Big Tobacco, Alcohol, and Food and NCDs in LMICs: An Inconvenient Truth and Call to Action; Comment on “Addressing NCDs: Challenges From Industry Market Promotion and Interferences”

In their editorial, Tangcharoensathien et al1 describe the challenges of industry market promotion and policy interference from Big Tobacco, Alcohol, and Food in addressing non-communicable diseases (NCDs). They provide an overview of the increasing influence of corporate interest in emerging economies and government attempts to implement the World Health Organization (WHO) ‘best buy’ interventions. The authors largely draw on examples from Asia and a few selected countries, but provide little detail as to how aggressive marketing and policy interference plays out in a context of poor legislation and regulation in many low- and middle-income countries (LMICs), where the burden of NCDs is increasing at an alarming rate and governments face a high burden of disease with a limited budget for countering industry interference. This commentary provides some poignant examples of the influence of Big Tobacco, Alcohol, and Food on market regulation and policy interference in LMICs and argues for more policy coherence and accountability in terms of multisectoral action and civil society activism. Securing funds for health promotion and establishing health promotion foundations could help achieve that goal

Study protocol for the SMART2D adaptive implementation trial: a cluster randomised trial comparing facility-only care with integrated facility and community care to improve type 2 diabetes outcomes in Uganda, South Africa and Sweden

INTRODUCTION Type 2 diabetes (T2D) is increasingly contributing to the global burden of disease. Health systems in most parts of the world are struggling to diagnose and manage T2D, especially in low-income and middle-income countries, and among disadvantaged populations in high-income countries. The aim of this study is to determine the added benefit of community interventions onto health facility interventions, towards glycaemic control among persons with diabetes, and towards reduction in plasma glucose among persons with prediabetes. METHODS AND ANALYSIS An adaptive implementation cluster randomised trial is being implemented in two rural districts in Uganda with three clusters per study arm, in an urban township in South Africa with one cluster per study arm, and in socially disadvantaged suburbs in Stockholm, Sweden with one cluster per study arm. Clusters are communities within the catchment areas of participating primary healthcare facilities. There are two study arms comprising a facility plus community interventions arm and a facility-only interventions arm. Uganda has a third arm comprising usual care. Intervention strategies focus on organisation of care, linkage between health facility and the community, and strengthening patient role in selfmanagement, community mobilisation and a supportive environment. Among T2D participants, the primary outcome is controlled plasma glucose; whereas among prediabetes participants the primary outcome is reduction in plasma glucose. ETHICS AND DISSEMINATION The study has received approval in Uganda from the Higher Degrees, Research and Ethics Committee of Makerere University School of Public Health and from the Uganda National Council for Science and Technology; in South Africa from the Biomedical Science Research Ethics Committee of the University of the Western Cape; and in Sweden from the Regional Ethical Board in Stockholm. Findings will be disseminated through peer-reviewed publications and scientific meetings. Trial registration number ISRCTN11913581; Pre-results

Expanding the prevention armamentarium portfolio: A framework for promoting HIV-conversant communities within a complex, adaptive epidemiological landscape

The article describes a design journey that culminated in an HIV-Conversant Community Framework that is now being piloted in the Limpopo Province of South Africa. The objective of the initiative is to reduce the aggregate community viral load by building capacity at multiple scales that strengthens peoples’ HIV-related navigational skill sets—while simultaneously opening a ‘chronic situation’ schema. The framework design is based upon a transdisciplinary methodological combination that synthesises ideas and constructs from complexity science and the management sciences as a vehicle through which to re-conceptualise HIV prevention. This resulted in a prototype that included the following constructs: managing HIV-prevention in a complex, adaptive epidemiological landscape; problematising and increasing the scope of the HIV knowledge armamentarium through education that focuses on the viral load and Langerhans cells; disruptive innovation and safe-fail probes followed by the facilitation of path creations and pattern management implementation techniques. These constructs are underpinned by a ‘middle-ground’ prevention approach which is designed to bridge the prevention ‘fault line’, enabling a multi-ontology conceptualisation of the challenge to be developed

Determinants of dietary patterns in school going adolescents in Urban Zambia

Understanding dietary patterns in a population is critical for decision making. This study aimed to identify the prevailing dietary patterns and their associated individual and school environment factors among school going adolescents in Lusaka, Zambia. Method: A cross-sectional study involving 404 Grade 10 pupils from 10 secondary schools in Lusaka district was conducted. A 108-item unquantified Food Frequency Questionnaire (FFQ) was used to assess the learner's food intake practices

Motivational determinants of physical activity in disadvantaged populations with (pre)diabetes: A cross-cultural comparison

Understanding motivational determinants of physical activity (PA) is essential to guide the implementation of PA at individual and population level. Knowledge about the cross-cultural generalizability of these determinants is lacking and they have mostly been studied as separate factors. This study compares a motivational process model across samples from diverse populations with, or at risk of diabetes.Measurement invariance of barrier identified regulation, barrier self-efficacy and social support was assessed in a rural Ugandan sample (n=712) and disadvantaged samples with high proportions of immigrants in urban South Africa (n=566) and Sweden (n=147). These motivational determinants were then compared through multigroup structural equation modeling

School food environment in urban Zambia: A qualitative analysis of drivers of adolescent food choices and their policy implications

Identifying context specific points for reforming policy to promote healthier food environments and consumer behavior in critical life stages like adolescence is crucial in addressing the double burden of malnutrition. Using a qualitative study design, we conducted 20 focus group discussions with grade 10 pupils from ten secondary schools in Lusaka. Turner’s framework which conceptualizes the food environment into two domains—the external domain (availability, pricing, vendor and product properties, and marketing and regulation of food) and the internal domain (accessibility, affordability, convenience, and desirability of food)—was used to guide thematic data analysis and results interpretation. Adolescents stated their food choices are largely based on personal preference linked to the need for social acceptability among peers

Reducing the Role of the Food, Tobacco, and Alcohol Industries in Noncommunicable Disease Risk in South Africa

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs

Combining the theory of change and realist evaluation approaches to elicit an initial program theory of the MomConnect program in South Africa

One of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. In South Africa, the flagship National Department of Health MomConnect program was launched in 2014 to strengthen the quality of maternal and child health (MCH) services and improve mortality outcomes. MomConnect was rapidly rolled out with a limited understanding of how and why the program was expected to work even though studies had shown the effectiveness of the MomConnect program in improving the uptake of MCH services. This study aimed to unearth the initial program theory of the MomConnect program based on explicit and implicit assumptions of how the program was organized and expected to work

Integrated knowledge translation to advance noncommunicable disease policy and practice in South Africa: Application of the exploration, preparation, implementation, and sustainment (epis) framework

In response to the “know–do” gap, several initiatives have been implemented to enhance evidenceinformed decision-making (EIDM). These include individual training, organizational culture change management, and legislative changes. The importance of relationships and stakeholder engagement in EIDM has led to an evolution of models and approaches including integrated knowledge translation (IKT). IKT has emerged as a key strategy for ensuring that engagement is equitable, demand-driven, and responsive. As a result, the African-German Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) incorporated an IKT approach to infuence non‑ communicable diseases (NCD) policy and practice. We documented the phased process of developing, implement‑ ing, and monitoring the IKT approach in South Africa; and explored the appropriateness of using the exploration, preparation, implementation, and sustainment (EPIS) framework for this purpose

Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis

Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers