Photovoice: Enhancing health and nutrition for Mozambique’s adolescent girls

What we know: Iron-deficiency anaemia is a leading cause of disability-adjusted life years (DALYs) lost among adolescent girls, particularly in low- and middle-income countries where poor diets and harmful cultural practices worsen micronutrient deficiencies. Adolescents, especially girls, often face barriers in decision-making regarding their nutrition, with their voices typically excluded from health interventions and policies.

What this adds: This study demonstrates the effectiveness of using Photovoice as a participatory research method to engage adolescent girls in identifying barriers and opportunities related to their nutrition, specifically regarding consumption of iron-rich foods in Mozambique. The findings highlight the strong preference among adolescent girls for indigenous foods, their willingness to engage in farming, and the significant challenges they face due to limited social connections, poor nutrition knowledge, and harmful cultural practices.

Iron-deficiency anaemia is the most common micronutrient deficiency and is a leading cause of DALYs lost among adolescent girls aged 10-19 years (Canavan & Fawzi, 2019). While anaemia does affect boys, girls experience more years lived with disability (Safiri et al, 2021). Malnutrition, especially iron-deficiency anaemia, undermines girls’ learning, income potential, self-care abilities, and maternal and infant health outcomes. In Mozambique, 56% of girls aged 1 -19 years suffer from anaemia (Mozambique MOH, 2018).

Shifting dietary patterns among adolescents in low- or middle-income countries, whereby iron and nutrient-rich foods are replaced by sugary drinks and ultra-processed foods, contribute to anaemia. In low- and middle-income countries, 42% of adolescents consume carbonated drinks daily, while 46% eat fast food once a week (UNICEF, 2019). Reliance on grain and cereal-based diets in low-income contexts hinders iron absorption (Bhatnagar & Padilla-Zakour, 2021), further exacerbating the problem.

Harmful cultural practices and social norms also drive iron-deficiency anaemia among adolescent girls. Intra-household food allocation often favours men and boys (Harris-Fry et al, 2017). Child marriage, early pregnancy, and high fertility rates further challenge the prevention of anaemia. In Mozambique, 53% of girls marry before they are aged 18 years, the fifth highest percentage in the world (Girls Not Brides, 2022). Undernourished girls who marry and give birth early continue the cycle of undernutrition, as micronutrient-deficient mothers are more likely to have low birthweight babies (Imdad & Bhutta, 2012).

Adolescents face barriers in decision-making regarding their nutrition and sexual reproductive health needs. Their voices are often excluded from health interventions and policies (Pincock & Jones, 2020). Addressing micronutrient deficiencies requires shifting the conversation from a biomedical issue to one of social justice and health equity, especially among vulnerable adolescents in low-resource settings (Tang & Sholzberg, 2024). Empowering adolescent girls to control their lives in regard to education, health and nutrition is crucial. Formative research and human-centred design can help identify their needs and increase their adoption of behaviours to reduce anaemia.

World Vision, in partnership with the Ministries of Health, Culture, and Education of Mozambique, implemented the Photovoice project (March-November 2023) to explore nutrition experiences, needs, and priorities of adolescent girls and young women aged 13-20 years in Monapo District, Mozambique. Photovoice is a participatory research method developed in the 1990s (World Vision, 2024a). Cameras are given to community members who typically don’t have a voice in decision- making, to allow them to document their experiences in a way that breaks down traditional communication barriers (Seitz & Orsini, 2022). For our study, we used Photovoice in two ways: as a formative research tool to explore barriers to, and opportunities for, consuming iron-rich foods, and as an advocacy tool to create opportunities for dialogue with influential individuals within the health and education systems.

The study involved 16 girls from rural and peri-rural secondary schools, divided equally into two age groups (13-16 years and 17-20 years) to capture varying perspectives. Participants received digital cameras and training on photography, ethics, and study objectives. The girls and their caregivers signed consent forms allowing the girls to participate. The girls also collected relevant release forms for their photos to be used publicly. Over one week, they photographed challenges and opportunities related to healthy eating, particularly eating iron-rich foods, as well as social and gender norms influencing their diets.

Following the week of photo-taking, two five-hour workshops were held (one for each age group). Participants discussed their two or three most compelling photos (each girl took 50-60 photos) using the SHOWeD methodology (Box 1), which encourages reflection on what is seen, what is happening, and how it relates to individuals’ lives. The workshops also explored participants’ understanding of ‘healthy’ and ‘unhealthy’ foods, their food preferences, and barriers to and facilitators for accessing iron-rich foods.  

Because some of the photos elicited strong emotions during the workshops, follow-up individual interviews were conducted with each participant to give them time and the opportunity to explore the photos in more depth. During the individual interviews, each participant was asked to select one photo she felt best represented a challenge or opportunity related to health and nutrition.

The resulting 16 photos, along with the participants’ headshots and quotes, were developed into printed photobooks (in Portuguese) and published digitally (in English) (World Vision, 2024b). Hard copies of the photobooks were shared with the Ministry of Health at the federal, provincial, and district levels and the district Ministry of Education and Ministry of Culture. Each participant also received a photobook and prints of all the photos they had taken. We also conducted three key informant interviews with the District Ministry of Health, Ministry of Education, and Ministry of Culture to assess the current feasibility and performance of government-supported nutrition interventions within Monapo District. We used the key informant interviews to triangulate findings from the Photovoice workshops to gain a deeper understanding of our research problem and to validate our qualitative research findings.

The Photovoice workshop, individual interviews, and key informant interview transcripts were conducted and recorded in Portuguese, translated into English, and uploaded into MAXQDA 2022 Plus for analysis. We developed a codebook using deductive and inductive reasoning focussing on descriptive, process, emotional, value, and concept codes. We used horizontal analysis to identify emerging themes across both workshop transcripts, while we used vertical analysis to highlight significant quotes and stories. We then generated coded segment reports to categorise common emerging themes and sub-themes. 

Below, we describe key themes that emerged from the photographs regarding opportunities for and barriers to promoting nutrition behaviours, like growing and consuming indigenous iron-rich foods.

Opportunities

Pride in indigenous foods

The findings revealed adolescents’ strong preference for locally grown foods and home-cooked meals, and indicated that there is limited access to processed and sugary foods. Commonly consumed indigenous foods included chima (cassava porridge), maçanica (fruit), rice, green beans, cassava, sugarcane, potatoes, banana, cucumber, peanuts, cabbage, okra, and sesame. Many of these frequently consumed foods are low in iron and other nutrients. Regarding protein and iron-rich animal foods, field rats were frequently consumed by girls aged 13-16 years, while older girls (17-20) had mixed levels of acceptance of them. Chicken, fish, goat, and grasshoppers, while accessible, were consumed infrequently, and frogs in particular were strongly disliked.

Willingness to farm and help mothers with cooking responsibilities

Adolescents expressed a strong desire to participate in agricultural activities; most participants worked on their family farm at least once a week. Mothers were often responsible for their own plots of farmland (separate from their husbands), and adolescent girls supported their mothers in sowing and harvesting cassava, tomatoes, rice, spinach, guava, and mangoes.

“We usually go to the farm at 5 am and come back around 9 or 10 am on Saturdays.” – Participant 5

“We usually plant tomatoes and manioc (cassava), my father has his field, but my mother’s field produces the most.” – Participant 1

Adolescent girls also actively participated in preparing and cooking food, which often occurred over an open fire.

Family and friendships were strongly valued

Participants deeply valued family, friendships, and their community. Most girls photographed happy moments with loved ones during meals and outside their homes. They expressed a strong desire to study and pursue careers to support their families, with teaching and healthcare being the most common career aims.

Barriers

Limited connections to influential people

Interestingly, participants more often defined poverty as a lack of connections to people with power and influence, rather than a lack of money, and felt that was the most significant barrier to achieving their dreams.

“I have a dream of becoming a teacher (but) I’m afraid that I won’t be able to achieve my dream.” – Participant 2

When asked to describe the obstacles to achieving their aspirations, like becoming a teacher, a lack of social capital was strongly associated with limited career opportunities.

Limited nutrition knowledge

The findings revealed that participants' knowledge of the nutrient content of certain foods was lacking, while some participants expressed a strong dislike for some micronutrient-dense foods, such as carrots. Participants also had very limited knowledge around Vitamin C as a nutrient that can enhance iron absorption.

Inequitable household responsibilities

The hypothesis that food was inequitably shared within the household did not emerge as a strong theme from the analysis of the qualitative data. However, inequitable household responsibilities between girls and boys were consistently found in our analysis, with girls being responsible for far more chores than boys. Adolescent girls’ household responsibilities included caring for younger siblings, planting and harvesting, collecting water, cleaning the compound, cooking, and washing clothes. In comparison, boys were responsible for some agricultural activities.

Harmful cultural practices

Among the workshop and key informant interview participants, early marriage, religious beliefs, and initiation rites were commonly identified as major socio-cultural challenges to accessing and consuming iron-rich food and contributing to undernutrition:

“The biggest challenge of all is early marriage. As you know, if a child marries early, one of the biggest consequences is malnutrition…for the child who is born and for the mother after childbirth.” – Key informant interview, Ministry of Culture

Seasonal barriers to accessing foods in the right quantity and of the right quality

Several participants reported that there are times of the year when they struggle to find enough food to consume, especially during March and April. Many girls shared that during these months, their daily meals consist of only cassava leaves. The participants reported that obstacles to accessing sufficient food during this time of the year include poor food market systems.

“Producers sell all the products they grow, without thinking about the times when resources become scarcer… sellers often increase the prices of products on the market [during this period].” – Participant 7

Adolescents found the cameras intuitive to use

Despite only receiving a short one-hour training on basic photography and no prior experience with smartphones or cameras, the participants produced excellent, clear photos. Concerns from secondary school teachers about the cameras being stolen or broken were addressed as the participants kept the cameras in their protected cases. All cameras were returned to World Vision unbroken.

In a digital age, printed photos are still of value to facilitate workshop discussions

During the workshops, photos were projected on a screen, but printed copies would have helped in categorising images. We recommend printing the photos, if feasible. Printing photos also supported advocacy efforts at district level.

Tact and sensitivity are essential when conducting adolescent formative research

Some participants expressed shame over their photos, especially photos of cooking over an open fire that participants associated with higher levels of poverty. Photovoice implementers should be aware that even photos of the food environment can be sensitive and can invoke strong emotions. Workshop and group facilitators should be trained to navigate these discussions tactfully and with sensitivity. Individual interviews can provide more opportunities for privacy and exploring sensitive issues in more depth. To maximise the benefits, we recommend both group and individual discussions.

Unexpected, additional benefits in cultivating the enabling environment

We originally began this project with the purpose of using Photovoice as a tool to elicit deeper discussions during the workshops. We quickly realised that the photos could be used to advocate for increased government support for adolescent nutrition interventions. The photobooks generated excitement among participants, their peers, and government stakeholders. They encouraged participation in a cluster randomised trial that delivered a contextualised intervention with nutrition messages, iron and folic acid supplementation, and a multimedia messaging service to 490 adolescent girls. The findings were also used to design a contextualised adolescent nutrition curriculum. This included modules on the promotion of iron-rich indigenous foods, becoming agents of change, and service projects to build empowerment and agency.

Photovoice can optimise impact using minimal resources

We found Photovoice to be an engaging, enjoyable, and efficient research method. It leverages simple tools, such as cameras or smartphones, allowing participants to act as data collectors and analysts, reducing the need for extensive staff or infrastructure. The approach generated rich, actionable insights without requiring complex analysis or high costs. By engaging participants directly and using visual storytelling, Photovoice can maximise impact, with minimal resources, making it particularly suited for resource-limited settings. 

Photovoice heeds the proverb “a picture tells a thousand words” and amplifies the stories and voices of population groups that are often marginalised. The photos in this research provided rich visual data about the lived experiences of adolescent girls living in rural Monapo District, without the bias of an outsider researcher interpreting everyday realities. This supports intervention design for adolescent nutrition issues, such as iron-deficiency anaemia. The data visualisations gave deeper meaning to narrative data to inform the refinement of the adolescent nutrition curriculum. Photovoice can be a powerful approach to elevate the voices of adolescent girls, as they document their perceptions, preferences, and needs through photography. It can also create opportunities for dialogue and sharing with people of power and influence within the health system. 

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