Nutrient profile and energy cost of food sold by informal food vendors to learners in primary and secondary schools in the Eastern Cape, South Africa.

OBJECTIVE: To assess type, nutrient profile and cost of food items sold by informal vendors to learners; and to determine nutrient content of corn-based processed snacks frequently sold. DESIGN: Cross-sectional survey. SETTING: Quintile 1 to 3 schools (n 36) randomly selected from six education districts; Eastern Cape, South Africa. PARTICIPANTS: Informal food vendors (n 92) selling inside or immediately outside the school premises. RESULTS: Food items sold at most schools were corn-based processed snacks (94 % of schools), sweets (89 %), lollipops (72 %) and biscuits (62 %). Based on the South African Nutrient Profiling model, none of these foods were profiled as healthy. Foods less commonly sold were fruits (28 % of schools) and animal-source foods; these foods were profiled as healthy. Mean (sd) energy cost (per 418 kJ (100 kcal)) was highest for animal-source foods (R2·95 (1·16)) and lowest for bread and vetkoek (R0·76 (0·21)), snacks (R0·76 (0·30)) and confectionery products (R0·70 (0·28)). The nutrient profiling score was inversely related to the energy cost of the food item (r = -0·562, P = 0·010). Compared with brand-name corn-based processed snacks, non-branded snacks had lower energy (2177 v. 2061 kJ; P = 0·031) content per 100 g. None of the brand-name samples contained sucrose; six of the nine non-branded samples contained sucrose, ranging from 4·4 to 6·2 g/100 g. CONCLUSIONS: Foods mostly sold were unhealthy options, with the healthier food items being more expensive sources of energy.

Association between school-level attributes and weight status of Ghanaian primary school children.

BACKGROUND: Little is known about the impact of the school environmental context on the emerging trend of childhood obesity in Africa. We examined the association of the schools' contextual factors with body mass index (BMI), abdominal obesity and overweight (including obesity) in urban Ghana. METHOD: Using cross-sectional data from 543 school children aged 8-11 years attending 14 primary schools, we applied multilevel logistic regressions and linear regression models to investigate the association of child- and school level attributes with overweight, abdominal obesity, and BMI. RESULTS: We observed significant variance of the random effects of schools in BMI (2.65, p <  0.05), abdominal obesity (0.85, p <  0.05), and overweight (1.41, p < 0.05), with school contextual levels accounting for 19.7, 20.6, and 30.0% of the total variability observed in BMI, abdominal obesity and overweight respectively. Attending high socioeconomic (SES) level school, private school and school with increased after-school recreational facilities were associated with higher BMI. Children were more likely to be overweight if they attended a high SES level school, had access to healthful foods at school, and after-school recreational facilities. With regards to abdominal obesity, attending a school with increased physical activity facilities decreased the odds of abdominal obesity; however the odds increased if they attended a school with access to after-school recreational facilities. CONCLUSION: A number of school-level factors were associated with BMI, overweight and abdominal obesity of children in the present study. Our results provide support for improved school environment to reduce overweight.

Effectiveness of a screening programme in identifying individuals with increased risk of cardiovascular disease in South Africa.

Background: To determine the proportion of participants identified with previously undiagnosed diabetes and untreated hypertension in the Heart and Stroke Foundation South Africa's screening programme. Methods: This cross-sectional study was conducted nationally in 2013 among ≥18-year-old adults self-selected for screening. Data collection included medical history and behaviours related to diet, physical activity, smoking and alcohol use. Clinical measurements comprised blood pressure, anthropometry and point-of-care random blood glucose and cholesterol assessments. Results: Among the 7711 participants, 2488 men and 5223 women, mean ages were 47.6 years and 48.6 years, respectively. Prevalence of diabetes was 13.8% in men and 12.8% in women but only 1.8% (45) and 0.9% (47), respectively, were newly diagnosed. Another 14.5% (men) and 12.4% (women) had impaired glycaemia. Only 32.9% and 36.3% with known diabetes were controlled. Hypertension was prevalent in 51.8% of men and 48.9% of women, 52.0% and 63.1% of whom were using anti-hypertensive medication; 43.2% of men and 45.5% of women on anti-hypertensive medication were controlled. Conclusions: Very few individuals with newly diagnosed diabetes were identified, which underscores the need for cost-effective targeted screening of high-risk individuals to optimize diagnosis. Furthermore, the suboptimal levels of diabetes and hypertension control highlights the need for improved care.

The relationship between objectively-measured attributes of the built environment and selected cardiovascular risk factors in a South African urban setting.

BACKGROUND: Evidence concerning the relationship between objectively-measured attributes of the built environment with cardio-metabolic risk in populations from lower- and middle-income countries is lacking. In this paper, we describe the association between the objectively-measured built environment with body mass index, blood pressure and physical activity in adult South Africans. METHODS: This cross-sectional study included 341 adults aged ≥35 years drawn from the Cape Town arm of the Prospective Urban Rural Epidemiology (PURE) cohort study. All Cape Town PURE participants were invited to take part in the study. Actigraph GT3X accelerometer and Geographic Information Systems were used to measure physical activity and built environment attributes (community center, shopping center and taxi rank). RESULTS: In age and sex adjusted models (reference 500 m), access to community centers (1000 m) was positively related to body mass index [beta 4.70 (95%CI: 2.06 to 7.34)] and diastolic blood pressure [4.97 (0.00 to 9.95)]. Distance from a community center (1600 m) was positively related to diastolic blood pressure [6.58 (1.57 to 11.58)] and inversely with moderate-to-vigorous physical activity [- 69.30 (- 134.92 to - 3.70)]. Distance to a shopping center (1600 m) was positively related to body mass index [4.78 (1.11 to 8.45)] and shopping center (1000 m) was positively related to systolic blood pressure respectively [76.99 (0.03 to 83.95)]. CONCLUSION: Distance to community and shopping centers were significantly associated with BMI, systolic, diastolic blood pressure and moderate-to-vigorous physical activity. Future research should include multiple aspects of built environment variables in order to provide for a broader understanding of their effect on cardiovascular risk profile of African populations.

The HealthKick Study: Modifiable Lifestyle Factors in Primary Caregivers of Primary School Learners from Two School Districts in the Western Cape Province, South Africa.

Background: The HealthKick (HK) study showed that educators (teachers) had a high prevalence of risk factors for the development of non-communicable diseases (NCDs). Little data are available on parents or other primary caregivers of learners from disadvantaged schools. Aim: The aim of our study was to determine modifiable risk factors for the development of NCDs in a sample of caregivers of schools included in the HK intervention program. Participants: Caregivers of grade 4 children from 25 schools were invited to take part in the study and 175 participated. Caregivers were Black Africans and of mixed ethnic origin. Methods: Dietary intake was measured using a validated frequency questionnaire. Physical activity was measured by completing the Global Physical Activity Questionnaire (GPAQ). Caregivers described their smoking habits and alcohol usage. Weight and height were measured for each participant and body mass index (BMI) was calculated. Results: Eighty percent women and 50% men had a BMI ≥25 (overweight or obese). The most frequently consumed categories of foods were processed foods, energy-dense foods, and high-fat foods representing unhealthy food choices. More than half of the total group (81.7%) and both males and females were meeting physical activity recommendations of 600 METs/week. Many caregivers, particularly men (53%), smoked cigarettes and reportedly consumed alcohol during the week and on weekends. Conclusion: Caregivers of children in the HK study population presented with a large number of modifiable health risk behaviors. These results highlight the importance of engaging caregivers, as part of a whole school intervention, to promote healthy eating and physical activity.

Primary School Children's Nutrition Knowledge, Self-Efficacy, and Behavior, after a Three-Year Healthy Lifestyle Intervention (HealthKick).

OBJECTIVE: This study aimed to evaluate the effects of HealthKick(HK), a healthy lifestyle intervention, on nutrition knowledge, behavior, and dietary self-efficacy of school children in the Western Cape Province of South Africa. DESIGN: A three-year cluster randomized control trial at primary schools in low socioeconomic settings with a baseline study in 2009 and follow-up in 2010 and 2011. PARTICIPANTS: Participants were Grade four children (n=500) at eight schools in the intervention group and at eight schools in the control group (n=498). METHODS: An action planning process was followed with educators whereby they identified their own school health priorities and ways to address them. Schools were provided with nutrition resources, including curriculum guidelines and the South African food-based dietary guidelines. Children completed a questionnaire comprising nutrition knowledge, self-efficacy and behavioral items. RESULTS: The intervention significantly improved the knowledge of the intervention group at the first (mean difference =1.88, 95%CI: .32 to 3.43, P=.021) and second follow-up (mean difference=1.92, 95%CI: .24 to 3.60, P=.031) compared with the control group. The intervention effect for self-efficacy was not significant at the first follow-up (mean difference=.32, 95%CI: -.029 to .94, P=.281) whereas a significant effect was observed at the second follow-up (mean difference=.71, 95%CI: .04 to 1.38, P=.039). There were no significant differences between the intervention and control groups for nutritional behavior scores at any of the follow-up time points. CONCLUSIONS: The HK intervention improved nutrition knowledge and self-efficacy significantly in primary schoolchildren; however, it did not improve their eating behavior.

The feasibility of implementing food-based dietary guidelines in the South African primary-school curriculum.

OBJECTIVE: To explore the perceptions of educators from the Western Cape Province about the feasibility of implementing South African food-based dietary guidelines (FBDG) in the national curriculum of primary schools. DESIGN: Combined quantitative and qualitative methods. We report on the quantitative component. SETTING: Twelve public primary schools of different socio-economic status in three education districts of the Western Cape: Metro Central, Metro East and Cape Winelands. SUBJECTS: Educators (n 256) participated in the self-completed questionnaire survey. RESULTS: Educators assessed that FBDG were appropriate to South African schoolchildren (94%), could be used as an education tool (97%) and fill gaps in the current curriculum about healthy dietary habits (91%). Besides Life Orientation, FBDG could be taught in other learning areas from grades 3 to 7 (9-13 years old). Important barriers to implementing FBDG in the curriculum were educators' workload (61%), insufficient time (46%), learners' disadvantaged background (43%) and educators' lack of knowledge (33%). Other approaches to teach children about FBDG included linking these to the National School Nutrition Programme (82%), school tuck shops (79%), parent meetings (75%), school nutrition policy (73%) and school assembly (57%). Educators in high-income schools perceived that learners' lifestyle was significantly worse (P < 0·001) and that tuck shops and the school assembly were the best means to teach pupils about FBDG (P < 0·001 and P < 0·05). CONCLUSIONS: Implementing FBDG in the national school curriculum is seen as important together with optimizing the school physical environment. Key factors required for successful implementation in the curriculum are sufficient educational materials, adequate time allocation and appropriate educator training.

Health status of primary school educators in low socio-economic areas in South Africa.

BACKGROUND: Non-communicable Diseases (NCDs) are major health concerns in South Africa. According to the life cycle approach NCD prevention strategies should target children. Educators are important external factors influencing behaviour of learners. The objective of this study was to assess the prevalence of selective NCD risk factors in educators of primary school learners. METHODS: A cross-sectional design was used to assess the body mass index (BMI) and waist circumference (WC), blood glucose (BG), cholesterol (BC), blood pressure (BP), perceived health and weight, and parental NCD history of 517 educators in the Western Cape of South Africa. RESULTS: The sample included 40% males and 60% females; 64% urban and 36% rural, 87% were mixed ancestry, 11% white and 2% black. Mean age for the total group was 52 ± 10.1 years, BMI 30 ± 1.2 kg/m(2) (31% overweight, 47% obese), diastolic BP 84 ± 10.0 mmHg, systolic BP 134 ± 18.7 mmHg (46% high BP), BG 4.6 ± 2.3 mmol/L (2% high BG), BC 4.4 ± 0.9 (30.4% high BC) and WC 98 ± 14.1 cm for males (38% high WC) and 95 ± 15.3 for females (67% high WC). BMI was higher (p = 0.001) and systolic (p = 0.001) and diastolic (p = 0.005) BP lower in females. Rural educators were more obese (p = 0.001). BMI (p = 0.001) and systolic BP (p = 0.001) were lower in younger educators. Correct awareness of personal health was 65% for BP, 79.2% for BC and 53.3% for BG. Thirty-eight percent overweight/obese females and 33% males perceived their weight as normal. CONCLUSION: The findings of this study demonstrated a number of characteristics of educators in the two study areas that may influence their risk for developing NCDs and their potential as role models for learners. These included high levels of obesity, high blood pressure, high waist circumference, high cholesterol levels, and high levels of blood glucose. Furthermore, many educators had a wrong perception of their actual body size and a lack of awareness about personal health.

Did HealthKick, a randomised controlled trial primary school nutrition intervention improve dietary quality of children in low-income settings in South Africa?

BACKGROUND: Numerous studies in schools in the Western Cape Province, South Africa have shown that children have an unhealthy diet with poor diversity and which is high in sugar and fat. HealthKick (HK) was a three-year randomised controlled trial aimed at promoting healthy eating habits. METHODS: Sixteen schools were selected from two low-income school districts and randomly allocated to intervention (n = 8) or control school (n = 8) status. The HK intervention comprised numerous activities to improve the school nutrition environment such as making healthier food choices available and providing nutrition education support. Dietary intake was measured by using a 24-h recall in 2009 in 500 grade 4 learners at intervention schools and 498 at control schools, and repeated in 2010 and 2011. A dietary diversity score (DDS) was calculated from nine food groups and frequency of snack food consumption was determined. A school level analysis was performed. RESULTS: The mean baseline (2009) DDS was low in both arms 4.55 (SD = 1.29) and 4.54 (1.22) in the intervention and control arms respectively, and 49 % of learners in HK intervention schools had a DDS ≤4 (=low diversity). A small increase in DDS was observed in both arms by 2011: mean score 4.91 (1.17) and 4.83 (1.29) in the intervention and control arms respectively. The estimated DSS intervention effect over the two years was not significant [0 .04 (95 % CI: -0.37 to 0.46)]. Food groups least consumed were eggs, fruit and vegetables. The most commonly eaten snacking items in 2009 were table sugar in beverages and/or cereals (80.5 %); followed by potato crisps (53.1 %); non-carbonated beverages (42.9 %); sweets (26.7 %) and sugar-sweetened carbonated beverages (16 %). Unhealthy snack consumption in terms of frequency of snack items consumed did not improve significantly in intervention or control schools. DISCUSSION: The results of the HK intervention were disappointing in terms of improvement in DDS and a decrease in unhealthy snacking. We attribute this to the finding that the intervention model used by the researchers may not have been the ideal one to use in a setting where many children came from low-income homes and educators have to deal with daily problems associated with poverty. CONCLUSIONS: The HK intervention did not significantly improve quality of diet of children.

Implementation of the HealthKick intervention in primary schools in low-income settings in the Western Cape Province, South Africa: a process evaluation.

BACKGROUND: The HealthKick intervention, introduced at eight primary schools in low-income settings in the Western Cape Province, South Africa, aimed to promote healthy lifestyles among learners, their families and school staff. Eight schools from similar settings without any active intervention served as controls. METHODS: The Action Planning Process (APP) guided school staff through a process that enabled them to assess areas for action; identify specific priorities; and set their own goals regarding nutrition and physical activity at their schools. Educators were introduced to the APP and trained to undertake this at their schools by holding workshops. Four action areas were covered, which included the school nutrition environment; physical activity and sport environment; staff health; and chronic disease and diabetes awareness. Intervention schools also received a toolkit comprising an educator's manual containing planning guides, printed resource materials and a container with physical activity equipment. To facilitate the APP, a champion was identified at each school to drive the APP and liaise with the project team. Over the three-years a record was kept of activities planned and those accomplished. At the end of the intervention, focus group discussions were held with school staff at each school to capture perceptions about the APP and intervention activities. RESULTS: Overall uptake of events offered by the research team was 65.6% in 2009, 75% in 2010 and 62.5% in 2011. Over the three-year intervention, the school food and nutrition environment action area scored the highest, with 55.5% of planned actions being undertaken. In the chronic disease and diabetes awareness area 54.2% actions were completed, while in the school physical activity and sport environment and staff health activity areas 25.9 and 20% were completed respectively. According to educators, the low level of implementation of APP activities was because of a lack of parental involvement, time and available resources, poor physical environment at schools and socio-economic considerations. CONCLUSIONS: The implementation of the HealthKick intervention was not as successful as anticipated. Actions required for future interventions include increased parental involvement, greater support from the Department of Basic Education and assurance of sufficient motivation and 'buy-in' from schools.

"HealthKick": formative assessment of the health environment in low-resource primary schools in the Western Cape Province of South Africa.

BACKGROUND: This study evaluated the primary school environment in terms of being conducive to good nutrition practices, sufficient physical activity and prevention of nicotine use, with the view of planning a school-based health intervention. METHODS: A sample of 100 urban and rural disadvantaged schools was randomly selected from two education districts of the Western Cape Education Department, South Africa. A situation analysis, which comprised an interview with the school principal and completion of an observation schedule of the school environment, was done at all schools. RESULTS: Schools, on average, had 560 learners and 16 educators. Principals perceived the top health priorities for learners to be an unhealthy diet (50%) and to far lesser degree, lack of physical activity (24%) and underweight (16%). They cited lack of physical activity (33%) and non-communicable diseases (NCDs; 24%) as the main health priorities for educators, while substance abuse (66%) and tobacco use (31%) were prioritised for parents. Main barriers to health promotion programmes included lack of financial resources and too little time in the time table. The most common items sold at the school tuck shops were crisps (100%), and then sweets (96%), while vendors mainly sold sweets (92%), crisps (89%), and ice lollies (38%). Very few schools (8%) had policies governing the type of food items sold at school. Twenty-six of the 100 schools that were visited had vegetable gardens. All schools reported having physical activity and physical education in their time tables, however, not all of them offered this activity outside the class room. Extramural sport offered at schools mainly included athletics, netball, and rugby, with cricket and soccer being offered less frequently. CONCLUSION: The formative findings of this study contribute to the knowledge of key environmental and policy determinants that may play a role in the health behaviour of learners, their parents and their educators. Evidently, these show that school environments are not always conducive to healthy lifestyles. To address the identified determinants relating to learners it is necessary to intervene on the various levels of influence, i.e. parents, educators, and the support systems for the school environment including the curriculum, food available at school, resources for physical activity as well as appropriate policies in this regard.

Associations of leucocyte telomere length with cardio-metabolic risk profile in a South African HIV-infected population.

ABSTRACT: Leukocyte Telomere length (LTL) is an independent predictor of cardio-metabolic diseases (CMDs) and Human Immuno Virus (HIV) infection. However, studies are lacking on the association between LTL with CMD profile in people with HIV. Accordingly, we investigated the association between LTL and CMD profile in HIV-infected adult South Africans.This cross-sectional study included 728 HIV patients (20.6% men; median age 38 years) recruited across 17 public healthcare facilities in Cape Town. CMD markers were compared across quartiles of LTL, and spearman correlations assessed the continuous association of LTL with CMD markers. Linear and logistic regressions were then used to relate LTL with CMD risk profile, with appropriate adjustment for confounders.The prevalence of obesity, hypertension and diabetes were 34.8%, 36.8%, and 8.4%, respectively. In age, sex and body mass index adjusted models, increasing Log10LTL was associated with decreasing systolic (ß = -10.52) and diastolic (ß = -6.74) blood pressures, HOMA-ß (ß = -70.72), increasing total cholesterol (ß = 0.544), non-high-density lipoprotein cholesterol (ß = 0.472), and waist-to-height-ratio > 0.5 (odds ratio [OR] = 5.67), all P < .05. Compared to those in the bottom quarter, those in the top LTL quarter had lower prevalence of hypertension (OR = 0.65), and higher prevalence of total cholesterol > 5 mmol/L (OR = 1.94), and low-density lipoprotein-cholesterol > 3 mmol/L (OR = 1.62), all P < .05. LTL was not associated with diabetes nor general obesity. It was associated with Alanine Transaminase (ALT) and heart rate in univariable analyses.LTL shortening was associated with some CMD risk factors in HIV-infected adults on anti-retroviral therapy in South Africa. Prospective research is needed to explore the direction and implications of these associations.

Perceptions and experiences of young Black South African women with obesity from a low socioeconomic community after following a 12-week structured exercise intervention.

Background: Previous research has shown that Black South African (SA) women perceive a bigger body size to be acceptable and desirable, but nonetheless have shown interest in participating in community-based exercise programmes. This study aimed to investigate perceptions and experiences of participating in a 12-week exercise intervention designed to study the mechanisms of insulin sensitivity and secretion in young Black SA women with obesity. Methods: Qualitative data was collected from young (23 ± 2.9 years) Black SA women (n = 17) residing in a low-income setting in Cape Town, who took part in a 12-week structured exercise intervention. Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted 1-4 months after the completion of the intervention. These were all audio recorded and took between 45 and 60 min. The recordings were transcribed, translated and qualitative content analysis, entailing a systematic process of coding and identification of salient themes, was conducted using the ATLAS.ti software. Results: Six broad themes were identified from participants' experiences and perceptions: motivational factors, acceptability of the programme, barriers, sustainability and influencing others, benefits of being physically active, definitions and perceptions of exercise. Anticipated weight loss and financial remuneration were identified as motivational factors for enrolment and retention in the exercise programme. Aspects of the training environment and feelings of wellness appeared in the acceptability, sustainability and benefits themes, whereas time scheduling and travel constraints were regarded as barriers. Exercise was perceived as the maintenance of a healthy body, and in some cases, only relevant for specific groups. Conclusion: Financial considerations played an important role in participants enrolling and staying in the 12-week exercise intervention. Participants liked many aspects of the intervention and identified physical and mental benefits that seemingly outweighed the barriers and disliked aspects of the programme. Optimizing the acceptability of exercise programmes and maximizing the opportunity for participants to experience improved mental well-being may contribute to attracting and retaining young Black SA women in exercise programmes.

What's in the lunchbox? Dietary behaviour of learners from disadvantaged schools in the Western Cape, South Africa.

OBJECTIVE: To identify and describe factors associated with food shop (known as tuck shop in South Africa) and lunchbox behaviours of primary-school learners in South Africa. DESIGN: Analysis of data collected in 2008 from a cross-sectional survey. SETTING: Sixteen primary schools in the Western Cape, South Africa. SUBJECTS: A total of 717 grade 4 learners aged 10-12 years. RESULTS: A 24 h recall established that 69 % of learners carried a lunchbox to school and 49 % had consumed at least one item purchased from the school food shop/vendor. Most lunchboxes contained white bread with processed meat, whereas the most frequent food shop/vendor purchase comprised chips/crisps. Learners who carried a lunchbox to school had significantly lower BMI percentiles (P = 0·002) and BMI-for-age (P = 0·034), compared with their counterparts. Moreover, they were younger, had higher standard-of-living and dietary diversity scores, consumed more meals per day, had greater self-efficacy and came from predominantly urban schools, compared with those who did not carry a lunchbox to school. Learners who ate food shop/vendor purchases had a lower standard-of-living score and higher dietary diversity and meal scores. Only 2 % of learners were underweight, whereas 19 % were stunted and 21 % were overweight/obese (BMI ≥ 25 kg/m2). CONCLUSIONS: Children who carried a lunchbox to school appeared to have greater dietary diversity, consumed more regular meals, had a higher standard of living and greater nutritional self-efficacy compared with those who did not carry a lunchbox to school.

A Scoping Review of Policies Related to the Prevention and Control of Overweight and Obesity in Africa.

To address the issue of obesity, the World Health Organization (WHO) recommends a set of comprehensive programmes aimed at changing the obesogenic environments to provide opportunities for healthy food options and increased physical activity in the school, home, and at the population level. The objectives of this study were to examine the nature and range of policies related to overweight and obesity prevention in Africa, and to assess how they align with international guidelines. An existing methodological framework was adapted for this scoping review. A search of publicly available national documents on overweight/obesity, general health, and non-communicable diseases (NCDs) was undertaken from relevant websites, including WHO, ministries, and Google Scholar. Additional requests were sent to key contacts at relevant ministries about existing policy documents. The documents were reviewed, and the policies were categorised, using the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. The framework categorises the environmental drivers of obesity into four domains (physical, economic, legislative, and socio-cultural) and two scales: macro (national, regional, sectors, food industries, media, etc.) and micro (household, institutional, and community). This review included documents from 41 African countries. The policy initiatives to prevent overweight/obesity target the school, family and community settings, and macro environments, and broadly align with global recommendations. The NCD documents were in the majority, with only two on obesity. The majority of the documents detailed strategies and key interventions on unhealthy diets and physical inactivity. The physical, legislative, and sociocultural domains were largely featured, with less emphasis on the economic domain. Additionally, nutrition- and diet-related policies were in the majority. Overlaps and interactions of policies were observed in the application of the ANGELO framework. This study has provided information on national policies and programmes in Africa and can be useful as a first point of call for policymakers. The overlapping and interaction in the initiatives demonstrate the importance of multi-sectoral partnerships in providing supportive environments for healthy behaviours.

HealthKick: a nutrition and physical activity intervention for primary schools in low-income settings.

BACKGROUND: The burden of non-communicable diseases, including type 2 diabetes, is growing in South Africa. This country has a complex mix of over- and under-nutrition, especially in low-income communities, and concerning levels of physical inactivity in children and youth. This paper describes HealthKick, a school-based nutrition and physical activity intervention in primary schools in these settings aimed at reducing diabetes risk factors. METHODS/DESIGN: This study includes schools within historically disadvantaged, low-income communities from an urban area close to the city of Cape Town and from two rural areas outside of Cape Town, South Africa. The three Educational Districts involved are Metropole North, Cape Winelands and the Overberg. The study has three phases: intervention mapping and formative assessment, intervention development, and outcome and process evaluation. Sixteen schools were purposively selected to participate in the study and randomly allocated as intervention (eight schools) and control (eight schools).The primary aims of HealthKick are to promote healthful eating habits and increase regular participation in health-enhancing physical activity in children, parents and teachers, to prevent overweight, and reduce risk of chronic diseases (particularly type 2 diabetes); as well as to promote the development of an environment within the school and community that facilitates the adoption of healthy lifestyles.The components of HealthKick are: action planning, toolkit (resource guide, a resource box and physical activity resource bin), and an Educators' Manual, which includes a curriculum component. DISCUSSION: This study continues to highlight the key role that educators play in implementing a school-based intervention, but that developing capacity within school staff and stakeholders is not a simple or easy task. In spite of the challenges experienced thus far, valuable findings are being produced from this study, especially from Phase 1. Materials developed could be disseminated to other schools in low-income settings both within and outside of South Africa. Owing to the novelty of the HealthKick intervention in low-income South African primary schools, the findings of the evaluation phase have the potential to impact on policy and practice within these settings.

Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers.

AIM: The increasing burden of comorbid HIV infection and hypertension necessitates a focus on healthcare services providing care for chronic multi-morbidities. The aim of this study was to evaluate the perceptions and experiences of 1) people living with HIV infection and comorbid hypertension, and 2) their healthcare providers, related to their diagnoses and interactions with chronic healthcare services in South Africa. METHODS: This study comprised quantitative and qualitative arms with a multi-layered approach. We randomly selected 17 public healthcare facilities providing HIV care across Cape Town and surrounding rural municipalities. RESULTS: Interviews were conducted with clinicians (n = 11), specialised nursing professionals (n = 10), lay counsellors (n = 12), six patients focus groups (n = 35) and 20 in-depth individual patient interviews. There were mixed views on being treated at integrated vs. separate chronic care facilities regarding quality of care and privacy/anonymity. Specialised clinics offered better care for HIV infection while hypertension and other non-communicable diseases were neglected. Privacy about HIV status maybe better maintained in integrated clinics but not if status was disclosed by having the green-coloured HIV treatment card. A single appointment date was considered advantageous as it saved time and money leading to greater compliance; however, waiting times at clinics were longer with perhaps fewer patients seen. CONCLUSIONS: The mixed reactions elicited to the integration of healthcare services for HIV, hypertension and other non-communicable diseases highlights the complexities involved in implementing such services. Greater human resources with retraining and reskilling of healthcare staff is required for the optimal management of chronic multi-morbidities.

Tobacco smoking and associated factors in human immunodeficiency virus-infected adults attending human immunodeficiency virus clinics in the Western Cape province, South Africa.

BACKGROUND: In human immunodeficiency virus (HIV)-infected individuals, smoking increases both HIV-related and non-related negative health outcomes. OBJECTIVES: To determine the prevalence and associations of smoking in HIV-infected adults receiving antiretroviral therapy at public healthcare facilities in the Western Cape province, South Africa. METHODS: Participants comprised 827 HIV-infected patients, who were > 18 years old and randomly selected from 17 HIV healthcare facilities. Self-reported smoking was defined as smoking tobacco daily or occasionally. Serum cotinine levels confirmed smoking status. RESULTS: Participants included 653 women and 174 men. The overall mean (standard deviation [SD]) age was 38.9 (9.0) years, 41.1 (8.9) years in men and 37.7 (8.9) years in women (p ˂ 0.001). The median diagnosed duration of HIV infection was 5 years. Smoking prevalence was 22% overall, and 26% in men and 21% in women (p = 0.022). The prevalence of former smoking was 14%. About a quarter of participants (185/751; 24.6%) had serum cotinine levels > 100 mg/mL with similar prevalence of high levels across smoking status (current smokers: 27.2%, former smokers: 29.6% and never smokers: 22.7%, p = 0.564) and did not vary by age, gender, cluster of differentiation 4 count or known duration of HIV. There was no agreement between self-reports and cotinine levels at ranking smoking exposure. CONCLUSIONS: Prevalence of current tobacco smoking in HIV-infected patients on care is within the range of that in the general population. This highlights the potential missed opportunity or challenges of co-addressing smoking cessation in individuals already in regular contact with the health system.

Dietary Practices and Adolescent Obesity in Secondary School Learners at Disadvantaged Schools in South Africa: Urban-Rural and Gender Differences.

South Africa has a high prevalence of obesity in black female adolescents and a paucity of knowledge regarding contributing dietary practices. The aim of this study was to assess the dietary practices and weight status of male and female adolescents at secondary schools in the Eastern Cape province in urban and rural areas. Sixteen schools and grade 8-12 learners (N = 1360) were randomly selected from three health districts comprising poor disadvantaged communities. A short unquantified food frequency questionnaire was used to collect data on learners' usual eating practices with regards to weekly meal pattern, breakfast consumption, foods taken to school, takeaways, and snacks eaten while watching television (TV). Body mass index measurements were determined for each learner. Prevalence of combined overweight and obesity differed significantly between genders, 9.9% in males versus 36.1% in females (p < 0.001). Significant gender differences were noted regarding eating practices. Females had a higher frequency of eating sugary snacks (p < 0.001) and a lower frequency of eating breakfast (p < 0.01) than males. Females ate significantly more fried fish (p < 0.05), pizza (p < 0.05) fat cakes (fried dough balls) (p < 0.05), hotdogs (p < 0.01), candy (p < 0.001), cake (p < 0.01), and crisps (p < 0.001). Compared to urban areas, the frequency of eating breakfast (p < 0.01) and sugary snacks (p < 0.05) was significantly higher in rural areas. Significantly more learners in urban areas consumed boerewors (beef sausage) rolls (p = 0.027), hamburgers (p = 0.004), and soft drinks (p = 0.019), while more learners in the rural areas consumed cordial (p = 0.001). In conclusion, a high prevalence of combined overweight and obesity was found in black female adolescents and a high prevalence of poor dietary practices was observed, with significant gender and urban-rural differences.