Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis.

The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.

Prevalence of disease complications and risk factor monitoring amongst diabetes and hypertension patients attending chronic disease management programmes in a South African Township.

BACKGROUND: South Africa established chronic disease management programmes (CDMPs) called 'clubs' to ensure quality diabetes care. However, the effectiveness of these clubs remains unclear in terms of disease risk factor monitoring and complication prevention. AIM: We assessed risk factor monitoring, prevalence and determinants of diabetes related complications amongst type-2 diabetes (T2D) and hypertension (HTN) patients attending two CDMPs. SETTING: Urban Township in Cape Town, South Africa. METHODS: Cross-sectional survey combined with a 10-year retrospective medical records analysis of adult T2D/HTN patients attending two CDMPs, using a structured survey questionnaire and an audit tool. Statistical Software for Social Sciences (SPSS) version 25 was used to analyse risk factor monitoring and calculate prevalence of complications. Potential determinants of complications were explored through logistic regression. RESULTS: There were 379 patients in the survey, 372 (97.9%) had HTN whilst 159 (41.9%) had T2D and HTN; 361 medical records were reviewed. Blood pressure (87.7%) and weight (86.6%) were the best monitored risk factors. Foot care (0.0% - 3.9%) and eye screening (0.0% - 1.1%) were least monitored. Nearly 22.0% of patients reported one complication, whilst 9.2% reported ≥ 3 complications. Medically recorded complications ranged from 11.1% (1 complication) to 4.2% with ≥ 3 complications. The most common self-reported and medically recorded complications were eye problems (33%) and peripheral neuropathy (16.4%), respectively. Complication occurrence was positively associated with age and female gender and negatively associated with perceived illness control. CONCLUSIONS: Type-2 diabetes and hypertension patients experienced diabetes related complications and inadequate risk factor monitoring despite attending CDMPs. Increased self-management support is recommended to reduce complication occurrence.

Re-envisioning health promotion: Thinking and acting salutogenically towards equity for historically resilient communities.

This paper explores how the salutogenic theory can enable us to re-envision health promotion work with marginalized communities, towards an approach that acknowledges and honours their resilience. We use the three core concepts in Antonovsky's salutogenic model of health - sense of coherence, generalized resistance resources and specific resistance resources - to explore the theory's relevance to health equity, thus presenting new opportunities for how we might radically re-evaluate current health promotion approaches. We conclude that a more equitable health promotion requires increased participation of marginalized communities in shaping their futures and suggest a new model for historically grounded salutogenic health promotion.

Black Lives Matter in health promotion: moving from unspoken to outspoken.

Racism is a public health crisis. Black communities (including Africans, the African diaspora and people of African descent) experience worse health outcomes as demonstrated by almost any measure of health and wellbeing-e.g. life expectancy; disease prevalence; maternal mortality rates. While health promotion has its foundation in promoting equity and social justice, it is clear that however well-intended, we are not affecting meaningful change for Black communities quickly enough. Through this article, we outline the intersection of social determinants of health and anti-Black racism. We describe how in the first 8 months of 2020 Black communities around the globe have been disproportionately affected by COVID-19, while also having to respond to new instances of police brutality. We assert that the time has come for health promotion to stop neutralizing the specific needs of Black communities into unspoken 'good intentions'. Instead, we offer some concrete ways for the field to become outspoken, intentional and honest in acknowledging what it will take to radically shift how we promote health and wellbeing for Black people.

Snapshots of Urban and Rural Food Environments: EPOCH-Based Mapping in a High-, Middle-, and Low-Income Country from a Non-Communicable Disease Perspective.

A changing food environment is implicated as a primary contributor to the increasing levels of non-communicable diseases (NCDs). This study aimed to generate snapshots of selected external food environments to inform intervention strategies for NCD prevention in three countries: Uganda (low income), South Africa (middle income) and Sweden (high income), with one matched pair of urban-rural sites per country. Fifty formal and informal food retail outlets were assessed, and descriptive and comparative statistical analyses were performed. We found that formal food retail outlets in these countries had both positive and negative traits, as they were the main source of basic food items but also made unhealthy food items readily available. The Ugandan setting had predominantly informal outlets, while the Swedish setting had primarily formal outlets and South Africa had both, which fits broadly into the traditional (Uganda), mixed (South Africa) and modern (Sweden) conceptualized food systems. The promotion of unhealthy food products was high in all settings. Uganda had the highest in-community advertising, followed by South Africa and Sweden with the lowest, perhaps related to differences in regulation and implementation. The findings speak to the need to address contextual differences in NCD-related health interventions by incorporating strategies that address the food environment, and for a critical look at regulations that tackle key environment-related factors of food on a larger scale.

Big Tobacco, Alcohol, and Food and NCDs in LMICs: An Inconvenient Truth and Call to Action Comment on "Addressing NCDs: Challenges From Industry Market Promotion and Interferences".

In their editorial, Tangcharoensathien et al1 describe the challenges of industry market promotion and policy interference from Big Tobacco, Alcohol, and Food in addressing non-communicable diseases (NCDs). They provide an overview of the increasing influence of corporate interest in emerging economies and government attempts to implement the World Health Organization (WHO) 'best buy' interventions. The authors largely draw on examples from Asia and a few selected countries, but provide little detail as to how aggressive marketing and policy interference plays out in a context of poor legislation and regulation in many low- and middleincome countries (LMICs), where the burden of NCDs is increasing at an alarming rate and governments face a high burden of disease with a limited budget for countering industry interference. This commentary provides some poignant examples of the influence of Big Tobacco, Alcohol, and Food on market regulation and policy interference in LMICs and argues for more policy coherence and accountability in terms of multisectoral action and civil society activism. Securing funds for health promotion and establishing health promotion foundations could help achieve that goal.

Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes.

This paper reports on the use of reciprocal learning for identifying, adopting and adapting a type 2 diabetes self-management support intervention in a multisite implementation trial conducted in a rural setting in a low-income country (Uganda), a periurban township in a middle-income country (South Africa) and socioeconomically disadvantaged suburbs in a high-income country (Sweden). The learning process was guided by a framework for knowledge translation and structured into three learning cycles, allowing for a balance between evidence, stakeholder interaction and contextual adaptation. Key factors included commitment, common goals, leadership and partnerships. Synergistic outcomes were the cocreation of knowledge, interventions and implementation methods, including reverse innovations such as adaption of community-linked models of care. Contextualisation was achieved by cross-site exchanges and local stakeholder interaction to balance intervention fidelity with local adaptation. Interdisciplinary and cross-site collaboration resulted in the establishment of learning networks. Limitations of reciprocal learning relate to the complexity of the process with unpredictable outcomes and the limited generalisability of results.

Reducing the Role of the Food, Tobacco, and Alcohol Industries in Noncommunicable Disease Risk in South Africa.

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs.

Job satisfaction and turnover intent of primary healthcare nurses in rural South Africa: a questionnaire survey.

AIM: This paper is a report of a correlational study of the relationships between demographic variables, job satisfaction, and turnover intent among primary healthcare nurses in a rural area of South Africa. BACKGROUND: Health systems in Southern Africa face a nursing shortage fuelled by migration, but research on job satisfaction and turnover intent of primary healthcare nurses remains poorly described. METHOD: A cross-sectional study with survey design was conducted in 2005 in all local primary healthcare clinics, including nurses on duty at the time of visit (n = 143). Scale development, anova, Spearman's rank correlation, and logistic regression were applied. RESULTS: Nurses reported satisfaction with work content and coworker relationships and dissatisfaction with pay and work conditions. Half of all nurses considered turnover within two years, of whom three in ten considered moving overseas. Job satisfaction was statistically significantly associated with unit tenure (P < 0·05), professional rank (P < 0·01) and turnover intent (P < 0·01). Turnover intent was statistically significantly explained by job satisfaction, age and education (P < 0·001), with younger and higher educated nurses being more likely to show turnover intent. Satisfaction with supervision was the only facet significantly explaining turnover intent when controlling for age, education, years of nursing and unit tenure (P < 0·001). CONCLUSION: Strategies aimed at improving job satisfaction and retention of primary healthcare nurses in rural South Africa should rely not only on financial rewards and improved work conditions but also on adequate human resource management.