Whole-of-community and intersectoral interventions that address alcohol-related harms: A scoping review.

Alcohol harms threaten global population health, with youth particularly vulnerable. Low - and middle-income countries (LMIC) are increasingly targeted by the alcohol industry. Intersectoral and whole-of-community actions are recommended to combat alcohol harms, but there is insufficient global evidence synthesis and research examining interventions in LMIC. This paper maps existing literature on whole-of - community and intersectoral alcohol harms reduction interventions in high-income countries (HIC) and LMIC. Systematic searching and screening produced 61 articles from an initial set of 1325: HIC (n = 53), LMIC (n = 8). Data were extracted on geographic location, intersectoral action, reported outcomes, barriers, and enablers. HIC interventions most often targeted adolescents and combined community action with other components. LMIC interventions did not target adolescents or use policy, schools, alcohol outlets, or enforcement components. Programme enablers were a clear intervention focus with high political support and local level leadership, locally appropriate plans, high community motivation, community action and specific strategies for parents. Challenges were sustainability, complexity of interventions, managing participant expectations and difficulty engaging multiple sectors. A learning agenda to pilot, scale and sustain whole-of-community approaches to address alcohol harms in settings is crucial, with consideration of local contexts and capacities, more standardised methods, and a focus on community-driven action.

Whole-of-community interventions that address alcohol-related harms: protocol for a scoping review.

INTRODUCTION: Alcohol-related harm is a rising global concern particularly in low-income and middle-income countries where alcohol use fuels the high rates of violence, road traffic accidents and is a risk factor for communicable diseases such as HIV/AIDS and tuberculosis. Existing evidence to address alcohol-related harm recommends the use of intersectoral approaches, however, previous efforts have largely focused on addressing individual behaviour with limited attention to whole-of-community approaches. Whole-of-community approaches are defined as intersectoral interventions that are systematically coordinated and implemented across the whole community. The objective of this scoping review is to synthesise the existing literature on multisectoral, whole-of-community interventions which have been used to modify or prevent alcohol-related harms. METHODS AND ANALYSIS: This scoping review will follow the six-step approach that involves; (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, (5) collating, summarising and reporting the results and (6) expert consultation. Published literature from 2010 to 2021 will be accessed through PubMed, Web of Science, CINAHL Plus and Scopus databases. Search terms will focus on the concepts of 'interventions', 'community-based', 'harm reduction' and 'alcohol'. There will be no restrictions on the type of study methodology or country of origin. Title and abstract followed by full-text screening will be conducted by two reviewers to identify relevant articles based on the inclusion and exclusion criteria. Data from selected articles will be extracted and charted in Excel software. Findings will be analysed qualitatively and presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review. ETHICS AND DISSEMINATION: This review makes use of published and publicly available data and no ethics approval is required. The results from this study will be disseminated via publication in peer-reviewed journals and presentations at relevant academic research fora and conferences.

'I've become so healthy that I can't live anymore': exploring 'health as balance' discourses and the construction of health and identity among young urban South African adults.

Social science research on health in South Africa tends to focus on illness and how to address health problems. Qualitative empirical research focussing on lay understandings and experiences of healthiness, or health discourses, in South Africa is fairly limited. This article addresses this gap by critically exploring how young South African adults used discourses of balance to make sense of what it means to be a healthy person and highlights the implications of these discourses for identity. Foucault's concepts of 'technologies of the self' and 'techniques of discipline' are discussed as a theoretical grounding for this paper. Data were collected from 20 in-depth semi-structured interviews, and analysed using Foucauldian discourse analysis. This paper will specifically explore a key discourse identified through the analysis: 'health as balance' and 2 interrelated sub-discourses which fall within it. Through this discourse, healthiness was constructed as requiring a broad focus on improving all aspects of one's life ('health as holistic') and the avoidance of any behaviours or emotions which could be classified as extreme ('health as moderation'). Constant, careful management of the self, or 'calibration', functions to both perpetuate a cycle of 'anxiety and control' and to obscure ways in which health discourses can be harmful or problematic.

A scoping review of the determinants of foetal alcohol spectrum disorder in South Africa: an intersectional perspective.

Foetal alcohol spectrum disorder (FASD) affects babies born to mothers who consume alcohol while pregnant. South Africa has the highest prevalence of FASD in the world. We review the social determinants underpinning FASD in South Africa and add critical insight from an intersectional feminist perspective. We undertook a scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. Drawing from EBSCOhost and PubMed, 95 articles were screened, with 21 selected for analysis. We used the intersectionality wheel to conceptualize how the social and structural determinants of FASD identified by the literature are interconnected and indicative of broader inequalities shaping the women and children affected. Key intersecting social determinants that facilitate drinking during pregnancy among marginalized populations in South Africa documented in the existing literature include social norms and knowledge around drinking and drinking during pregnancy, alcohol addiction and biological dependence, gender-based violence, inadequate access to contraception and abortion services, trauma and mental health, and moralization and stigma. Most of the studies found were quantitative. From an intersectional perspective, there was limited analysis of how the determinants identified intersect with one another in ways that exacerbate inequalities and how they relate to the broader structural and systemic factors undermining healthy pregnancies. There was also little representation of pregnant women's own perspectives or discussion about the power dynamics involved. While social determinants are noted in the literature on FASD in South Africa, much more is needed from an intersectionality lens to understand the perspectives of affected women, their social contexts and the nature of the power relations involved. A critical stance towards the victim/active agent dichotomy that often frames women who drink during pregnancy opens up space to understand the nuances needed to support the women involved while also illustrating the contextual barriers to drinking cessation that need to be addressed through holistic approaches.

Policy foundations for transformation: a gender analysis of adolescent health policy documents in South Africa.

The Sustainable Development Goals (SDGs) and the United Nations Global Strategy (2016-30) emphasize that all women, children and adolescents 'survive, thrive and transform'. A key element of this global policy framework is that gender equality is a stand-alone goal as well as a cross-cutting priority. Gender inequality and intersecting social and structural determinants shape health systems, including the content of policy documents, with implications for implementation. This article applies a gender lens to policy documents by national government bodies that have mandates on adolescent health in South Africa. Data were 15 policy documents, authored between 2003 and 2018, by multiple actors. The content analysis was guided by key lines of enquiry, and policy documents were classified along the continuum of gender blind to gender transformative. Only three policy documents defined gender, and if gender was addressed, it was mostly in gender-sensitive ways, at times gender specific, but rarely gender transformative. Building on this, a critical discourse analysis identified what is problematized and what is left unproblematized by actors, identifying the key interrelated dominant and marginalized discourses, as well as the 'silences' embedded in policy documents. The discourse analysis revealed that dominant and marginalized discourses reflect how gender is conceptualized as fixed, categorical identities, vs as fluid social processes, with implications for how rights and risks are understood. The discourses substantiate an over-riding focus on adolescent girls, outside of the context of power relations, with minimal attention to boys in terms of their own health or through a gender lens, as well as little consideration of LGBTIQ+ adolescents beyond HIV. Dynamic and complex relationships exist between the South Africa context, actors, content and processes, in shaping both how gender is problematized and how 'solutions' are represented in these policies. How gender is conceptualized matters, both for policy analysis and for praxis, and policy documents can be part of foundations for transforming gender and intersecting power relations.

"To be healthy to me is to be free": how discourses of freedom are used to construct healthiness among young South African adults.

PURPOSE: Healthiness is constructed, in Western culture, as a moral ideal or supervalue. This paper will interrogate the assumption that health and the pursuit of healthiness is always and unquestionably positive, by exploring how discourses of health and freedom interact to reinforce the current inequalities and detract from social transformation. METHOD: Twenty young South African adults were interviewed about their understandings and experiences of health. These discussions were analysed using Foucauldian discourse analysis. RESULTS: Participants constructed healthiness as facilitating the experience of freedom, while at the same time being dependent on a personal orientation towards freedom (as opposed to merely submitting to dominant health authorities). Freedom discourses also played a role in connecting health to neoliberal discourses idealizing economic productivity and hard work. Participants were able to construct a self that is active, productive, valuable, hopeful, and self-assured when talking about health using discourses of freedom. However, these discourses also functioned to moralise and idealise healthiness, which contributed to blaming poor health on its sufferers. CONCLUSION: Health/freedom discourses can further reinforce the neoliberal value of individual responsibility by constructing self-improvement and self-work as the solution to ill-health, thereby contributing to victim-blaming and weakening support for public health interventions.