Body size preferences for women and adolescent girls living in Africa: a mixed-methods systematic review.

OBJECTIVE: To synthesise evidence on body size preferences for females living in Africa and the factors influencing these. DESIGN: Mixed-methods systematic review including searches on Medline, CINHAL, ASSIA, Web of Science and PsycINFO (PROSPERO CRD42015020509). A sequential-explanatory approach was used to integrate quantitative and qualitative findings. SETTING: Urban and rural Africa. PARTICIPANTS: Studies of both sexes providing data on body size preferences for adolescent girls and women aged ≥10 years. RESULTS: Seventy-three articles from twenty-one countries were included: fifty quantitative, fifteen qualitative and eight mixed methods. Most studies reported a preference for normal or overweight body sizes. Some studies of adolescent girls/young women indicated a preference for underweight. Factors influencing preferences for large(r) body sizes included: socio-demographic (e.g. education, rural residency), health-related (e.g. current BMI, pubertal status), psycho-social (e.g. avoiding HIV stigma) and socio-cultural factors (e.g. spouse's preference, social standing, cultural norms). Factors influencing preferences for slim(mer) body sizes included: socio-demographic (e.g. higher socioeconomic status, urban residency, younger age), health-related (e.g. health knowledge, being nulliparous), psycho-social (e.g. appearance, body size perception as overweight/obese) and socio-cultural factors (e.g. peer pressure, media). CONCLUSIONS: Preference for overweight (not obese) body sizes among some African females means that interventions need to account for the array of factors that maintain these preferences. The widespread preference for normal weight is positive in public health terms, but the valorisation of underweight in adolescent girls/young women may lead to an increase in body dissatisfaction. Emphasis needs to be placed on education to prevent all forms of malnutrition.

Community perceptions on the factors in the social food environment that influence dietary behaviour in cities of Kenya and Ghana: a Photovoice study.

OBJECTIVE: To explore communities' perspectives on the factors in the social food environment that influence dietary behaviours in African cities. DESIGN: A qualitative study using participatory photography (Photovoice). Participants took and discussed photographs representing factors in the social food environment that influence their dietary behaviours. Follow-up in-depth interviews allowed participants to tell the 'stories' of their photographs. Thematic analysis was conducted, using data-driven and theory-driven (based on the socio-ecological model) approaches. SETTING: Three low-income areas of Nairobi (n 48) in Kenya and Accra (n 62) and Ho (n 32) in Ghana. PARTICIPANTS: Adolescents and adults, male and female aged ≥13 years. RESULTS: The 'people' who were most commonly reported as influencers of dietary behaviours within the social food environment included family members, friends, health workers and food vendors. They mainly influenced food purchase, preparation and consumption, through (1) considerations for family members' food preferences, (2) considerations for family members' health and nutrition needs, (3) social support by family and friends, (4) provision of nutritional advice and modelling food behaviour by parents and health professionals, (5) food vendors' services and social qualities. CONCLUSIONS: The family presents an opportunity for promoting healthy dietary behaviours among family members. Peer groups could be harnessed to promote healthy dietary behaviours among adolescents and youth. Empowering food vendors to provide healthier and safer food options could enhance healthier food sourcing, purchasing and consumption in African low-income urban communities.

Individual-level drivers of dietary behaviour in adolescents and women through the reproductive life course in urban Ghana: A Photovoice study.

Evidence on the individual-level drivers of dietary behaviours in deprived urban contexts in Africa is limited. Understanding how to best inform the development and delivery of interventions to promote healthy dietary behaviours is needed. As noncommunicable diseases account for over 40% of deaths in Ghana, the country has reached an advanced stage of nutrition transition. The aim of this study was to identify individual-level factors (biological, demographic, cognitive, practices) influencing dietary behaviours among adolescent girls and women at different stages of the reproductive life course in urban Ghana with the goal of building evidence to improve targeted interventions. Qualitative Photovoice interviews (n = 64) were conducted in two urban neighbourhoods in Accra and Ho with adolescent girls (13-14 years) and women of reproductive age (15-49 years). Data analysis was both theory- and data-driven to allow for emerging themes. Thirty-seven factors, across four domains within the individual-level, were identified as having an influence on dietary behaviours: biological (n = 5), demographic (n = 8), cognitions (n = 13) and practices (n = 11). Several factors emerged as facilitators or barriers to healthy eating, with income/wealth (demographic); nutrition knowledge/preferences/risk perception (cognitions); and cooking skills/eating at home/time constraints (practices) emerging most frequently. Pregnancy/lactating status (biological) influenced dietary behaviours mainly through medical advice, awareness and willingness to eat foods to support foetal/infant growth and development. Many of these factors were intertwined with the wider food environment, especially concerns about the cost of food and food safety, suggesting that interventions need to account for individual-level as well as wider environmental drivers of dietary behaviours.

Transnational social networks, health, and care: a systematic narrative literature review.

While transnational social ties and exchanges are a core concern within migration studies, health researchers have often overlooked their importance. Continuous and circular exchanges of information within transnational networks, also defined as social remittances, facilitate the diffusion of innovations, potentially driving contemporary social and cultural change. Influences on health, wellbeing, and care-seeking are important, but under-researched, dimensions for consideration. We undertook a systematic narrative evidence synthesis to describe the current state of knowledge in this area and to identify gaps and future directions for health researchers to take. Between April 2017 and May 2019, an iterative series of searches in Medline, Embase, PsycINFO and PubMed, plus backward and forward citation searches identified 1173 potential papers. Screening resulted in 36 included papers, eighteen focused on migrant populations and eighteen on those who remain behind. The top three health topics were health-seeking strategies, sexual and reproductive health issues, and healthcare support. And, while not always explicitly identified, mental health and wellbeing was a further prominent, cross-cutting theme. Articles on migrant populations were all conducted in the global North and 13 out of 18 used qualitative methods. Five main themes were identified: therapeutic effect of the continuing social relationships, disrupted social relationships, hybridisation of healthcare, facilitation of connections to healthcare providers, and factors encouraging or undermining transnational social exchanges. Papers concerned with those who remain behind were mainly focused on the global South and used a mix of qualitative and quantitative approaches. Four main themes were identified: transnational transfer of health-related advice, norms, and support; associations between migrant linkages and health behaviours/outcomes; transnational collective transfer of health knowledge; and power and resistance in exchanges. Findings suggest that transnational social exchanges can both support and undermine the health of migrants and those who remain behind. This review confirms that the volume and quality of research in this area must be increased so that health policy and practice can be informed by a better understanding of these important influences on the health of both migrants and those who remain behind.

Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review.

OBJECTIVE: To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research. DESIGN: We systematically reviewed published/grey literature (protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro. SETTING: Urban food environments in Africa. PARTICIPANTS: Studies involving adolescents and adults (11-70 years, male/female). RESULTS: Thirty-nine studies were included (six adolescent, fifteen adolescent/adult combined and eighteen adult). Quantitative methods were most common (twenty-eight quantitative, nine qualitative and two mixed methods). Studies were from fifteen African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual-level factors that specifically emerged for adolescents included self-esteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment-level factors more, for example, sharing food with friends. The physical food environment was more commonly explored in adults, for example, convenience/availability of food. Macro-level factors associated with dietary behaviours were food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women. CONCLUSIONS: The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries.

Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries.

OBJECTIVE: To synthesise evidence of urban dietary behaviours (macronutrients, types of foods, dietary diversity and dietary practices) in two African countries in relation to postulated changes in the context of nutrition transition. DESIGN: Systematic review and meta-analyses, including six online databases and grey literature, 1971-2018 (Protocol CRD42017067718). SETTING: Urban Ghana and Kenya. PARTICIPANTS: Population-based studies of healthy adolescents and adults. RESULTS: The forty-seven included studies encompassed 20 726 individuals plus 6526 households. Macronutrients were within WHO-recommended ranges: mean energy intake was 1867 kcal/d (95 % CI 1764, 1969) and the proportions of macronutrients were carbohydrate 61·2 % (58·4, 64·0), fat 25·3 % (22·8, 28·0) and protein 13·7 % (12·3, 15·1). The proportion of population consuming fruit and vegetables was 51·6 %; unhealthy foods, 29·4 %; and sugar-sweetened beverages (SSBs), 39·9 %. Two-thirds (68·8 %) consumed animal-source proteins. Dietary diversity scores were within the mid-range. Meal patterns were structured (typically three meals per day), with evidence lacking on snacking or eating out. CONCLUSIONS: Population-level diets fell within WHO macronutrient recommendations, were relatively diverse with structured meal patterns, but some indications of nutrition transition were apparent. The proportion of population consuming fruit and vegetables was low compared to healthy-eating recommendations, and consumption of SSBs was widespread. A paucity of evidence from 1971 to 2010 precluded a longitudinal analysis of nutrition transition. Evidence from these two countries indicates which aspects of dietary behaviours may be contributing to increasing overweight/obesity, namely a low proportion of population consuming fruit and vegetables and widespread consumption of SSBs. These are potential targets for promoting healthier diets.

Dietary Patterns Are Associated with Predicted 10-Year Risk of Cardiovascular Disease Among Ghanaian Populations: the Research on Obesity and Diabetes in African Migrants (RODAM) Study.

BACKGROUND: Sub-Saharan African populations are disproportionately affected by cardiovascular disease (CVD). Although diet is an important lifestyle factor associated with CVD, evidence on the relation between dietary patterns (DPs) and CVD risk among sub-Saharan African populations is limited. OBJECTIVE: We assessed the associations of DPs with estimated 10-y atherosclerotic cardiovascular disease (ASCVD) risk in Ghanaian adults in Ghana and Europe. METHODS: Three DPs ('mixed'; 'rice, pasta, meat, and fish'; and 'roots, tubers, and plantain') were derived by principal component analysis (PCA) based on intake frequencies obtained by a self-administered Food Propensity Questionnaire in the multi-center, cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study. The 10-y ASCVD risk was estimated using the Pooled Cohort Equations (PCE) for 2976 subjects, aged 40-70 y; a risk score ≥7.5% was defined as 'elevated' ASCVD risk. The associations of DPs with 10-y ASCVD risk were determined using Poisson regression with robust variance. RESULTS: Stronger adherence to a 'mixed' DP was associated with a lower predicted 10-y ASCVD in urban and rural Ghana and a higher 10-y ASCVD in Europe. The observed associations were attenuated after adjustment for possible confounders with the exception of urban Ghana (prevalence ratio [PR] for Quintile 5 compared with 1: 0.70; 95% CI: 0.53, 0.93, P-trend = 0.013). The 'rice, pasta, meat, and fish' DP was inversely associated with 10-y ASCVD across all study sites, with the adjusted effect being significant only in urban Ghana. A 'roots, tubers, and plantain' DP was directly associated with increased 10-y ASCVD risk. CONCLUSIONS: Adherence to 'mixed' and 'rice, pasta, meat, and fish' DPs appears to reduce predicted 10-y ASCVD risk in adults in urban Ghana. Further investigations are needed to understand the underlying contextual-level mechanisms that influence dietary habits and to support context-specific dietary recommendations for CVD prevention among sub-Saharan African populations.

"I cannot sit here and eat alone when I know a fellow Ghanaian is suffering": Perceptions of food insecurity among Ghanaian migrants.

In the UK, ethnic minority groups tend to have higher levels of poverty than the white British population and therefore may be at high risk of food insecurity. Ghanaians, living in Ghana or as migrants are thought to have a high level of social support in their communities, but the role of this resource in relation to food security is unknown. We explored participants' perceptions of social and economic factors influencing food security among Ghanaian migrants in Greater Manchester. Participants aged ≥25 years (n = 31) of Ghanaian ancestry living in Greater Manchester were interviewed using a semi-structured interview guide developed by the researchers. Participants varied in socioeconomic status (SES), gender and migration status. Interviews were transcribed verbatim and analysed thematically using a framework approach. Participants offered similar accounts of the social and economic factors influencing food security. Accounts were based on participants' perceptions and/or personal experiences of food insecurity within the community. Participants indicated that they and their fellow Ghanaians can 'manage' even when they described quite challenging food access environments. This has negative implications on their food choices in the UK. Participants reported food insecure households may be reluctant to make use of food banks for fear of 'gossip' and 'pride'. Paradoxically, this reluctance does not extend to close network. Many participants described the church and other social groups as a trusted base in which people operate; support given through these channels is more acceptable than through the 'official context'. Government assisted food banks could partner with the social groups within this community given that these are more trusted. Keywords: food insecurity; food choice; social networks; Ghanaians; healthy eating; migrants.

Developing a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe - a DEDIPAC study.

BACKGROUND: Some ethnic minority populations have a higher risk of non-communicable diseases than the majority European population. Diet and physical activity behaviours contribute to this risk, shaped by a system of inter-related factors. This study mapped a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe, to inform research prioritisation and intervention development. METHODS: A concept mapping approach guided by systems thinking was used: i. Preparation (protocol and terminology); ii. Generating a list of factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe from evidence (systematic mapping reviews) and 'eminence' (89 participants from 24 academic disciplines via brainstorming, an international symposium and expert review) and; iii. Seeking consensus on structuring, rating and clustering factors, based on how they relate to each other; and iv. Interpreting/utilising the framework for research and interventions. Similar steps were undertaken for frameworks developed for the majority European population. RESULTS: Seven distinct clusters emerged for dietary behaviour (containing 85 factors) and 8 for physical activity behaviours (containing 183 factors). Four clusters were similar across behaviours: Social and cultural environment; Social and material resources; Psychosocial; and Migration context. Similar clusters of factors emerged in the frameworks for diet and physical activity behaviours of the majority European population, except for 'migration context'. The importance of factors across all clusters was acknowledged, but their relative importance differed for ethnic minority populations compared with the majority population. CONCLUSIONS: This systems-based framework integrates evidence from both expert opinion and published literature, to map the factors influencing dietary and physical activity behaviours in ethnic minority groups. Our findings illustrate that innovative research and complex interventions need to be developed that are sensitive to the needs of ethnic minority populations. A systems approach that encompasses the complexity of the inter-related factors that drive behaviours may inform a more holistic public health paradigm to more effectively reach ethnic minorities living in Europe, as well as the majority host population.

Drivers of dietary behaviours in women living in urban Africa: a systematic mapping review.

OBJECTIVE: To (i) systematically review the literature to determine the factors influencing diet and dietary behaviour in women living in urban Africa; (ii) present these in a visual map; and (iii) utilize this to identify potentially important areas for future research. DESIGN: Systematic mapping review. The review protocol was registered at PROSPERO (http://www.crd.york.ac.uk/PROSPERO/; registration number CRD42015017749). Six databases were systematically searched, followed by reference and citation searching. Eligibility criteria included women aged 18-70 years living in urban Africa, any design/methodology, exploring any driver, using any measure of dietary behaviour. Quality appraisal occurred parallel with data extraction. Twelve predominantly cross-sectional quantitative studies were included; reported in seventeen publications. Determinants were synthesized narratively and compiled into a map adapted from an existing ecological model based on research in high-income countries. SETTING: Urban Africa. SUBJECTS: African women aged 18-70 years. RESULTS: Determinants significantly associated with unhealthy dietary behaviour ranged from the individual to macro level, comprising negative body image perception, perceptions of insufficient food quantity and poorer quality, poorer food knowledge, skipping meals, snacking less, higher alcohol consumption, unhealthy overall lifestyle, older age, higher socio-economic status, having an education, lower household food expenditure, frequent eating outside the home and media influence. Marital status and strong cultural and religious beliefs were also identified as possible determinants. CONCLUSIONS: Few studies have investigated drivers of dietary behaviours in urban African settings. Predominantly individual-level factors were reported. Gaps in the literature identified a need for research into the neglected areas: social, physical and macro-level drivers of food choice.

The influence of migration on dietary practices of Ghanaians living in the United Kingdom: a qualitative study.

BACKGROUND: Previous studies have identified a process of dietary acculturation when migrant groups adopt the food patterns of the host country. AIM: The aim of this study was to explore the influence of migration on dietary practices and the process of dietary acculturation amongst Ghanaians living in the UK. SUBJECT AND METHODS: A qualitative study of adults aged ≥25 years (n = 31) of Ghanaian ancestry living in Greater Manchester using face-to-face interviews. Participants varied in socioeconomic status, gender and migration status. Interviews were transcribed verbatim and analysed thematically. RESULTS: Three distinct dietary practice typologies were discernible that differed in terms of typical meal formats, meal contexts, structure and patterning of meals, food preparation and purchasing behaviours: (i) continuity practices; (ii) flexible practices; and (iii) changed practices. The identified practices were shaped by interrelating factors that fell into four main clusters: social and cultural environment; accessibility of foods; migration context; and food beliefs/perceptions. CONCLUSION: Participants retained, to a varying degree, some aspects of Ghanaian dietary practices, whilst adopting key features of UK food culture. This study demonstrates the complexity of dietary change, indicating that it is not a linear process and it is dependent on several factors.

Systematic mapping review of the factors influencing dietary behaviour in ethnic minority groups living in Europe: a DEDIPAC study.

BACKGROUND: Europe has a growing population of ethnic minority groups whose dietary behaviours are potentially of public health concern. To promote healthier diets, the factors driving dietary behaviours need to be understood. This review mapped the broad range of factors influencing dietary behaviour among ethnic minority groups living in Europe, in order to identify research gaps in the literature to guide future research. METHODS: A systematic mapping review was conducted (protocol registered with PROSPERO 2014: CRD42014013549). Nine databases were searched for quantitative and qualitative primary research published between 1999 and 2014. Ethnic minority groups were defined as immigrants/populations of immigrant background from low and middle income countries, population groups from former Eastern Bloc countries and minority indigenous populations. In synthesizing the findings, all factors were sorted and structured into emerging clusters according to how they were seen to relate to each other. RESULTS: Thirty-seven of 2965 studies met the inclusion criteria (n = 18 quantitative; n = 19 qualitative). Most studies were conducted in Northern Europe and were limited to specific European countries, and focused on a selected number of ethnic minority groups, predominantly among populations of South Asian origin. The 63 factors influencing dietary behaviour that emerged were sorted into seven clusters: social and cultural environment (16 factors), food beliefs and perceptions (11 factors), psychosocial (9 factors), social and material resources (5 factors), accessibility of food (10 factors), migration context (7 factors), and the body (5 factors). CONCLUSION: This review identified a broad range of factors and clusters influencing dietary behaviour among ethnic minority groups. Gaps in the literature identified a need for researchers to explore the underlying mechanisms that shape dietary behaviours, which can be gleaned from more holistic, systems-based studies exploring relationships between factors and clusters. The dominance of studies exploring 'differences' between ethnic minority groups and the majority population in terms of the socio-cultural environment and food beliefs suggests a need for research exploring 'similarities'. The evidence from this review will feed into developing a framework for the study of factors influencing dietary behaviours in ethnic minority groups in Europe.

Digitising diabetes education for a safer Ramadan: Design, delivery, and evaluation of massive open online courses in Ramadan-focused diabetes education.

AIMS: Ramadan-focused diabetes education is critical to facilitate safer Ramadan fasting amongst Muslim people living with diabetes. We present the design, delivery, and evaluation of two parallel massive open online courses (MOOCs) in Ramadan-focused diabetes education for people with diabetes and HCPs. METHODS: Two Ramadan-focused diabetes education MOOCs were developed and delivered for Ramadan 2023: one for HCPs in English, and another for people with diabetes in English, Arabic and Malay. A user-centred iterative design process was adopted, informed by user feedback from a 2022 pilot MOOC. Evaluation comprised a mixed-methods evaluation of pre- and post-course user surveys. RESULTS: The platform was utilised by people with diabetes and their family, friends and healthcare professionals. Overall, a total of 1531 users registered for the platform from 50 countries, 809 started a course with a 48% subsequent completion rate among course starters. Qualitative analysis showed users found the course a user-friendly and authoritative information source. In the HCP MOOC, users reported improved post-MOOC Ramadan awareness, associated diabetes knowledge and ability to assess and advise patients in relation to their diabetes during Ramadan (p<0.01). CONCLUSIONS: We demonstrate the potential of MOOCs to deliver culturally tailored, high-quality, scalable, multilingual Ramadan-focused diabetes education to HCPs and people with diabetes.

Transitioning food environments and diets of African migrants: implications for non-communicable diseases.

Non-communicable diseases disproportionately affect African migrants from sub-Saharan Africa living in high-income countries (HICs). Evidence suggests this is largely driven by forces that include migration, globalisation of unhealthy lifestyles (poor diet, physical inactivity and smoking), unhealthy food environments, socio-economic status and population ageing. Changes in lifestyle behaviours that accompany migration are exemplified primarily by shifts in dietary behaviours from more traditional diets to a diet that incorporates that of the host culture, which promotes the development of obesity, diabetes, hypertension and CVD. The current paper presents a critical analysis of dietary change and how this is influenced by the food environment and the socio-economic context following migration. We used a food systems framework to structure the discussion of the interaction of factors across the food system that shape food environments and subsequent dietary changes among African migrant populations living in HICs.

Addressing the marketing and availability of unhealthy food and beverages in and around selected schools in Ghana: a community readiness appraisal.

OBJECTIVE: This study assessed stakeholder readiness to address unhealthy food and beverage marketing and availability in/around Public Basic Schools (for children 4-15 years) in Greater Accra Region, the highly urbanised administrative capital of Ghana. DESIGN: The community readiness model was used to conduct in-depth mixed methods interviews with stakeholders. Using predefined anchored rating statements, quantitative readiness scores ranging from 1 to 9 were generated. Thematic qualitative analysis was undertaken to understand barriers and facilitators that could influence the implementation of interventions. SETTING: Greater Accra Region, Ghana. PARTICIPANTS: 18 key informants from various school/education/citizen sectors, which together represented the 'school community' of Greater Accra Region. RESULTS: The mean readiness scores indicated that the 'school community' was at the 'preplanning' stage of readiness (4.44±0.98) to address the marketing and availability of unhealthy food and beverages in and around schools. The mean readiness score for 'leadership' was the highest of all dimensions (5.36±1.60), corresponding to the 'preparation' stage. The lowest scores were found for 'community knowledge of efforts' (3.19±2.45) and 'resources for efforts' (3.64±0.87), both of which were at a 'vague awareness' stage. CONCLUSIONS: The 'school community' recognised that the marketing and availability of unhealthy food and beverages was a problem. Additionally, current leadership was actively supportive of continuing/improving efforts that create healthier children's food environments. However, actions that aim to increase the 'school community's' knowledge of existing interventions and securing resources to sustain those interventions are needed before introducing readiness appropriate strategies.

Socioeconomic Determinants of Cardiovascular Diseases, Obesity, and Diabetes among Migrants in the United Kingdom: A Systematic Review.

There has been little agreement on the role that socioeconomic factors play in the aetiology of cardiovascular diseases (CVDs), obesity, and diabetes among migrants in the United Kingdom (UK). We systematically reviewed the existing evidence on this association to contribute to filling this gap in the literature. Two reviewers were involved at each stage of the review process to ensure validity. We comprehensively searched through several electronic databases and grey literature sources to identify potentially eligible papers for our review. We extracted data from our finally included studies and appraised the methodological rigour of our studies. A narrative synthesis approach was used to synthesise and interpret the extracted data. We sieved through 2485 records identified from our search and finally obtained 10 studies that met our inclusion criteria. The findings of this review show that there is a trend towards an association between socioeconomic factors and CVDs, diabetes, and obesity among migrants in the UK. However, the picture was more complex when specific socioeconomic variables and migrant subgroups were analysed. The evidence for this association is inconclusive and its causal relationship remains speculative. There is, therefore, the need for further research to understand the exact association between socioeconomic factors and CVD, diabetes, and obesity among migrants in the UK.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network.

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

Food Security in Ghanaian Urban Cities: A Scoping Review of the Literature.

Urbanisation in Ghana could be negatively impacting the state of food security, especially in economically vulnerable groups. Food supply, safety, and quality are all aspects of food security which could be impacted. We conducted a scoping literature review to understand the nature and magnitude of evidence available on the urban food security situation in Ghana. A literature search was conducted in Medline, CINAHL, Embase, Global Health, Scopus, Web of Science, Africa Wide Information and Google Scholar to identify relevant peer-reviewed and grey literature. 45 studies, mainly cross-sectional surveys/food samples analysis, met the inclusion criteria. The majority of studies were concentrated in the Greater Accra Region (n = 24). Most studies focused on food safety and quality (n = 31). Studies on supply and stability were, however, scarce. Qualitative research methods were uncommon in the included studies. The existing literature on food security are concentrated in two regions: The Greater Accra and Ashanti regions. Future studies exploring food security in urban Ghana should focus on exploring the lived experiences and perceptions of food insecurity and food stability by urban-dwellers using qualitative methods. The evidence suggesting that the safety/quality of foods sold in Ghanaian markets is poor should be a concern to consumers and policy makers.

The African urban food environment framework for creating healthy nutrition policy and interventions in urban Africa.

This study developed, validated, and evaluated a framework of factors influencing dietary behaviours in urban African food environments, to inform research prioritisation and intervention development in Africa. A multi-component methodology, drawing on concept mapping, was employed to construct a framework of factors influencing dietary behaviours in urban Africa. The framework adapted a widely used socio-ecological model (developed in a high-income country context) and was developed using a mixed-methods research approach that comprised: i. Evidence synthesis consisting of a systematic review of 39 papers covering 14 African countries; ii. Qualitative interview data collected for adolescents and adults (n = 144) using photovoice in urban Ghana and Kenya; and iii. Consultation with interdisciplinary African experts (n = 71) from 27 countries, who contributed to at least one step of the framework (creation, validation/evaluation, finalisation). The final framework included 103 factors influencing dietary behaviours. Experts identified the factors influencing dietary behaviours across all the four levels of the food environment i.e. the individual, social, physical and macro levels. Nearly half (n = 48) were individual-level factors and just under a quarter (n = 26) were at the macro environmental level. Fewer factors associated with social (n = 15) and physical (14) environments were identified. At the macro level, the factors ranked as most important were food prices, cultural beliefs and seasonality. Factors ranked as important at the social level were household composition, family food habits and dietary practices. The type of food available in the neighbourhood and convenience were seen as important at the physical level, while individual food habits, food preferences and socioeconomic status were ranked highly at the individual level. About half of the factors (n = 54) overlap with those reported in an existing socio-ecological food environment framework developed in a high-income country context. A further 49 factors were identified that were not reported in the selected high-income country framework, underlining the importance of contextualisation. Our conceptual framework offers a useful tool for research to understand dietary transitions in urban African adolescents and adults, as well as identification of factors to intervene when promoting healthy nutritious diets to prevent multiple forms of malnutrition.

Urban physical food environments drive dietary behaviours in Ghana and Kenya: A photovoice study.

We identified factors in the physical food environment that influence dietary behaviours among low-income dwellers in three African cities (Nairobi, Accra, Ho). We used Photovoice with 142 males/females (≥13 years). In the neighbourhood environment, poor hygiene, environmental sanitation, food contamination and adulteration were key concerns. Economic access was perceived as a major barrier to accessing nutritionally safe and healthy foods. Home gardening supplemented household nutritional needs, particularly in Nairobi. Policies to enhance food safety in neighbourhood environments are required. Home gardening, food pricing policies and social protection schemes could reduce financial barriers to safe and healthy diets.