Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries.

At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term

A protocol for a systematic review on intersectoral interventions to reduce non-communicable disease risk factors in African cities

Objectives To present the protocol for a systematic review synthesising quantitative and qualitative evidence in academic and grey literature on intersectoral interventions to address non-communicable disease risk factors in urban Africa. Study design This protocol is developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses Protocols guidelines. Databases to be searched include PubMed, Global Health, SCOPUS, and Web of Science. Grey literature will be sourced from Google, local, regional, and international agencies, colleagues within the GDAR network, international organisations such as the WHO and UN-Habitat, UNICEF’s Child Friendly Cities Initiative, Partnership for Healthy Cities, WHO Alliance for Healthy Cities, the African Centre for Cities, as well as grey literature databases such as Greynet and Opengrey. Methods We will include all quantitative and qualitative study designs that describe any initiatives to address non-communicable disease risk factors through intersectoral interventions, and those that describe associations between such interventions and behavioural health or wellbeing outcomes. We will also include health service interventions that have an intersectoral component and are focused on noncommunicable disease prevention. Studies must have been conducted in African countries, published in the past 30 years, and contain primary or secondary data as well as an analysis of these data. Results We will use the qualitative checklist and the cohort study checklist of the Critical Appraisal Skills Programme (CASP), to appraise the quality of each study included in this review. While the specific framework for data synthesis will be concluded after reviewing the extracted data, we anticipate using a parallel convergent method to synthesise the parallel strands of our study, as it involves analysing the qualitative and quantitative papers separately and then integrating them. Conclusions This will be the first systematic review to explore intersectoral interventions to address noncommunicable disease risk in African cities, thus filling a crucial gap in the literature. The findings of this study will be disseminated across global organisations whose mandates cut across noncommunicable diseases prevention, health promotion and healthy urban development. These include but are not limited to the World Health Organization, UN-Habitat, the UN Interagency Task Force on Noncommunicable Diseases Prevention and Control and the NCD Global Coordination Mechanism. We also plan to disseminate our findings to national and provincial stakeholders such as local governments, Ministries of Health and grassroots organisations; intergovernmental organisations such as the African Development Bank, and local and international private foundations such as Dangote Foundation and the Gates Foundation. The pan-African scope of this study makes it eligible to serve as a regional body of work and a resource to inform future interventions, practices, and policies

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations-women, girls, and adolescents-requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.This research was funded by the National Institute for Health Research (NIHR) (GHR: 16/137/34) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Anna Brugulat-Panés is funded by the UKRI Economic Social Research Council Doctor-al Training Program (ESRC DTP), and by the MRC Epidemiology Unit School of Clinical Medicine, University of Cambridge. Amy is supported by the PEAK Urban programme, funded by UKRI’s Global Challenge Research Fund, Grant Ref: ES/P011055/

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

Active travel and paratransit use in African cities: Mixed-method systematic review and meta-ethnography.

Active travel, as a key form of physical activity, can help offset noncommunicable diseases as rapidly urbanising countries undergo epidemiological transition. In Africa a human mobility transition is underway as cities sprawl and motorization rises and preserving active travel modes (walking, cycling and public transport) is important for public health. Across the continent, public transport is dominated by paratransit, privately owned informal modes serving the general public. We reviewed the literature on active travel and paratransit in African cities, published from January 2008 to January 2019. We included 19 quantitative, 14 mixed-method and 8 qualitative studies (n = 41), narratively synthesizing the quantitative data and meta-ethnographically analysing the qualitative data. Integrated findings showed that walking was high, cycling was low and paratransit was a critical mobility option for poor peripheral residents facing long livelihood-generation journeys. As an indigenous solution to dysfunctional mobility systems shaped by colonial and apartheid legacies it was an effective connector, penetrating areas unserved by formal public transport and helping break cycles of poverty. From a public health perspective, it preserved active travel by reducing mode-shifting to private vehicles. Yet many city authorities viewed it as rogue, out of keeping with the 'ideal modern city', adopting official anti-paratransit stances without necessarily considering the contribution of active travel to public health. The studies varied in quality and showed uneven geographic representation, with data from Central and Northern Africa especially sparse; notably, there was a high prevalence of non-local authors and out-of-country funding. Nevertheless, drawing together a rich cross-disciplinary set of studies spanning over a decade, the review expands the literature at the intersection of transport and health with its novel focus on paratransit as a key active travel mode in African cities. Further innovative research could improve paratransit's legibility for policymakers and practitioners, fostering its inclusion in integrated transport plans

Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries

At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term

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

The Potential for Healthy, Sustainable, and Equitable Transport Systems in Africa and the Caribbean: A Mixed-Methods Systematic Review and Meta-Study

The Human Mobility Transition model describes shifts in mobility dynamics and transport systems. The aspirational stage, ‘human urbanism’, is characterised by high active travel, universal public transport, low private vehicle use and equitable access to transport. We explored factors associated with travel behaviour in Africa and the Caribbean, investigating the potential to realise ‘human urbanism’ in this context. We conducted a mixed-methods systematic review of ten databases and grey literature for articles published between January 2008 and February 2019. We appraised study quality using Critical Appraisal Skills Programme checklists. We narratively synthesized qualitative and quantitative data, using meta-study principles to integrate the findings. We identified 39,404 studies through database searching, mining reviews, reference screening, and topic experts’ consultation. We included 129 studies (78 quantitative, 28 mixed-methods, 23 qualitative) and 33 grey literature documents. In marginalised groups, including the poor, people living rurally or peripheral to cities, women and girls, and the elderly, transport was poorly accessible, travel was characterised by high levels of walking and paratransit (informal public transport) use, and low private vehicle use. Poorly controlled urban growth (density) and sprawl (expansion), with associated informality, was a salient aspect of this context, resulting in long travel distances and the necessity of motorised transportation. There were existing population-level assets in relation to ‘human urbanism’ (high levels of active travel, good paratransit coverage, low private vehicle use) as well as core challenges (urban sprawl and informality, socioeconomic and gendered barriers to travel, poor transport accessibility). Ineffective mobility systems were a product of uncoordinated urban planning, unregulated land use and subsequent land use conflict. To realise ‘human urbanism’, integrated planning policies recognising the linkages between health, transport and equity are needed. A shift in priority from economic growth to a focus on broader population needs and the rights and wellbeing of ordinary people is required. Policymakers should focus attention on transport accessibility for the most vulnerable.National Institute for Health Researc