The world, and particularly resource-constrained settings, are experiencing multiple forms of malnutrition (characterized by micronutrient deficiencies, childhood undernutrition, and an unprecedented surge in overweight and obesity). In 2016, 70% of the global burden of overweight/obesity was found in Low Middle-Income Countries (LMICs) (1). Agyemang et al. (2) reported an increase in the prevalence of overweight individuals increased by 70% in West Africa between 1990 and 2015. In 2014, the Ghana Statistical Service estimated that over 40% of Ghanaian adults were either overweight or obese (3) with the prevalence of overweight and obesity among Ghanaian children between 9 and 15 years being equally high at 17% (4).

Poor diets are the leading cause of overweight/obesity (5). Itself a non-communicable disease (NCD), obesity is a risk factor for other NCDs such as coronary heart diseases, hypertension, stroke, and diabetes (6, 7). Nutrition transition, characterized by a shift in people's diets from less processed toward highly processed energy-dense foods coupled with reduced physical activity (8), is acknowledged as a contributory factor (2, 9–13).

Poor diets, or nutrition transition, are influenced by food environments. Defined as the collective physical, economic, political, and sociocultural surroundings, opportunities, and conditions that influence people's food and beverage choices and nutritional status (14), food environments include food availability and physical access (proximity); economic access (affordability); promotion, advertising, and information; and food quality and safety. The food environment can be an important entry point for interventions aimed at improving people's diet (15–18). One of the key dimensions of the food environment is the retail food sector – grouped under the typology of built food environment (15). A retail food establishment can be informal or formal depending on whether they are regulated through formal governance structures (19). Typical examples of informal food retail include wet markets, street vendors, kiosks, mobile vendors, and some corner stores. The formal market environments include those regulated through formal governance and typically include supermarkets and hypermarkets (15, 16). Both formal and informal establishments provide the majority of foods that consumers are able to access within the built food environment (20).

Evidence suggests that most supermarkets in Ghana offer highly processed food such as corn flakes, biscuits, cake, and cookies (21); packaged foods such as pasta, sugar, edible oil, coffee, tea, and cocoa drinks; beverages such as sodas, beer, wine, and evaporated and condensed milk; condiments; confectioneries; and minimally processed foods such as maize, flour, or whole wheat bread (21–23). The few supermarkets in Ghanaian cities that offer fresh animal and plant-based food often allocate little shelf or storage space to less healthy food options (21, 24). Other types of retail outlets, such as traditional markets and corner stores, also offer both ultra-processed and fresh food products (23, 24).

The food retail space is expanding rapidly in Ghana, particularly in urban settings (22). However, informal shops and small mobile retailers dominate the retail sector in Ghana. Kroll et al. (23), upon mapping out retail outlets in Ghana's second city Kumasi, reported that formal retailers (i.e., supermarkets) constituted only 7% of retail outlets, while informal shops, stalls, and mobile traders each constituted about 24% of the sample.

Policy actions to improve consumers' food environment by reducing unhealthy diets and increasing the availability of healthy foods within food retail outlets are ongoing in Ghana. These policy actions were considered by the Ministry of Health during a consultative meeting on 30^th September 2021 with academics and other experts (25). Knowing the role that food retailers play in influencing people's food purchasing behavior and consumption, it is important that such policy actions are evidence-informed. This study explored Accra-based food retailers' perceptions and understanding of healthy food as well as the measures they adopt to encourage healthy food choices.

This study aimed to elucidate retailers' understanding of healthy food, their perceptions of the healthiness of the food they vend, and the measures that they adopt to encourage healthy food choices. Overall, Accra-based food retailers' characterization of what they sell is similar to the current scientific depictions of healthy food. The retailers described healthy food as edible substances that provide positive health outcomes to consumers and which should not cause or contribute to illness. In their descriptions, they mentioned terms like “balanced diet” and “diversity,” or referred to the nutrient profile that a healthy food should have. Currently, some of the science-based models for classifying food as healthy or unhealthy are nutrient-based (32, 33), food-based (34), or based on the level of processing (35).

To illustrate, in the US, the FDA defines healthy food as based on the nutrition profile of the food. They consider healthy food to be food products low in total fat and saturated fat, and which provide at least 10% of the recommended daily intake of certain vitamins and minerals (36). The International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) classifies foods as healthy based on their nutrient profile. INFORMAS has developed five food groups considered “core”: grains and grain products; vegetables and legumes/beans; fruits; milk and milk products; lean meat, fish, poultry, eggs, nuts, and legumes (37). Foods considered less healthy are referred to as non-core and included sweet breads, cakes, sweet biscuits, high fat savory biscuits, pastries, tinned meats, sweet snack foods, chips, extruded snacks, ice cream, etc. A third category, miscellaneous, includes foods such as recipe additions e.g., cubes, oils, dried herbs, tea, and coffee (excluding sweetened powder-based teas and coffees), etc., (37).

Retailers in Accra associated healthy food with safety, origin, and accessibility. They mentioned dimensions such as sanitation, hygiene, certification, and country of origin as important. Food safety concerns affect consumer behaviors and diets in low and middle-income countries (38) and those based in Accra as well (13). According to Liguori et al. (38), such concerns include fear of pesticides, hygiene in/around food outlets, unhygienic vendor practices, and household storage/preparation methods. These concerns may increase the stocking, vending, and consumption of less healthy starchy staples and processed/packaged foods compared to fresh fruit and vegetables.

Accra-based food retailers did not consider the extent of processing as a criterion for healthiness. The NOVA System classifies food based on the extent of processing (35). Although this classification system does not directly make any distinction about what food is healthy or not, individuals can use it to make important health-related decisions. Classifying foods from unprocessed/minimally processed foods (relatively healthier) through to ultra-processed foods (relatively less healthy), the NOVA system recommends that consumers limit their intake of ultra-processed foods compared to unprocessed and minimally processed foods.

As to the extent of availability and stocking of ultra-processed foods in food retails outlets of Accra, a related study conducted in Accra provides evidence (21). The study estimated that, for every 1 m² of shelf space allotted to healthy foods, there was 6 m² equivalent of space allocated to less healthy foods or ultra-processed foods. It is possible that these stocking practices observed in the supermarkets or retail shops in Accra may be a response to consumers' demand for less healthy food. Indeed, respondents in the current study mentioned that their food stocking practices correlated with consumer demand.

Some retailers in Accra adopt limited measures to encourage consumers to adopt healthy food choices. Some of their efforts include sourcing foods from local wet or open markets for healthy food. Most retailers indicated providing guidance on healthier food options they have, but only if their customers expressed the need.

Globally, scholars and practitioners are now suggesting encouragement as a promising intervention to increase healthy food consumption (39). The potential of encouragement to increase healthy food decisions was underscored by Arno and Thomas (40) who showed that this leads to an overall increase in healthier food choices by 15.3%. Van Gestel et al. (41) also reported that repositioning healthy food products at the checkout counter increases the sales of those healthy food products. Their findings imply that there are clear opportunities to improve food choices by acting directly on the retail sector (15). Those opportunities can be seized by deploying a mix of high agency interventions that improve nutrition literacy and healthy food choices through nudges or counter-marketing strategies as well as low agency interventions zoning regulations, food-related fiscal policies, and improvement of food retail environments. To clarify, intervention agency usually refers to the resources (e.g., personal, psychological, cognitive, financial, material) on which individuals draw to engage successfully with an intervention (42). Those interventions that require individuals to invest fewer individual personal and psychological resources are described as low agency (fortification of food with micronutrients, marketing restrictions, fiscal policies, and product reformulations). In contrast, high agency interventions such as educational interventions, mass media campaigns, or front of pack labelling require substantial agency in terms of accessing, understanding, and applying the information provided (42).

Our study is not flawless. Participating stores were identified and recruited from a purposive sample rather than through a probabilistic sampling approach. It is also possible that managers/owners who agreed to participate in the study were those with a predilection for healthy food retail. A large proportion of our sample were corner stores and a small fraction consisted of independent supermarkets. No chain supermarkets were included in our study. This limits the generalizability of our findings to other types of supermarkets and food retail outlets. Besides, this study did not cover rural settings/communities in Ghana. Such areas may have unique challenges not captured in our study. Therefore, the findings of this study need to be interpreted or extrapolated with the stated limitations and delimitations in mind.

The Accra-based retailers included in this study have a fair understanding of what constitutes healthy food. Some of the retailers employ limited measures to encourage healthy food stocking and choices. There is an opportunity for policy and interventions in the food retail sector in Ghana. Such interventions may improve consumers' dietary choices.

We recommend nutrition literacy interventions targeted at food retailers as well as retail-level training programs that seek to inculcate healthy retail strategies, such as nudging, to retailers. Given that Ghana is in the middle of a food environment policy reform, addressing these gasps in the retail sector will further enhance the anticipated success of the food environment transformation in Ghana.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, and upon reasonable request.

The studies involving human participants were reviewed and approved by the Ethics Review of the Humanities, University of Ghana (Approval # ECH 152-18-19), and the Ghana Health Service Ethical Review Committee (Approval # GHS-ERC 005-06-19). The patients/participants provided their written informed consent to participate in this study.

AL conceived and led the design of the study. SN, AA, and GA contributed to the design. AL and GA supervised the implementation of the fieldwork. SN and AA conducted the interviews with retailers and transcribed and coded them. GA supported data management and analysis. SN drafted the manuscript and received significant and relevant inputs from AL. All authors contributed to the article and approved the submitted version.

This paper was supported by the Measuring the Healthiness of Ghanaian Children's Food Environments to Prevent Obesity and Non-communicable Diseases (MEALS4NCDs) Project and funded by the International Development Research Centre (IDRC) Food, Environment, and Health Programme–IDRC, Canada (Grant #108983).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.