Perceived barriers to vegetable intake among urban adolescents from socioeconomically disadvantaged backgrounds: A qualitative study from the perspective of youth workers and teachers.

Eating habits established during adolescence have been shown to track into adulthood. Adolescents from lower socioeconomic status groups tend to have lower intakes of vegetables as compared with their more affluent peers. However, there is limited evidence about the determinants of vegetable intake in this population group. Therefore, this study aimed to explore the barriers to vegetable intake in adolescents living in socioeconomically disadvantaged areas through the perspective of school teachers and youth workers. A total of 20 semi-structured interviews were conducted with post-primary school teachers and youth workers from disadvantaged areas in Dublin, Ireland. Thematic analysis was applied to analyze the data. Eleven themes were identified and fitted within the Socioecological Model of Health: adolescent ’ s food preferences, lack of early exposure and familiarity with vegetables, lack of interest, knowledge and skills at the individual and family level, parenting practices around nutrition, living difficulties, peers ’ influence and social norms around nutrition, dual role of social media, lack of resources and support to promote healthy eating, competition between unhealthy food vs. vegetables, lack of adequate approaches & initiatives at the community and at the public policy levels, and lack of State support to promote healthy eating. Although several actions could be taken at the personal and interpersonal levels, more efforts are needed at the organizational, community and public policy levels to improve dietary choices and vegetable intake among adolescents in socioeconomically deprived areas. These findings will inform the development of tailored intervention strategies and policies for these vulnerable youths.


Introduction
The current worldwide pandemic of childhood obesity represents a matter of concern for public health authorities due, in part, to its association with premature death and disability in adulthood [67]. Furthermore, children with overweight and obesity are more likely to remain in this condition during adulthood and to develop other chronic diseases such as diabetes and cardiovascular diseases at a younger age [67]. Unhealthy eating, characterized by low fruit and vegetable intake coupled with high intakes of salt-, sugar-, and fat-rich products, has been identified as one of the main causes of the current high prevalence of childhood obesity [66,67]. In this regard, the international Health Behaviour in School-aged Children (HBSC) survey showed that only 38% of the adolescents ate vegetables on a daily basis with intake being even lower among those from less affluent backgrounds [68]. In Ireland, national findings from the HBSC survey found that only 21% of the adolescents consumed vegetables more than once a day [33]. Furthermore, and in agreement with the international report, those from lower socioeconomic groups were less likely to consume vegetables more than once a day than their peers from more affluent backgrounds [33]. In addition, a recent report revealed that, in 2020, the cost of a healthy food basket for Irish families on low income was one third of their weekly home income and that they frequently encountered many challenges to balance the cost of a healthy diet with essential household expenses [55]. Hence, healthy eating interventions and policies should aim to narrow the existing gap between people on high-vs low-income.
In their systematic review of quantitative studies, Di Noia and Byrd-Bredbenner [21] identified fruit and vegetable preferences and maternal fruit and vegetable intake to be consistently associated with fruit and vegetable intake in children and adolescents from low-income families. However, another systematic review exclusively focusing on the determinants of vegetable intake in urban adolescents within socioeconomically disadvantaged areas investigated through quantitative studies concluded that nutrition knowledge, the only determinant that was examined consistently across studies, was unrelated to vegetable intake in this population group [7]. No other determinants were consistently associated with vegetable intake. Focusing on qualitative studies, multiple factors have been identified as determinants of vegetable intake in urban socioeconomically disadvantaged adolescents such as sensory attributes of vegetables, psychosocial factors, lifestyle factors, home food environment, friends' influence, school food environment or availability and accessibility of vegetables in the community, among others [6]. Although some of the determinants of intake reported in the literature seem to be common across populations, country-specific cultural and sociodemographic aspects also play a role in shaping dietary behaviors and their determinants. Thus, identification of determinants of vegetable intake within the target population group is crucial to develop effective intervention programs and policies, yet the evidence specific to adolescents from socioeconomically disadvantaged areas remains limited, especially within European populations. In this regard, no studies in Ireland have focused on the determinants of vegetable intake in adolescents from less affluent backgrounds.
Adolescence is the transition from childhood to adulthood and it is a period of life characterized by rapid physical, cognitive and psychosocial growth and development [65]. Patterns of behavior such as those related to diet, physical activity, substance use, and sexual activity, are also established during this phase [65]. In fact, existing research suggests that eating behaviors established during this time tend to track into adulthood [1,60]. Therefore, adolescence is an important time to lay the foundations of good health (World Health Organization) and may represent a particularly important and effective intervention period to support young people to grow and develop good health behaviors.
However, theory needs to be integrated within practice to better understand how to effectively encourage healthy dietary behaviors [5]. In this regard, the Social Ecological Model (SEM), a theory-based framework, depicts the multifaceted and interactive effects of personal and environmental factors that determine health behaviors [14,42] by addressing five hierarchical levels: individual (knowledge, attitudes, behaviors), interpersonal (family, friends, social networks, etc.), organizational (organizations and social institutions, e.g., schools), community (relationships between organizations), and policy/enabling environment (national, state, local laws). Multiple public health prevention interventions have effectively applied the SEM approach to change individuals' behavior by targeting all the levels of the model [45,63]. Thus, relying on the SEM model to examine the determinants of vegetable intake among adolescents of socioeconomically disadvantaged backgrounds will allow the identification of those factors that need to be addressed to influence behavior change at each of those levels.
Many adolescents' social relationships occur in schools and youth centers. For that reason, the organizational level of the SEM focuses on those settings to emphasize the impact that the social and physical environment in these places has on adolescents' lives. In fact, there is evidence of the major influence that teachers can have on the students' wellbeing and development [28,49]. As opposed to parents, teachers engage with a large number of adolescents and are exposed to a diversity of adolescent behaviors on a daily basis [29,53]. Hence, they may be able to provide information from a more external and broader point of view considering adolescents' behavior within the school setting, the interactions with their peers and the impact of the school environment on their lifestyle. On the other hand, youth workers may also contribute to shape adolescents' behaviors. They are in close contact with young people on a day-to-day basis and have built trust and strong relationships with them [19]. Furthermore, youth workers know the personal circumstances and understand the problems that young people often experience in their daily lives [19], and they may act as counselors and role-models for young people. For that reason, both teachers' and youth workers' perceptions can add further insights into the aspects that may prevent disadvantaged adolescents from eating vegetables. Therefore, the aim of the current study was to use the SEM to gain an understanding of the barriers which impact adolescents' intake of vegetables in socioeconomically disadvantaged areas from the perspective of teachers and youth workers. Identifying such barriers will provide a starting point towards the design and development of tailored interventions and policies that can be effective in promoting vegetable intake in this population group.

Methods
Online one-to-one interviews were carried out with youth workers and post-primary school teachers based in Dublin to explore their perceptions of the barriers to vegetable intake among adolescents from socioeconomically disadvantaged backgrounds living in Dublin. The standards for reporting qualitative research by O'Brien et al. [47] were used to comprehensively report all the aspects of this qualitative research.

Research team and reflexivity
All the interviews were conducted by a female research scientist (SBS) with a background in nutrition and dietetics and a PhD in nutritional epidemiology and with experience in qualitative research. This researcher has longstanding research interests in the role of energy balance-related behaviors in the onset of obesity and other noncommunicable chronic diseases in children and adolescents, especially among the most vulnerable. A second researcher collaborated with the analytic process. The second researcher (PK) was a female master's student in Health Education and Promotion with a degree in nutritional sciences. Her research interest focus on developing, evaluating, and disseminating theory-and evidence-based health promotion and prevention programs and strategies. The interviewees described themselves as having experience working with adolescents through their roles either as youth workers or post-primary school teachers. The interviewer met the interviewees for the first time at the start of the interview during which time they were informed about the purpose of the study and were made aware that there were no right or wrong answers.
A phenomenological perspective was adopted for this study with a focus on the participants' lived experiences around the phenomenon of interest [18]. The social constructivism frame guided our interpretation of the findings in that it suggests that individual meaning arises from cultural, societal and environmental constructs together with lived experiences [2].

Study design
Ethical approval was obtained from the University College Dublin Human Research Ethics Committee (reference number LS-20-41-Bel-Serrat). A qualitative methodology was employed using semi-structured one-to-one interviews to explore youth workers' and school teachers' beliefs and experiences. Due to social distancing measures in place during the COVID-19 pandemic, online interviews were necessary.
Previous research with adult participants has shown that the content of the data generated through in-person versus online methods is similar [64].
Alongside this study, adolescents' and parents' perspectives were also obtained through one-to-one interviews and focus groups, respectively, to strengthen the validity of findings and/or to identify any discrepancies in perspectives. These findings will be reported separately.

Participants
The sample consisted of 13 youth workers and seven teachers from DEIS (Delivering Equality of Opportunity in Schools) schools in disadvantaged communities in county Dublin. DEIS schools are classified by the Irish Department of Education based on the following variables: percentage of unemployed parents, percentage of local authority accommodation, percentage of lone parenthood, percentage of Travellers (Irish ethnic minority), percentage of children eligible for free book grants and percentage of large families (i.e. ≥5 children) [3].
Purposive sampling followed by snowball sampling were conducted to recruit study participants. A total of 12 youth organizations and 2 sports clubs located in socioeconomically disadvantaged areas of county Dublin were approached by phone or email via intermediary organizations (e.g., National Youth Council of Ireland) from which five youth organizations agreed to take part in the study. Participating youth workers within each organization were asked for referral to other colleagues and/or teachers in nearby DEIS post-primary schools. Furthermore, teachers were recruited from a publicly available list of postprimary DEIS school principals from the Irish Department of Education and Skills website. Researchers sent a recruitment e-mail to teachers via 20 post-primary DEIS school principals. These schools were located in the same area as the participating youth organizations. Two teachers from two schools responded to that email. Furthermore, another two schools were approached through the youth organizations. Snowball sampling was then used whereby recruited participants suggested potential additional participants. Although teachers of all subjects were approached, only five Home Economics teachers, a deputy principal and a home-school community liaison teacher agreed to take part in the study. Hard and electronic online versions of information sheets and consent forms were available. Electronic online versions were created on QualtricsXM software (SAP Software Solutions, London, England). Information sheets and consent forms were read and signed by each participant prior to the scheduling of each interview.

Data collection
Semi-structured interviews were carried out by a researcher (SBS) between October and November 2020 with youth workers, and November 2020 and March 2021 with teachers. Recruitment lasted until the data saturation point was met as the researcher began to hear the same comments from new interviewees, and no new ideas were emerging in the data. A semi-structured protocol was followed with questions addressing the barriers and facilitators which impact on the intake of vegetables particularly and healthy eating in general. Questions about the contribution of youth centers and schools in promoting healthy eating and vegetable intake among adolescents from socioeconomically disadvantaged communities were also included ( Table 2). The interview topic guide was developed using both the SEM and previous research on vegetable intake among adolescents and was reviewed by two other researchers regarding comprehensibility and content. Furthermore, it was refined and revised appropriately after each interview. Open-ended questions were asked to avoid biasing respondents' answers, and follow-up probes were employed when necessary [57]. Due to government restrictions and social distancing guidelines in place during the COVID-19 pandemic, all interviews were carried out using an online video calling software (Zoom Video Communications, Inc, San Jose, CA, US), except two interviews, which were conducted over the phone. Video interviews were audio recorded for transcription purposes using the built-in record function. Phone interviews were recorded with a recorder. Recordings were exported and stored in a secure folder and were transcribed verbatim and de-identified. Interviews lasted on average 39 min.

Data analysis
Following data collection, the transcripts were reviewed with the audio recordings for quality checking purposes. Data analysis was carried out collaboratively between PK and SBS (second coder). Both researchers listened to each of the 20 interview audio recordings multiple times for familiarisation. An initial sample of three transcripts randomly selected was analysed for code development and the generated codes were compared and discussed among the two researchers (SBS and PK). All the transcripts were then transferred to the qualitative analysis software NVivo12 (QRS International Pty Ltd, Chadstone, Victoria, Australia) where the remaining analysis took place. An inductive thematic analytic approach was taken in which codes and themes were identified from the data. Revision of codes took place and some codes were merged, deleted or renamed for clarity. The second coder reviewed 50% of the transcripts. Multiple meetings between the first (PK) and second coder (SBS) were held to discuss new codes, amendments to codes or to the general coding structure. Once agreement between coders was reached, theme development was undertaken by SBS. Throughout this process, the two researchers discussed the theme development process at length and the generation of themes. Themes and codes were identified at a semantic level and the guidelines from Braun and Clarke [11] were followed to conduct thematic analysis.

Results
Thirteen youth workers including eight males and five females aged 20-59 years took part in the study (Table 1). Within post-primary schools, one deputy principal, one home-school community liaison teacher and five Home Economics teachers were interviewed as part of the study. School staff were all females (n = 7) aged 30-59 years.
A total of 11 themes were identified from the data, which were fitted within the SEM (Figs. 1 and 2). The barriers that influence adolescents' vegetable intake included (1.1) adolescents' food preferences, (1.2) lack of early exposure and familiarity with vegetables, (1.3 and 2.2) lack of interest, knowledge and skills, (2.1) parenting practices around  Table 3.

Adolescents' food preferences
Participants noted that most of the adolescents they work with have a strong preference for ultra-processed foods and sugary drinks, particularly those sold in fast-food and takeaway outlets: "They walk around and they're constantly eating pizzas or takeaways or drinking these milkshakes" (YW 12). Two participants, one school teacher and one youth worker, described this preference as an addiction: "Because literally they're just addicted to junk food, is just very, very simple, and that's why it's huge." (YW 13). It was also mentioned the convenient, cheap and ready-to-eat nature of these products as determinants of intake among adolescents: "I think the major one that is the convenience thing of, it's easier to get delivery to get takeaway, or even processed food, erm, and then the pro of processed food is also cheaper than, you know, your organic vegetables or wherever it might be and, erm, I mean, that's their major factors on it" (YW 3). On the other hand, participants pointed out that the flavor and taste of vegetables were relevant factors preventing adolescents from eating them, e. g.: "the second part of it [adolescents not eating vegetables] is probably the flavor and taste, you know" (YW 1). Adolescents' attitude towards vegetables was also relevant, as reflected by this participant: "Like we'll have young people coming in and we'll always, we would do hot meals whether it's a chicken and potatoes with some veg and it's compulsory that the veg goes on the plate as well, a small bit of broccoli or whatever. So, and they'll all go 'no, no, I don't eat veg', 'I can't have veg', 'I don't like veg' or 'I'm allergic to veg', you know, all the silly excuses coming out like. But it's just down to they don't want to eat it, simple as, and like let's just make excuses for not wanting to eat it." (YW 10)

Lack of early exposure & familiarity with vegetables
The perceived lack of early exposure and lack of familiarity with vegetables during childhood emerged as a major barrier to vegetable intake among adolescents: "Some of them just don't like vegetables, you know, it's really, erm, I suppose they just haven't been used to eat them, you know, so rather than them saying, I don't like vegetables, I don't think they've actually ever tried them, they just don't, they don't find them important enough to I suppose" (YW 5). In this regard, participants highlighted the importance of exposing children to vegetables from an early age, as noted by one participant: "If you're not exposed to the taste of it [vegetables] as a small child, I think it's harder to adapt to it as you get older." (YW 3), and of slowly introducing these adolescents into vegetables by providing tasting opportunities, e.g. "So we need to find a way that, you know, sometimes you can do workshops around let's have a testing workshop. We'll test foods. Test our broccoli. Taste that broccoli. Making it fun, making them involved. You know, 'taste, go on I dare you, try it. Try it, bet you won't try it'. All that kind of stuff you know." (YW 6). Adolescents' perceived reluctance to try new foods, including vegetables, was also pointed out by the participants: "They would be a lot more, erm, wary of foods, like, if they don't recognize the food they would often, you know, their assumption is it's disgusting, 'I'm not trying it', erm, we would, we would have always done Christmas dinner and we would have always cooked in here, now, I'm not the cookery teacher, but I would hear them saying, 'oh, I'm not trying that or it's disgusting', and it would be the things that maybe we would take for granted, you know, even things like garlic or basil or stuff that we would use pretty normally now, they wouldn't and they wouldn't be open to trying it." (YW 4)

Adolescents' lack of interest, knowledge & skills
Several participants pointed out a lack of knowledge around nutrition aspects among adolescents which includes both limited knowledge about types of vegetables (e.g.: "I've worked with a couple of young people that they don't know what certain vegetables are. They've never tasted them. They've never seen them. Like, and they are teenagers like that don't know certain vegetables." (YW 8)) and how to cook them as described by one participant: "…even preparing the vegetables, they don't know how to peel a potato they don't know how to peel a carrot, you know, there's no, green beans they don't know what to do with them." (YW 11). Besides, adolescents seem to lack information about vegetables which translate into misconceptions around them: "I think that lack of information, people just perceive it [vegetables] to be expensive and not convenient, erm, but there is definitely there's definitely places to buy them and there is lots of them on offer around, they are affordable, if you do your research, I suppose, and shop around." (YW 2). It was also noted that eating healthily and eating vegetables is not a priority for adolescents and that they lack awareness about the consequences of eating unhealthily: "They haven't got the awareness that maybe it's [fast food] not suited for my body whether I like it or not I can eat it maybe cut it out for the rest of the week and eat it as a treat but I can't eat shit like that, they don't know." (YW 12). Participants considered that providing more nutrition education opportunities to these adolescents could encourage them to eat more vegetables. One participant mentioned the following in this regard: "I think education like actual real hands-on education as to what these fruit and vegetables are actually like how to prepare them and how to bring them into your everyday diet in a simple way is really, really important." (ST 6). Another participant reflected in the difficulties that adolescents seem to experience in translating knowledge into behavior: "I'll talk for a forty-minute class about saturated fat they'll go to the deli counter on the way home and buy four sausage rolls or whatever and there isn't a connection always between, you know, and I'll give examples and talk about foods that have huge amounts of fat but nonetheless unless it's almost in their face how much fat is in this item that you are going to buy or how much sugar is in this item you are going to buy it's really hard for some kids to make the connection." (ST 7).

Parenting practices around nutrition
Both youth workers and school teachers highlighted their perception of the strong influence exerted by parents' attitudes, preferences and behaviors around nutrition on their children's attitudes and behaviors towards food and vegetables, in particular. For example, as illustrated by one individual, parental food preferences dictate what is purchased, cooked and consumed in the household: "Like for instance I've seen adults, you know, going, erm, I wouldn't eat carrots, so therefore they won't cook a carrot for their kid, you know, so the kid could just probably grow up not ever tasting a carrot because the parent doesn't like it." (YW 9). A perceived lack of rules and routines around mealtimes was also mentioned, with families not putting enough emphasis on sitting together and sharing a hot meal, for example: "Nobody eats as a family anymore, it's very rare to hear people that they eat as a family that somebody actually mentioned that young people will eat their food lying on a bed looking at their phone alone in their bedroom." (YW 11). Participants believe that this lack of structure around mealtimes leads adolescents to eat whatever it is easily available to them such as fast-food as noted by this participant: "But there's no mealtimes or not, you know, it's like there's 20 quid go over to the chipper [type of takeaway] and don't be annoying me (laughing), you know what I mean." (P.8), which is coupled by a perceived lack of parental support to eat healthily as illustrated by this quote: "Lack of encouragement from the parents, the parents don't and the parents are the same, they're not going to eat anything different, it has to start at home." (YW 11)

Parental lack of interest, knowledge & skills
Another perceived barrier that emerged was the lack of parental knowledge around nutrition and of cooking skills on how to prepare a meal regardless of the fact whether it is healthy or unhealthy. This perceived inability to cook seems to translate into a reliance in convenient and ready-to-eat foods as described by this participant: "They raise their kids the way they were raised and it's, you know, they don't believe in cooking healthy foods, they're not aware of it, they probably don't even know how to cook a healthy dinner, probably never been shown how to cook a           . However, this perceived lack of knowledge and skills seems to co-occur with a certain degree of parental disinterest in providing a healthy and balanced diet. As illustrated by one individual, parents do not seem to consider their children's diet as a priority: "Becomes like a kind of cycle that kind of, you know, the kids just see that, that putting time aside for planning your meals better having a balanced diet just isn't a priority just falls further down the list, school is priority, friends are priority and work, things like that." (YW 2).

Living difficulties
The living difficulties adolescents and their families are exposed to not only within their households, but also at the community level, were perceived as a salient barrier and were mentioned by the majority of the youth workers and school teachers. Poverty, homelessness, alcoholism, smoking, drug abuse and drug dealing are highly prevalent in these areas. These issues affect adolescents and their families in many ways, including mental health illnesses, lack of home structure and lack of parental presence and control as described by this participant: "You are looking at an area, you know, as it classed a disadvantaged area. There are addiction issues, poverty, mental health, you know, and that's reality, you know. For a lot of young people, they are living in that and looking after themselves, you know. And, and there's no structure in the house. So, I mean, that's the reality like unfortunately, you know what I mean." (YW 8). Participants noted that these circumstances lead families to live in 'survival' mode and to not prioritize other aspects such as healthy eating: "I don't think, erm, they are in the position to eat much vegetables. I don't think the background they come from allows them to eat that kind of food. I think the area where we are is very, erm, based around, there's a lot of poverty in the area, so I mean people choosing to buy food that's cheap because we all know healthy food is not, is not cheap. Erm, so I mean, people, families who are struggling, who are in poverty, will just buy the basic and that can tend to be not healthy food." (YW 6). In some cases, families may not even have the facilities to cook a meal as described by one participant: "Families that don't have access to, don't have the facilities to cook food for their families." (YW 9). Parental lack of time to cook meals due to family structure, i.e., single-parent families, and long working hours was described as another barrier: "If you're, I don't know, you're a single parent that you're working, erm you know, you're working a job when you're trying in and out of childcare with the younger kids, you have kids in school, you're trying to juggle all that, it's easier to pick up the phone and order, you know, chipper or Chinese or whatever it is, erm, I think it's like that's particularly". (YW 3). Participants suggested that adolescents living in households with these circumstances tend to spend a lot of time on their own without an adult present in the home. For that reason, these adolescents feed themselves with the easy option, which usually is takeaway food. One individual reflected on this aspect as follows: "You are not getting a hot cooked meal at home because, you know, there's those issues in the home. Or there's nobody there to do it for you. And you have three quid in your pocket, you're gonna go in and buy a chicken fillet roll." (YW 8). This is coupled with the fact that eating takeaway and fast food is perceived as the norm in these areas of socioeconomic disadvantage as noted by this participant: "It's widespread within the community, the way people would eat, I think it's more, it's more common within the community the way people eat, than maybe in other areas where people have maybe, I don't know, better skills or where people have maybe more resources to afford more expensive foods which are the fresh foods." (YW 4).

Peers' influence & social norms around nutrition
In addition to adolescents' families, peers are also perceived as highly influential on adolescents' attitudes and behaviors, including those related to food. One school teacher noted the following: "Yeah, I think their friends, their peers are absolute definite. You know, I see it in cookery all the time if we make a smoothie and they are saying 'I don't want to taste it' and I'm telling them 'it's lovely' and to taste it. It doesn't matter . Furthermore, hanging around takeaway outlets and eating their food is regarded as a social activity by adolescents. There is a strong social component attached to this behavior as described in these two quotes from two youth workers: "It's just, a lot of these young people will hang around outside kind of chippers and deli and shops and stuff. They would kind of just amalgamate there." (YW 10), and "Yeah, yeah, I think friends have a lot of influence and, I mean, very rarely you would go and buy pizza on your own. Or you'd go buy a bag of chips on your own. You'll go to say, if we're on the street as a young person you say 'come on we go get a bag of chips. Come on we go, go to McDonalds, come on, we go get a pizza'. You'd never really go 'I'm going to get pizza on my own or I'm going to get a bag of chips on my own'. Again, it comes from being out on the street and being able to stay on the street and still, still have food with your friends, you know. So, it depends what your perspective is, I think a lot of young people like to be on the street and being able to eat on the street is easy for them." (YW 6). On the other hand, participants also suggested that this strong influence exerted by peers could be used to promote heathier dietary habits among adolescents as noted by one school teacher: "Yeah, I think so, I think, a teenager will do what other teenagers will do. If they see their friends eating healthily, you know, on the positive side if they see them eating healthily they are definitely more influenced to try things out themselves. Like if you have a teenager saying 'oh here try a pepper it's nice, like I eat them all the time' their friend will likely try it, whereas if it coming from me, their teacher (laughing), they won't, they won't try it." (ST 6)

Dual role of social media
The role of social media on adolescents' lives was described as 'huge'. However, respondents provided contradictory messages on how it impacts adolescents in terms of diet, that is, whether it has a positive or negative effect as pointed out by one respondent: "It's a bit of a double edged sword, I think it can be quite dangerous too, erm, if you see somebody that's out after doing, I don't know, ten kilometer run and then they're coming home, and they're just having a banana, you're going to assume that that's the right thing to do whereas it's really not the right thing to do, erm, so I think it's, yeah, I think this is double edged sword, it has its benefits, erm, but it also has negatives with it too." (YW 2). Social media could be used as a tool to provide adolescents with information about eating healthily and to promote dietary behavior change through celebrities or influencers. One respondent said in this regard: "I can see the benefits of it [social media], and in terms of healthy eating, you know, you see, erm, lots of people pulling up now like, especially during lockdown, you see lots of people pulling up like home workouts and, you know, the benefit of going for a run or things like that and lots of people do meal prep and all these balanced diets that they are having and all there's X amount of protein, there's X amount of carbs, all this kind of stuff, erm, and that's all, yes, you know, can be a good kind of culture and good environment to kind of encourage that among them." (YW 2). Among the negative aspects of social media, was the suggestion that it provides misleading nutrition information, promotes eating disorders and cyberbullying. One respondent mentioned the following: "I think that [social media] can have a negative impact on young people in terms of eating and, you know, how they view their body, what's the word, like how they see their body like, you know what I mean, or how they view the way they should look. Because of that, so that can have an impact on even like creating eating disorders and, you know, things like that for young people." (YW 8). As highlighted by one school teacher, adolescents' lack of knowledge around nutrition can hinder their ability to distinguish between true and false information provided through social media platforms: "I know that there's a huge number of influencers who talk about food and nutrition, now I'm not sure how many of my students listen to them and I'm not sure if they would understand who has accurate information when they are listening to them, so they may pick up on the bits that look very easy like erm, 'oh, eat this or drink this and you'll lose weight in two weeks' or I would be afraid that they would go for that end of the information that's out there and not fully understand what they're hearing because they don't have the knowledge, again knowledge, they don't have the basic information." (ST 4).

Lack of resources & support to promote healthy eating
Youth centers and schools are considered to have a crucial role in promoting healthy dietary habits by teaching on healthy eating and/or providing healthy and nutritious food to adolescents. However, participants found that more could be done in this regard, mainly in terms of teaching culinary skills to adolescents: "I think definitely secondary schools should be where they should be learning the culinary skills how to cook, you know, how to be independent around, how to cook nutritional meals and then also to know what a nutritional meal looks like and what it consists of and the timeframe you should be eating meals and the size of your meals and the quantity of your meals, you know, these are all really important, erm, kind of theories that have a good baseline on as a young person growing up because it gives you a better informed choice of what to eat and how to eat and when to eat, you know, so then it's down to a personal choice then to eat healthy or you don't." (YW 5). Lack of resources in terms of staff, facilities and money was also described as a barrier encountered in both youth centers and schools as mentioned by one respondent: "We had a cafe that usually opened to the public and the funding for that was taken away, so we basically can only provide young people with meals whereas we used to provide a lot of the community with it, erm, and the funding was taken away from us or maybe if we had more resources and more funding and we're able to employ more people around the kitchen, we think that have a greater impact on what type of food and nutrition and what type of service we were promoting." (YW 5). Another issue that youth workers and school teachers noted was the lack of support from the center management and/or staff to promote healthy eating among adolescents as described by one school teacher: "We do, we technically have a policy [on healthy eating], technically, but do we have support from management when that policy is broken, no we don't. That's just honestly, no, we don't have that respect unfortunately." (ST 5). Provision of nutrition education to all staff and/or availability of healthy eating policies, mainly in youth centers, were suggestions made by the respondents to provide healthier food options in their premises: "If there was a policy in place at some level around even, you know, the food that we provide them with, that it has to be of a certain quality or level or amount of sugar or whatever it is in it that, you know, if we sort of had a baseline that we started from but, erm, you know, we do, we try, we try and provide them with fruit and yogurt and dairy and cereal, erm, but it's not the top priority, being honest, no, it's not." (YW 4)

Availability of unhealthy food
Another barrier that was perceived to play a pivotal role in adolescents' eating habits is the huge proliferation and availability of takeaway and fast-food outlets in these areas. The fact that these places are easily accessible physically or through the phone, have long opening hours, and provide affordable options, mainly through special offers contribute to the high consumption of these sort of foods by adolescents and their families. One youth worker noted the following: "I've often seen young people, you know, it could be in there, half 8 in the morning quarter to 9 and they are going to school and it's a race around to get their sausage rolls and their jambons before they go to school." (YW 10). This same participant reflected on how takeaway outlets target young people: "And that's just shops being clever, well, like especially targeting, targeting young kids by giving them kind of student deals and stuff, which look it they are out to make money. It is kind of a hindrance." (YW 10). Another participant noted the lack of affordable and convenient healthy alternatives to fast food in the area: "I don't think there is a there's no in our, in our area, I don't think there is a cheap convenient alternative to fast food, like so if you want, if you're relying on something that's cheap and convenient, your only option is unhealthy food, like, you know, you have to go, you have to have McDonald's, they have to have chipper whatever." (YW 3). Supermarkets and restaurants selling healthy foods such as vegetables are also available in the area, but to a lesser extent, for example: "There is one, there is one supermarket which provides healthy food, but there's like five supermarkets, five shops that outweigh that by selling, you know, takeaway food. Like it's Subway, Subway is an example of a healthy food, there is one Subway in the whole of where I live, but there is like four takeaway restaurants, you know, so that's what you are against. It's in, it's almost like it's in your face to buy it, you know that kind of way." (YW 6). However, participants described how even in these supermarkets, healthy foods compete with other unhealthy options: "There's a new Lidl [supermarket] open beside us there and I walked in and it has all the fresh vegetables and fruit, and everything is out, when you walk in, and it's just nice to see that, it was nice to just see that, going look at all, now they have the cakes as well at the start which distracts you a little bit." (P.8). Despite this fact, the availability of vegetables in these areas does not seem to be a problem and families could easily get them at an affordable price if they wanted to: "Yeah, now there is like, where we are, there's definitely plenty of places to go and buy them [vegetables] and I actually don't think, you know, they're that expensive when you look at the, like to say, like Lidl [supermarket] or whatever, there's a Lidl really close to us, erm you know, they do their deals of whatever it is for 49 cents." (YW 2)

Lack of adequate approaches & initiatives to promote healthy eating
A major issue raised by the participants was the need for implementing more healthy eating community-centered approaches as opposed to individual-centered approaches as described by this youth worker: "I think on a community level that's probably, you know, do you know like, where I suppose we kind of go quite individually with this sort of stuff [healthy eating initiatives] whereas we need to be more of a community approach, you know" (YW 1). While many initiatives target the school setting, it was noted the need to develop activities within other community settings so adolescents could benefit from them even when not attending school. One respondent said the following in regard to this: "I think schools are often chosen as the only avenue of things of this rather than like in a community setting, erm, and I think that was particularly relevant when we've seen that when all the schools had to close [due to the COVID-19 pandemic] young people were kind of left in the lurch." (YW 3).
Participants made a number of suggestions on initiatives that could be implemented at the community level to support adolescents and their families to eat healthier and include vegetables in their diets. Limiting the availability of takeaway and fast-food outlets in the community, mainly around schools, together with increasing the number of places providing affordable ready-to-eat healthy meals was one of these suggestions: "I know there was recommendations with the government to remove fast food outlets from within a certain radius of schools but that is something that I think would be massively helpful." (ST 6). Another aspect that could be improved was the labeling of food products and the provision of point of sale information towards more child-friendly systems that could aid adolescents to make more informed choices on the food items they purchase as described by this respondent: "Whether you could have a system then with the salads and, you know, the green, a green and a red, things that will help them make choices that, that they can, that they have to be educated at the point

Lack of adequate approaches & initiatives to promote healthy eating
Although both schools and youth centers reported that they have initiatives in place about nutrition, they usually are once-off programs that the centers carry out based on their needs: "Last year we did a workshop on sugar, you know, like so we do like, we kind of do it, respond to the needs, you know that kind of way, when they're coming up not like we wouldn't plan, wouldn't be in our plan for the year that we do it like that, we do the sweets when they're constantly bringing sweets and all the time and we're like, okay, we need to do something to maybe try and get them to look at this behavior" (YW 1). Participants made several suggestions that could aid the development of more effective approaches to promote healthy eating and vegetable intake among adolescents from socioeconomically disadvantaged backgrounds. There is a need for more informal, enjoyable and hands-on approaches such as visits to farms and/or supermarkets, cookery classes, menu planning, batch cooking, etc. Among these, the provision of vegetable tasting opportunities was a common suggestion made by the respondents: "So I think it's, it's hugely important that teenagers do try and experience fruit and vegetables and to, I suppose, to encourage them to taste and to try them and to bring them in as a normal part of their eating." (ST 6). However, participants highlighted the importance of tailoring these initiatives by consulting adolescents on what their interests and needs are and involving them as much as possible in the development and implementation process as reflected by this youth

Lack of state support to promote healthy eating
A general sense of neglect by national authorities towards people living in disadvantaged areas was made evident by one of the respondents: "All comes down to money, they don't but, you know, why because it comes down to postal codes, where we are, where these people are, I don't mind them being, let's leave them there, let's not care about them, if that was in a different part of Dublin with a different postal code or a more affluent area that restaurant would be up and running providing a service to the community with good healthy nourishing food" (YW 12). Major involvement from the government was deemed necessary by taking more action in promoting healthy eating and preventing any related chronic diseases such as obesity. Some suggestions made by the respondents included increasing advertising of vegetables, putting more resources into educating people or providing more support to schools and local health staff to promote healthier dietary habits among people living in disadvantaged areas. One school teacher pointed out the following regarding advertisement of vegetables: "If something could be done with more advertising of like make vegetables more attractive to people, erm, particularly to children too, I mean, you could get little cartoons […] and just putting more money into that getting more money for that like there should be grants for things like that to promote it more because I don't think I've ever seen a vegetable ad on TV." (ST 2).

Discussion
By means of the second-hand account of post-primary school teachers and community youth workers, we explored the factors that affect vegetable intake among adolescents from socioeconomically disadvantaged areas of Dublin. A total of 11 barriers were identified and were mapped to the levels of the SEM in an attempt to show the complex interplay that exists between these factors.
On the individual level, food preferences are widely recognized determinants of individuals' food intake [8]. These adolescents were reported to have a strong preference for ultra-processed foods and sugary drinks which have been described as potentially addictive foods, mainly those with added sugar [38]. Ultra-processed foods, which are characterized by being fat-, salt-and/or sugar-rich products, are highly palatable as opposed to other healthy food items such as vegetables [44]. In agreement with previous literature [34], the taste and flavor of vegetables often discourage young people from eating them. Neophobia is a natural human response to new foods and some foods need to be tasted up to 15 times before an individual can like them [8]. Keeping this in mind, lack of familiarity with vegetables together with limited or no exposure to vegetables at younger ages, may be among some of the reasons why these adolescents refuse to eat vegetables. In this regard, previous findings emphasize that early and continuous exposure to vegetables is crucial to overcome vegetable aversion among children and adolescents [25,30,31]. However, vegetables not only compete in terms of taste and flavor with other unhealthy foods, but also in terms of price [19,24,27,50] and convenience [35,46,59]. According to the study participants, the adolescents discussed in this study seem to rely a lot on takeaway and fast foods which are regarded as cheap and ready-to-eat foods and are highly available in low-income neighborhoods as shown in previous research [39,40]. As described in this study, these outlets are not only highly predominant in the areas where these adolescents live, they also have very long opening hours and special offers that specifically target adolescents. Thus, the perception of the adults interviewed is that adolescents in socioeconomically deprived areas are continuously exposed to an obesogenic environment which encourages consumption of unhealthy foods and, consequently, hinders any potential attempts to eat healthily. However, the perceived frequent use of fast-food outlets by these adolescents could be used as an opportunity to provide point-of-sale nutrition education by identifying healthy and unhealthy food options which would allow adolescents to make more informed choices. This approach has been shown to lead to healthier customer purchasing behavior [15].
The research participants perceived the most common barriers to healthy eating among both adolescents and their parents were the lack of interest, knowledge and skills around healthy eating and vegetables. Quantitative research on the determinants of vegetable intake in adolescents from deprived backgrounds does not support an association between nutrition knowledge and vegetable intake in this population group [7]. However, findings from previous qualitative studies have also reported limited knowledge about types of vegetables among adolescents from socioeconomic deprived backgrounds as potential determinants of intake [13,50]. Other studies have also reported lack of knowledge about healthy eating [19] or the health benefits of eating healthy and vegetables [50] as barriers to healthy eating. Although the perception of the participants in this study is that adolescents lack awareness of the health consequences of unhealthy eating rather than the advantages of eating healthily, being aware of the effect of these food items on their health could still promote healthier food choices. Study participants also described that, in some instances, adolescents seemed to know what eating healthy entailed, but they had difficulties in translating knowledge into behavior. This could be partly caused by the lack of cooking skills within the family on how to prepare vegetables. This perceived barrier was a recurrent aspect that emerged in most of the interviews. Gerritsen et al. [24] also found that lack of cooking skills together with lack of time were among those factors responsible for the low consumption of fruit and vegetables in low-income children and adolescents from New Zealand. Perceived lack of parental time to prepare nutritious food was also noted by study participants which together with the lack of cooking skills led families to opt for more convenient and ready-to-eat foods.
Another major barrier to vegetable intake was the perceived lack of importance given to healthy eating by both adolescents and their families. This perceived lack of importance placed on food and health was also described in a study conducted among unemployed young people from Northern Ireland [19]. According to the Social Cognitive Theory [4], the individual has to both value the behavior and associate the outcome of the behavior with positive expectancies for a specific behavior to occur. Furthermore, it should be kept in mind that some of these families may be exposed to difficult living circumstances such as poverty, homelessness, alcoholism, smoking, drug abuse and/or drug dealing which may result in mental health illnesses, lack of home structure and lack of parental presence and control. Both the school teachers and the youth workers also perceived that rules and routines around mealtimes are frequently lacking and shared mealtimes seem to be non-existent in families with a socioeconomically deprived background. There is extensive quantitative and qualitative research on the pivotal influence exerted by parental behaviors, attitudes and knowledge and the household food environment on the eating habits and food choices of adolescents regardless of the socioeconomic level [21,34,41,48,52,54,61]. For instance, results from a meta-analysis showed that children and adolescents who shared fewer than 3 family meals together per week were less likely to have healthy dietary and eating patterns [26]. In addition, the limited provision of healthful foods in the home environment is considered as a barrier to healthy eating by the adolescents themselves [23].
During adolescence, peers play a crucial role in decision-making and have a major impact on many aspects of adolescents' lives such as taste, clothing or engagement in risky behaviors like drug use [17,58]. The sense of belonging to a social group is crucial for adolescents and they may feel pressured to comply with specific social norms in order to feel part of that group. A recent systematic review concluded that the influence of peers on eating behaviors tends to be more negative than positive by increasing the intake of energy-dense and low-nutrition value foods [51]. Study participants described the social component attached to takeaways outlets among adolescents in socioeconomically disadvantaged areas as a meeting point with friends and enjoyable leisure time activity. However, there is also evidence that peers' social influence can promote healthy behaviors [62] and reduce risk-taking attitudes [9]. Therefore, further research needs to find effective ways to encourage healthy eating behaviors in adolescents through their peers [51]. On the other hand, social media has a strong influence on adolescents regardless of their social class. In agreement with our findings, popular social media platforms can impact both adolescents' healthful eating behaviors, i.e., intake of fruits and vegetables, and unhealthful eating behaviors related to fast food advertising and can promote eating disorders [16]. As suggested by Chung et al. [16], social media can act as a powerful change agent; however, adolescents need to be provided with the tools and the knowledge to make proper use of the volume of information available on social media platforms.
Although there is little evidence on how the school environment influences fruit and vegetable intake among children and adolescents from a socioeconomically disadvantaged background, available research shows that adolescents attending low-socioeconomic status schools are more likely to have unhealthy dietary habits and to eat fewer vegetables than their peers attending schools in more affluent areas [6,21,32,56]. The food environment within the school and near the school, policies, curricula, teaching and learning, and school staff all have an influence in promoting healthy eating among adolescents. However, a salient topic among interviewees was the lack of support in schools and youth centers to promote healthy eating. Two main sorts of support were noted to be lacking: 1) from the government in terms of enhancing healthy eating and skills around healthy eating through both the school curriculum and the school/youth center premises together with allocating more funding to schools for this purpose, i.e., resources, staff and facilities, and 2) from the management team and/or other center staff in promoting healthier food environments, endorsing healthy eating initiatives, providing healthy and nutritious food, and setting a good example for young people.
At the community level, study participants emphasized the need for community-centered approaches to support adolescents and their families to eat healthier. In fact, obesity prevention efforts focusing on the individual are gradually shifting to upper levels of the SEM [36]. On the other hand, while schools are often the preferred setting to implement health promotion and prevention interventions [22], community-based studies targeting other settings such as youth centers and environmental change interventions are scarce [10]. In addition, most of the programs, regardless of the implementation level, tend to be once-off initiatives rather than programs than run on a rolling basis which would increase the likelihood of achieving long-term behavior changes. Furthermore, the development of programs aiming to promote healthy eating should include experiential learning strategies such as cookery classes, vegetable gardens, etc., that adolescents and their families can find enjoyable. In this regard, experiential learning approaches have been proven to be effective in improving dietary habits [20,22,37].

Practical implications and recommendations
Based on the findings of this study, there is a range of practical implications that could potentially assist adolescents in socioeconomically disadvantaged areas and their families in making healthier dietary choices and increasing their intake of vegetables by improving the school and the community food environment. At the individual level, programs aiming to provide early exposure to vegetables could represent an alternative for those children who are not frequently exposed to vegetables within their household. In Ireland, the European Union School Scheme supports the distribution of fruit and vegetables to primary-school children. However, the program does not run on a regular basis and the schools opt into the program. Therefore, it may not be sufficient to build long-lasting positive experiences with vegetables. Adolescents could also benefit from a similar program implemented annually in all post-primary schools nationwide. In addition, healthy eating programs targeting adolescents may need to include more practical activities to draw adolescents' attention and to teach them how to translate nutrition knowledge into behavior. Lack of interest among these adolescents may hinder the adoption of any sort of program or policy. For that reason, future approaches may utilize modern technology to trigger adolescents' motivation and engagement in such initiatives.
In addition, nutrition education lessons for youth center and school staff could be advantageous to promote a shared common vision and values around nutrition aspects among all the staff. Furthermore, more investment is needed to fund community-level initiatives in socially deprived areas that promote the availability of affordable food and support healthy food choices by combining infrastructure improvements and policy changes [12]. Particularly, banning fast food outlets near primary and post-primary schools together with promoting affordable ready-to-eat healthy options around schools and within the whole neighborhood could encourage adolescents in socioeconomically deprived areas to make healthier dietary choices and to eat more vegetables. In fact, the presence of fast-food environments around post-primary schools has been associated with less fruit and vegetable intake among Irish adolescents [32].
As described by Monsivais et al. [43], unhealthy diets are indicative of wider social disadvantages and inequities; however, existing food environment interventions do not generally consider the drivers of these inequities. Therefore, it is key to work with adolescents and their families and, in general, with people living in socioeconomically disadvantaged communities when developing dietary behavior change interventions and policies. This will allow researchers and policy makers to understand the whole context, find out what their needs are and listen to their suggestions on how to act to promote healthy eating and vegetable intake, in particular, in the area.

Strengths and limitations
One of the strengths of this study is that all the interviews were carried out by the same interviewer. The interview topic guide was developed using both the SEM and previous research on vegetable intake among adolescents and was reviewed by another researcher regarding comprehensibility and content. In addition, the interview guide was refined continuously throughout the process. Furthermore, the number of interviews conducted can be considered as satisfactory given that the data saturation point was met as no new information was emerging. Another strength is the fact that data were analyzed by two separate coders. In addition, the fact the study participants were very experienced in working with adolescents within disadvantaged areas can be seen as another strength of this study.
This study is subject to several limitations. More male youth workers were interviewed than female youth workers, while post-primary school staff were all females. Therefore, it cannot be ruled out the presence of certain respondent bias caused by this gender imbalance. However, all the respondents provided comparable answers regardless of their gender and workplace, i.e., youth center versus post-primary school. For that reason, we are confident that this aspect had little impact on the study results and that similar findings would have been obtained if more female youth workers and male school staff had taken part in the study. In addition, the generalizability of these findings to wider populations and different settings requires further study. We may hypothesize that most of the barriers identified in this study may be applicable to other adolescents in low-income areas in Ireland and overseas, particularly those described at the upper levels of the SEM such as the schools, youth centers and the community. Due to the global COVID-19 pandemic, interviews were conducted online through video calling software as opposed to the originally planned face-to-face interviews. However, ease of communication and building of rapport between the interviewer and the interviewee were not impacted. It should be noted, though, that the conversations carried out by phone did not flow as fluently as those conducted online. This could partially be explained by the fact that interviewer and interviewee could not see each other which hampered building rapport.

Conclusion
Findings from this study will inform both the development of quantitative surveys aiming to further explore the determinants of vegetable intake and the design of intervention programs and policies targeting adolescents living in socioeconomically disadvantaged areas. It can be concluded from our results that study participants perceived multiple barriers to vegetable intake and, in general, to healthy eating in this population group. These perceived barriers do not occur in isolation; they are all interrelated and need to be taken into consideration as such when developing new programs and policies. Lastly, researchers and policy makers may need to consider more innovative and pragmatic strategies to successfully increase vegetable intake and promote healthier dietary choices in adolescents living in socioeconomically disadvantaged areas.

Funding
This work was supported by the Health Research Board [grant number ARPP-A-2018-004]. The funding source had no involvement in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. The opinions, findings and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the funding agency.

Data and code availability
Data used in this study are available upon request. The lead author has full access to the data reported in the manuscript.

Declaration of Competing Interest
None.

Data availability
Data will be made available on request.