Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa.

BACKGROUND: Cardiovascular diseases (CVD) were responsible for 20.5 million annual deaths globally in 2021, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the collaborative multi-country project that employed citizen science and a co-design approach to (i) explore CVD risk perceptions, (ii) develop tailored prevention strategies, and (iii) support advocacy in different low-income settings in SSA. METHODS: This is a participatory citizen science study with a co-design component. Data was collected from 205 participants aged 18 to 75 years in rural and urban communities in Malawi, Ethiopia and Rwanda, and urban South Africa. Fifty-one trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100-150 photographs and 150-240 voice recordings on CVD risk perceptions, communication and health-seeking intentions. Thematic and comparative analysis were undertaken with the citizen scientists and the results were used to support citizen scientists-led stakeholder advocacy workshops. Findings are presented using bubble graphs based on weighted proportions of key risk factors indicated. RESULTS: Nearly three in every five of the participants interviewed reported having a relative with CVD. The main perceived causes of CVD in all communities were substance use, food-related factors, and litter, followed by physical inactivity, emotional factors, poverty, crime, and violence. The perceived positive factors for cardiovascular health were nutrition, physical activity, green space, and clean/peaceful communities. Multi-level stakeholders (45-84 persons/country) including key decision makers participated in advocacy workshops and supported the identification and prioritization of community-specific CVD prevention strategies and implementation actions. Citizen science-informed CVD risk screening and referral to care interventions were piloted in six communities in three countries with about 4795 adults screened and those at risk referred for care. Health sector stakeholders indicated their support for utilising a citizen-engaged approach in national NCDs prevention programmes. The citizen scientists were excited by the opportunity to lead research and advocacy. CONCLUSION: The collaborative engagement, participatory learning, and co-designing activities enhanced active engagement between citizen scientists, researchers, and stakeholders. This, in turn, provided context-specific insights on CVD prevention in the different SSA settings.

Plausible conditions and mechanisms for increasing physical activity behavior in men with prostate cancer using patient education interventions: sequential explanatory mixed studies synthesis.

PURPOSE: This mixed studies synthesis sought to evaluate structured patient education interventions (PEIs) to elucidate relevant conditions and mechanisms for increasing physical activity behavior in men with prostate cancer (PCa). METHODS: Studies that randomized men diagnosed with PCa, assessed PEIs, and reported (1) between-group changes in the outcome measures of exercise self-efficacy, PA level, or patient-centered outcomes (cancer-related fatigue, aerobic fitness, and quality of life) at baseline and post-intervention, and/or (2) men's perceptions of structured PEIs were synthesized. Results from five RCTs reporting data on 895 men and qualitative reports from four studies were respectively and sequentially analyzed with narrative and thematic syntheses. Findings from both syntheses were further integrated using the context-mechanism-outcome configuration (CMO) to elucidate potential "contextual factors" or "conditions" that may support plausible PEI mechanisms. RESULTS: Structured PEIs were associated with a beneficial increase in task self-efficacy, vigorous-intensity PA, minutes/week of resistance exercise, the proportion of men meeting ≥ 150 minutes/week of moderate-vigorous intensity aerobic exercise, and overall PA. No effects were found on patient-centered outcomes. Drawing upon the CMO configuration, the inclusion of a referral process, access to "credible influence" (e.g., involving former patients as program facilitators), and adopting hybrid service delivery are likely critical conditions that may explain the success of PEIs in men with PCa. CONCLUSION: PEIs can increase PA behavior in men with PCa. The likelihood of success is higher for multicomponent interventions that prioritized credible influence and exercise referral as critical components besides offering access to interventions within hospital settings, with home-based sessions in addition.

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. PARTNERSHIP: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. CONCLUSION: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.

Electrophysiological indices of visual food cue-reactivity. Differences in obese, overweight and normal weight women.

Heightened food cue-reactivity in overweight and obese individuals has been related to aberrant functioning of neural circuitry implicated in motivational behaviours and reward-seeking. Here we explore the neurophysiology of visual food cue-reactivity in overweight and obese women, as compared with normal weight women, by assessing differences in cortical arousal and attentional processing elicited by food and neutral image inserts in a Stroop task with record of EEG spectral band power and ERP responses. Results show excess right frontal (F8) and left central (C3) relative beta band activity in overweight women during food task performance (indicative of pronounced early visual cue-reactivity) and blunted prefrontal (Fp1 and Fp2) theta band activity in obese women during office task performance (suggestive of executive dysfunction). Moreover, as compared to normal weight women, food images elicited greater right parietal (P4) ERP P200 amplitude in overweight women (denoting pronounced early attentional processing) and shorter right parietal (P4) ERP P300 latency in obese women (signifying enhanced and efficient maintained attentional processing). Differential measures of cortical arousal and attentional processing showed significant correlations with self-reported eating behaviour and body shape dissatisfaction, as well as with objectively assessed percent fat mass. The findings of the present study suggest that heightened food cue-reactivity can be neurophysiologically measured, that different neural circuits are implicated in the pathogenesis of overweight and obesity, and that EEG techniques may serve useful in the identification of endophenotypic markers associated with an increased risk of externally mediated food consumption.

Charting a Course: Navigating Rigor and Meaning in Global Health Research.

In the rapidly evolving landscape of global health research, the tension between scientific rigor and contextual meaning presents a critical challenge. Drawing on our work with the Global Diet and Physical Activity Network, this commentary explores the complexities of conducting environmental audits for physical activity and diet in 4 rapidly urbanizing African cities: Yaoundé, Lagos, Cape Town, and Soweto. We illustrate the competing demands and tensions that researchers face in balancing rigor and meaning. We discuss the adaptation of internationally validated audit tools to local contexts and the importance of area-level deprivation in interpreting data. We also examine the feasibility of virtual assessment tools, emphasizing the value of local expertise. We argue for a balanced approach that marries research rigor with contextual meaning, advocating for transparency, humility, and meaningful community engagement.

Physical Activity and Excess Body Weight and Adiposity for Adults. American College of Sports Medicine Consensus Statement.

ABSTRACT: Excessive body weight and adiposity contribute to many adverse health concerns. The American College of Sports Medicine (ACSM) recognizes that the condition of excess body weight and adiposity is complex, with numerous factors warranting consideration. The ACSM published a position stand on this topic in 2001 with an update in 2009, and a consensus paper on the role of physical activity in the prevention of weight gain in 2019. This current consensus paper serves as an additional update to those prior ACSM position and consensus papers. The ACSM supports the inclusion of physical activity in medical treatments (pharmacotherapy, metabolic and bariatric surgery) of excess weight and adiposity, as deemed to be medically appropriate, and provides perspectives on physical activity within these therapies. For weight loss and prevention of weight gain, the effects may be most prevalent when physical activity is progressed in an appropriate manner to at least 150 min·wk-1 of moderate-intensity physical activity, and these benefits occur in a dose-response manner. High-intensity interval training does not appear to be superior to moderate-to-vigorous physical activity for body weight regulation, and light-intensity physical activity may also be an alternative approach provided it is of sufficient energy expenditure. Evidence does not support that any one single mode of physical activity is superior to other modes for the prevention of weight gain or weight loss, and to elicit holistic health benefits beyond the effects on body weight and adiposity, multimodal physical activity should be recommended. The interaction between energy expenditure and energy intake is complex, and the effects of exercise on the control of appetite are variable between individuals. Physical activity interventions should be inclusive and tailored for sex, self-identified gender, race, ethnicity, socioeconomic status, age, and developmental level. Intervention approaches can also include different forms, channels, and methods to support physical activity.

The pandemic of physical inactivity: global action for public health.

Physical inactivity is the fourth leading cause of death worldwide. We summarise present global efforts to counteract this problem and point the way forward to address the pandemic of physical inactivity. Although evidence for the benefits of physical activity for health has been available since the 1950s, promotion to improve the health of populations has lagged in relation to the available evidence and has only recently developed an identifiable infrastructure, including efforts in planning, policy, leadership and advocacy, workforce training and development, and monitoring and surveillance. The reasons for this late start are myriad, multifactorial, and complex. This infrastructure should continue to be formed, intersectoral approaches are essential to advance, and advocacy remains a key pillar. Although there is a need to build global capacity based on the present foundations, a systems approach that focuses on populations and the complex interactions among the correlates of physical inactivity, rather than solely a behavioural science approach focusing on individuals, is the way forward to increase physical activity worldwide.

Advancing urban green and blue space contributions to public health.

Urban green and blue spaces (UGBS) have the potential to improve public health and wellbeing, address health inequities, and provide co-benefits for the environment, economy, and society. To achieve these ambitions, researchers should engage with communities, practitioners, and policy makers in a virtuous circle of research, policy, implementation, and active citizenship using the principles of co-design, co-implementation, co-evaluation, and co-translation. This Viewpoint provides an integrated perspective on the challenges that hinder the delivery of health-enhancing UGBS and recommendations to address them. Our recommendations include: strengthening the evidence beyond cross-sectional research designs, strengthening the evidence base on UGBS intervention approaches, evaluating the effects on diverse population groups and communities, addressing inequities in the distribution and quality of UGBS, accelerating research on blue space, providing evidence for environmental effects, incorporating co-design approaches, developing innovative modelling methods, fostering whole-system evidence, harnessing political drivers, creating collaborations for sustainable UGBS action, and advancing evidence in low-income and middle-income countries. The full potential of UGBS as public health, social, economic, and environmental assets is yet to be realised. Acting on the research and translation recommendations will aid in addressing these challenges in collaboration with research, policy, practice, and communities.

Sleep characteristics associated with nocturnal blood pressure nondipping in healthy individuals: a systematic review.

OBJECTIVE: The current literature investigating nocturnal blood pressure (BP) nondipping has largely focused on clinical populations, however, conditions such as hypertension, obstructive sleep apnoea and insomnia are recognized confounding factors for BP dipping. The exact mechanisms responsible for BP nondipping remain unclear, therefore, there is a need to investigate BP nondipping in healthy individuals to better understand the underlying mechanisms. This review identifies sleep characteristics that may contribute to BP nondipping in healthy individuals. It is anticipated that an understanding of the sleep characteristics that contribute to BP nondipping may inform future sleep-related behavioral interventions to ultimately reducing the burden of cardiovascular disease. METHODS: The PubMed, Scopus and Web of Science databases were searched for relevant, English language, peer-reviewed publications (from inception to March 2022). The search identified 550 studies. After duplicates were removed, the titles and abstracts of the remaining 306 studies were screened. Of these, 250 studies were excluded leaving 56 studies to test for eligibility. Thirty-nine studies were excluded such that 17 studies fully met the inclusion criteria for the review. RESULTS: Findings from this review indicate that short sleep duration, more sleep fragmentation, less sleep depth and increased variability in sleep timing may be associated with BP nondipping in healthy individuals. CONCLUSION: While there is no evidence-based approach for the treatment of nocturnal BP nondipping, it seems promising that addressing one's sleep health may be an important starting point to reduce the prevalence of BP nondipping and perhaps the progression to cardiovascular disease.

Implementing and Evaluating Community Health Worker-Led Cardiovascular Disease Risk Screening Intervention in Sub-Saharan Africa Communities: A Participatory Implementation Research Protocol.

The increasing burden of non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) in low- and middle-income countries (LMICs) poses a considerable threat to public health. Community-driven CVD risk screening, referral and follow-up of those at high CVDs risk is essential to supporting early identification, treatment and secondary prevention of cardiovascular events such as stroke and myocardial infarction. This protocol describes a multi-country study that aims to implement and evaluate a community health worker (CHW)-led CVD risk screening programme to enhance referral linkages within the local primary care systems in sub-Saharan Africa (SSA), using a participatory implementation science approach. The study builds upon a prior community-driven multicentre study conducted by the Collaboration for Evidence-based Health Care and Public Health in Africa (CEBHA+). This is a participatory implementation research. The study will leverage on the CVD risk citizen science pilot studies conducted in the four selected CEBHA+ project countries (viz. Ethiopia, Rwanda, Malawi, and South Africa). Through planned engagements with communities and health system stakeholders, CHWs and lay health worker volunteers will be recruited and trained to screen and identify persons that are at high risk of CVD, provide referral services, and follow-up at designated community health clinics. In each country, we will use a multi-stage random sampling to select and then screen 1000 study participants aged 35-70 years from two communities (one rural and one urban). Screening will be done using a simple validated non-laboratory-based CVD risk assessment mobile application. The RE-AIM model will be used in evaluating the project implementation outcomes, including reach, fidelity, adoption and perceived effectiveness. Developing the capacities of CHWs and lay health worker volunteers in SSA to support population-based, non-invasive population-based CVD risk prevention has the potential to impact on early identification, treatment and secondary prevention of CVDs in often under-resourced communities. Using a participatory research approach to implementing mobile phone-based CHW-led CVD risk screening, referral and follow-up in SSA will provide the evidence needed to determine the effectiveness of CVD risk screening and the potential for scaling up in the wider region.

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations-women, girls, and adolescents-requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.

A Mixed-Methods Participatory Intervention Design Process to Develop Intervention Options in Immediate Food and Built Environments to Support Healthy Eating and Active Living among Children and Adolescents in Cameroon and South Africa.

Rates of obesity and related non-communicable diseases are on the rise in sub-Saharan Africa, associated with sub-optimal diet and physical inactivity. Implementing evidence-based interventions targeting determinants of unhealthy eating and physical inactivity in children and adolescents' immediate environments is critical to the fight against obesity and related non-communicable diseases. Setting priorities requires a wide range of stakeholders, methods, and context-specific data. This paper reports on a novel participatory study design to identify and address contextual drivers of unhealthy eating and physical inactivity of children and adolescents in school and in their home neighborhood food and built environments. We developed a three-phase mixed-method study in Cameroon (Yaoundé) and South Africa (Johannesburg and Cape Town) from 2020-2021. Phase one focused on identifying contextual drivers of unhealthy eating and physical inactivity in children and adolescents in each setting using secondary analysis of qualitative data. Phase two matched identified drivers to evidence-based interventions. In phase three, we worked with stakeholders using the Delphi technique to prioritize interventions based on perceived importance and feasibility. This study design provides a rigorous method to identify and prioritize interventions that are tailored to local contexts, incorporating expertise of diverse local stakeholders.

Global Matrix 4.0 Physical Activity Report Card Grades for Children and Adolescents: Results and Analyses From 57 Countries.

BACKGROUND: The Global Matrix 4.0 on physical activity (PA) for children and adolescents was developed to achieve a comprehensive understanding of the global variation in children's and adolescents' (5-17 y) PA, related measures, and key sources of influence. The objectives of this article were (1) to summarize the findings from the Global Matrix 4.0 Report Cards, (2) to compare indicators across countries, and (3) to explore trends related to the Human Development Index and geo-cultural regions. METHODS: A total of 57 Report Card teams followed a harmonized process to grade the 10 common PA indicators. An online survey was conducted to collect Report Card Leaders' top 3 priorities for each PA indicator and their opinions on how the COVID-19 pandemic impacted child and adolescent PA indicators in their country. RESULTS: Overall Physical Activity was the indicator with the lowest global average grade (D), while School and Community and Environment were the indicators with the highest global average grade (C+). An overview of the global situation in terms of surveillance and prevalence is provided for all 10 common PA indicators, followed by priorities and examples to support the development of strategies and policies internationally. CONCLUSIONS: The Global Matrix 4.0 represents the largest compilation of children's and adolescents' PA indicators to date. While variation in data sources informing the grades across countries was observed, this initiative highlighted low PA levels in children and adolescents globally. Measures to contain the COVID-19 pandemic, local/international conflicts, climate change, and economic change threaten to worsen this situation.

The Relationship between Physical Activity and the Objectively-Measured Built Environment in Low- and High-Income South African Communities.

There is limited data concerning the built environment and physical activity (PA) in a country with a history of sociopolitically motivated, spatial and economic disparities. We explored the extent to which objectively measured attributes of the built environment were associated with self-report or device-measured PA in low- and high-socioeconomic status (SES) communities. METHODS: In a convenient sample of residents (n = 52, aged 18-65 years) from four urban suburbs in low- and high-income settings near Cape Town, South Africa, self-reported transport- and leisure-time PA, and device-measured moderate-to-vigorous PA (MVPA) data were collected. Built environment constructs derived from individual-level street network measures (1000 m buffer, ArcGIS, 10.51) were obtained. We assessed PA between four groups, based on income and GIS walkability (derived by a median split, low or high SES and low or high walkable). RESULTS: No relationships between self-reported MVPA and GIS-measured walkability were found. Only intersection density was significantly, inversely associated with moderate and total MVPA (rho = -0.29 and rho = -0.31, respectively, p < 0.05). In the high SES group, vigorous PA was inversely associated with intersection density (rho = -0.39, p < 0.05). Self-report transport PA differed between groups (p < 0.013). CONCLUSIONS: Results suggest that the construct of walkability may relate to volitional (leisure) and utilitarian (transport) PA differently, in highly inequitable settings.

Efficacy of interactive video gaming in older adults with memory complaints: A cluster-randomized exercise intervention.

PURPOSE: The effects of aging on physical and mental health may be ameliorated by regular participation in physical activity (PA). There is also evidence for the benefits of various training modalities on cognition and functional ability in older adults. The aim of this study was to compare effects of a 12-week active video gaming intervention (X Box Kinect Sports) to conventional multimodal supervised exercise on fitness, functional ability and cognitive performance in older adults with memory complaints. METHODS: Participants (n = 45, 72±5 yrs.) were recruited from 6 retirement homes and cluster-randomized into the Interactive Video Gaming (IVG) group (N = 23) or Conventional Multimodal (CM) group (N = 22), meeting 2 x 1 hour sessions, weekly for 12 weeks. Pre-post measures included: 6 min walk, timed up and go, dynamic balance, functional reach, Mini-Mental State Examination, N-back Task and the Modified Stroop task. RESULTS: The IVG group demonstrated significant improvement in the total number correct responses on the Stroop task (P = 0.028) and for average reaction time of correct colour-words (P = 0.024), compared to the CM group. Functional ability improved significantly in the IVG group, including the 6-min walk (P = 0.017), dynamic balance (P = 0.03), timed up and go (P<0.001) and functional reach (P<0.0010). CONCLUSION: An active interactive video gaming intervention was more effective than conventional multimodal exercise in improving executive and global cognitive performance and functional capacity in older adults with subjective memory complaints. TRIAL REGISTRATION: Pan African Clinical Trial Registry-PACTR202008547335106.

Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol.

BACKGROUND: In sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk. METHODS: This protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy. DISCUSSION: Contextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Food Cue Reactivity and the Brain-Heart Axis During Cognitive Stress Following Clinically Relevant Weight Loss.

Successful weight loss maintainers are more vulnerable to stress induced eating. The aim of our study was to determine what effect an attention-demanding cognitive performance task had on brain-heart reactivity to visual food cues in women who maintained clinically relevant weight loss vs. women who had never weight cycled. A clinical weight loss group (CWL, n = 17) and a BMI-matched control group (CTL, n = 23) completed modified Stroop tasks that either included high calorie food pictures (Food Stroop) or excluded food cues (Office Stroop). ECG, breathing rate, and EEG were recorded. CWL participants: The Eating Restraint scores (Three Factor Eating Questionnaire) of the CWL participants correlated negatively with their heart rates recorded during the Food Stroop task (r = 0.62, p < 0.01). There was no such relationship in CTL participants. The P200 latencies in CWL participants evoked by the Stroop color-word cues at the C3 electrode were positively correlated to the log high frequency power in their cardiac spectrograms during the Food Stroop (r = 0.63, p < 0.02). There were no such relationships in the Office Stroop task nor in CTL participants. Combined Groups: Participants' heart rates were significantly lower (p < 0.05) and their RMSSD values and the log Total Power in their cardiac spectrograms were significantly greater during the Food Stroop vs. Office Stroop (p < 0.01, Bonferroni corrected). In conclusion Eating Restraint scores in CWL participants correlated with their Stroop heart rates, while the P200 latencies evoked by the Stroop cues correlated with the log high frequency power in their cardiac spectrograms (marker of cardiac vagal activation) during the Food Stroop task. This provides evidence that even 12 months after successful weight loss maintenance the cardiac ANS reactivity to food cues while completing a cognitive performance test was still different to that in individuals of normal weight who never weight cycled. Across all participants the cardiac ANS reactivity evoked by performing the Stroop task was lowered by food cues suggesting that the dampening effect of food cues on cardiac ANS reactivity may be one of the drivers of 'stress induced' eating.

Cross-cultural validation of the hill-bone compliance to high blood pressure therapy scale in a South African, primary healthcare setting.

OBJECTIVES: Hypertension is prevalent, under-diagnosed, and inadequately treated in Black South Africans. However, few studies have addressed barriers to hypertension care and control in this community. The aim of this study was to validate the Hill-Bone Compliance to High Blood Pressure Therapy Scale (HB Comp Scale) for use in a South African primary healthcare setting. This instrument consists of three subscales, medications-compliance, appointment making, and salt intake. METHODS: A demographic questionnaire and the HB scale were translated into the first language of the subjects and then back-translated into English. Hypertensive patients (N=98) were recruited from primary healthcare clinics in Cape Town. Blood pressure was measured with an Omron electronic blood pressure manometer, after 5 min of seated rest. Item-analysis was conducted to determine internal consistency of the HB Comp Scale; Spearman rank order correlations were used to assess the relationship between compliance scores and blood pressure. RESULTS: A modified scale consisting of only 10 items demonstrated reasonable internal consistency (item-total correlations all >.31, and a standardized Cronbach alpha of 0.79), with an average interitem correlation of .26. In addition, the modified scale had significant predictive validity in that noncompliance predicted higher diastolic blood pressures (p=.21, P<.05) and medication noncompliance tended to predict higher systolic blood pressures (p=.20, P<.06). Appointment-making and dietary salt-intake subscales were not internally consistent. CONCLUSIONS: We demonstrated criterion validity and internal consistency for a modified Hill-Bone Compliance Scale, in Black, urban, hypertensive, South African patients. Results compare favorably with those from an urban African-American setting (standardized Cronbach alpha was .74-.84).