"Good Food Causes Good Effects and Bad Food Causes Bad Effects": Awareness, Meanings and Perceptions of Malnutrition among Pakistani Adolescents Living in Slums through Photodiaries and Interviews.

Around 30% of the urban population of Southern Asia lives in a slum setting where basic necessities such as sanitation, education, employment, infrastructure are lacking, and people are more exposed to health problems. Children living in slums are at high risk of malnutrition. However, there is limited knowledge on adolescents living in slums. We explored awareness and meanings of malnutrition (under and over-nutrition) as well as examining malnutrition risk factors among adolescents living in a slum. A qualitative approach was undertaken using photodiaries and semi-structured interviews with 14 adolescents (13-16 years old) living in a slum in Karachi (Pakistan). An inductive strategy was used moving from open-ended data to patterns using reflexive thematic analysis. We identified widespread malnutrition awareness amongst these adolescents. Food consistently underpinned participants' narratives and photodiaries, which was reflected in how they made sense of malnutrition: undernutrition was understood as lack of food, while overnutrition as excess of food. This study identified malnutrition drivers: sanitation, exercise, families, peers, wellbeing, gender, nutritional knowledge, media, and most importantly, food. People's responsibility to eat healthily was highlighted by the participants, implying that people are to be blamed for their poor lifestyle choices. Following this responsibility discourse, most participants contemplated merely individually focused health interventions in order to overcome the problem of malnutrition in their area. It is necessary to study slum food environments better to implement effective nutrition programs and interventions to reduce malnutrition in slum settings.