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.

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.

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.

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.

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.