Participatory prioritisation of interventions to improve primary school food environments in Gauteng, South Africa.

BACKGROUND: In South Africa, overweight and obesity affect 17% of children aged 15-18. School food environments play a vital role in children's health, influencing dietary behaviours and resulting in high obesity rates. Interventions targeting schools can contribute to obesity prevention if evidence-based and context-specific. Evidence suggests that current government strategies are inadequate to ensure healthy school food environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. METHODS: A three-phased iterative study design was implemented. First, we identified contextual drivers of unhealthy school food environments through a secondary framework analysis of 26 interviews with primary school staff. Transcripts were deductively coded in MAXQDA software using the Behaviour Change Wheel and the Theoretical Domains Framework. Second, to identify evidence-based interventions, we utilised the NOURISHING framework and matched interventions to identified drivers. Third, interventions were prioritised using a Delphi survey administered to stakeholders (n = 38). Consensus for priority interventions was defined as an intervention identified as being 'somewhat' or 'very' important and feasible with a high level of agreement (quartile deviation ≤ 0.5). RESULTS: We identified 31 unique contextual drivers that school staff perceived to limit or facilitate a healthy school food environment. Intervention mapping yielded 21 interventions to improve school food environments; seven were considered important and feasible. Of these, the top priority interventions were to: 1) "regulate what kinds of foods can be sold at schools", 2) "train school staff through workshops and discussions to improve school food environment", and affix 3) "compulsory, child-friendly warning labels on unhealthy foods". CONCLUSION: Prioritising evidence-based, feasible and important interventions underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to tackle South Africa's childhood obesity epidemic effectively.

A human rights-based approach to coercive public health interventions: lessons from the HIV and COVID-19 pandemics.

The SARS-CoV-2 outbreak and its impact on countries across the globe has been unprecedented. The lack of pharmaceutical interventions to prevent or treat infection have left States with limited avenues to control the spread of the virus. Many countries have introduced stringent lockdowns along with regulatory regimes that give governments new powers to compel compliance with these regulations and to punish non-compliance. This article investigates the use of compelled public health interventions during both the HIV and COVID-19 pandemics and how these can be aligned to human rights. This includes discussion on the use of interventions such as mandatory quarantine and isolation, compelled testing, criminalisation of HIV and SARS-CoV-2 transmission in Africa. This article also outlines what State obligations are in relation to pandemic responses, both in terms of mandating an effective response and which human rights principles should underscore these responses.Using South Africa as a case study, this article analyses whether the use of these interventions complies with international human rights law. We assess the use of compelled public health interventions in both the HIV and COVID-19 pandemics against established human rights principles applicable to pandemic responses. This article discusses lessons to be learnt about the relationship between human rights and public health interventions across both pandemics so as to guide human rights-based approaches to future pandemics as well as subsequent stages of the SARS-CoV-2 pandemic.

Industry strategies in the parliamentary process of adopting a sugar-sweetened beverage tax in South Africa: a systematic mapping.

BACKGROUND: In 2016, the South African government became the first in the African region to announce the introduction of an SSB tax based on sugar content as a public health measure to reduce obesity. This tax was introduced against the backdrop of South Africa having a large sugar production and SSB manufacturing industry, as well as very high unemployment rates. The introduction of fiscal measures, such as a SSB tax, has been met with well-coordinated and funded opposition in other countries. METHODS: The aim of this study is to describe and analyse the arguments and strategies utilised by industry during policymaking processes to oppose regulatory actions in LMIC. This study analyses arguments and strategies used by the beverage and related industries during the public consultation phase of the process to adopt the South African SSB tax. RESULTS: Industry opposition to the SSB tax was comprehensive and employed several tactics. First, industry underscored its economic importance and the potential job losses and other economic harms that may arise from the tax. This argument was well-received by policymakers, and similar to industry tactics employed in other middle income countries like Mexico. Second, industry discussed self-regulation and voluntary measures as a form of policy substitution, which mirrors industry responses in the US, the Caribbean and Latin America. Third, industry misused or disputed evidence to undermine the perceived efficacy of the tax. Finally, considerations for small business and their ability to compete with multi-national corporations were a unique feature of industry response. CONCLUSIONS: Industry opposition followed both general trends, and also introduced nuanced and context-specific arguments. The industry response experienced in South Africa can be instructive for other countries contemplating the introduction of similar measures.

The passage and implementation of a Health Promotion Levy in South Africa as a case study of fair financing procedures.

Procedural fairness is an accepted requirement for health decision-making. Fair procedures promote the acceptability and quality of health decisions while simultaneously advancing broader goals of participatory democracy. We conducted a case study of the Sugary Beverage Tax in South Africa known as the Health Promotion Levy (HPL), which was legislated in 2018. The case study examines the process around the adoption of the HPL from the perspective of procedural fairness with the view of identifying local gaps and lessons transferable to other local decision-making processes and other jurisdictions. We conducted a desk review of publically available data relating to the passage and implementation of the HPL, including a review of the policy documents, public submissions during the public participation process, response documents from policymakers, review of national legislative committee minutes, legal instruments and academic literature capturing public awareness, stakeholder views and media content. The data collection is novel in terms of the large scope of data considered, as well as the variety of sources. An analytical framework consisting of key criteria for procedural fairness, informed by a scoping review of the literature, guided the analysis of the decision-making process in South Africa. The process of the adoption and passage of the HPL met the majority of the procedural fairness criteria. However, a shortcoming, which impacted several criteria, was the failure to actively source the participation of community representatives and the larger public. Non-governmental organizations did not adequately fulfil this representative role. Industry interests were also disproportionately considered. The case study highlights the overall importance of viewing general members of the public as interested parties in health policies and the dangers of over-involving policy opponents under a mistaken understanding that this constitutes meaningful public engagement in decision-making procedures.

Stakeholder arguments during the adoption of a sugar sweetened beverage tax in South Africa and their influence: a content analysis.

BACKGROUND: Sugar-sweetened beverage (SSB) taxes are recognised as an effective intervention to prevent obesity. More countries are adopting SSB taxes, but the process of the adoption is politically complex. OBJECTIVE: This study aimed to analyse how public participation processes influenced the South African tax. METHODS: We conducted a content analysis of documents associated with the process of adopting the tax. Records were identified utilising the Parliamentary Monitoring Group database, including draft bills, meeting minutes and written submissions. The records were categorised and then inductively coded to identify themes and arguments. RESULTS: We identified six cross-cutting themes advanced by stakeholders: economic considerations, impact on the vulnerable, responsiveness of an SSB tax to the problem of obesity, appropriateness of an SSB tax in South Africa, procedural concerns, and structure of the tax. Stakeholder views and arguments about the tax diverged based on their vested interests. The primary policymaker was most responsive to arguments concerning the economic impact of a tax, procedural concerns and the structure of the tax, reducing the effective rate to address industry concerns. CONCLUSION: Both supportive and opposing stakeholders influenced the tax. Economic arguments had a significant impact. Arguments in South Africa broadly echoed arguments advanced in many other jurisdictions.

Beverage industry's advertising expenditures and airtimes in South Africa from 2013 to 2019 target children and families.

With the growing burden of non-communicable diseases (NCDs), countries across the globe are finding ways to reduce the consumption of ultra-processed food and drinks including sugar-sweetened beverages (SSBs). South Africa implemented a health promotion levy (HPL) in April 2018 as one strategy to reduce sugar intake. Such efforts are frequently countered or mitigated by industry action in various ways, including through marketing and advertising strategies. To better understand trends in the extent of advertising, this paper analyses advertising expenditures and exposure of children to SSB advertisements in South Africa. Using Nielsen's monthly data on advertising expenditure before and after the introduction of the HPL, for the period January 2013 to April 2019, the results show that manufacturers spent ZAR 3683 million to advertise their products. Advertising expenditure on carbonated drinks accounted for over 60% (ZAR 2220 million) of the total expenditure on SSBs. The results also show that companies spend less in advertising powdered SSBs (an average of ZAR 0.05 million per month). Based on expenditure patterns, television (TV) was the preferred medium of advertisements, with companies prioritizing what is often considered children's and family viewing time. Urgent mandatory regulations are needed to prevent child-directed marketing.

Identifying priority interventions using the Behaviour Change Wheel to improve public primary school food environments in urban South Africa.

BACKGROUND: In South Africa, overweight and obesity affects 13% of children and 17% of adolescents. School food environments play a vital role in dietary behaviours and resulting obesity rates. Interventions targeting schools can be effective if evidence-based and context relevant. There are substantial gaps in policy and implementation of government strategies to promote healthy nutrition environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. METHODS: A multiphased secondary analysis of individual interviews with 25 primary school staff was undertaken. First, we identified risk factors influencing school food environments using MAXQDA software; then deductively coded these using the Capability, Opportunity, Motivation-Behaviour model, which informs the Behaviour Change Wheel framework. To identify evidence-based interventions, we used the NOURISHING framework and matched interventions to risk factors. Last, interventions were prioritised through a Delphi survey, administered to stakeholders (n=38) representing health, education, food service, and not-for-profit sectors. Consensus for priority interventions was defined as an intervention being either somewhat or very important and feasible, with high level of agreement (quartile deviation ≤0·5). FINDINGS: We identified 21 interventions to improve school food environments. Of these, seven were endorsed as important and feasible to enable school stakeholders', policy makers', and children's capability, motivation, and opportunity of having healthier foods within schools. Prioritised interventions targeted a range of protective and risk factors, including issues of affordability and availability of unhealthy foods within school premises. As such, top priority interventions included (1) regulations on what kinds of foods can be sold at schools; (2) compulsory, child-friendly warning labels on unhealthy foods; and (3) training of school staff through workshops and discussions to improve school nutrition environment. INTERPRETATION: This is the first study to use the Behaviour Change Wheel and stakeholder engagement to identify intervention priorities to improve food environments in South African schools. Prioritisation of evidence-based, feasible, and important interventions that are underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to effectively tackle South Africa's childhood obesity epidemic. FUNDING: This research was funded by the National Institute for Health Research (NIHR; grant number 16/137/34) using UK Aid from the UK Government to support global health research. AE, PK, TR-P, SG, and KJH are supported by the SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA (grant number 23108).

The Right to Free Commercial Speech in South Africa and its Tension with Public Health Interventions.

Marketing restrictions to promote public health invoke competing rights, including the right to free commercial speech which for-profit entities use to protect their freedom to market products without undue regulation. The right to free commercial speech in South Africa has been developed through case law since the adoption of the first democratic constitution in South Africa in 1996. This article examines the impact of this recent judgment and the lessons for policy makers to ensure effective regulation of marketing practices in South Africa.

A Mixed-Methods Participatory Intervention Design Process to Develop Intervention Options in Immediate Food and Built Environments to Support Healthy Eating and Active Living among Children and Adolescents in Cameroon and South Africa.

Rates of obesity and related non-communicable diseases are on the rise in sub-Saharan Africa, associated with sub-optimal diet and physical inactivity. Implementing evidence-based interventions targeting determinants of unhealthy eating and physical inactivity in children and adolescents' immediate environments is critical to the fight against obesity and related non-communicable diseases. Setting priorities requires a wide range of stakeholders, methods, and context-specific data. This paper reports on a novel participatory study design to identify and address contextual drivers of unhealthy eating and physical inactivity of children and adolescents in school and in their home neighborhood food and built environments. We developed a three-phase mixed-method study in Cameroon (Yaoundé) and South Africa (Johannesburg and Cape Town) from 2020-2021. Phase one focused on identifying contextual drivers of unhealthy eating and physical inactivity in children and adolescents in each setting using secondary analysis of qualitative data. Phase two matched identified drivers to evidence-based interventions. In phase three, we worked with stakeholders using the Delphi technique to prioritize interventions based on perceived importance and feasibility. This study design provides a rigorous method to identify and prioritize interventions that are tailored to local contexts, incorporating expertise of diverse local stakeholders.

An Analysis of the Adoption and Implementation of A Sugar-Sweetened Beverage Tax in South Africa: A Multiple Streams Approach.

This paper describes a case study of the adoption and implementation of the sugar-sweetened beverage tax in South Africa, termed the Health Promotion Levy. Qualitative data extraction and analysis of institutional documents, such as policy proposals and parliamentary debate records, stakeholder submissions to Parliament and media reports, were guided by the Kingdon Multiple Streams Theory as adapted to study agenda setting, policy adoption, and implementation. We present the following key findings: First, consistent messaging from policy entrepreneurs, consisting of advocacy groups, health organizations, and research entities, was key to ensuring that a tax policy solution was proposed and passed. Second, the continuity of certain key policymakers contributed to the relatively expedient passage of the tax policy. Third, the use of an excise tax was, amongst others, an appealing policy solution because of its revenue-raising potential; however, uncertainty regarding the purpose of the tax negatively impacted public attitudes toward it. Fourth, industry arguments, relating to unemployment, were effective in restructuring the tax in favor of industry actors. Finally, regulatory action by sectors outside of finance and health impacted stakeholder perceptions of the tax and possibly obstructed regular annual adjustments for inflation.

Barriers to, and facilitators of, the adoption of a sugar sweetened beverage tax to prevent non-communicable diseases in Namibia: a policy landscape analysis.

Background: Nutrition-related non-communicable diseases contribute to approximately half of the premature deaths in Namibia. Westernisation and urbanisation of communities have resulted in changing dietary patterns that see people eating more refined and high sugar content foods that are a risk for nutrition-related non-communicable diseases. Sugar-sweetened beverage taxation has been found to influence consumer purchasing behaviour and to raise revenue for health-promoting activity in other low- and middle-income countries.Objectives: To analyse Namibia's non-communicable diseases prevention policy landscape and assess the readiness of the Government to adopt sugar-sweetened beverage taxation policies for public health.Methods: Government policy documents relating to nutrition-related non-communicable diseases were analysed, utilising predetermined variables based on policy theory. Thirteen key informant interviews were conducted with stakeholders from Government, non-governmental organisations and academic institutions. Data sets were analysed utilising Kingdon's analytical theory for agenda setting.Results: Nutrition-related non-communicable diseases are an increasing problem that requires immediate action. Diet and lifestyle are recognised as major contributors to non-communicable diseases. The Government has adopted a multisectoral approach to the control and prevention of non-communicable diseases in Namibia. A sugar-sweetened beverage tax is envisaged in policy, but there is no progress towards its enactment. At the highest level of Government, the Ministry of Finance has ruled out immediate action towards sugar-sweetened beverage taxation. There is little publicly available information about the Namibian beverages industry, but it is closely tied to the South African drinking industry and is influenced by policy action in that country.Conclusion: The Government of Namibia has taken positive steps and the policy environment is friendly towards an SSB tax. The proximity of trade and the competitive nature of the Namibian drinks industry with South Africa suggest that a regional perspective to advocacy would be of value.