Multisectoral interventions for urban health in Africa: a mixed-methods systematic review.

Increasing evidence suggests that urban health objectives are best achieved through a multisectoral approach. This approach requires multiple sectors to consider health and well-being as a central aspect of their policy development and implementation, recognising that numerous determinants of health lie outside (or beyond the confines of) the health sector. However, collaboration across sectors remains scarce and multisectoral interventions to support health are lacking in Africa. To address this gap in research, we conducted a mixed-method systematic review of multisectoral interventions aimed at enhancing health, with a particular focus on non-communicable diseases in urban African settings. Africa is the world's fastest urbanising region, making it a critical context in which to examine the impact of multisectoral approaches to improve health. This systematic review provides a valuable overview of current knowledge on multisectoral urban health interventions and enables the identification of existing knowledge gaps, and consequently, avenues for future research. We searched four academic databases (PubMed, Scopus, Web of Science, Global Health) for evidence dated 1989-2019 and identified grey literature from expert input. We identified 53 articles (17 quantitative, 20 qualitative, 12 mixed methods) involving collaborations across 22 sectors and 16 African countries. The principle guiding the majority of the multisectoral interventions was community health equity (39.6%), followed by healthy cities and healthy urban governance principles (32.1%). Targeted health outcomes were diverse, spanning behaviour, environmental and active participation from communities. With only 2% of all studies focusing on health equity as an outcome and with 47% of studies published by first authors located outside Africa, this review underlines the need for future research to prioritise equity both in terms of research outcomes and processes. A synthesised framework of seven interconnected components showcases an ecosystem on multisectoral interventions for urban health that can be examined in the future research in African urban settings that can benefit the health of people and the planet.Paper ContextMain findings: Multisectoral interventions were identified in 27.8% of African countries in the African Union, targeted at major cities with five sectors present at all intervention stages: academia or research, agriculture, government, health, and non-governmental.Added knowledge: We propose a synthesised framework showcasing an ecosystem on multisectoral interventions for urban health that can guide future research in African urban settings.Global health impact for policy and action: This study reveals a crucial gap in evidence on evaluating the long-term impact of multisectoral interventions and calls for partnerships involving various sectors and robust community engagement to effectively deliver and sustain health-promoting policies and actions.

The bidirectional temporal relationship between parenting stress and child maltreatment: A cross-lagged study based on intervention and cohort data.

BACKGROUND: Parenting stress has long been proposed as a major risk factor for child maltreatment. However, there is a lack of evidence from existing studies on the temporal sequence to establish a causal relationship. This study aims to examine bidirectional temporal relationships between parenting stress and child maltreatment. METHODS: Longitudinal data from two different sources were analysed: a pre-post study of an online parenting programme conducted across six countries - the ePLH Evaluation Study, and a prospective cohort study in the United States - LONGSCAN. Cross-lagged panel model on parenting stress and child maltreatment was used in each dataset. RESULTS: Based on repeatedly measured data of 484 caregivers in the ePLH study across five time points (every two weeks), we found that parenting stress at an earlier time point predicted later child maltreatment (IRR = 1.14, 95 % CI: 1.10,1.18). In addition, the occurrence of child maltreatment was associated with higher subsequent short-term parenting stress (IRR = 1.04, 95 % CI: 1.01,1.08) and thus could form a vicious circle. In the LONGSCAN analysis with 772 caregivers who were followed up from child age of 6 to child age of 16, we also found parenting stress at an earlier time point predicted later child maltreatment (ß = 0.11, 95 % CI: 0.01,0.20), but did not observe an association between child maltreatment and subsequent long-term parenting stress. LIMITATIONS: Potential information bias on the measurements. CONCLUSIONS: This study provides evidence for a bidirectional temporal relationship between parenting stress and child maltreatment, which should be considered in parenting intervention programmes.

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.

Perceived cardiovascular disease risk and tailored communication strategies among rural and urban community dwellers in Rwanda: a qualitative study.

BACKGROUND: In Rwanda, cardiovascular diseases (CVDs) are the third leading cause of death, and hence constitute an important public health issue. Worldwide, most CVDs are due to lifestyle and preventable risk factors. Prevention interventions are based on risk factors for CVD risk, yet the outcome of such interventions might be limited by the lack of awareness or misconception of CVD risk. This study aimed to explore how rural and urban population groups in Rwanda perceive CVD risk and tailor communication strategies for estimated total cardiovascular risk. METHODS: An exploratory qualitative study design was applied using focus group discussions to collect data from rural and urban community dwellers. In total, 65 community members took part in this study. Thematic analysis with Atlas ti 7.5.18 was used and the main findings for each theme were reported as a narrative summary. RESULTS: Participants thought that CVD risk is due to either financial stress, psychosocial stress, substance abuse, noise pollution, unhealthy diets, diabetes or overworking. Participants did not understand CVD risk presented in a quantitative format, but preferred qualitative formats or colours to represent low, moderate and high CVD risk through in-person communication. Participants preferred to be screened for CVD risk by community health workers using mobile health technology. CONCLUSION: Rural and urban community members in Rwanda are aware of what could potentially put them at CVD risk in their respective local communities. Community health workers are preferred by local communities for CVD risk screening. Quantitative formats to present the total CVD risk appear inappropriate to the Rwandan population and qualitative formats are therefore advisable. Thus, operational research on the use of qualitative formats to communicate CVD risk is recommended to improve decision-making on CVD risk communication in the context of Rwanda.

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.

Socioeconomic and gendered inequities in travel behaviour in Africa: Mixed-method systematic review and meta-ethnography.

Travel has individual, societal and planetary health implications. We explored socioeconomic and gendered differences in travel behaviour in Africa, to develop an understanding of travel-related inequity. We conducted a mixed-methods systematic review (PROSPERO CRD42019124802). In 2019, we searched MEDLINE, TRID, SCOPUS, Web of Science, LILACS, SciELO, Global Health, Africa Index Medicus, CINAHL and MediCarib for studies examining travel behaviour by socioeconomic status and gender in Africa. We appraised study quality using Critical Appraisal Skills Programme checklists. We synthesised qualitative data using meta-ethnography, followed by a narrative synthesis of quantitative data, and integrated qualitative and quantitative strands using pattern matching principles. We retrieved 103 studies (20 qualitative, 24 mixed-methods, 59 quantitative). From the meta-ethnography, we observed that travel is: intertwined with social mobility; necessary to access resources; associated with cost and safety barriers; typified by long distances and slow modes; and dictated by gendered social expectations. We also observed that: motorised transport is needed in cities; walking is an unsafe, 'captive' mode; and urban and transport planning are uncoordinated. From these observations, we derived hypothesised patterns that were tested using the quantitative data, and found support for these overall. In lower socioeconomic individuals, travel inequity entailed reliance on walking and paratransit (informal public transport), being unable to afford travel, travelling less overall, and travelling long distances in hazardous conditions. In women and girls, travel inequity entailed reliance on walking and lack of access to private vehicles, risk of personal violence, societally-imposed travel constraints, and household duties shaping travel. Limitations included lack of analytical rigour in qualitative studies and a preponderance of cross-sectional quantitative studies (offering a static view of an evolving process). Overall, we found that travel inequity in Africa perpetuates socioeconomic and gendered disadvantage. Proposed solutions focus on improving the safety, efficiency and affordability of public transport and walking.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol.

BACKGROUND: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. OBJECTIVE: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. METHODS: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. RESULTS: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. CONCLUSIONS: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26739.

The Science of Scale for Violence Prevention: A New Agenda for Family Strengthening in Low- and Middle-Income Countries.

Ending all violence against children by 2030 is a core part of Sustainable Development Goals 5 and 16. A number of promising violence reduction strategies have been identified in research studies. However, we lack an understanding of the implementation and impact of these programs in respect to their delivery at a large scale or within existing service systems, particularly in low- and middle-income countries (LMICs). We advocate for greater collaboration between researchers, policymakers, donors, governments, non-governmental organizations, and program managers and staff to study how violence prevention programs operate on a large scale. We describe a new initiative aiming to foster such collaborations in the field of family strengthening programs.

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.

A Systematic Scoping Review of the Impacts of Community Food Production Initiatives in Kenya, Cameroon, and South Africa.

BACKGROUND: Even before the COVID-19 pandemic, one in two people in Africa were food insecure. The burden of malnutrition remains high (e.g. childhood stunting, anaemia in women of reproductive age) or are increasing (e.g. overweight and obesity). A range of coordinated actions are required to improve this situation, including increasing local food production and consumption. The aim of this review was to provide a systematic and comprehensive overview of recently published research into the health, social, economic, and environmental impacts of community food production initiatives (CFPIs) in Kenya, Cameroon and South Africa. METHODS: We searched eight electronic databases covering health, social, environmental, economic and agricultural sciences. Primary research studies published from 1 January 2014 to 31 December 2018 were considered. Data on geographic location, study design, type of CFPI and the impacts assessed were abstracted from eligible articles. FINDINGS: We identified 4828 articles, 260 of which required full-text review and 118 met our eligibility criteria. Most research was conducted in Kenya (53.4%) and South Africa (38.1%). The categories of CFPIs studied were (in order of decreasing frequency): crop farming, livestock farming, unspecified farming, fisheries, home / school gardens, urban agriculture, and agroforestry. The largest number of studies were on the economic and environmental impacts of CFPIs, followed by their health and social impacts. The health impacts investigated included food security, nutrition status and dietary intake. One study investigated the potential impact of CFPIs on non-communicable diseases. Over 60% of studies investigated a single category of impact. Not one of the studies explicitly used a theoretical framework to guide its design or interpretation. CONCLUSIONS: Our findings on research studies of CFPIs suggest the need for a greater focus on interdisciplinary research in order to improve understanding of the relationships between their health, environmental, economic, and social impacts. Greater use of explicit theoretical frameworks could assist in research design and interpretation, helping to ensure its relevance to informing coordinated intersectoral interventions and policy initiatives.

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 purchasing behaviour of shoppers from different South African socio-economic communities: results from grocery receipts, intercept surveys and in-supermarkets audits.

OBJECTIVE: To identify factors associated with food purchasing decisions and expenditure of South African supermarket shoppers across income levels. DESIGN: Intercept surveys were conducted, grocery receipts collated and expenditure coded into categories, with each category calculated as percentage of the total expenditure. In-supermarket food quality audit and shelf space measurements of foods such as fruits and vegetables (F&V) (healthy foods), snacks and sugar-sweetened beverages (SSB) (unhealthy foods) were also assessed. Shoppers and supermarkets were classified by high-, middle- and low-income socio-economic areas (SEA) of residential area and location, respectively. Shoppers were also classified as "out-shoppers" (persons shopping outside their residential SEA) and "in-shoppers" (persons shopping in their residential SEA). Data were analysed using descriptive analysis and ANOVA. SETTING: Supermarkets located in different SEA in urban Cape Town. PARTICIPANTS: Three hundred ninety-five shoppers from eleven purposively selected supermarkets. RESULTS: Shelf space ratio of total healthy foods v. unhealthy foods in all the supermarkets was low, with supermarkets located in high SEA having the lowest ratio but better quality of fresh F&V. The share expenditure on SSB and snacks was higher than F&V in all SEA. Food secure shoppers spent more on food, but food items purchased frequently did not differ from the food insecure shoppers. Socio-economic status and food security were associated with greater expenditure on food items in supermarkets but not with overall healthier food purchases. CONCLUSION: Urban supermarket shoppers in South Africa spent substantially more on unhealthy food items, which were also allocated greater shelf space, compared with healthier foods.

A citizen science approach to determine perceived barriers and promoters of physical activity in a low-income South African community.

The study's objective was to assess the feasibility of using citizen science to identify and address physical activity (PA) barriers in a low-income South African community. We purposively selected as citizen scientists, eleven participants (21-45 years) from a cohort study who expressed interest in becoming physically active or were already active. They used the Stanford Neighborhood Discovery Tool mobile application to take photos and provide audio narratives of factors in their community that were barriers to or facilitated PA. Thereafter, in a facilitated workshop, citizen scientists thematically reviewed their findings, prioritised issues and proffered potential solutions. Researchers also thematically coded these data. PA levels were measured using standard questionnaires. None of the citizen scientists owned a car, and their PA was either work- or transport-related. Themes identified as priorities that hindered citizen scientists' PA were dirt, sidewalks appropriated by vendors or homeowners, parks and gym vandalisation, and personal safety fears. Access to stadiums and parks enabled PA. Citizen scientists identified their local councillors and street committee chairpersons as fundamental for advocacy for a PA-friendly environment. Low-income community members can be empowered to gather meaningful data using mobile technology and work together to identify potential solutions for promoting PA-friendly environments.

Evaluating the dissemination and scale-up of two evidence-based parenting interventions to reduce violence against children: study protocol.

Background: Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs. Methods: The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification. Discussion: This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.

Weight underestimation and body size dissatisfaction among black African adults with obesity: Implications for health promotion.

BACKGROUND: Body image perception has an impact on modifiable cardiovascular disease (CVD) risk, lifestyle and psychological health in many populations. AIM: To assess weight discordance (underestimating own weight) and body size dissatisfaction (perceiving body size as either 'too small' or 'too large') among overweight and obese South Africans, the associated factors and the implications for health promotion. SETTING: A rural community and an urban township in two provinces of South Africa. METHODS: An ancillary study within a prospective cohort involving 920 adults aged 35-78 years. Information on body image perception, anthropometry, risk factors and weight change were obtained on year 4 follow-up. Obesity was described as having a body mass index (BMI) 25 kg/m2. Descriptive and multivariate analyses were undertaken. RESULTS: Most obese and overweight adults, respectively, underestimated their own weight (85% vs. 79%) and considered their body sizes as either 'too large' (59%) or 'too small' (57%). Those who perceived CVD threat, compared with those who did not, were 3.0 times more likely to be dissatisfied with their body sizes (p 0.0001) and 1.6 times more likely to underestimate their own weight (p 0.001). Those who indicated their willingness to lose weight were seven times more likely to be dissatisfied with their body sizes and unlikely to have discordant weight status (p = 0.0002). CONCLUSION: Body size dissatisfaction and weight underestimation were influenced by perceived threat of CVD and the willingness to lose weight. Obesity prevention should leverage on perceived CVD threat messaging and self-motivation for attaining a healthy weight.

Low intake of commonly available fruits and vegetables in socio-economically disadvantaged communities of South Africa: influence of affordability and sugary drinks intake.

BACKGROUND: Consumption of fruits and vegetables reduces the risk of obesity, diabetes, cancer, cardiovascular mortality and all-cause mortality. The study assessed the pattern of intake and the factors that influence daily intake of commonly available fruits and vegetables in economically disadvantaged South African communities. METHODS: This is a cross-sectional study nested on an ongoing longitudinal study in South Africa. Two communities (a rural and urban) of low socio-economic status were purposely selected from two of the nine provinces. A sample of 535 participants aged 30-75 years was randomly selected from the longitudinal cohort of 1220; 411 (78%) women. Data were collected using validated food frequency and structured interviewer-administered questionnaires. Descriptive and multivariate regression analysis were undertaken. RESULTS: A higher proportion of participants in the urban township compared to their rural community counterparts had purchased fruits (93% vs. 51%) and vegetables (62% vs. 56%) either daily or weekly. Only 37.8% of the participants consumed at least two portions of commonly available fruits and vegetables daily, with no differences in the two communities. Daily/weekly purchase of sugar sweetened beverages (SSBs) was associated with daily intake of fruits and vegetables (p = 0.014). Controlling for age and gender, analysis showed that those who spent R1000 (USD71.4) and more on groceries monthly compared to those who spent less, and those who travelled with a personal vehicle to purchase groceries (compared to those who took public transport) were respectively 1.6 times (AOR, 95% CI: 1.05-2.44; p = 0.030) and 2.1 times (AOR, 95% CI: 1.06-4.09; p = 0.003) more likely to consume at least two or more portions of fruits and vegetables daily. Those who purchased SSBs daily or weekly were less likely (AOR, 95% CI: 0.54, 0.36-0.81, p = 0.007) to consume two or more portions of fruits and vegetables daily. The average household monthly income was very low (only 2.6% of households earned R5000 (US$357.1); and education level, attitude towards fruits and vegetables and owning a refrigerator had no significant association with fruits and vegetable daily intake. CONCLUSION: These findings indicate that affordability and frequency of purchase of sugary drinks can influence daily intake of fruits and vegetables in resource-limited communities.

A modified Delphi study towards developing a guideline to inform policy on fetal alcohol spectrum disorders in South Africa: a study protocol.

INTRODUCTION: Maternal alcohol consumption during pregnancy can result in mental and physical birth defects in individuals. These birth defects are usually described as fetal alcohol spectrum disorders (FASDs). With an estimated 183-259 per 1000 children born with FASDs, South Africa is identified to have the highest prevalence of FASDs in the world. Nevertheless, there is a lack of appropriate policies, guidelines and interventions addressing the issues around FASDs. This protocol outlines a proposed process for developing a guideline to inform policies on FASDs. METHODS AND ANALYSIS: This process will have three phases. Phase I will be carried out in three steps; we plan to conduct a document review of available policies on the prevention and management of FASDs and update the existing systematic review on FASDs interventions. The aim of the two reviews is to explore the availability and content of existing policies and global interventions on FASDs. In addition, we will conduct two exploratory qualitative studies to obtain the perspectives of various stakeholders on the existing or possible guidelines and policies for the management of FASDs and available interventions and services. In phase II, we will aggregate the findings of the previous phase to develop a prototype guideline. In phase III, using the developed prototype, we will apply the Delphi approach with experts on FASDs, soliciting their opinions on the nature and content of the proposed guidelines for policies. The information gathered will be used to modify the prototype to formulate a policy guideline on FASDs. The data will be analysed using thematic analysis and narrative synthesis. ETHICS AND DISSEMINATION: Ethical clearance has been obtained from the ethics committee of the university and governmental departments. The findings will be disseminated through publications and the guideline will be submitted to relevant departments.

Perceptions of body size, obesity threat and the willingness to lose weight among black South African adults: a qualitative study.

BACKGROUND: The obesity epidemic is associated with rising rates of cardiovascular disease (CVD) among adults, particularly in countries undergoing rapid urbanisation and nutrition transition. This study explored the perceptions of body size, obesity risk awareness, and the willingness to lose weight among adults in a resource-limited urban community to inform appropriate community-based interventions for the prevention of obesity. METHOD: This is a descriptive qualitative study. Semi-structured focus group discussions were conducted with purposively selected black men and women aged 35-70 years living in an urban South African township. Weight and height measurements were taken, and the participants were classified into optimal weight, overweight and obese groups based on their body mass index (Kg/m(2)). Participants were asked to discuss on perceived obesity threat and risk of cardiovascular disease. Information on body image perceptions and the willingness to lose excess body weight were also discussed. Discussions were conducted in the local language (isiXhosa), transcribed and translated into English. Data was analysed using the thematic analysis approach. RESULTS: Participants generally believed that obesity could lead to health conditions such as heart attack, stroke, diabetes, and hypertension. However, severity of obesity was perceived differently in the groups. Men in all groups and women in the obese and optimal weight groups perceived obesity to be a serious threat to their health, whereas the overweight women did not. Obese participants who had experienced chronic disease conditions indicated strong perceptions of risk of obesity and cardiovascular disease. Obese participants, particularly men, expressed willingness to lose weight, compared to the men and women who were overweight. The belief that overweight is 'normal' and not a disease, subjective norms, and inaccessibility to physical activity facilities, negatively influenced participants' readiness to lose weight. CONCLUSION: Low perception of threat of obesity to health particularly among overweight women in this community indicates a considerable challenge to obesity control. Community health education and promotion programmes that increase awareness about the risk associated with overweight, and improve the motivation for physical activity and maintenance of optimal body weight are needed.

Factors Associated with Excessive Body Fat in Men and Women: Cross-Sectional Data from Black South Africans Living in a Rural Community and an Urban Township.

OBJECTIVE: To determine the factors associated with excessive body fat among black African men and women living in rural and urban communities of South Africa. METHODS: This is a cross-sectional analysis of data from the Prospective Urban and Rural Epidemiology (PURE) study, Cape Town, South Africa conducted in 2009/2010. The study sample included 1220 participants (77.2% women) aged 35-70 years, for whom anthropometric measurements were obtained and risk factors documented through face-to-face interviews using validated international PURE study protocols. Sex-specific logistic regression models were used to evaluate socio-demographic, lifestyle and psychological factors associated with three excessive body fat indicators, namely body mass index (BMI), waist circumference (WC) and body fat percent (BF%). RESULTS: The prevalence of excessive body fat based on BF%, WC and BMI cut-offs were 96.0%, 86.1%, and 81.6% for women respectively, and 62.2%, 25.9%, and 36.0% for men respectively. The significant odds of excessive body fat among the currently married compared to unmarried were 4.1 (95% CI: 1.3-12.5) for BF% and 1.9 (95% CI: 1.3-2.9) for BMI among women; and 4.9 (95% CI: 2.6-9.6), 3.2 (95% CI: 1.6-6.4) and 3.6 (95% CI: 1.9-6.8) for BF%, WC and BMI respectively among men. Age ≤50 years (compared to age >50 years) was inversely associated with excessive BF% in men and women, and less-than-a-college education was inversely associated with excessive BMI and WC in men. Tobacco smoking was inversely associated with all three excessive adiposity indicators in women but not in men. Unemployment, depression, and stress did not predict excessive body fat in men or women. CONCLUSION: The sex-differences in the socio-demographic and lifestyle factors associated with the high levels of excessive body fat in urban and rural women and men should be considered in packaging interventions to reduce obesity in these communities.