Validation of a roadmap for mainstreaming nutrition-sensitive interventions at state level in Nigeria.

BACKGROUND: National programs are often developed with little consideration to the sub-national local factors that might affect program success. These factors include political support, capacity for implementation of program and variation in malnutrition indices being tackled. State context factors are evident in the distribution of malnutrition (e.g. high prevalence or gap among Local Government Areas), in the implementation of nutrition-sensitive interventions (e.g. access to early childhood education) and in the political economic context (e.g. presence of external funding agencies). Context is shaped by the economy, population, religion, and poverty, which impact everyday lives. Considering these contexts, a roadmap was developed and validated. The aim of this paper is to report expert review and stakeholder validation to determine feasibility of the developed contextualised roadmap for two Nigerian states. METHODS: A validation tool was developed and reviewed using three experts. The content review occurred in two rounds to obtain recommendation and revisions of the developed roadmap and the validation tool. A pilot test of the roadmap and validation tool was done using two stakeholders in South Africa. The roadmap and the validation tool were then sent to the stakeholders and potential end-users in Nigeria using electronic media. Two research assistants were also engaged to deliver and collect hard copies to those who preferred it. RESULTS: Of the ten stakeholders invited, nine responded. All participants showed an adequate understanding of the roadmap as evidenced by the scores given. Responses regarding the translation of the roadmap to implementation varied. The majority (86,6%) either strongly agreed or agreed that the actions were translatable (43.0 and 43.6% respectively). CONCLUSIONS: The final roadmap comprises of actions that are appropriate for the state's context. It is recommended that stakeholders or end-users of any programme must be involved in the validation of such contextual programmes to improve chances of success.

A qualitative analysis of perceptions of various stakeholders on nutrition-sensitive agricultural interventions, including the taxation on sugar-sweetened beverages (SSBs), to improve overall health and nutrition in South Africa.

BACKGROUND: As a low-middle income country, South Africa has seen an upsurge in the double burden of malnutrition (DBM). Owing to the rising costs of obesity on healthcare in South Africa, the National Treasury implemented a fiscal policy for the taxation of SSBs, known as the Health Promotion Levy, in line with the WHO recommendation. Potential negative impacts of the policy on the sugar cane industry and economic and rural development have been voiced by different sectors. By including a subsection in the SSBs fiscal policy and aligning the goals with existing policies, government could have made provisions for sugar cane farms to substitute crops with alternatives, including nutritional alternatives where possible, while supporting existing small-scale farms to produce nutrient-dense, local and culturally acceptable crops. Thus, the purpose of the study is to understand the perceptions of the various stakeholders on combining nutrition-sensitive agricultural interventions with the taxation on sugar-sweetened beverages (SSBs) to improve overall health and nutrition in South Africa. METHODS: Semi-structured, in-depth interviews were conducted with each participant. The interviews were audio-recorded, transcribed intelligent verbatim, and cross-checked against the audio-recordings by the principal researcher. ATLAS.ti 8 software was used to navigate the data and assist with thematic analysis. RESULTS: Perceptions of combining SSB taxation with agricultural policies to improve food and nutrition security were positive. The participants found it to be an innovative idea in theory but questioned the feasibility of combining policies. Participants highlighted education as an essential element for successfully changing behaviour to ensure a positive impact of the combined policy approach. Participants believed that before government could scale up nutrition-sensitive agricultural interventions, basic services and government functions would first need to run optimally. CONCLUSION: Overall, perceptions with regard to combining the taxation on SSBs with nutrition-sensitive agricultural policies to improve overall health and nutrition in South Africa were positive. Although participants questioned the feasibility of combining these policies, it was viewed as a way to combat alleged collateral damage linked to the tax, with a specific focus on developing small-scale farmers. More research into these combined policy approaches in a South African context is required.

Awakening from the listeriosis crisis: Food safety challenges, practices and governance in the food retail sector in South Africa.

Background: The recent listeriosis outbreak in South Africa brought food safety concerns to the fore in terms of both policy and practice. These concerns encompass both health and nutrition aspects, as well as the economy, because the food system in South Africa contributes significantly to economic growth and food security. However, the food sector is challenged with food safety risks, such as foodborne diseases, food fraud and a general lack of effective enforcement of regulation. The inability of government to effectively regulate the food sector is a contributing factor to increased food safety risks. Focusing on the formal sector, which is subject to regulation, this review provides an overview of the current state of food safety policies and regulations, food safety challenges, and food safety practices in the food system, after the listeriosis crisis of 2017 and 2018. Method: This study used a systematic process to review three sets of data in South Africa: food safety related public policies and regulations, company reports (2013-2018) and media articles (May 2017-May 2018). Food safety policies were selected from a food system policy database created by the research team. The company reports were retrieved from their websites. Factivia was used to search for the media articles. The data were thematically analyzed. The analysis framework was informed by the Food and Agriculture Organization's (FAO) food safety risk analysis. Activities related to food safety risk analysis: risk assessment, risk management, and risk communication were searched for in each material included in the study. Results: Seventy-four documents made up of 13 policies, 47 media articles and 15 company reports were reviewed. Food safety is regulated by three governments departments: Department of Health (DOH), Department of Agriculture, Forestry and Fisheries (DAFF), and Department of Trade and Industry (DTI) through bylaws and regulations. The departments are directly (DAFF) or indirectly (DOH through municipal or metro Environmental Health Professional) involved in food safety enforcement, surveillance, and education. The enforcement of different regulatory processes is often poorly coordinated. Responding to this regulatory environment, food safety activities of the food retail industry include a self-regulatory system reliant on internal and third-party food audits, worker training, external testing, and consumer education. Given this fragmented framework and the lack of interaction, it is clear that the governance of the South African food safety system is not "fit for purpose" in that there is a gap in the effectiveness of government regulation and the self-regulation of the formal sector, and a growing risk from an inability to regulate the large informal sector. Food safety challenges identified in our analysis included disease outbreaks, concerns over mislabeling, and lack of regulation for food handling and distribution. Conclusion: The findings suggest that there should be a combination of responsibility from all levels of stake-holders in the food retail sector in order to improve food safety and prevent food safety breaches. In addition, strong governance of the food safety system is required to enable effective legislation and enforcement.

Food security and nutrition interventions in response to the AIDS epidemic: assessing global action and evidence.

The number of people receiving antiretroviral therapy in developing countries has increased dramatically. The last decade has brought an increased understanding of the interconnectedness between HIV/AIDS, food insecurity, and undernutrition and a surge of evidence on how to address the food security and nutrition dimensions of the epidemic. We review this evidence as well as the corresponding evolution of policy support for incorporating food security and nutrition concerns into HIV programming. The available evidence, although varied in scope and methodologies, shows that nutrition supplementation and safety nets in the form of food assistance and livelihood interventions have potential in certain contexts to improve food security and nutrition outcomes in an HIV/AIDS context. In the face of funding uncertainties and competing priorities, we must maintain momentum towards effective and sustainable solutions to the epidemic through continued systematic research to inform policy and through the strengthening of monitoring systems to dynamically inform intervention development.

A Qualitative Exploratory Study of the Political Commitment for Nutrition Programming: A Case Study of Anambra and Kebbi States of Nigeria.

In Nigeria, varying levels of malnutrition across states present a critical challenge to public health, demanding tailored policy responses. This paper delves into the specific issues and dynamics influencing nutrition programs in the country. Advocating for nutrition-sensitive actions requires analyzing context-specific political commitment. This article presents a case study on two Nigerian states with varying malnutrition profiles to explore the political economy of nutrition. The study used stakeholder analysis, in-depth interviews, and semi-structured interviews through workshops, incorporating the Political Commitment Rapid Assessment Tool. The objective was to measure political commitment, the window of opportunity for action, and stakeholder analysis. The results showed that despite having a significant child malnutrition problem, Kebbi State received a high political commitment to nutrition, with proportions ranging from 0.67 to 1 in each of the six domains measured. On the other hand, Anambra State, where malnutrition was less severe, had varying commitment levels. Institutional commitment was marginally high (0.67), expressed commitment was high (0.71), and budgetary commitment was lower at 0.33. Kebbi had better support for programs dependent on foreign donors than Anambra. Both states need to use media to increase awareness about nutrition issues. When the nutrition situation is severe, foreign donors' influence grows. In conclusion, there are opportunities for strategic framing and advocacy of the nutrition profile of the states. Local state media can be effective, and institutional coordination committees that include various sectors already facilitate commitment to nutrition actions. However, individual, uncoordinated sectoral action can counterbalance the benefits of these committees. Further possibilities to generate political commitment for nutrition in the states are available. This study not only offers insights into the effectiveness of political strategies in addressing malnutrition but also lays the groundwork for future research and provides actionable recommendations for government policymaking.

Dietary diversity of formal and informal residents in Johannesburg, South Africa.

BACKGROUND: This paper considers the question of dietary diversity as a proxy for nutrition insecurity in communities living in the inner city and the urban informal periphery in Johannesburg. It argues that the issue of nutrition insecurity demands urgent and immediate attention by policy makers. METHODS: A cross-sectional survey was undertaken for households from urban informal (n = 195) and urban formal (n = 292) areas in Johannesburg, South Africa. Foods consumed by the respondents the previous day were used to calculate a Dietary Diversity Score; a score < 4 was considered low. RESULTS: Statistical comparisons of means between groups revealed that respondents from informal settlements consumed mostly cereals and meat/poultry/fish, while respondents in formal settlements consumed a more varied diet. Significantly more respondents living in informal settlements consumed a diet of low diversity (68.1%) versus those in formal settlements (15.4%). When grouped in quintiles, two-thirds of respondents from informal settlements fell in the lowest two, versus 15.4% living in formal settlements. Households who experienced periods of food shortages during the previous 12 months had a lower mean DDS than those from food secure households (4.00 ± 1.6 versus 4.36 ± 1.7; p = 0.026). CONCLUSIONS: Respondents in the informal settlements were more nutritionally vulnerable. Achieving nutrition security requires policies, strategies and plans to include specific nutrition considerations.

Disrupting the opportunity narrative: navigating transformation in times of uncertainty and crisis.

COVID-19 posed threats for health and well-being directly, but it also revealed and exacerbated social-ecological inequalities, worsening hunger and poverty for millions. For those focused on transforming complex and problematic system dynamics, the question was whether such devastation could create a formative moment in which transformative change could become possible. Our study examines the experiences of change agents in six African countries engaged in efforts to create or support transformative change processes. To better understand the relationship between crisis, agency, and transformation, we explored how they navigated their changed conditions and the responses to COVID-19. We document three impacts: economic impacts, hunger, and gender-based violence and we examine how they (re)shaped the opportunity contexts for change. Finally, we identify four kinds of uncertainties that emerged as a result of policy responses, including uncertainty about the: (1) robustness of preparing a system to sustain a transformative trajectory, (2) sequencing and scaling of changes within and across systems, (3) hesitancy and exhaustion effects, and (4) long-term effects of surveillance, and we describe the associated change agent strategies. We suggest these uncertainties represent new theoretical ground for future transformations research. Supplementary Information: The online version contains supplementary material available at 10.1007/s11625-023-01340-1.

Stories of change in nutrition: lessons from a new generation of studies from Africa, Asia and Europe.

How does nutrition improve? We need to understand better what drives both positive and negative change in different contexts, and what more can be done to reduce malnutrition. Since 2015, the Stories of Change in Nutrition studies have analysed and documented experiences in many different African and Asian countries, to foster empirically-grounded experiential learning across contexts. This article provides an overview of findings from 14 studies undertaken in nine countries in South Asia, sub-Saharan Africa, and Europe between 2017 and 2021. The studies used a combination of methods, including regression-decomposition analyses of national datasets to assess determinants of nutritional change; policy process and food environment analyses; and community-level research assessing attitudes to change. This article takes a narrative synthesis approach to identify key themes across the studies, paying particular attention to multisectoral determinants, changes in the food environment, the role of structural factors (including longstanding social inequities), and changes in political commitment, cross-sectoral coherence and capacity. Given the inherent multisectoral nature of nutrition, many countries are experimenting with different models of ensuring coherence across sectors that are captured in this body of work. The relative immaturity of the policy sector in dealing with issues such as obesity and overweight, and associated influences in the wider food environment, adds a further challenge. To address these interrelated issues, policy must simultaneously tackle nutrition's upstream (social/economic/equity) and downstream (health and dietary) determinants. Studies synthesised here provide empirically-driven inspiration for action.

Cochrane corner: community-level interventions to increase access to food in low- and middle-income countries.

Food insecurity and hunger is a continuing problem in Africa, with access to food being critical to address it. Community-level interventions may help to increase access to food, specifically, nutritious food. We highlight a Cochrane review that assessed community level interventions aiming to increase access to nutritious food in low- and middle-income countries (LMICs), including those that improve buying power, address food prices, and the social environment. Randomised controlled trials and prospective controlled studies that assessed the effects of these interventions on food security and nutritional status were included, providing relevant implications for practice in LMICs. Findings suggest that unconditional cash transfers (UCTs) are important for improving food security, and that UCTs and food vouchers may increase dietary diversity and reduce stunting. This highlights the importance of current programmes in Africa, the need to reflect and refine where needed, and expand their capacity. A holistic approach to address food insecurity in the region.

The complex challenge of governing food systems: The case of South African food policy.

International experience reveals that food policy development often occurs in silos and offers few tangible mechanisms to address the interlinked, systemic issues underpinning food and nutrition insecurity. This paper investigated what South African government policies cover in terms of different aspects of the food system, who is responsible for them, and how coordinated they are. Policy objectives were categorized into seven policy domains relevant to food systems: agriculture, environment, social protection, health, land, education, economic development, and rural development. Of the ninety-one policies reviewed from 1947-2017, six were identified as being "overarching" with goals across all the domains. About half of the policies focused on agriculture and the environment, reflecting an emphasis on agricultural production. Policies were formulated and implemented in silos. As a result, learning from implementation, and adjusting to improve impact has been limited. Particularly important is that coordination during implementation, across these complex domains, has been partial. In order to achieve its stated food and nutrition outcomes, including Sustainable Development Goal (SDG) 2, South Africa needs to translate its policies into tangible, practical plans and processes guided by effective coordination and alignment. Key recommendations are practically to align policies to a higher-level "food goal", establish better coordination mechanisms, consolidate an effective monitoring and evaluation approach to address data gaps and encourage learning for adaptive implementation. Actively engaging the existing commitments to the SDGs would draw stated international commitments together to meet the constitutional commitment to food rights into an overarching food and nutrition security law.

Playing the role of a 'boundary organisation': getting smarter with networking.

BACKGROUND: This paper discusses the practices of organisations that cross the boundary between research and politics, to promote evidence-based policies and programmes. METHODS: It uses the experience of a network of organisations in Africa to describe the methodology, challenges and successes of efforts to promote utilisation of research on the inter-connections between HIV/AIDS, food security and nutrition in South Africa. It emphasises that crossing the boundary between science and politics can be done systematically and is inevitable for any attempt that seeks influence policy making. RESULTS: The paper reveals the complexity of the research-policy making interface and identifies key lessons for the practice of networking and engaging policy and decision-makers. CONCLUSION: The concept of boundary organisation is a helpful means to understand the methodological underpinnings of efforts to get research into policy and practice and to understand the 'messy' process of doing so.

Addressing Malnutrition: The Importance of Political Economy Analysis of Power.

BACKGROUND: The exercise of power is central to understanding global health and its policy and governance processes, including how food systems operate and shape population nutrition. However, the issue of power in food systems has been little explored empirically or theoretically to date. In this article, we review previous work on understanding power in addressing malnutrition as part of food systems that could be used in taking this issue further in future food systems research. In particular, we examine why acknowledging power is vital in addressing food systems for better nutritional outcomes, approaches to assessing power in empirical research, and ways of addressing issues of power as they relate to food systems. METHODS: We undertook a narrative review and synthesis. This involved identifying relevant articles from searches of PubMed and Scopus, and examining the reference lists of included studies. We considered for inclusion literature written in English and related to countries of all income levels. Data from included articles were summarized under several themes. RESULTS: We highlight the importance of acknowledging power as a critical issue in food systems, present approaches that can be taken by food-systems researchers and practitioners in assessing power to understand the ways in which power works in food systems and wider society, and present material relating to addressing power and developing strategies to improve food systems for better nutrition, health and well-being. CONCLUSION: A range of research approaches exist that can inform examination of power in food systems, and support the development of strategies to improve food systems for better nutrition, health and well-being. However, there is considerable scope for further work in this under-researched area. We hope that this review will support the necessary research to understand further power in food systems and drive the much-needed transformative change.

Planning for change: Transformation labs for an alternative food system in Cape Town, South Africa.

There has been a call for more participatory processes to feed into urban planning for more resilient food systems. This paper describes a process of knowledge co-production for transforming towards an alternative food system in Cape Town, South Africa. A 'transformative space' was created though a T-Lab process involving change-agents advocating for an alternative food system, and was designed to discuss challenges in the local food system from a range of perspectives, in order to co-develop potentially transformative innovations that could feed into government planning. In this paper, we describe and reflect on the T-lab in order to consider whether its design was able to meet its objective: to initiate an experimental phase of coalition-building by diverse actors that could feed into the provincial government's strategic focus on food and nutrition security. Our findings indicate that T-labs have the potential to be important mechanisms for initiating and sustaining transformative change. They can be complementary to urban planning processes seeking to transform complex social-ecological systems onto more sustainable development pathways. However, as with all experimental co-production processes, there is significant learning and refinement that is necessary to ensure the process can reach its full potential. A key challenge we encountered was how to foster diversity and difference in opinions in the context of significant historical legacies of inequality, whilst simultaneously acting for 'the common good' and seeking ways to scale impact across different contexts. The paper concludes with deliberations on the nature of planning and navigating towards systemic transformative change.

Food System Transformation: Integrating a Political-Economy and Social-Ecological Approach to Regime Shifts.

Sustainably achieving the goal of global food security is one of the greatest challenges of the 21st century. The current food system is failing to meet the needs of people, and at the same time, is having far-reaching impacts on the environment and undermining human well-being in other important ways. It is increasingly apparent that a deep transformation in the way we produce and consume food is needed in order to ensure a more just and sustainable future. This paper uses the concept of regime shifts to understand key drivers and innovations underlying past disruptions in the food system and to explore how they may help us think about desirable future changes and how we might leverage them. We combine two perspectives on regime shifts-one derived from natural sciences and the other from social sciences-to propose an interpretation of food regimes that draws on innovation theory. We use this conceptualization to discuss three examples of innovations that we argue helped enable critical regime shifts in the global food system in the past: the Haber-Bosch process of nitrogen fixation, the rise of the supermarket, and the call for more transparency in the food system to reconnect consumers with their food. This paper concludes with an exploration of why this combination of conceptual understandings is important across the Global North/ Global South divide, and proposes a new sustainability regime where transformative change is spearheaded by a variety of social-ecological innovations.

Multiple stressors in Southern Africa: the link between HIV/AIDS, food insecurity, poverty and children's vulnerability now and in the future.

Several countries in Southern Africa now see large numbers of their population barely subsisting at poverty levels in years without shocks, and highly vulnerable to the vagaries of the weather, the economy and government policy. The combination of HIV/AIDS, food insecurity and a weakened capacity for governments to deliver basic social services has led to the region experiencing an acute phase of a long-term emergency. "Vulnerability" is a term commonly used by scientists and practitioners to describe these deteriorating conditions. There is particular concern about the "vulnerability" of children in this context and implications for children's future security. Through a review of literature and recent case studies, and using a widely accepted conceptualisation of vulnerability as a lens, we reflect on what the regional livelihoods crisis could mean for children's future wellbeing. We argue that an increase in factors determining the vulnerability of households - both through greater intensity and frequency of shocks and stresses ("external" vulnerability) and undermined resilience or ability to cope ("internal" vulnerability) - are threatening not only current welfare of children, but also their longer-term security. The two specific pathways we explore are (1) erosive coping strategies employed by families and individuals; and (2) their inability to plan for the future. We conclude that understanding and responding to this crisis requires looking at the complexity of these multiple stressors, to try to comprehend their interconnections and causal links. Policy and programme responses have, to date, largely failed to take into account the complex and multi-dimensional nature of this crisis. There is a misfit between the problem and the institutional response, as responses from national and international players have remained relatively static. Decisive, well-informed and holistic interventions are needed to break the potential negative cycle that threatens the future security of Southern Africa's children.

Strengthening families to support children affected by HIV and AIDS.

This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDS's Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of children's potential through early child development efforts.

A systematic review on the meaning of the concept 'AIDS Orphan': confusion over definitions and implications for care.

Global publications on the international AIDS epidemic report on the existence of an ever-increasing number of orphans and vulnerable children. It has been suggested that by the end of this decade there will be in excess of 25 million AIDS orphans globally, an issue which will require understanding and organisation of long-term medical, psychological and social support. This study provides a systematic review to examine the use, overuse and misuse of the term orphan and explores the benefits and limitations of this approach. It then summarises the knowledge on orphans to date. Using a search strategy of published studies and recent conference abstracts, 383 papers were identified where the concept of AIDS and Orphan was raised. The papers were systematically coded and reviewed to understand when and how a child is labelled an orphan, and to summarise the effect of orphanhood on outcome measures, most notably psychologically and physically. All controlled studies published prior to 2006 were reviewed. A consistent picture of negative effects of parental death (however defined) on a wide range of physical, socioeconomic and psychological outcomes were recorded. Seventeen studies met criteria for in-depth review (empirical, fully published, control group). The majority of studies are cross-sectional (two are longitudinal) and employ a very wide array of measures - both standardised and study specific. This detailed analysis shows a mixed picture on outcome. Although most studies report some negative effects, there are often no differences and some evidence of protective effects from quality of subsequent care and economic assistance. The lack of consistent measures and the blurring of definitions are stumbling blocks in this area.

Broadening psychology's contribution to addressing issues of HIV/AIDS, poverty and nutrition: structural issues as constraints and opportunities.

HIV/AIDS, more than any other public health problem, challenges dominant models of the role of psychology in health promotion and prevention. This paper focuses on poverty and resulting food insecurity as a structural risk factor for HIV infection. The paper considers the role of health psychology in global health concerns and argues that, while individual-based interventions are important, health psychology needs to shift to playing a proper role in broader level initiatives. Health psychology, in thinking about global health concerns such as HIV, needs to view an understanding of health, education and nutrition delivery programmes in low resourced contexts as at the core of the discipline.

Urban health in Johannesburg: the importance of place in understanding intra-urban inequalities in a context of migration and HIV.

Developing country urban contexts present multiple challenges to those responsible for ensuring the good health of urban populations. These include urban growth, migration, informal settlements, intra-urban inequalities and - in some cases - high HIV prevalence. Using Johannesburg as a case study, this paper explores the complexities of the urban context by comparing the social determinants of urban health between migrant groups residing in the inner-city and a peripheral urban informal settlement. It is argued that any attempt to improve the health of urban populations in the context of migration and HIV requires understanding that 'place matters'.