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.

Physical Activity and Its Association With Body Mass Index: A Cross-Sectional Analysis in Middle-Aged Adults From 4 Sub-Saharan African Countries.

BACKGROUND: This study aimed to explore association of self-reported physical activity domains of work, leisure, and transport-related physical activity and body mass index (BMI) in 9388 adult men and women from the Africa-Wits-INDEPTH partnership for Genomic (AWI-Gen) study in Africa. Africa-Wits-INDEPTH partnership for Genomic is a large, population-based cross-sectional cohort with participants from 6 sites from rural and urban areas in 4 sub-Saharan African countries. METHODS: A sex-stratified meta-analysis of cross-sectional data from men and women aged 29-82 years was used to assess the association of physical activity with BMI. RESULTS: Overall, meeting physical activity guidelines of at least 150 minutes per week was associated with 0.82 kg/m2 lower BMI in men (ß = -0.80 kg/m2; 95% confidence interval [CI], -1.14 to -0.47) and 0.68 kg/m2 lower BMI in women (ß = -0.68 kg/m2; 95% CI, -1.03 to -0.33). Sex and site-specific differences were observed in the associations between physical activity domains and BMI. Among those who met physical activity guidelines, there was an inverse association between transport-related physical activity and BMI in men from Nanoro (Burkina Faso) (ß = -0.79 kg/m2; 95% CI, -1.25 to -0.33) as well as work-related physical activity and BMI in Navrongo men (Ghana) (ß = -0.76 kg/m2; 95% CI, -1.25 to -0.27) and Nanoro women (ß = -0.90 kg/m2; 95% CI, -1.44 to -0.36). CONCLUSIONS: Physical activity may be an effective strategy to curb rising obesity in Africa. More studies are needed to assess the impact of sex and geographic location-specific physical activity interventions on obesity.

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.

Prevalence of pregnancy induced hypertension and pregnancy outcomes among women seeking maternity services in Harare, Zimbabwe.

BACKGROUND: Pregnancy induced hypertension (PIH) is one of the most common causes of both maternal and neonatal morbidity, affecting about 5 - 8 % of pregnant women. It is associated with adverse pregnancy outcomes as well as maternal morbidity and mortality. Harare City experienced an increase in referrals due to PIH to central hospitals from 2009 to 2011. We conducted a study to determine the prevalence of PIH and pregnancy outcomes among women with PIH. METHODS: An analytic cross sectional study was conducted. Interviewer administered questionnaires were used to capture demographic data, obstetric history and knowledge on PIH management. Records were reviewed for pregnancy outcomes while key informants were also interviewed on patient management. RESULTS: PIH prevalence was 19.4 %. Women with PIH were three times more likely to deliver a low birth weight baby (OR 3.00, p = 0.0115), 4.3 times more likely to have still birth (OR 4.34, p = 0.0517) and four times more likely to have a baby with low Apgar score at 5 minutes (OR 4.47, p = 0.0155) compared to women without PIH. There was no statistically significant difference in delivery before 37 weeks gestation between women with PIH and those without (OR 1.70, p = 0.1251). 12,5 % of the women delivered by caesarean section. Methyldopa was the drug of choice for management of PIH. Less than half of the health workers had sufficient knowledge on definition or management of PIH. Delay in seeking care and shortage of resources were the major reported challenges in the proper management of PIH. CONCLUSION: PIH prevalence was high. Women with PIH were at higher risk of adverse pregnancy outcomes than those without. Poor knowledge of management of PIH and inadequate resources are a threat to the proper management of PIH. This underscores the need for increased human resources and capacity building as well as resource mobilisation for proper management of pregnant women. Urinalysis must be routinely done for all pregnant women regardless of their blood pressure.

Typhoid outbreak investigation in Dzivaresekwa, suburb of Harare City, Zimbabwe, 2011.

INTRODUCTION: Typhoid fever is a systemic infection caused by a Gram negative bacterium, Salmonella typhi. Harare City reported 1078 cases of suspected typhoid fever cases from October 2011 to January 2012. We initiated an investigation to identify possible source of transmission so as to institute control measures. METHODS: An unmatched 1:1 case-control study was conducted. A questionnaire was administered to study participants to identify risk factors for contracting typhoid. A case was a resident of Dzivaresekwa who presented with signs and symptoms of typhoid between October and December 2011. Water samples were collected for microbiological analysis. RESULTS: 115 cases and 115 controls were enrolled. Drinking water from a well (OR=6.2 95% CI (2.01-18.7)), attending a gathering (OR=11.3 95% CI (4.3-29.95)), boiling drinking water (OR=0.21 95% CI (0.06-0.76)) and burst sewer pipe at home (OR=1.19 95% CI (0.67-2.14)) were factors associated with contracting typhoid. Independent risk factors for contracting typhoid were drinking water from a well (AOR=5.8; 95% CI (1.90-17.78)), and burst sewer pipe at home (AOR=1.20; 95% CI (1.10-2.19)). Faecal coli forms and E. coli were isolated from 8/8 well water samples. Stool, urine and blood specimens were cultured and serotyped for Salmonella typhi and 24 cases were confirmed positive. Shigella, Giardia and E coli were also isolated. Ciprofloxacin, X-pen and Rocephin were used for case management. No complications were reported. CONCLUSION: Contaminated water from unprotected water sources was the probable source of the outbreak. Harare City Engineer must invest in repairing water and sewage reticulation systems in the city.

Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe.

Supplementation with lipid-based nutrient supplements (LiNS) is promoted as an approach to prevent child undernutrition and growth faltering. Previous LiNS studies have not tested the effects of improving the underlying diet prior to providing LiNS. Formative research was conducted in rural Zimbabwe to develop feeding messages to improve complementary feeding with and without LiNS. Two rounds of Trials of Improved Practices were conducted with mothers of infants aged 6-12 months to assess the feasibility of improving infant diets using (1) only locally available resources and (2) locally available resources plus 20 g of LiNS as Nutributter®/day. Common feeding problems were poor dietary diversity and low energy density. Popular improved practices were to process locally available foods so that infants could swallow them and add processed local foods to enrich porridges. Consumption of beans, fruits, green leafy vegetables, and peanut/seed butters increased after counselling (P < 0.05). Intakes of energy, protein, vitamin A, folate, calcium, iron and zinc from complementary foods increased significantly after counselling with or without the provision of Nutributter (P < 0.05). Intakes of fat, folate, iron, and zinc increased only (fat) or more so (folate, iron, and zinc) with the provision of Nutributter (P < 0.05). While provision of LiNS was crucial to ensure adequate intakes of iron and zinc, educational messages that were barrier-specific and delivered directly to mothers were crucial to improving the underlying diet.

Beyond food insecurity: how context can improve complementary feeding interventions.

BACKGROUND: The role of context has not been elaborated with respect to current recommendations for complementary feeding interventions, apart from a gross distinction based on food security. OBJECTIVE: Our objective was to compare two food-insecure settings in sub-Saharan Africa to determine how context (i.e., the set of local social, cultural, and physical circumstances) influences complementary feeding practices and nutrient intakes and how the results can help in the design of a suitable intervention strategy. METHODS: We conducted formative research using 24-hour dietary recalls, household interviews, and focus group discussions with mothers of 6- to 12-month-old infants in rural Zimbabwe (n = 32) and Pemba Island, Zanzibar, Tanzania (n = 44). RESULTS: In both settings, many infants had suboptimal nutrient intakes, poor dietary diversity, and poor hygiene. Breastfeeding practices were poor in Pemba, and the infants' diet had low energy density in Zimbabwe. Beyond food insecurity, contextual determinants of practices included inaccurate indigenous knowledge, time-consuming maternal livelihoods, family eating behaviors, local agriculture, and the local ecosystem. Both settings would require nutrition education, but it should target the broader indigenous ways of learning and family eating behaviors in order to achieve the necessary behavior change. A home-based fortificant would probably be enough for Pemban children, because the ecosystem of the island provides sufficient sources of macronutrients. However, Zimbabwean children appear to need a fortified food-based supplement to overcome the poor agricultural and economic context. CONCLUSIONS: Assessing context was essential to intervention design. A framework to guide future formative research is proposed.

Heat treatment of expressed breast milk is a feasible option for feeding HIV-exposed, uninfected children after 6 months of age in rural Zimbabwe.

In the context of a prevention of mother to child transmission of HIV program promoting exclusive breast-feeding (EBF) to 6 mo and offering HIV-PCR testing at approximately 6 mo, we ascertained the feasibility of expressing and heat-treating (EHT) all breast milk fed to HIV-exposed, uninfected infants following 6 mo of EBF. Twenty mother-baby pairs were enrolled from a hospital in rural Zimbabwe. Research nurses provided lactation, EHT, and complementary feeding counseling through 21 home visits conducted over an 8-wk period and collected quantitative and qualitative data on the mothers' EHT experiences, children's diets, and anthropometric measurements. Mothers kept daily logs of EHT volumes and direct breast-feeding episodes. Mothers successfully initiated and sustained EHT for 4.5 mo (range, 1-11 mo), feeding 426 +/- 227 mL/d (mean +/- SD). By wk 2 of follow-up, children were receiving EHT and Nutributter-enriched complementary foods that satisfied 100% of their energy requirements. During the 8-wk follow-up period, no growth faltering was experienced [changes in weight-for-age, weight-for-length, and length-for-age Z scores = +0.03 +/- 0.50; +0.77 +/- 1.59; and +0.02 +/- 0.85 (mean +/- SD), respectively]. Stigma was not a major deterrent, likely due to a social marketing campaign for EBF that promoted EHT as a practice to sustain breast-feeding for all women. This study provides evidence that resource-poor rural women can initiate and sustain EHT given family and health systems support. EHT provides a strategy for improving the diets of HIV-exposed but uninfected children after direct breast-feeding has ceased.