Intersectoral Action for Addressing NCDs through the Food Environment: An Analysis of NCD Framing in Global Policies and Its Relevance for the African Context.

Noncommunicable diseases contribute the greatest to global mortality. Unhealthy diet-a prominent risk factor-is intricately linked to urban built and food environments and requires intersectoral efforts to address. Framings of the noncommunicable disease problem and proposed solutions within global and African regional diet-related policy documents can reveal how amenable the policy landscape is for supporting intersectoral action for health in low-income to middle-income countries. This study applied a document analysis approach to undertake policy analysis on global and African regional policies related to noncommunicable disease and diet. A total of 62 global and 29 African regional policy documents were analysed. Three problem frames relating to noncommunicable disease and diet were identified at the global and regional level, namely evidence-based, development, and socioeconomic frames. Health promotion, intersectoral and multisectoral action, and evidence-based monitoring and assessment underpinned proposed interventions to improve education and awareness, support structural changes, and improve disease surveillance and monitoring. African policies insufficiently considered associations between food security and noncommunicable disease. In order to effectively address the noncommunicable disease burden, a paradigm shift from 'health for development' to 'development for health' is required across non-health sectors. Noncommunicable disease considerations should be included within African food security agendas, using malnutrition as a possible intermediary concept to motivate intersectoral action to improve access to nutritious food in African low-income to middle-income countries

Protocol for a Multi-Level Policy Analysis of Non-Communicable Disease Determinants of Diet and Physical Activity: Implications for Low- and Middle-Income Countries in Africa and the Caribbean.

Non-communicable diseases (NCDs) are the leading cause of death globally. Despite significant global policy development for addressing NCDs, the extent to which global policies find expression in low-and-middle income countries' (LMIC) policies, designed to mitigate against NCDs, is unclear. This protocol is part of a portfolio of projects within the Global Diet and Activity Research (GDAR) Network, which aims to support the prevention of NCDs in LMICs, with a specific focus on Kenya, Cameroon, South Africa and Jamaica. This paper outlines the protocol for a study that seeks to explore the current policy environment in relation to the reduction of key factors influencing the growing epidemic of NCDs. The study proposes to examine policies at the global, regional and country level, related to the reduction of sugar and salt intake, and the promotion of physical activity (as one dimension of healthy placemaking). The overall study will comprise several sub-studies conducted at a global, regional and country level in Cameroon, Kenya and South Africa. In combination with evidence generated from other GDAR workstreams, results from the policy analyses will contribute to identifying opportunities for action in the reduction of NCDs in LMICs

Immune response to hepatitis B vaccine following complete immunization of children attending two regional hospitals in the Southwest region of Cameroon: a cross sectional study.

BACKGROUND: Hepatitis B virus (HBV) infection despite being a vaccine preventable disease remains a global public health problem. In Cameroon, the hepatitis B vaccine was introduced in the expanded program on immunisation in 2005, but there has been limited evaluation of the HBV surface antibody response post vaccination. OBJECTIVE: We investigated the immune response to hepatitis B vaccine in infants who received the DPT-Hep B-Hib vaccine, and we assessed HBsAg carriage in non-responders. We also investigated factors associated with non-response or poor response. METHODS: Using a hospital based cross sectional design and a structured questionnaire over a four-month period (January to April 2019), we collected data to determine factors associated with hepatitis B surface antibody (anti-HBs) response from infants aged 6 to 9 months attending infant welfare clinics (IWC) at the Buea and Limbe regional hospitals. We collected venous blood and measured anti-HBs titres using a quantitative Foresight® ELISA. We entered and analysed data using EpiData version 3.1 and SPSS version 25 respectively. RESULTS: Of the 161 infants enrolled, 159 (98.8%) developed anti-HBs antibodies. Of these 159, 157 (97.5%) and 117 (72.7%) developed ≥ 10.0 mIU/ml (seroprotection) and ≥ 100.0 mIU/ml anti-HBs titres respectively. Being younger (6 months old) was associated with seroprotection (Cramer V = 0.322, p = 0.001). Spearman rho's relational analysis showed that immunity against HBV reduced as the duration since the last dose increased (r = -0.172; P = 0.029). However, a Firth logistic regression showed no significant association of factors with inadequate immunity. All 12 (7.5%) infants exposed to HBV at birth, received the hepatitis B vaccine at birth, including four who received HBIG, and all were protected. Four infants (2.5%) had anti-HBs titres < 10.0 mIU/mL (non-responders) but had no peculiarity. CONCLUSION: The seroprotective rate following hepatitis B vaccination of infants is high even in exposed infants. Our study suggests that Cameroon's HBV vaccine in the Expanded Program on Immunisation (EPI) is effective against HBV, although we could not account for the 2.5% non-response rate. Large scale studies are needed to further explore non-response to the vaccine

Health impacts of changes in travel patterns in Greater Accra Metropolitan Area, Ghana

Highlights • Increase in car trips can lead to 400 extra deaths and 20,500 YLL per year. • Rise in motorcycles can respond to 370 extra deaths and over 18,500 YLL per year. • Changes to bus trips can avert over 600 deaths and 31,500 YLL per year. • Road traffic fatalities were the largest contributor to changes in deaths and YLL.Background: Health impact assessments of alternative travel patterns are urgently needed to inform transport and urban planning in African cities, but none exists so far. Objective: To quantify the health impacts of changes in travel patterns in the Greater Accra Metropolitan Area, Ghana. Methods: We estimated changes to population exposures to physical activity, air pollution, and road traffic fatality risk and consequent health burden (deaths and years of life lost prematurely – YLL) in response to changes in transportation patterns. Five scenarios were defined in collaboration with international and local partners and stakeholders to reflect potential local policy actions. Results: Swapping bus and walking trips for car trips can lead to more than 400 extra deaths and 20,500 YLL per year than travel patterns observed in 2009. If part of the rise in motorisation is from motorcycles, we estimated an additional nearly 370 deaths and over 18,500 YLL per year. Mitigating the rise in motorisation by swapping long trips by car or taxi to bus trips is the most beneficial for health, averting more than 600 premature deaths and over 31,500 YLL per year. Without significant improvements in road safety, reduction of short motorised trips in favour of cycling and walking had no significant net health benefits as non-communicable diseases deaths and YLL benefits were offset by increases in road traffic deaths. In all scenarios, road traffic fatalities were the largest contributor to changes in deaths and YLL. Conclusions: Rising motorisation, particularly from motorcycles, can cause significant increase in health burden in the Greater Accra Metropolitan Area. Mitigating rising motorisation by improving public transport would benefit population health. Tackling road injury risk to ensure safe walking and cycling is a top priority. In the short term, this will save lives from injury. Longer term it will help halt the likely fall in physical activity

Analysis of Cameroon's Sectoral Policies on Physical Activity for Noncommunicable Disease Prevention.

Physical inactivity is increasing in low- and middle-income countries (LMICs), where noncommunicable diseases (NCDs), urbanisation and sedentary living are rapidly growing in tandem. Increasing active living requires the participation of multiple sectors, yet it is unclear whether physical activity (PA)-relevant sectors in LMICs are prioritising PA. We investigated to what extent sectors that influence PA explicitly integrate it in their policies in an LMIC such as Cameroon. We systematically identified policy documents relevant to PA and NCD prevention in Cameroon; and using the Walt and Gilson policy triangle we described, analysed, and interpreted the policy contexts, contents, processes, and actors. We found 17 PA and NCD policy documents spanning from 1974 to 2019 across seven ministries. Thirteen (13/17) policies targeted infrastructure improvement, and four (4/17) targeted communication for behaviour change, all aiming to enhance leisure domain PA. Only the health sector explicitly acknowledged the role of PA in NCD prevention. Notably, no policy from the transport sector mentioned PA. Our findings highlight the need for intersectoral action to integrate PA into policies in all relevant sectors. These actions will need to encompass the breadth of PA domains, including transport, while emphasising the multiple health benefits of PA for the population

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

Cycling behaviour in 17 countries across 6 continents : levels of cycling, who cycles, for what purpose, and how far?

International comparisons of cycling behaviour have typically been limited to high-income countries and often limited to the prevalence of cycling, with lack of discussions on demographic and trip characteristics. We used a combination of city, regional, and national travel surveys from 17 countries across the six continents, ranging from years 2009 through 2019. We present a descriptive analysis of cycling behaviour including level of cycling, trip purpose and distance, and user demographics, at the city-level for 35 major cities (>1 million population) and in urbanised areas nationwide for 11 countries. The Netherlands, Japan and Germany are among the highest cycling countries and their cities among the highest cycling cities. In cities and countries with high cycling levels, cycling rates tend to be more equal between work and non-work trips, whereas in geographies with low cycling levels, cycling to work is higher than cycling for other trips. In terms of cycling distance, patterns in high- and low-cycling geographies are more similar. We found a strong positive association between the level of cycling and women’s representation among cyclists. In almost all geographies with cycling mode share greater than 7% women made as many cycle trips as men, and sometimes even greater. The share of cycling trips by women is much lower in geographies with cycling mode shares less than 7%. Among the geographies with higher levels of cycling, children (60 years) remain underrepresented in all geographies but have relatively better representation where levels of cycling are high. In low-cycling settings, females are underrepresented across all the age groups, and more so when older than 16 years. With increasing level of cycling, representation of females improves across all the age groups, and most significantly among children and older adults. Clustering the cities and countries into homogeneous cycling typologies reveals that high cycling levels always coincide with high representation of females and good representations of all age groups. In low-cycling settings, it is the reverse. We recommend that evaluations of cycling policies include usage by gender and age groups as benchmarks in addition to overall use. To achieve representation across different age and gender groups, making neighbourhoods cycling friendly and developing safer routes to school, should be equally high on the agenda as cycling corridors that often cater to commuting traffic

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

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts

Abstract: Background: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. Partnership: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. Conclusion: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups

Modelling the health impacts of urban transport in Africa

Africa is rapidly urbanising and motorising, complicating its existing urban transport impacts such as high road traffic injuries, air pollution, and decreasing physical activity derived from walking and cycling. This situation highlights a need to develop healthy and sustainable urban transport systems on the continent. Modelling studies can help unpack the effects of urban transport plans and policies, thus facilitating evidence generation for policymaking. However, the use of modelling approaches in Africa is limited. This thesis aimed to increase understanding of the health impacts of changes in African urban transport systems through modelling. I started by exploring travel and physical activity behaviours and their data sources in selected African cities to elicit the context and address some challenges related to model data inputs from surveys. Secondly, I explored health integration in urban transport policies to gauge the transport sector’s commitment to supporting health goals and the range of meaningful modelling scenarios for engaging stakeholders in the African context. Thirdly, I reviewed modelling studies on transport health impacts to synthesise modelling approaches and guide model selection and adaptation. Finally, I modelled urban transport health impacts in five African cities for four scenarios: cycling, bus, car and motorcycle. Each scenario represented a 5% increase in the chosen transport mode. Surveys using travel and time-use diaries were valuable sources of travel behaviour data. Travel behaviour case studies from four cities, Nairobi and Kisumu (Kenya), Yaoundé (Cameroon), and Accra (Ghana), showed a wide variation of immobility and daily travel duration across cities, with walking as the primary mode and privately owned small-capacity public transport as the second. Motorcycles were also an essential component of public transportation in some cities. The physical activity case study from Accra showed high levels of background physical activity with a substantial contribution from transport. However, there was a significant disagreement between the Global Physical Activity Questionnaire and travel diary physical activity measurements, signalling precaution when using these crucial data sources for modelling. The policy analysis from Cameroon showed the integration of physical activity and non-communicable diseases in the policies of some sectors but not the transport sector, suggesting that modellers need simple illustrative scenarios to pitch transport health benefits to the naive transport sector. The systematic review identified several models in different contexts and various scenarios. Studies on the application of models in low-and middle-income countries were scarce, but overall review findings could guide transport health impact modelling in African cities. The modelling study in five African cities showed reduced adverse outcomes from shifts towards cycling and bus for public transport, mainly from gains in physical activity and reduction in air pollution, as road traffic fatalities were significant for the cycling scenario in some cities. Comparatively, car and motorcycle scenarios showed increased adverse outcomes from air pollution and physical inactivity, with additional road injuries for the motorcycle scenario across cities. The thesis sheds light on using relatively complex tools to elicit the health impacts of changes in urban transport in contexts with limited data, making a case for transport policies that favour active travel even in settings where active travel is already prevalent. It provides cross-city results, which help cities compare the effects of similar policies in different contexts, supporting collaboration amongst cities and increasing opportunities to learn from one another. Additionally, the thesis highlights our limited understanding of travel behaviour from available surveys and caveats in model adaptation as priority areas for future research