactful and well-rounded image.
8. When evaluating the study results, was there any feedback that surprised you?
NJ: Children carrying lunchboxes to school was debated a lot! This I did not expect! In some areas, children are not encouraged to bring packed lunches to school. One of the reasons was that it encouraged bullying.
Another was not surprising but interesting. In one image about keeping clean food environments, we showed a gentleman washing dishes. However, participants shared that this did not reflect the reality of home life for most families. Based on this, we revised the image to depict more traditional gender roles.
9. On a personal level, what lessons did you learn from this project that you plan to apply to future Digital Medic work (e.g. when it comes to localizing content for specific audiences)?
NJ: You will always have something to learn from your end users or target audience. Always. It is essential to take the time to immerse yourself in the context of your target audience. Interventions, regardless of how well-intentioned they are, will fail if they fail to recognise context.
SF: I could say so much about this project! Stand up for myself and my work. Art is important. For so many reasons, one of those being low literacy levels. Yes, it’s pretty to look at, but it can communicate so much more. Concepts and ideas can be expressed across languages, across cultures, across all the barriers we put in place to stop people from having a better life. Knowledge can be shared through art.
"Concepts and ideas can be expressed across languages, across cultures, across all the barriers we put in place to stop people from having a better life. Knowledge can be shared through art."
- Shân Fischer, Illustrator at Digital Medic