An Analysis of Healthy Food Access Amongst Womenin Peri-urban Honiara
Penny Farrell PhD; Anne Marie Thow PhD; Mia Rimon MPPM; Andy Roosen PhD;
Pavle Vizintin MIPH; and Joel Negin PhD
Abstract
Highly processed and energy-dense foods are contributing to the high andrising rates of non-communicable diseases and nutrient deficiencies in Solomon Islands. Non-communicable diseases currently cause 69% of deaths
in Solomon Islands, and the rate is rising, fuelled in part by limited healthsystem capacity to treat these conditions. Solomon Islands also has thehighest reported undernourishment rate in the Pacific. Recent decades haveseen several factors change the food and economic environment in Solomon
Islands. Importantly, rural-to-urban migration has caused a disconnect between
urban residents and access to land and home gardens. This study aimed to
examine the complexities of nutritious food access in urban Solomon Islands.
Data were collected from 32 women in Honiara, the islands’ capital, using anovel survey instrument. There were 3 important findings: (1) the dominant
influencers of the diet patterns described by participants in this study were
food affordability and access to land on which to grow it, (2) all participants
experienced food insecurity, and (3) reported diet patterns reflected unhealthy
diets which were particularly high in processed and sugary foods. These findings suggest a need for improvements in the food environment in Honiara.

Keywords
diet, Pacific, Solomon Islands, nutrition transition, non-communicable disease,
Pacific Island Countries and Territories

Abbreviations and Acronyms
NCD = Non-communicable disease
PICTs = Pacific Island Countries and Territories

Introduction
Non-communicable diseases (NCDs), including cardiovasculardisease and diabetes, are the leading cause of death and disability
in the Pacific region, imposing significant economic strain, pressure on overstretched health systems, and high levels of societal
loss from premature deaths.1,2 Highly processed, energy-dense
foods containing low amounts of micronutrients contribute to
the high and rising rates of NCDs and nutrient deficiencies
in Pacific Island Countries and Territories (PICTs), including
Solomon Islands.1,3 Solomon Islands is an archipelago country
in the Southwest Pacific with around 1000 islands, with an estimated population of 600 000.4 NCDs currently cause 69% ofdeaths in Solomon Islands, and the rate is rising. The problem
is exacerbated by a limited health system capacity to treat these

diseases.5-7 Solomon Islands also has the highest reported total
population undernourishment rate in the Pacific at almost 14%,
rising 2% in the last decade.8 The country currently faces a
triple burden of malnutrition: nearly 40% of adult women andchildren have anaemia, 33% of children have stunted physicalgrowth, and more than half of adults are overweight or obese.9-12
Recent decades have seen a number of factors change the foodand economic environment in Solomon Islands. Five years ofcivil unrest from 1998 to 2003, the global financial crisis, rapid
population growth, natural disasters, and urbanization contributeto ongoing cultural and economic change.3 Solomon Islands
ranks 152 of 189 countries in the Human Development Index.13
Approximately 80% of people in Solomon Islands live in rural
areas and access food via subsistence agriculture14,15; however,an annual urban population growth of 4.7% has caused a disconnect between urban residents and access to land and homegardens.15-17 Cash poverty is common in Solomon Islands, andfood prices are high relative to monetary earnings.15
There is a significant lack of data on food and nutrition security in PICTs,18 including Solomon Islands. This lack of datais hampering efforts to build effective policies and regulatory
frameworks to improve food systems.3 The present study was
designed to provide policy-relevant insight to start to address
this research gap. The study focuses on women because thereis global evidence that autonomy of women is positively linked
with their household’s nutritional status.19 Women are more
vulnerable to food insecurity than men, and the prevalence ofobesity worldwide is 50% higher in women than in men.20,21
Between 1975 and 2014, increases in body mass index for womenin PICTs were amongst the largest globally.22 Prevalence ofoverweight and obesity is higher in women in Solomon Islands
than in men.7 Importantly, women in Solomon Islands experience strong inequalities in access to resources and control ofhousehold decision making within households.15
This study aimed to understand the nuanced complexities ofnutritious food access in urban Solomon Islands by examining
the following factors: (1) food security and patterns of consumption of key food groups and specific foods, and (2) the mostimportant drivers of diet amongst participants to help informtargeted program and policy design.

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Methods

to classify each participant as household, individual, or childfood insecure.

Study Design
This study was informed by validated tools to collect data on
food security and food consumption patterns.23,24 Data were collected using a structured questionnaire (see Appendix) startingwith questions about demographic characteristics and general
health indicator information. Food security was measured withan adapted Radimer/Cornell tool based on that used by Shoae
et al.23 This tool included a series of questions about household, individual, and child food insecurity, and participants
were asked to answer “always,” “sometimes,” or “never” toeach question. Diet patterns were assessed using a shortened
version of a food frequency questionnaire used in a publishedstudy of 785 adults in Samoa.24 The aim of this data collection
was not to quantify exact dietary intake levels but to ascertain
broad patterns of food consumption in our study participants
to explore the reasons for such diet patterns. Participants werethen asked a series of open-ended questions about their dietpatterns, which explored drivers and barriers to consumptionof a nutritious diet.

The answers to the questions about food access and diet patterns
were analyzed using thematic analysis to determine the mostimportant reasons for dietary patterns.26
The study was approved by Solomon Islands National HealthResearch and Ethics Committee.
Results
Study Demographics
The study participants (n=32) were all women living in suburbs and villages close to Honiara. Table 1 summarizes the
key demographics of the study population. Of note, 71% ofparticipants (n=22) were under the age of 40, and 81% ofparticipants (n=26) cared for their families full time without adirect source of personal income. The average number of years
lived in Honiara was 19, and the average household size was
5 adults and 3 children.

Data Collection

Food Consumption Patterns

The study took place in Honiara, the capital of Solomon Islands.
In-depth interviews were conducted with 32 women with children in their care attending local primary schools. Participants
were recruited using convenience sampling, which was directedby school staff. Invited participants were given detailed information about the study in the form of a participant information sheet
and verbal explanation. Informed consent forms were signed
before each interview commenced. There were no withdrawals from the study. Participants were reimbursed with funds topurchase lunch and bus transport.

Table 2 presents a summary of key food items in participants’reported diet patterns. The most commonly consumed foodgroup was energy foods. Among energy foods, white rice wasconsumed the most, with 86% of participants (n=24) consuming
this daily. The second most commonly consumed food group
was body building food. Fish was the most commonly consumed
body building food; this food was consumed daily by 63% ofparticipants (n=20). Less than a quarter (23%) of participants(n=7) reported consuming fruit daily, and 57% of participants
reported consuming vegetables daily (n=17).

Participants were interviewed individually in a private room.
Interviews were run and transcribed in English by trained
members of the research team. Research assistants were alsopresent and translated the questions and responses into andfrom Solomon Islands Pijin when required.

Cooking Style

Data Analysis
Interview answers were entered into Microsoft Excel. Foodfrequency data were classified into energy foods (carbohydratebased foods), protective foods (fruit and vegetables), and bodybuilding foods (foods high in protein) using the Pacific Guidelines for Healthy Living.25 These guidelines further classify
energy foods into the following categories: “energy foods tochoose” (for example, root crops, whole grains), “energy foods
to limit” (foods high in refined carbohydrate including whitebread and white rice), and “energy foods to avoid” (foods highin fat, highly processed, high in sugar including sugar-sweetened
beverages).25 Food security questionnaire responses were used

Most participants cooked food in fresh coconut cream 3 or moretimes per week (data not shown). The main foods cooked incoconut were cabbage, fish, and starchy vegetables. Most participants cooked foods in oil at least weekly. The most common
cooking oil mentioned was palm oil, and participants also usedpeanut and vegetable oil. The main foods cooked in oil were
fish, cabbage, and chicken. Most participants also preparedfoods in soups at least weekly. The main foods prepared assoups were starchy vegetables and chicken.
Reasons for Diet Patterns
Table 3 demonstrates that the most commonly mentioned reason
for selecting particular types of food for consumption was affordability (84%, n=27). Other reasons given were availabilityof processed food (44%, n=14), availability of land (47%, n=15),
taste (28%, n=9), pursuit of health (19%, n=6), and culture

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(9%, n=3). When participants explained these reasons, somespecific foods were mentioned as illustrative examples. For
example, tinned fish was mentioned in relation to affordability.
White bread, white rice, and tea with sugar were mentioned inrelation to affordability and convenience. Participants noted
noodles were easy to prepare. In addition, Table 3 shows that
63% of participants (n=20) reported that the cooking facilities
available to them influenced the foods they were able to cook.
Participants were not directly asked which cooking facilities
they used, so it was impossible to quantify the most common
cooking facilities used. Still, participants mentioned using
firewood, gas stoves, and earth ovens.

When participants were asked who in their household decides
how much money was spent on food (Table 4), 55% of participants reported a joint decision (n=17, 15 of which was madejointly with the husband). Further, 23% (n=7) reported not
being involved in the decision. Among those who reported not
being involved in the decision, the participant’s husband was
the person most frequently mentioned to be responsible for thisdecision (n=7). Overall, 19% of participants (n=6) reported
being solely responsible for the decision.
Food Security
All participants (n=32, 100%) reported experiencing foodinsecurity in their household (Table 5). The majority (n=29,91%) also reported individual food insecurity, and 24 (75%)
reported child food insecurity.

As shown in Table 3, all participants who responded to thequestion of whether their diets were different from those eatenby their grandparents when they were the same age stated they
were (n=31, 100% of responses). Participant responses describeda shift away from diets high in fresh fruit and vegetables andwild-caught meat eaten in previous generations and towards
diets high in energy-dense processed and convenience foods.
Table 1. Study Participant Demographics (N=32)
Age (years)

n (%)

n (%)

n (%)

n (%)

20 to 29

30 to 39

40 to 49

No Response

5 (16)

17 (55)9 (29)

1

Average Household Size
Occupation
Education
Province of Origin

AdultsChildren530Care for family

Teacher

RetailOther

26 (81)

2 (6)

2 (6)

2 (6)

Primary school

High school

University

No Response

14 (50)11 (39)3 (11)

4

Guadalcanal

MalaitaOther

No Response

6 (19)

23 (72)3 (9)0Average Number Years Livedin Honiara

19

5

Table 2. Reported Frequency of Consumption of Commonly Consumed Foods (N=32)
Daily
n (%)

Food Item

3 Times Per Weekn (%)

Once Per weekn (%)

Less Frequently
Than Once Per Weekn (%)

No Response

Energy Foods
White rice

24 (86)

2 (7)

2 (7)

0 (0)

4

White bread

19 (61)5 (16)

7 (23)0 (0)1Cassava

14 (45)6 (19)

11 (35)0 (0)1Energy foods to limit (eg, doughnuts, pancakes)

17 (53)7 (22)

7 (22)1 (3)0Sugar sweetened hot beverages

19 (63)1 (3)6 (20)

4 (13)2Fish

20 (63)6 (19)

5 (16)1 (3)0Chicken

3 (10)

5 (16)

9 (29)

14 (45)1

Fruit

7 (23)

10 (32)

11 (35)

3 (10)

1

Vegetables

17 (57)8 (27)

4 (13)1 (3)2Body Building Foods

Protective Foods

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Table 3. Key Drivers of Diet Patterns (N=32)
Driver/s of Diet Patterns

Participants Who Describe Driver as Significant
n (%)

Example Quotation

Affordability

27 (84)

We grow our own local sweet potatoes which doesn’t
cost any money (23 year old participant)Availability of land on which to grow food

15 (47)

If I had good soil to grow my own fruits, root crops, andvegetables, I would eat healthy (44 year old participant)Availability of processed food

14 (44)[my grandparents] depended on food from garden. Today,
we live on money and depend on processed food fromthe shop (34 year old participant)Type of cooking facilities available, ease of preparation

20 (63)Yes [the cooking facilities available to me influence thetype of food I prepare], because we only use fire so I tend
to boil, fry, and stew our food (33 year old participant)

Perceived healthiness

6 (19)

Because it is a healthy meal and it is available at home
(35 year old participant)Taste

9 (28)[I consume soda because] it tastes good and is cold (43year old participant)Culture3 (9)Affordability, culture, and availability [have the strongest
influence on my diet patterns] (33 year old participant)Comparison of Diet with Grandparents’ Dietn (%)

No response

Participant diet different from those of grandparents

31 (100)

1

Table 4. Household Decision Making Status (N=32)n (%)

No response

Participant Only

6 (19)

1

Joint Decision
Of those with joint decision (N=17), decision made with husband

17 (55)15 (88)10Someone ElseOf those with decision made by someone else (N=7), decision made by husband

7 (23)
7 (100)

1
0

Table 5. Food Security Status of Participants (N=32)
Food Security Statusn (%)

No responseHousehold food insecurea
Of participants who were household food insecure (N=32), participant has been
concerned household food will run out (Appendix Section 8: Q1)

32 (100)
28 (88)00Individual adult food insecureb
Of participants who were individual food insecure (N=29), participant sometimes
does not eat for whole days at a time (Appendix Section 8: Q10)

29 (91)13 (45)00Child food insecurec
24 (75)0
Of participants who were child food insecure (N=24), participant’s children
6 (25)
0sometimes don’t eat for a whole day (Appendix Section 8: Q15)aHousehold food secure: Answered ‘sometimes true’ or ‘always true’ to one or more question related to household food insecurity(Questions [Q] 1–6 in Appendix Section 8).
b
Individual adult food insecure: Answered ‘sometimes true’ or ‘often true’ in one or more adult-level items (Q7 –Q10 in Appendix
Section 8).
cChild food insecure: Answered ‘sometimes true’ or ‘often true’ in one or more child-level items (Q11–Q15 in Appendix Section 8).

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Discussion
Summary of Results and Likely Implications
Our study aimed to provide policy-relevant insights about accessto a nutritious diet in contemporary Honiara in light of the current
triple burden of malnutrition and the rapid changes to the urban
population size and economy.9,16 This was a methodologicallynovel study in Solomon Islands and the results provide useful
information on the under-researched area of food insecurity
and diet behaviour in Solomon Islands and other PICTs. The 3
most important findings were: (1) the dominant influencers ofthe diet patterns described by participants in this study were
food affordability and access to land on which to grow fruitand vegetables; (2) all participants experienced food insecurity,
meaning they all at least sometimes experienced difficulty accessing nutritious food, and some regularly skipped their own,
or their children’s, meals; (3) reported diet patterns reflectedunhealthy diets which were particularly high in processed andsugary energy foods. There were no obvious patterns between
socio-demographic characteristics, food security status, and dietpatterns observed in this small descriptive study.
These 3 key findings are deeply interconnected and suggest the
study participants are living in a food environment that is notsupportive of good health. The dominant story told by the study
participants was that they did not have the cash to purchaseadequate nutritious food for themselves and their households,
nor access to the land to grow it and that because of thesechallenges with nutritious food access (otherwise defined asfood security), they are consuming inexpensive foods which
are energy-dense, often highly processed, and low in nutrients.
These foods have been implicated as key to the high rates of
NCDs and micronutrient deficiencies in the Pacific.1,3 There isevidence that in a food-insecure environment, consumption ofenergy-dense, highly processed foods is the main mechanism
whereby food insecurity can lead to obesity.27
The diet patterns reported in this small study are consistent
with grey literature reports that people in Honiara generallypurchase food with cash, and as heavily processed, often imported foods are usually less expensive, these are increasingly
becoming the main feature of people’s diets.3,7,17 The findings
from this study reflect reports of a worsening food security situation throughout the Pacific region. Connell reported that foodinsecurity has increased in the region in recent decades—due
to cost, convenience, and prestige, diets are high in imported
and processed foods, especially rice.28
The most frequently reported energy foods consumed by thestudy participants are classified as “energy foods to limit” and“energy foods to avoid” in the Pacific Guidelines25: the mostcommon of these were white bread, white rice, pancakes, anddonuts. Of further concern is that the vast majority of participants

reported consuming sugar-sweetened beverages (usually sugarin tea) at least weekly, and almost two-thirds consumed thisdaily. Sugar-sweetened beverages are classified as energy foodto avoid in the Pacific Guidelines for Healthy Living. There
are several potential poor health consequences of consumingthese “energy foods to limit” and “energy foods to avoid.” Forexample, consuming sugar-sweetened beverages increases therisk of diabetes.29 It is notable that diabetes is now the leading
cause of death and disability in Solomon Islands.30
The diet patterns reported by participants in this study suggestthat fruit and vegetable consumption is likely to be well below
the 5 servings per day recommended in the Pacific Guidelines
for Healthy Living.25 The most recent STEPwise approach tosurveillance, known as STEPS, survey showed that 93% of theSolomon Islands population ate less than 5 servings of fruitand vegetables per day; the average daily consumption was
0.8 servings of fruit and 1.3 servings of vegetables.31 There isevidence from Solomon Islands that households in urban areas
and those with low incomes are vulnerable to insufficient fruitand non-starchy vegetable consumption.32
In Solomon Islands society, food and land are owned collectively – people are socially required to share food and housingwith their extended kin, or Wantok.7 This has implications forthe way resources are distributed and preparing high-volume,
low-cost meals often mean low-nutrient, high-volume foods likerice are sought.7 The participants in this study were generally
from large households. Although a pattern between household
size and diet patterns was not observed in this small descriptive
study, recent research from Solomon Islands found that thoseliving in households with 7 or more people acquired less fruitand non-starchy vegetables than those in small households.32
The relationship between inter-household sharing of resources,
poverty, and food security was not explored in this study but
warrants attention in future research. It has been suggested that
remittance funds sent to the rural population by their Wantok in
Honiara are decreasing due to decreased food affordability in
Honiara17, which demonstrates that urban welfare is connectedwith national development.16
Strengths and Limitations
This study was designed to understand dietary patterns, foodpreferences, and interactions with food environments, not exact
food intake levels. The food frequency questionnaire results offer
indicative descriptive figures only due to the small sample size
and relied on self-reported diet information, which could haveintroduced bias. The question about vegetable consumption did
not distinguish between starchy (an energy food) and non-starchy
vegetables (protective foods). The survey was conducted in
Honiara only, so may not be representative of all urban areas.

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The survey was performed before the most recent Pacific
Guidelines for Healthy Living were published, 25 so its recommendations about portions of energy, body building, andprotective foods could not be built into the survey. However,these were used when analyzing the data, thus making thefindings directly applicable to policy makers in the Pacific. The
tool used to measure food security was designed based on thebest available resources; however, there is no validated foodsecurity measurement tool for Solomon Islands.
The question about household decision-making in this study
was simple, and as a result, the responses were likely more
superficial than the lived reality for participants. Although mostparticipants reported they had some say in household decision
making around food purchasing, it should be noted that in
Solomon Islands, “women are responsible for decisions about
raising children, providing food, and running the household,but men have the power to beat them if they get it wrong.”15
More time and attention should be given to this vital but highly
sensitive topic in the future.
Recommendations
The findings of this study call for urgent action in improving access to a nutritious and affordable diet in urban Solomon Islands.
As the combination of rural-urban migration, lack of accessto garden land, low incomes, and high formal unemployment
in urban populations is a serious problem in many PICTs,3,33
the methods and findings from this study have value acrossthe region. The methodology used in this study may have use
as a foundation in gathering further baseline and subsequent
progress information, where food systems interventions andpolicy changes are implemented.
The combined findings of high food insecurity and diets high inprocessed foods match those of other studies from the Pacific.
Connell declared that food insecurity in PICTs is “an increasingly urban problem,” with the solution embedded in broad
economic growth and poverty reduction, 28 and cross-sectoral
action not limited to the agriculture or health sectors. The issue of urban food poverty in Solomon Islands will affect more
and more people as urbanization continues to grow. The rise inurban population size—at a rate of 4.7% per year, faster than
the national growth rate of 2.3%—means that poverty reduction
and provision of basic services are in need of urgent attention
by the national government.16
A 2018 review spanning 172 countries has shown that imports
of processed food and sugar significantly increase average bodymass index.34 The promotion of healthier food imports throughconsideration of nutrition in trade policy design and input of
the health sector in trade policy has strong potential to improve
diets in the Pacific region.35,36

Increased alignment between local agriculture and nutritionand health outcomes is needed at high priority.3 Policies thatprovide support for marketplaces to sell fresh local foods ataffordable prices relative to other foods on the market; and to
facilitate different cooking options for households can increasenutritious food consumption. The findings from this study add
to the small amount of existing evidence from Melanesiancountries that financial and physical access to nutritious foodis an important barrier to its consumption.7,32,37 There is the potential to trial programs that have worked in other countries toaddress these issues. For instance, research from a low-income
area of the United States has shown that an intervention where
mobile markets sell fruit and vegetables, combined with an
education program, significantly increased consumption offruit and vegetables.38
Conflict of Interest
None of the authors identify a conflict of interest.
Acknowledgments
The authors would like to express their thanks to the study participants, theschools through which they were recruited, The Pacific Community Honiara
NCD Warrior team for their support.
Authors’ Affiliations:- Sydney School of Public Health, Edward Ford Building A27, The University ofSydney, NSW, 2006, Australia (PF, PV, JN)- Menzies Centre for Health Policy, Charles Perkins Centre D17, The University ofSydney, NSW, 2006, Australia (AMT)- Pacific Community (SPC). Port Vila, Vanuatu and Honiara, Solomon Islands (MR)- Synergies Ltd, Ngossi Ridge, Honiara, Solomon Islands (AR)Correspondence to:Penny Farrell PhD; Sydney School of Public Health, Edward Ford Building A27,
The University of Sydney, NSW, 2006, Australia;
E-Mail: penny.farrell@sydney.edu.au
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1, 2019.
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Appendix: Survey Instrument

3.05 Please briefly explain what you do (e.g. study, type of employment, unemployed,care for family at home)
3.06 Number of adults including yourself (18 and over) in household
3.07 Number of children (18 and under) in household
3.08 Did you grow up in Honiara, if not where did you live as a child?
3.09 How long have you been living in Honiara?
3.10 Do you mainly live in Honiara?

Understanding the socio-demographic determinants of access to healthy food
SURVEY INSTRUMENT FOR INDIVIDUAL INTERVIEWSCONFIDENTIAL
Interviewer name
Date
School at which interview conductedParticipant ID
1. Participant consent
1.01 Information sheet given and verbally explained
1.02 Consent form given and signed?
2. Introduction
Thank you for agreeing to participate in this survey. We are Penny Farrell and … and… from The University of Sydney in Australia.
We will ask a series of questions about your diet and the interview will go for aroundan hour.
Your participation is confidential and will not be linked to your child in any way. We will
not share the answers with anyone including your child’s school.
You can interrupt the interview at any point to ask questions, voice concerns or end
the interview if you wish.
There are contact details for our research team on the participant information sheet
which is yours to keep.
3. General information about participant
3.01 Age (in years, as at last birthday):3.02 Sex:
3.03 Village & district live in:Village:
District:
3.04 Could you tell me the final class you graduated from at school or in your education? Circle one of: Did not finish primary school, finished primary school, finished highschool, has university degree)

4. Food frequency questionnaire
We will now work through a list of food items and ask how often (never, <1/month, few
times a month, 1/week, 2-4/week, 1/day, 2-3/day, >4/day) you consume one serve ofeach item. [Refer to printed card]
How often do you eat one serve of:
MEAT
Beef in soy sauce, Beef curry,Tinned Corned beef, Salt beef, BBQ chicken, Fried
chicken, Chicken curry with coconut cream, Chicken in soy sauce, Baked chicken,
Roasted pork (if Y, what cut – or do you eat the whole pig?), Pork baked in earth oven
(if Y, what cut – or do you eat the whole pig?), Fried fish, Boiled fish in coconut cream,
Tinned fish, Fish prepared in any other ways – how often, Other seafood (ask to list),
BBQ lamb chop, Mutton in any other form (if yes, what cut and how is it prepared?),BBQ sausage, Other meat (if yes, what cut and how is it prepared?)
STAPLE/ENERGY
Taro, Potato, Sweet potato, White bread, Wholemeal bread, Cassava, White rice,
Green/cooking banana; If yes, how is it prepared, Coco yam, Yam, Cereal; If any,
what type, Breadfruit
FRUIT & VEG
How often do you eat 1 serve of fruit? [reiterate serve: half a pawpaw or whole guava,
eating banana], How often do you eat 1 serve of vegetables? [reiterate serve: fistful]

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DRINKS
Fruit juice (packaged), Fruit juice (fresh), Cordial drink e.g. Tang e.g. raro or sprim,
Soda can, Tea or coffee WITH milk, Tea or coffee WITH sugar, Young drinking coconut,
Milo, 3 in 1 coffee sachets
SNACKS/TREATS
Lollies, Ice cream, Nuts (e.g. peanuts), Fried snacks, Pizza, Beef burger, Meat pie,
Packaged potato chips, Twisties, Hot potato chips, Instant dried noodle, Pancakes,
Donuts, Cake, Cream biscuits, Cabin crackers, Sausage roll, Cream bun, Coconut bun
5. Summary of commonly eaten foods
5.01 With the most commonly eaten item in each of the 5 categories in the previous
question, why do you eat them – what influences your food choices (if need prompting,rank the most important reasons (affordability, availability, advertising, taste, convenience,
habit, healthiness, or culture) for eating these foods?
5.02 [Show flip card of food pyramid.] This is the guideline for the healthy amounts of eachfood type you should eat. What would help you to eat your meals in these proportions?
5.03 Do you think your overall diet is different to what your grandparents ate when
they were your age? Why?

5. We eat the same food for several daysin a row, because we don’t have enoughmoney to buy different kinds of food
6. I only prepare a few kinds of cheap foodand can’t make different food because I
don’t have enough money
Individual adult items – how often are these true for you?
7. How often are these true for you:(a) I have one meal per day(b) I have 2 meals per day(c) I have 3 meals per day
8. I can’t eat nutritious food because I
don’t have money to buy it
9. Due to lack of money and enough food,I only eat bread, rice or noodles
10. Sometimes I don’t eat all day

6. Ways of preparing food6.01 Which main type of cooking oil do you use and why?
6.02 How often do you cook with coconut?
6.03 Which are the main foods you cook in coconut?
6.04 How often do you fry foods in oil?
6.05 Which are the main foods you cook in oil?
6.06 How often do you prepare (or eat) soup?
6.07 Which are the main foods you prepare in soups?
6.08 List the type of cooking equipment you have at home: (E.g. open fire, small gas burner,oven etc. Do the cooking facilities in your home influence the food you cook?.) How?

Individual child items how often are these true for the children in your care?

7. Food consumption and living situation
7.01 During a typical week day, what do you eat, and where do you get it from? Why
do you choose this food? For example, in the morning after you wake up and before
you leave home, what do you eat and why? [Continue to prompt until participant has
explained source of all foods typically eaten in a day – will ask this open-ended question via interpreter]7.02 What is their role in food purchasing in their household?
7.03 Who decides how money is spent on food in your household? (Participant, joint
decision [with whom]) or someone else’s decision [who])
7.04 What is your household income, including remittances? What proportion of yourhousehold income is from remittances?
7.05 What is your personal income?
7.06 Can you estimate how much money you spend on food each week for yourself?
7.07 Can you estimate how much money you spend on food each week for your family?
7.08 Can you describe what is a healthy meal?
7.09 Can you list ways to make a meal healthier and balanced?
7.10 Please point to the body shape you think looks attractive for men [Show flash card]
7.11 Please point to the body shape you think looks most attractive for women [Showflash card]
7.12 Please point to the body shape you think looks most healthy for men [Show flash card]
7.13 Repeat for most healthy for men and most healthy for women [Show flash card]

14. My child/children have their mealsizes cut because I don’t have enoughmoney to buy food

8. Food security
Participants will be asked to answer the following questions in relation to the past 12
months: (Remind of confidentiality)
Household questions
1. I have been worried that our foodwill run out
2. I have been thinking that I wish I had
more money and I could buy more foodOften true/Sometimes true/Not true

11. I can’t feed my child/children nutritious
food because I don’t have enough money
12. Sometimes my child/children only
have bread or rice because I don’t havemoney to buy more of other foods
13. I know that my child/children sometimes is/are hungry but I don’t have money
to buy more food

15. Sometimes my child/children don’t
eat all day

Household secure: Answered ‘not true’ to all questions
Household insecure: Answered ‘sometimes true’ or ‘always true’ to one or morequestion related to household food insecurity (Q1– Q6).
Individual adult insecure: Answered ‘sometimes true’ or ‘often true’ in one ormore adult-level items (Q7–Q10).
Child food insecure: answered ‘sometimes true’ or ‘often true’ in one or morechild-level items (Q11–Q15).

Adapted from Shoae et al. 2007: Is the adapted Radimer/Cornell questionnaire valid to measure
food insecurity of urban households in Tehran, Iran?; Public Health Nutrition: 10(8), 855–861;
and Derrickson et al. The core food security module scale measure is valid and reliable whenused with Asians and Pacific Islanders; The Journal of Nutrition; Nov 2000; 130, 11.

9. Health information
9.01 How frequently do you do exercise where your heart rate is fast for 30 minutes ormore? __ < 1 X a week, __ 1-3 X a week, __ >3 X a week
9.02 Are you pregnant? If pregnant, how many months (number of completed months
if known)
9.03 Have you ever been diagnosed with diabetes? (Y/N)
9.04 Have you ever been diagnosed with heart disease or high blood pressure? (Y/N)
9.05 Alcohol consumption (Y/N)
9.06 If Y: How many times a week do you drink, how many drinks do you have on average when you drink? how many drinks per week on average (1-3; 4-7; 8+)9.07 Do you smoke? (Y/N)

3. When I want to make a meal, thematerials needed for making it haverun out and it’s hard for me to get more
4. I can’t prepare meals that I think arehealthy for my family, because the materials needed to make it have run out, andI don’t have money to buy them again

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