Facilitators and Barriers to Fruit and Vegetable Consumption: A Qualitative Study of the Perceptions of the Public and Experts/Policymakers

Research Article

Int J Nutr Sci. 2022; 7(2): 1066.

Facilitators and Barriers to Fruit and Vegetable Consumption: A Qualitative Study of the Perceptions of the Public and Experts/Policymakers

Mustafa S¹, Haque CE¹* and Islam K²

¹Natural Resources Institute, University of Manitoba, Winnipeg, Canada

²Institute of Nutrition and Food Sciences, University of Dhaka, Dhaka, Bangladesh

*Corresponding author: C Emdad HaqueProfessor, Natural Resources Institute, University of Manitoba, 70 Dysart Road, Winnipeg, Manitoba, Canada

Received: October 29, 2022; Accepted: December 15, 2022; Published: December 21, 2022


Purpose: To map perceptions and knowledge among the public and experts/policymakers regarding the low levels of fruit and vegetable consumption in Bangladeshi society, and to identify the facilitators and barriers to increasing the consumption of these food sources.

Design/Methodology/Approach: The empirical investigation involved two specific groups: the public and experts/policymakers. Interviews were conducted with expert/policymaker key informants, and focus groups were organized with the public in selected rural and urban areas of Bangladesh. Thirty public-consumers aged 18 and over, and seven expert/policymaker key informants. Using the results of these sessions, a modified mental model approach was employed to help formulate perception and knowledge models, and pertinent juxtapositions were identified.

Findings: The public relies on first-hand experience, while the experts/policymakers depend more on scientific-technical knowledge. Additionally, the public holds several misconceptions relating to the recommended daily intake of fruits and vegetables, as well as food safety concerns. Furthermore, the experts/policymakers are inclined to suggest a ‘one size fits all’ solution that is likely not appropriate for the Bangladeshi context.

Practical Implications: Considerable perceptual gaps exist between the public and experts/policymakers regarding the low levels of fruit and vegetable consumption in Bangladesh. Thus, experts/policymakers must work to improve communication with the public, as this will lead to greater engagement and, consequently, the formulation of more effective policies for increasing fruit and vegetable consumption in Bangladesh.

Originality/Value: This study fulfils an identified need to study the facilitators and barriers to fruit and vegetable consumption in the face in increasing non-communicable diseases in Bangladesh, and identifies the existing gaps in knowledge and perceptions of the public and experts/policymakers.

Keywords: Fruits and vegetables; Food habit; Consumption;Vitamins; Minerals; Protein; Meat; Fish; Bangladesh


For centuries, the main function of food was to satisfy hunger; in the present day, food is a vital contributor to physical wellbeing, a major source of pleasure, worry and stress, and, worldwide, the single greatest category of expenditure [33]. Significantly, food is alsowidelyrecognized as being a critical contributor to good health. However, changes in diet over the past 40 years have had a negative effect on people’s health worldwide, especially in Low- and Middle-Income Countries (LMICs), resulting in an epidemic of obesity and Non-Communicable Diseases (NCDs), such as heart disease and diabetes. Indeed, modern dietary practices are the main driver of the increasing prevalence of obesity and Non-Communicable Diseases (NCDs). A survey of the global literature reveals that these dietary changes have been profoundly influenced by the globalization of the market economy [29] and the accompanying spread of the ‘Western’ diet, which is predicated on large amounts of livestock, dairy products, fats, and oils, and fewer staple foods such as fruits and vegetables [17].

As the globalizations process since the 1990s brought the local Bangladeshi economy closer to the international economy, primarily through trade liberalization, it also affected a change in the dietary pattern. According to Vepa [42], there are three expected outcomes of globalization on food intake: i) shifts from cereal to more protective foods, i.e. meat, fish, fruits and vegetables, ii) shifts towards more processed food, and iii) rise of transnational fast food industry. The nutrition transition theory proposes that trending globalization along with an economic growth will shift the diet from minimally processed staple to highly processed foods, meat, and diets high in vegetable oils [7,30,31]. This rapid change in diet towards highly processed food is the major contributor to the rising trend of non-communicable diseases in LMICs [19,34]. It is suggested that that without considerable policy interventions, this trend of increasing processed food consumption is likely to continue [23].

Since many diseases are directly related to diet, it follows that dietary changes can play a key role in reducing the severity of a disease. As such, government policy, marketing campaigns, and interventions by private sectors and NGOs have all been deployed to promote the consumption of healthy foods in countries around the world. Unfortunately, our understanding of how to encourage more healthy eating behaviours among humans is still very poor, a fact that has been acknowledged by the World Health Organization (WHO) [5]. The World Health Organization recognizes that our understanding of how to change human behaviour towards healthy eating is still very poor [43].

One of the main barriers to promoting healthier eating habits through intervention is gaps in communication between experts/policymakers and the public. In the fields of health and the environment (i.e., climate change, cardiovascular disease control), the literature on risk perception and risk communication cites gaps between experts and the public, particularly as they relate to knowledge, attitudes, and perceptions [9,36]. There have always been gaps in understanding each other between the scientists, policymakers and the public. Scientist usually tend to regard the policy processes as politically motivated and are not scientifically evidence-based [40], while policymakers perceive scientists as rigid groups in applying methods, and myopic in scope [18]. However, policymakers and the scientists both have a consensus in that the public are often driven by emotion without assessing the facts and figures [22,32,35]. Notably, the public criticize scientists for taking a narrow (silo) perspective and using unintelligible scientific language and allege that the policymakers are usually too cautious to act on anything driven by mass sentiment [6,32]. One of the most popular methods for addressing such communication problems is the mental model approach, which was first applied for this purpose by Morgan and his colleagues [24] almost two decades ago. The general principle of this model, as formulated by Craik [4], is that the opinions and perceptions of experts are rational, standard, superior, and more correct compared to those the layperson [37]. In earlier versions of the mental model, scientists/experts were considered to be knowledge producers or validators, whereas the public comprises the ‘political world’, operating in the societal complex. Consequently, scientists and/or experts are the spokes persons of ‘rationality’, while the public and policy are considered ‘emotional and political’, and thus, inferior [6,22]. Notably, the literature contains no reports of the use of a mental model to investigate the gaps in communication between the experts and the public regarding low fruit and vegetable intake.

Nonetheless, a modified mental model was applied in a recent study [3], which produced findings that challenged the conventional belief that learning flows only from the expert to the layperson. These results were supported by those of several alternative studies, which found that experts may be ‘cognitively handicapped’ with respect to understating a layperson’s limitations in receiving and processing knowledge [13]. These findings imply the existence of not only communication and knowledge gaps between the knowledge provider and the receiver, but also limitations in understanding each other’s perspectives and comprehension abilities.

Against this backdrop, we explore the similarities and differences in the knowledge, attitudes, and perceptions of experts/policymakers and the public that hamper the effectiveness of interventions, as well as the formulation of policy and behavioural-change tools. Specifically, this study aims to map the public’s and expert/policymakers’ perceptions of and knowledge about fruit and vegetable consumption in Bangladeshi society, and to identify the facilitators and barriers to increasing the consumption of these food sources.

The ‘Mental Model Approach’ In Food and Nutrition Studies

Environmental and health problems are often a direct result of human decisions and actions. As such, these problems can be addressed via social-science constructs like attitudes and behaviours. However, the mental model approach is a unique tool, as it helps to predict the outcome or explore the cause-effect relationships between the concerned variables under study. The mental model approach is most popular in cognitive science and psychology, where it is described as the ‘internal’ representation of the ‘external’ reality [4,14]. As one of the major challenges of using the model is finding a way to illustrate the results of the analysis, different visualization techniques are generally applied in different fields of study (e.g., organizational research, risk communication, and education) [21,24,39].

The gap between the experts/policymakers’ messaging and the general public’s response was identified much earlier in the risk-communication literature [24]. To address this problem, Morgan and his co-researchers (2002) formulated a mental model that compared an ‘expert model’ and a ‘public model’ in order to ‘map’ the gaps between them and develop effective intervention tools. This elicitation technique was also employed in the Carnegie Mellon University-based mental model methodology, which suggested developing an ‘influence diagram’ to illustrate expert opinions [3]. The initial influence diagram was developed based on the beliefs, values, and attitudes of experts as recorded in a Focus Group Discussion (FGD) setting. The ‘expert model’ was considered the standard that was to be compared with the public or other community models during final analysis. In a nutshell, mental model can identify and dissolve misconceived “public ideas” for the expert/policymakers to reconsider [10]. The mental model approach has been adopted in many fields, including natural resources management, environmental studies, and risk communication, to explore similarities and differences between the understandings of various stakeholder groups, to integrate the perspectives of different communities, or to identify misconceptions and barriers against behavioural change [1,24,28]. Nonetheless, the application of the mental model approach in the field of food and nutrition has yet to be explored, especially in the context of public health issues.

Materials and Methods

Setting and Study Plan

This study is part of a multi component initiative by the International Development Research Centre (Ottawa, Canada) aimed at investigating fruit and vegetable consumption and NCDs in Bangladesh. A total with a distribution of 62% rural and 38% urban population influenced the researcher to investigate the locational differences as they represent distinct characteristics (The World Bank, 2019). The focus of the IDRC project was to explore the prevalence and dietary risk factors (e.g. lower consumption of fruits and vegetables) associated with NDCs among the various segments of populations (urban, rural and indigenous people) in Bangladesh. Sylhet division was selected for the rural and indigenous representations and Dhaka for the urban dwellers for the baseline survey. However, in the present study no indigenous respondent was interviewed. Study areas for the qualitative study were selected using a simple random procedure from the IDRC baseline survey.

A total of three Upazilas (sub-districts, which are the third tier in a four-tier hierarchical administrative system) and the capital city of Dhaka South were selected following a simple random sampling procedure. These spatial units represented primary producers in agriculture and retails businesses in rural areas, and service sectors and other quaternaryoccupations in urban areas. The sampling frames of the Upazilas in two districts were obtained from the Bureau of Statistics, Government of Bangladesh, and for the City of Dhaka South was from the City Corporation Authority. The selected areas included the Borolekha and Kamolgonj Upazilas from the Maulovibazar District and the Derai Upazila from the Sunamganj District and four wards (new ward numbers 1, 11, 40, and 41) from the City Corporation of Dhaka South.


This study utilized a qualitative design consisting of four Focus Group Discussions (FGDs) and seven Key Informant Interviews (KIIs) aimed at understanding the barriers and facilitators to the consumption of fruits and vegetables in Bangladesh. Field data were collected by the first author between October 2018 and December 2018 with the verbal consent of the participants, which was provided at the time of collection. The Key Informant Interviewees (KIIs) and the participants of the Focus Group Discussions (FGDs) represnted two major stakeholder groups: i) consumers, and ii) experts/policymakers. The consumer group (i.e. buyers of fruits and vegetables) was selected randomly from the IDRC Project baseline survey. People affiliated with food-supplying jobs or the food-policymaking process were excluded. Policymakers were chosen from a wide range of government departments and reputable organizations in the field of agriculture and food policy formation and implementation.

All recruited participants were over 18 years of age, with most being women (4 males and 26 females). This asymmetry in the sample was primarily due to the unavailability of males during the daytime interviews and FGDs. The mean age of the participants was 40.3 years. In terms of religious background, the sample was almost equally divided between Muslims (n=14) and Hindus (n=16).The majority of the participants were housewives (n=18), while the remainder consisted of farmers (n=6), day labourers (n=3), small business owners (n=2), and a driver (n=1).

The key informants (n = 7) interviewed for this study included five government department specialists (science and technology, food safety, nutrition, agriculture, and agricultural extension), one agricultural economist from Bangladesh Agricultural University, and one supply chain specialist from Hortex (a private-sector company). Individuals were selected from different pertinent sectors to provide a range of expertise in the fields of horticulture cultivation, training, policy, and implementation.

The FGDs were held in the participants’ houses or the courtyards in which they lived. The FGDs and KIIs were led by a facilitator, and a rapporteur was present to take notes and assist the facilitator where necessary. All discussions were held in the local language of Bangla, audiotape recorded (with the participants’ consent), transcribed, and translated to English by the facilitator with input from the rapporteur.

Community members who were producers and consumers were engaged to represent the public in the formation of the ‘public perception and knowledge model’, and specialists and policy executives were engaged to form the ‘expert/policymaker perception and knowledge model’. The community members (i.e., the public) were invited to reflect on their knowledge, attitudes, and practices relating to their fruit and vegetable consumption, meal composition in their households, their household decisions regarding meal choices, major barriers to accessing fruits and vegetables, steps that could be taken to increase fruit and vegetable consumption, and other factors affecting their food intake.

The second cohort of participants, consisting of seven experts/policymakers, shared their perceptions and knowledge relating to appropriate methods of eating fruits and vegetables and related cooking procedures, major barriers preventing adequate consumption of fruits and vegetables, and how to increase the public’s consumption of these food items.

Data Analysis and Model Construction

All participants provided written or verbal consent, and all interviews were transcribed verbatim from audio recordings and checked for errors by the field research team. The transcripts were classified based on the broad categories of themes, major topics, and the interview guidebook. A final review of the emergent themes was conducted by the first author. Finally, the patterns that emerged from the tabulation of the qualitative data were structured into multiple tables for analysis (Table 1).