Young women's social support networks during pregnancy in Soweto, South Africa

BACKGROUND

Although studies from high-income countries have examined social support during pregnancy, it remains unclear what type of support is received by expectant mothers from low- and middle-income country settings.

AIM

To explore young women's social support networks during pregnancy in Soweto, South Africa.

SETTING

This study was undertaken in an academic hospital based in the Southwestern Townships (Soweto), Johannesburg, in Gauteng province, South Africa.

METHODS

An exploratory descriptive qualitative approach was employed. Eighteen (18) young pregnant women were recruited using a purposive sampling approach. In-depth interviews were conducted, and data were analysed using inductive thematic analysis.

RESULTS

Analysis of the data resulted in the development of two superordinate themes namely; (1) relationships during pregnancy and (2) network involvement. Involvement of the various social networks contributed greatly to the young women having a greater sense of potential parental efficacy and increased acceptance of their pregnancies. Pregnant women who receive sufficient social support from immediate networks have increased potential to embrace and give attention to pregnancy-related changes.

CONCLUSION

Focusing on less-examined characteristics that could enhance pregnant women's health could help in the reduction of deaths that arise because of pregnancy complications and contribute in globally accelerating increased accessibility to adequate reproductive health.Contribution: This study's findings emphasise the necessity for policymakers and healthcare providers to educate the broader community about the importance of partner, family and peer support to minimise risks that may affect pregnancy care and wellbeing of mothers.

Mobile Technology Use in Clinical Research Examining Challenges and Implications for Health Promotion in South Africa: Mixed Methods Study

BACKGROUND

The use of mobile technologies in fostering health promotion and healthy behaviors is becoming an increasingly common phenomenon in global health programs. Although mobile technologies have been effective in health promotion initiatives and follow-up research in higher-income countries and concerns have been raised within clinical practice and research in low- and middle-income settings, there is a lack of literature that has qualitatively explored the challenges that participants experience in terms of being contactable through mobile technologies.

OBJECTIVE

This study aims to explore the challenges that participants experience in terms of being contactable through mobile technologies in a trial conducted in Soweto, South Africa.

METHODS

A convergent parallel mixed methods research design was used. In the quantitative phase, 363 young women in the age cohorts 18 to 28 years were contacted telephonically between August 2019 and January 2022 to have a session delivered to them or to be booked for a session. Call attempts initiated by the study team were restricted to only 1 call attempt, and participants who were reached at the first call attempt were classified as contactable (189/363, 52.1%), whereas those whom the study team failed to contact were classified as hard to reach (174/363, 47.9%). Two outcomes of interest in the quantitative phase were "contactability of the participants" and "participants' mobile number changes," and these outcomes were analyzed at a univariate and bivariate level using descriptive statistics and a 2-way contingency table. In the qualitative phase, a subsample of young women (20 who were part of the trial for ≥12 months) participated in in-depth interviews and were recruited using a convenience sampling method. A reflexive thematic analysis approach was used to analyze the data using MAXQDA software (version 20; VERBI GmbH).

RESULTS

Of the 363 trial participants, 174 (47.9%) were hard to reach telephonically, whereas approximately 189 (52.1%) were easy to reach telephonically. Most participants (133/243, 54.7%) who were contactable did not change their mobile number. The highest percentage of mobile number changes was observed among participants who were hard to reach, with three-quarters of the participants (12/16, 75%) being reported to have changed their mobile number ≥2 times. Eight themes were generated following the analysis of the transcripts, which provided an in-depth account of the reasons why some participants were hard to reach. These included mobile technical issues, coverage issues, lack of ownership of personal cell phones, and unregistered number.

CONCLUSIONS

Remote data collection remains an important tool in public health research. It could, thus, serve as a hugely beneficial mechanism in connecting with participants while actively leveraging the established relationships with participants or community-based organizations to deliver health promotion and practice.

Associations Between Changes in 24-Hour Movement Behaviors in Children and Adolescents During the COVID-19 Pandemic: A Systematic Review and Mediation-Based Meta-Analysis

BACKGROUND

Although 24-hour movement behaviors are known to be interconnected, limited knowledge exists about whether change in one behavior during the COVID-19 pandemic (eg, increased screen time) was associated with change in another (eg, reduced physical activity or sleep). This review estimates mediational associations between changes in children's physical activity, screen time, and sleep during the COVID-19 pandemic.

METHODS

We included studies published between January 1, 2020 and June 27, 2022, in the PubMed/MEDLINE, Embase, PsycINFO, SPORTDiscus, and Web of Science databases. Summary data were extracted from included studies and analyzed with random-effects meta-regression.

RESULTS

This review included 26 studies representing 18,959 children across 18 mid-high-income countries (53% male; mean age, 11.5 [2.9] y). There was very good evidence of decreased total daily physical activity (factor change, 0.62; 90% CI, 0.47-0.81) and strong evidence of increased screen time (1.56; 90% CI, 1.38-1.77). There was very good evidence of decreased moderate to vigorous physical activity (0.75; 90% CI, 0.62-0.90) and weak evidence of increased sleep (1.02; 90% CI, 1.00-1.04). Mediational analysis revealed strong evidence that most of the reduction in total daily physical activity from before, to during, the pandemic was associated with increased screen time (0.53; 90% CI, 0.42-0.67). We observed no further mediational associations.

CONCLUSION

Increased reliance on and use of screen-based devices during the COVID-19 pandemic can be linked with reduced child and adolescent physical activity. This finding links COVID-related restrictions to potential displacement effects within child and adolescent 24-hour movement behavior.

Principles for Adapting Assessments of Executive Function across Cultural Contexts

Direct assessments of executive functions (EFs) are increasingly used in research and clinical settings, with a central assumption that they assess "universal" underlying skills. Their use is spreading globally, raising questions about the cultural appropriateness of assessments devised in Western industrialized countries. We selectively reviewed multidisciplinary evidence and theory to identify sets of cultural preferences that may be at odds with the implicit assumptions of EF assessments. These preferences relate to motivation and compliance; cultural expectations for interpersonal engagement; contextualized vs. academic thinking; cultural notions of speed and time; the willingness to be silly, be incorrect, or do the opposite; and subject-matter familiarity. In each case, we discuss how the cultural preference may be incompatible with the assumptions of assessments, and how future research and practice can address the issue. Many of the cultural preferences discussed differ between interdependent and independent cultures and between schooled and unschooled populations. Adapting testing protocols to these cultural preferences in different contexts will be important for expanding our scientific understanding of EF from the narrow slice of the human population that has participated in the research to date.

A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial

Community health workers (CHWs) play an important role in health systems in low- and middle-income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants' socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges. Trial registration: Pan African Clinical Trials Registry; PACTR201903750173871, Registered March 27, 2019.

The role of a community health worker-delivered preconception and pregnancy intervention in achieving a more positive pregnancy experience: the Bukhali trial in Soweto, South Africa

BACKGROUND

A patient-centered, human-rights based approach to maternal care moves past merely reducing maternal mortality and morbidity, towards achieving a positive pregnancy experience. When evaluating an intervention, particularly in the context of the complex challenges facing maternal care in South Africa, it is therefore important to understand how intervention components are experienced by women. We aimed to qualitatively explore (i) factors influencing the pregnancy and postpartum experience amongst young women in Soweto, South Africa, and (ii) the influence of Bukhali, a preconception, pregnancy, and early childhood intervention delivered by community health workers (CHWs), on these experiences.

METHODS

Semi-structured, in-depth interviews were conducted with 15 purposively sampled participants. Participants were 18-28-year-old women who (i) were enrolled in the intervention arm of the Bukhali randomized controlled trial; (ii) were pregnant and delivered a child while being enrolled in the trial; and (iii) had at least one previous pregnancy prior to participation in the trial. Thematic analysis, informed by the positive pregnancy experiences framework and drawing on a codebook analysis approach, was used.

RESULTS

The themes influencing participants' pregnancy experiences (aim 1) were participants' feelings about being pregnant, the responsibilities of motherhood, physical and mental health challenges, unstable social support and traumatic experiences, and the pressures of socioeconomic circumstances. In terms of how support, information, and care practices influenced these factors (aim 2), four themes were generated: acceptance and mother/child bonding, growing and adapting in their role as mothers, receiving tools for their health, and having ways to cope in difficult circumstances. These processes were found to be complementary and closely linked to participant context and needs.

CONCLUSION

Our findings suggest that, among women aged 18-28, a CHW-delivered intervention combining support, information, and care practices has the potential to positively influence women's pregnancy experience in South Africa. In particular, emotional support and relevant information were key to better meeting participant needs. These findings can help define critical elements of CHW roles in maternal care and highlight the importance of patient-centred solutions to challenges within antenatal care.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201903750173871, 27/03/2019.

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

Inadequate Access to Potable Water Impacts Early Childhood Development in Low-Income Areas in Cape Town, South Africa

Background

Water and sanitation are vital to human health and well-being. While these factors have been studied in relation to health, very little has been done to consider such environmental risk factors with child development. Here, we investigated possible relations between household water access/storage and early childhood development in four low-income settlements in the City of Cape Town, Western Cape province of South Africa. Our objectives were 1) to determine water access/storage practices in dwellings of children; 2) to assess early childhood development; and 3) and to understand the relationship between water access/storage practices in relation to early childhood development.

Methods

We used a questionnaire to assess household water risk factors and the International Development and Early Learning Assessment (IDELA) tool to assess child early learning / cognitive, socio-emotional and motor development.

Results

Mean age of the children (N = 192) was 4 years and 55% were female. The mean IDELA score was 48% (range: 36-54%) where the higher the score, the better the child's development. Around 70% of households had a tap inside their dwelling and half said that they stored water with the largest percentage of storage containers (21%) being plastic/no lid. Child IDELA scores were lower for children living in households that did not have an indoor tap and for households who stored water.

Conclusions

Given the risks associated with climate change and the already poor conditions many children face regarding water and sanitation, research is needed to further investigate these relations to provide evidence to support appropriate interventions and ensure healthy child development.

Navigating relationship dynamics, pregnancy and fatherhood in the Bukhali trial: a qualitative study with men in Soweto, South Africa

BACKGROUND

South Africa has a complex range of historical, social, political, and economic factors that have shaped fatherhood. In the context of the Bukhali randomised controlled trial with young women in Soweto, South Africa, a qualitative study was conducted with the male partners of young women who had become pregnant during the trial. This exploratory study aimed to explore individual perceptions around relationship dynamics, their partner's pregnancy, and fatherhood of partners of young women in Soweto, South Africa.

METHODS

Individual, in-depth interviews were conducted with male partners (fathers, n = 19, 25-46 years old) of Bukhali participants. A thematic approach was taken to the descriptive and exploratory process of analysis, and three final themes and subthemes were identified: (1) relationship dynamics (nature of relationship, relationship challenges); (2) pregnancy (feelings about the pregnancy, effect of the pregnancy on their relationship, providing support during pregnancy; and 3) fatherhood (view of fatherhood, roles of fathers, influences on views and motivation, challenges of fatherhood).

RESULTS

While most male participants were in a committed ("serious") relationship with their female partner, less than half of them were cohabiting. Most reported that their partner's pregnancy was not planned, and shared mixed feelings about the pregnancy (e.g., happy, excited, shocked, nervous), although their views about fatherhood were overwhelmingly positive. Many were concerned about how they would economically provide for their child and partner, particularly those who were unemployed. Participants identified both general and specific ways in which they provided support for their partner, e.g., being present, co-attending antenatal check-ups, providing material resources. For many, the most challenging aspect of fatherhood was having to provide financially. They seemed to understand the level of responsibility expected of them as a father, and that their involvement and presence related to love for and connection with their child. Participants' responses indicated that there were some changes in the norms around fatherhood, suggesting that there is a possibility for a shift in the fatherhood narrative in their context.

CONCLUSIONS

These findings suggest that the complex array of factors influencing fatherhood in South Africa continue to play out in this generation, although promising changes are evident.

Climate change is a threat multiplier for violence against children

BACKGROUND

The climate crisis is the biggest threat to the health, development, and wellbeing of the current and future generations. While there is extensive evidence on the direct impacts of climate change on human livelihood, there is little evidence on how children and young people are affected, and even less discussion and evidence on how the climate crisis could affect violence against children.

PARTICIPANTS AND SETTING

In this commentary, we review selected research to assess the links between the climate crisis and violence against children.

METHODS

We employ a social-ecological perspective as an overarching framework to organize findings from the literature and call attention to increased violence against children as a specific, yet under-examined, direct and indirect consequence of the climate crisis.

RESULTS

Using such a perspective, we examine how the climate crisis exacerbates the risk of violence against children at the continually intersecting and interacting levels of society, community, family, and the individual levels. We propose increased risk of armed conflict, forced displacement, poverty, income inequality, disruptions in critical health and social services, and mental health problems as key mechanisms linking the climate crisis and heightened risk of violence against children. Furthermore, we posit that the climate crisis serves as a threat multiplier, compounding existing vulnerabilities and inequities within populations and having harsher consequences in settings, communities, households, and for children already experiencing adversities.

CONCLUSIONS

We conclude with a call for urgent efforts from researchers, practitioners, and policymakers to further investigate the specific empirical links between the climate crisis and violence against children and to design, test, implement, fund, and scale evidence-based, rights-based, and child friendly prevention, support, and response strategies to address violence against children.

Executive functioning skills and their environmental predictors among pre-school aged children in South Africa and The Gambia

Executive functions (EFs) in early childhood are predictors of later developmental outcomes and school readiness. Much of the research on EFs and their psychosocial correlates has been conducted in high-income, minority world countries, which represent a small and biased portion of children globally. The aim of this study is to examine EFs among children aged 3-5 years in two African countries, South Africa (SA) and The Gambia (GM), and to explore shared and distinct predictors of EFs in these settings. The SA sample (N = 243, 51.9% female) was recruited from low-income communities within the Cape Town Metropolitan area. In GM, participants (N = 171, 49.7% female) were recruited from the rural West Kiang region. EFs, working memory (WM), inhibitory control (IC) and cognitive flexibility (CF), were measured using tablet-based tasks. Associations between EF task performance and indicators of socioeconomic status (household assets, caregiver education) and family enrichment factors (enrichment activities, diversity of caregivers) were assessed. Participants in SA scored higher on all EF tasks, but children in both sites predominantly scored within the expected range for their age. There were no associations between EFs and household or familial variables in SA, except for a trend-level association between caregiver education and CF. Patterns were similar in GM, where there was a trend-level association between WM and enrichment activities but no other relationships. We challenge the postulation that children in low-income settings have poorer EFs, simply due to lower socioeconomic status, but highlight the need to identify predictors of EFs in diverse, global settings. RESEARCH HIGHLIGHTS: Assessed Executive Functioning (EF) skills and their psychosocial predictors among pre-school aged children (aged 3-5 years) in two African settings (The Gambia and South Africa). On average, children within each setting performed within the expected range for their age, although children in South Africa had higher scores across tasks. There was little evidence of any association between socioeconomic variables and EFs in either site. Enrichment activities were marginally associated with better working memory in The Gambia, and caregiver education with cognitive flexibility in South Africa, both associations were trend-level significance.

A Cross-Sectional Study of the Associations between Biomarkers of Vitamin D, Iron Status, and Hemoglobin in South African Women of Reproductive Age: the Healthy Life Trajectories Initiative, South Africa

Background

Vitamin D deficiency and anemia impact the health of women of reproductive age. Evidence suggests an inverse relationship between serum vitamin D (25-hydroxyvitamin D [25(OH)D]) and anemia/iron deficiency, but less is known about these associations in women of reproductive age, in particular in a setting with a combined burden of micronutrient deficiency, food insecurity, and obesity.

Objective

We aimed to assess the associations between 25(OH)D and biomarkers of iron and anemia in a cohort of women of reproductive age from Soweto, South Africa. The prevalence of vitamin D deficiency was also assessed.

Methods

In this cross-sectional substudy of the Healthy Life Trajectories Initiative (HeLTI) South Africa pilot trial, 25(OH)D, iron markers (ferritin and soluble transferrin receptor [sTFR]), and altitude-adjusted hemoglobin (Hb) were measured in 493 women aged 18 to 25 years. Associations between iron deficiency/anemia and vitamin D status were evaluated using multivariable logistic regression, adjusting for confounders including fat mass index (FMI). Structural equation modeling (SEM) was performed to evaluate direct and indirect pathways between 25(OH)D, iron and anemia markers, and covariates.

Results

Of 493 participants, 136 (27.6%) had vitamin D insufficiency (25(OH)D ≥12-20 ng/mL), whereas 28 (5.6%) had vitamin D deficiency (<12 ng/mL). Anemia and iron deficiency were not significantly associated with vitamin D category (25(OH)D<20 ng/mL compared with ≥20 ng/mL) in multivariable logistic regression analyses. In SEM, log-transformed 25(OH)D was not significantly associated with Hb, ferritin, or sTFR, but it was significantly associated with season of data collection, hormonal contraceptive use, and FMI (total effects: B = 0.17, 95% CI: 0.104, 0.236, P < 0.001; B: 0.10, 95% CI: 0.041, 0.154, P < 0.001; B: -0.01, 95%CI: -0.016, -0.003, P = 0.003, respectively).

Conclusion

No significant association between vitamin D (25(OH)D), anemia (Hb), and iron markers was found. The inverse relationship between FMI and vitamin D status emphasizes the overlap between adiposity and micronutrient deficiencies in young South African women, exacerbating their risk of disease development.

Perceptions of the COVID-19 pandemic: a qualitative study with South African adults

INTRODUCTION

In South Africa, public perceptions of the COVID-19 pandemic and risk mitigation measures remain mixed. To better understand health behaviours in the context of COVID-19, a qualitative study was conducted, which aimed to investigate perceptions relating to the COVID-19 pandemic among the South African adult population.

METHODS

Twelve online focus groups were conducted across the following age groups: 18-34, 35-54, 55 + years old (total n = 70) in December 2021. Diversity across socioeconomic status, geographical areas, and urban and rural settings was maximised, with an equal representation of men and women. Focus groups were conducted, and audio recorded using an online platform, transcribed verbatim and thematically analysed using MAXQDA.

RESULTS

There were mixed perceptions around the pandemic, however, the majority of participants appreciated government actions at the onset of the pandemic and as a result government trust was reported to have initially been high. Nevertheless, as the pandemic progressed, challenges relating to government communication around the pandemic, the inconsistent application of preventative measures by government, the use of soldiers to enforce preventative measures, the banning of alcohol and cigarettes, government corruption and the pervasiveness of social media were reported to have eroded government trust, negatively impacting the uptake of preventative measures. Economic and psychological impacts were experienced differently across income groups. Low-income earners, who already had pre-existing economic challenges reported increased psychological and financial strain. While the once cushioned middle class reported an increase in job insecurity accompanied by psychological challenges. High income earners did not report economic challenges but reported being affected psychologically. Though, low-income earners reported an appreciation of the government financial relief afforded to them middle income earners appeared to not have received adequate financial support.

CONCLUSION

With the existing mistrust of government, there is need for government to leverage existing trusted sources in communities to aid in the implementation of preventative measures. These findings support the development of context specific solutions to address challenges faced at different socioeconomic levels.

Effectiveness of behavioural interventions to influence COVID-19 outcomes: A scoping review

Behavioural non-pharmaceutical interventions (NPIs) (e.g., mask wearing, quarantine, restriction on gatherings, physical distancing) have been used to interrupt transmission of COVID-19 and to reduce the impacts of the pandemic. The aim of this scoping review was to document the efficacy of behavioural NPIs to positively influence COVID-19 outcomes. Following PRISMA guidelines, a systematic search was conducted of PubMed, ScienceDirect, Psych INFO, Medline, CINAHL and Scopus for studies published between January 2020 and February 2023. Seventy -seven studies were eligible to be included in the review. Majority of the studies were conducted in high-income countries, with fewer studies in low- or middle-income countries. School closure, mask wearing, and non-essential business closure and shelter-in-place orders were the most prevalent NPIs investigated. School closure and mask wearing reported high effectiveness while shelter-in-place orders reported less effectiveness. Shelter-in-place orders when used in conjunction with other measures, did not enhance effectiveness. Public event bans, physical distancing, handwashing, and travel restrictions were largely effective, while the effectiveness of gathering restrictions depended on the limitation on numbers. Early implementation was associated with a higher effectiveness in reducing COVID-19 cases and deaths, the use of behavioural NPIs in combinations was reported to yield more effective results. Moreover, behavioural NPIs were reported to be dependent on their consistent use and were difficult behaviours to maintain, highlighting the need for behavioural change. This review highlighted the effectiveness of behavioural NPIs to positively influence COVID-19 reduction outcomes. Further research to promote country- and context-specific documents that will enhance the effectiveness of behavioural NPIs.

Development, Implementation, and Process Evaluation of Bukhali: An Intervention from Preconception to Early Childhood

The Healthy Life Trajectories Initiative, an international consortium developed in partnership with the World Health Organization, is addressing childhood obesity from a life-course perspective. It hypothesises that an integrated complex intervention from preconception, through pregnancy, infancy and early childhood, will reduce childhood adiposity and non-communicable disease risk, and improve child development. As part of the Healthy Life Trajectories Initiative in South Africa, the Bukhali randomised controlled trial is being conducted with 18–28-year-old women in Soweto, where young women face numerous challenges to their physical and mental health. The aims of this paper were to describe the intervention development process (including adaptations), intervention components, and process evaluation; and to highlight key lessons learned. Intervention materials have been developed according to the life-course stages: preconception (Bukhali), pregnancy (Bukhali Baby), infancy (Bukhali Nana; birth—2 years), and early childhood (Bukhali Mntwana, 2–5 years). The intervention is delivered by community health workers, and includes the provision of health literacy resources, multi-micronutrient supplementation, in-person health screening, services and referral, nutrition risk support, SMS-reminders and telephonic contacts to assist with behaviour change goals. A key adaption is the incorporation of principles of trauma-information care, given the mental health challenges faced by participants. The Bukhali process evaluation is focussing on context, implementation and mechanisms of impact, using a mixed methods approach. Although the completion of the trial is still a number of years away, the documentation of the intervention development process and process evaluation of the trial can provide lessons for the development, implementation, and evaluation of such complex life-course trials.

The voices of children on movement behaviours: implications for promoting international guidelines to support obesity-prevention efforts

BACKGROUND

As a key factor for the prevention of childhood obesity, WHO recommends a specific balance of movement behaviours (ie, physical activity, sedentary behaviour, and sleep) across the 24-h day for children younger than 5 years. Substantial evidence underpins our understanding of the benefits for healthy growth and development; however, little is known about young children's experiences and perceptions, and whether context-specific factors that might influence movement behaviours differ across the globe.

METHODS

Acknowledging children's agency as knowledgeable informants on matters affecting their lives, children aged 3-5 years from communities and preschools in urban and rural Australia, Chile, China, India, Morocco, and South Africa, were interviewed. Discussions were based on a socioecological framework of the multifactorial, complex influences on young children's movement behaviours. Prompts were adapted to ensure relevance across diverse study sites. Ethics approval and guardian consent were obtained, and the Framework Method used for analysis.

FINDINGS

156 children (101 [65%] from urban areas, 55 [45%] from rural areas; 73 [47%] female, 83 [53%] male) shared their experiences, perceptions, and preferences related to movement behaviours and the barriers and enablers of outdoor play. Physical activity, sedentary behaviour, and to a lesser degree screen time occurred predominantly through play. Barriers to outdoor play included weather, air quality, and safety concerns. Sleep routines varied considerably and were influenced by room or bed sharing. Screen use was ubiquitous, presenting a challenge to meeting recommendations. The effect of daily structure, degree of autonomy, and interactions were consistent themes, and differences in how these factors influenced movement behaviours across study sites were evident.

INTERPRETATION

The findings highlight that although movement behaviour guidelines are universal, contextual realities need to be considered in how socialisation and promotion of the guidelines are enacted. How young children's sociocultural and physical environments are constructed and influenced can foster or disrupt healthy movement behaviours, which might have implications for childhood obesity.

FUNDING

Beijing High Level Talents Cultivation Project for Public Health Academic Leader; Beijing Medical Research Institute (Public service development and reform pilot project); British Academy for the Humanities and Social Sciences; KEM Hospital Research Centre; Ministry of Education and Universidad de La Frontera (Innovation in Higher Education Program); and National Health and Medical Research Council (Investigator Grant Leadership Fellow, Level 2).

Evaluating implementation of the FIGO Nutrition Checklist for preconception and pregnancy within the Bukhali trial in Soweto, South Africa

OBJECTIVE

To evaluate implementation of the FIGO Nutrition Checklist in a low/middle-income South African setting.

METHODS

This is a mixed-methods study. Following administration of the FIGO Nutrition Checklist by a dietitian between July 2021 and May 2022, quantitative responses from pregnant (n = 96) and nonpregnant (n = 291) participants with overweight or obesity were analyzed, using logistic regression. Qualitative data from in-depth interviews with the dietitian and a subgroup of participants (n = 15) were analyzed using reflexive thematic analysis.

RESULTS

Of 387 participants, 97.4% (n = 377) answered 'no' to at least one diet quality question on the FIGO Nutrition Checklist, indicative of an at-risk dietary practice. Food insecurity was positively associated with having more than three at-risk practices (OR 1.87; 95% CI, 1.10-3.18; P = 0.021). Themes from the dietitian interview included ease of use of the checklist; required adaptations to it, including explanation and translation; and benefits of the tool. Despite challenges to healthy nutrition, participant interviews identified that the checklist is acceptable and supported improved awareness of dietary intakes.

CONCLUSION

Considering the high incidence of at-risk dietary practices identified by the FIGO Nutrition Checklist in this population, further research into use of the tool across South African healthcare settings is warranted.

Employee perceptions of non-communicable diseases health risks, absenteeism and the role of organisational support in a South African pharmaceutical manufacturing company

BACKGROUND

The growing prevalence of non-communicable diseases (NCDs) in South African workers has been shown to be associated with absenteeism and increased risk of morbidity. Low-income workers living in urban settings are particularly vulnerable. Consultation with workers is crucial for understanding risks and identifying opportunities for intervention to promote health in the workplace. The purpose of this study was to examine South African pharmaceutical manufacturing workers' perspectives of health risk factors and absenteeism, and to identify how they perceived a role for the organisation to initiate interventions to improve their health.

MATERIALS AND METHODS

Five focus groups were conducted to capture 27 employees' perspectives. The semi-structured focus group discussions were recorded and analysed using a thematic content analysis approach.

RESULTS

Participants indicated that they were aware of behavioural health risks such as prolonged sitting. They showed insight into strategies to prevent injuries and stay healthy, but also expressed dissatisfaction about the lack of organisational support, leading to stress and consequently absenteeism. Participants emphasized the responsibility of the organisation to support a range of health promoting strategies.

CONCLUSIONS

The findings of this study are important for cultivating a tailored workplace intervention to reduce NCD risk factors in the pharmaceutical manufacturing workforce. It is vital that these be supported by leadership of the company through the provision of funding and the development of internal healthcare services.

Child exposure to violence and self-regulation in South African preschool-age children from low-income settings

Biological and psychosocial stressors that have been associated with income include family dynamics such as household chaos, family conflict, maternal depression, harsh parenting, lower parental responsiveness, and exposure to violence. Research from high income countries has shown that exposure to violence may have detrimental effects on children's self-regulation, with possible flow-on implications for broad later-life outcomes, but less is known about such links in low- and- middle income countries, where many children live in violent communities and households and where physical punishment remains the norm. This study aimed to investigate exposure to violence, in addition to coercive parenting, and its associations with self-regulation among 243 3- to 5-year-olds (M = 4.7 ± 0.6; 51.9 % female) from low-income settings in Cape Town and who were not attending Early Childhood Care and Education (ECCE). Results showed that self-regulation was not associated with child exposure to community violence, but it was positively associated with coercive parenting (β = 0.17; p = 0.03). The null concurrent associations between exposure to violence and self-regulation suggest the need for additional research aimed at understanding later potential developmental sequelae. It is important that findings regarding coercive parenting are contextualised within local social norms around parenting styles, as well as the influence of living in dangerous communities on parenting practices.

Interventions to promote development in the next 1000 days: A mapping review

The next 1000 days - the period from 2 to 5 years of age - has been highlighted as a key developmental stage in the life-course. A mapping review was conducted to categorize existing literature on interventions in the next 1000 days that promote key developmental outcomes, including publications between 1990 and July 2020. A total of 805 intervention studies were included for data extraction in the review. The number of intervention studies has increased substantially from 2010. Most interventions were from high-income countries, with few (5%) from low- and lower-middle-income countries. Interventions including typically developing children (n = 593, 74%) were mostly (80%) implemented in early childhood care and education (ECCE) settings, with 15% taking place in the home or with families and 5% in community or healthcare settings. Children's literacy and language outcomes were the target of 27% of these interventions, while 25% of interventions targeted early childhood development more holistically or targeted multiple developmental domains. Social-emotional development and social skills were the target of 15% of interventions, motor development 13%, numeracy 8% and cognitive development 8%. For children with any developmental delay, disability, disease or exposure (n = 212), interventions frequently targeted Autism Spectrum Disorder (24%), language or literacy delays (21%), developmental delays or disability more generally (20%); 16% targeted behavioral (or conduct) problems; and 5% targeted attention deficit hyperactivity disorder. Almost half (49%) took place in ECCE settings; 24% occurred in the home or with families, or in community (13%) and/or healthcare (14%) settings. This review highlights the need for more intervention research in low- and middle-income countries and for interventions supporting development in the next 1000 days. While the evidence base for interventions to promote development in this age group continues to expand, the most vulnerable children are not benefiting from this evidence.

The prevalence of probable depression and probable anxiety, and associations with adverse childhood experiences and socio-demographics: A national survey in South Africa

Objective and methods

Mental health problems among adults are a growing public health concern, and middle-income countries such as South Africa are disproportionally affected. Using a large scale nationally representative weighted survey, we assessed the prevalence of probable depression, probable anxiety, and adverse childhood experiences (ACEs), and explored associations between probable depression, probable anxiety, ACEs, socio-economic status, and demographic characteristics.

Results

Nationally, 25.7, 17.8, and 23.6% of respondents, respectively, reported scores of ≥10 on the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), indicating probable depression or probable anxiety, and an ACE score of ≥4 (high exposure). Overall probable depression prevalence across South Africa varied from 14.7 to 38.8%. Both probable depression and probable anxiety were more frequently reported among adults who were: retired and older (>65 years of age), and widowed, divorced, or separated; living in metropolitan areas; and only had primary school education. In a multivariable adjusted logistic regression, the likelihood of reporting probable depression or probable anxiety was also found to increase with each standard deviation increase in the ACE score (p < 0.001), independent of other socio-demographic determinants.

Conclusion

The prevalence of probable depression among respondents in South Africa varies significantly across the nine provinces. Furthermore, higher ACE score and several socio-demographic determinants were associated with a higher likelihood of probable depression and probable anxiety. Adult mental health services are urgently needed to identify groups of the population vulnerable to mental health problems for better targeting of interventions. Given the range of probable depression prevalence across the country, provincial level plans and resources should also reflect the burden of mental health problems in that province.

A protocol for monitoring fidelity of a preconception-life course intervention in a middle-income setting: the Healthy Life Trajectories Initiative (HeLTI), South Africa

Introduction

Despite the importance of intervention fidelity in interpreting the outcomes of complex public health interventions, there is a lack of both reporting fidelity trial protocols and uniformity. In evaluating complex, adaptable/pragmatic interventions in resource-strapped settings with systemic issues, unique challenges to intervention adherence and monitoring are introduced, increasing the importance of a fidelity protocol. We aim to describe the intervention fidelity and monitoring protocol for the Healthy Life Trajectories Initiative (HeLTI) South Africa, a complex four-phase intervention set in urban Soweto, starting preconceptionally and continuing through to pregnancy, infancy, and early childhood to improve the health of young women and reduce the intergenerational risk of obesity.

Methods

The HeLTI SA fidelity protocol was based on the NIH Behaviour Change Consortium (NIH BCC) Treatment Fidelity Framework, outlining the following components of intervention fidelity: study design, provider training, intervention delivery, intervention receipt, and intervention enactment. Context-specific fidelity challenges were identified. The intervention fidelity components and associated monitoring strategies were developed to align with HeLTI SA. Strategies for fidelity monitoring include, amongst others, qualitative process evaluation methods, reviewing observed and recorded intervention sessions, monitoring of activity logs, standardized training, and intervention session checklists. Possible challenges to fidelity and fidelity monitoring include high provider turnover, lack of qualification amongst providers, difficulty tracing participants for follow-up sessions, participant health literacy levels, and the need to prioritize participants’ non-health-related challenges. Solutions proposed include adapting intervention delivery methods, recruitment methods, and provider training methods.

Discussion

The NIH BCC Treatment Fidelity Framework provided a solid foundation for reporting intervention fidelity across settings to improve intervention validity, ability to assess intervention effectiveness, and transparency. However, context-specific challenges to fidelity (monitoring) were identified, and transparency around such challenges and possible solutions in low- and middle-income settings could help foster solutions to improve adherence, reporting, and monitoring of intervention fidelity in this setting.

Trial registration

Pan African Clinical Trials Registry PACTR201903750173871. Registered on 27 March 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06696-w.

Global Changes in Child and Adolescent Physical Activity During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

IMPORTANCE

Numerous physical distancing measures were implemented to mitigate the spread of the COVID-19 virus, which could have negatively affected child and adolescent physical activity levels.

OBJECTIVES

To conduct a systematic review and meta-analysis of the literature that used validated measures to document changes in child and adolescent physical activity during the COVID-19 pandemic and to estimate whether changes in physical activity differed between participant-level, contextual, and methodological moderators.

DATA SOURCES

PubMed, PsycInfo, SPORTDiscus, Web of Science, Scopus, CINAHL, and MEDLINE were searched (from January 1, 2020, to January 1, 2022). A total of 1085 nonduplicate records were retrieved.

STUDY SELECTION

Studies were included if they reported (1) changes in the duration of physical activity at any intensity for children or adolescents (age ≤18 years) comparing before and during the COVID-19 pandemic using validated physical activity measurement tools and were (2) from general population samples, (3) peer-reviewed, and (4) published in English.

DATA EXTRACTION AND SYNTHESIS

A total of 126 articles underwent full-text review. Data were analyzed using a random-effects meta-analysis, which was conducted in January 2022.

MAIN OUTCOMES AND MEASURES

Change in the duration of engagement in physical activity at any intensity comparing before and during COVID-19.

RESULTS

Twenty-two studies including 46 independent samples and 79 effect sizes from 14 216 participants (median age, 10.5 years; range, 3-18 years) were included. The percentage change in the duration of engagement in total daily physical activity from before to during COVID-19 was -20% (90% CI, -34% to -4%). Moderation analyses revealed that changes were larger for higher-intensity activities (-32%; 90% CI, -44% to -16%), corresponding to a 17-minute reduction in children's daily moderate-to-vigorous physical activity levels. The reduction in physical activity was also larger for samples located at higher latitudes (37%; 90% CI, -1% to 89%) and for studies with a longer duration between physical activity assessments (25%; 90% CI, -0.5% to 58%).

CONCLUSIONS AND RELEVANCE

Children and adolescents have experienced measurable reductions in physical activity during the COVID-19 pandemic. Findings underscore the need to provide bolstered access to support and resources related to physical activity to ensure good health and social functioning among children and adolescents during pandemic recovery efforts.

Evaluation of a Text Messaging Intervention to Promote Preconception Micronutrient Supplement Use: Feasibility Study Nested in the Healthy Life Trajectories Initiative Study in South Africa

Background

Social messaging strategies such as SMS text messaging and radio are promising avenues for health promotion and behavior change in low- to middle-income settings. However, evidence of their acceptability, feasibility, and impact in the context of young women’s health and micronutrient deficiencies is lacking.

Objective

This study aimed to evaluate the feasibility of an automated 2-way text messaging intervention nested in an ongoing preconception health trial, the Healthy Life Trajectories Initiative (HeLTI; HeLTI Bukhali) in Soweto, South Africa. Second, we aimed to evaluate the acceptability of a health promotion radio serial, which aired concurrently in the region.

Methods

In this feasibility study, 120 participants enrolled in HeLTI Bukhali between November 2020 and February 2021 received the 6-month 2-way text messaging intervention. Quantitative and qualitative data on intervention acceptability, usability, interaction, perceived benefit, and fidelity were collected during 5 focus group discussions (FGDs) and from study data logs. During the FGDs, data were collected on the acceptability of the radio serial. Following the text messaging intervention, capillary hemoglobin levels were assessed, and a participant questionnaire provided information on adherence and attitudes toward supplements. The text messaging control group comprised the first 120 women recruited from November 2019 to February 2020, who received the Bukhali intervention but not the text messages. Statistical significance testing and a linear mixed model were used for indicative effect comparisons between the text message–receiving and control groups.

Results

The text messaging intervention was found to be acceptable and to have perceived benefits, including being reminded to take supplements, gaining knowledge, and feeling supported by the study team. The use of the 2-way text messaging reply function was limited, with only a 10.8% (13/120) response rate by week 24. Barriers to replying included a lack of interest or phone credit and technical issues. Regarding the indicative effect, participants receiving the text messages had higher self-reported adherence at follow-up than the text messaging control group (42/63, 67% vs 33/85, 39% taking supplements every time; P=.02), and altitude-adjusted hemoglobin increased more between baseline and follow-up in the SMS text message–receiving group than in the text messaging control group (1.03, 95% CI 0.49-1.57; P<.001). The radio serial content was acceptable, although few participants reported exposure before the FGD.

Conclusions

Women reported that the text messaging intervention was useful and described the benefits of receiving the messages. Examination of hemoglobin status indicated a promising beneficial effect of text messaging support on adherence to micronutrient supplementation, requiring further exploration through randomized controlled studies. Health promotion through radio and text messages were both found to be acceptable, although more research into the radio serial reach among young women is needed.

Trial Registration

Pan African Clinical Trials Registry (PACTR) PACTR201903750173871; https://tinyurl.com/4x6n32ff

Cross-sectional associations between mental health indicators and social vulnerability, with physical activity, sedentary behaviour and sleep in urban African young women

Background

Relationships between mental health and multiple health behaviours have not been explored in young South African women experiencing social constraints. The aim of this study was to identify associations between mental health indicators and risk factors with physical activity, sedentary behaviour, and sleep, amongst young women living in Soweto, a predominantly low-income, urban South African setting.

Methods

For this cross-sectional study, baseline measurements for participants (n = 1719, 18.0–25.9 years old) recruited for the Healthy Life Trajectories Initiative were used including: physical activity, sedentary behaviour (sitting, screen and television time), sleep (duration and quality), depression and anxiety indicators, emotional health, adverse childhood experiences, alcohol-use risk; social vulnerability, self-efficacy, and social support.

Results

Multiple regression analyses showed that depression (β = 0.161, p < 0.001), anxiety (β = 0.126, p = 0.001), adverse childhood experiences (β = 0.076, p = 0.014), and alcohol-use risk (β = 0.089, p = 0.002) were associated with poor quality sleep. Alcohol-use risk was associated with more screen time (β = 0.105, p < 0.001) and television time (β = 0.075, p < 0.016). Social vulnerability was associated with lower sitting time (β = − 0.187, p < 0001) and screen time (β = − 0.014, p < 0.001). Higher self-efficacy was associated with more moderate- to vigorous-intensity physical activity (β = 0.07, p = 0.036), better-quality sleep (β = − 0.069, p = 0.020) and less television time (β = − 0.079, p = 0.012). Having no family support was associated with more sitting time (β = 0.075, p = 0.022). Binomial logistic regression analyses supported these findings regarding sleep quality, with anxiety and depression risk doubling the risk of poor-quality sleep (OR = 2.425, p < 0.001, OR = 2.036, p = 0.003 respectively).

Conclusions

These findings contribute to our understanding of how mental health indicators and risk factors can be barriers to health behaviours of young women in Soweto, and that self-efficacy and social support can be protective for certain of these behaviours for these women. Our results highlight the uniqueness of this setting regarding associations between mental health and behaviours associated with non-communicable diseases risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01325-w.

Building knowledge, optimising physical and mental health and setting up healthier life trajectories in South African women (Bukhali): a preconception randomised control trial part of the Healthy Life Trajectories Initiative (HeLTI)

INTRODUCTION

South Africa's evolving burden of disease is challenging due to a persistent infectious disease, burgeoning obesity, most notably among women and rising rates of non-communicable diseases (NCDs). With two thirds of women presenting at their first antenatal visit either overweight or obese in urban South Africa (SA), the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and NCDs.

METHODS AND ANALYSIS

Bukhali is the first individual randomised controlled trial in Africa to test the efficacy of a complex continuum of care intervention and forms part of the Healthy Life Trajectories Initiative (HeLTI) consortium implementing harmonised trials in Canada, China, India and SA. Starting preconception and continuing through pregnancy, infancy and childhood, the intervention is designed to improve nutrition, physical and mental health and health behaviours of South African women to offset obesity-risk (adiposity) in their offspring. Women aged 18-28 years (n=6800) will be recruited from Soweto, an urban-poor area of Johannesburg. The primary outcome is dual-energy X-ray absorptiometry derived fat mass index (fat mass divided by height²) in the offspring at age 5 years. Community health workers will deliver the intervention randomly to half the cohort by providing health literacy material, dispensing a multimicronutrient supplement, providing health services and feedback, and facilitating behaviour change support sessions to optimise: (1) nutrition, (2) physical and mental health and (3) lay the foundations for healthier pregnancies and early child development.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Ethics Research Committee University of the Witwatersrand, Johannesburg, South Africa (M1811111), the University of Toronto, Canada (19-0066-E) and the WHO Ethics Committee (ERC.0003328). Data and biological sample sharing policies are consistent with the governance policy of the HeLTI Consortium (https://helti.org) and South African government legislation (POPIA). The recruitment and research team will obtain informed consent.

TRIAL REGISTRATION

This trial is registered with the Pan African Clinical Trials Registry (https://pactr.samrc.ac.za) on 25 March 2019 (identifier: PACTR201903750173871).

PROTOCOL VERSION

20 March 2022 (version #4). Any protocol amendments will be communicated to investigators, Institutional Review Board (IRB)s, trial participants and trial registries.

Prevalence and socio-structural determinants of tobacco exposure in young women: Data from the Healthy Trajectories Initiative (HeLTI) study in urban Soweto, South Africa

BACKGROUND

Tobacco use is a major public health risk worldwide, which has increased on the African continent over the past 40 years. Socio-economic factors impact tobacco use and exposure, but little is known about the scope of this problem in young women living in an urban, historically disadvantaged township in contemporary South Africa. This study aimed to identify the prevalence of tobacco use in a cohort of young South African women using serum cotinine, and to assess the association between a number of socio-economic and social factors and tobacco use in this setting.

METHODS

Secondary analysis was conducted on cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Serum cotinine was measured and a cut-off of ≥ 10 ng/mL was classified as tobacco use. Household socio-economic, socio-demographic and health information were collected by an interviewer-administered questionnaire.

RESULTS

Cotinine data was available for 1508 participants, of whom 29.2% (n = 441) had cotinine levels indicative of tobacco use. In regression analyses, moderate to severe socio-economic vulnerability (score 2-3 OR 1.66, p = 0.008; score ≥4: OR 1.63, p = 0.026) and multiparity (OR 1.74, p = 0.013) were associated with tobacco use. In addition, alcohol dependence (OR 3.07, p < 0.001) and drug use (OR 4.84, p < 0.001) were associated with tobacco use.

CONCLUSION

Young women with multiple children, moderate to severe socio-economic vulnerability, and alcohol and drug use were identified as more likely to use tobacco, indicating the need for targeted anti-tobacco interventions to curb the impact of tobacco on the growing burden of noncommunicable diseases in this setting.

Cognitive and Motor Development in 3- to 6-Year-Old Children Born to Mothers with Hyperglycaemia First Detected in Pregnancy in an Urban African Population

OBJECTIVES

Hyperglycaemia first detected in pregnancy (HFDP), on the rise in urban sub-Saharan Africa (SSA), may negatively impact foetal neurodevelopment, with potential long-term cognitive consequences for the child. Data on this association from SSA is lacking, and we aimed to investigate the association in 3- to 6-year-old children in Soweto, South Africa.

METHODS

In this comparative study, we compared cognitive skills measured with the Herbst Early Childhood Development Criteria test in 95 children born to mothers with HFDP and 99 participants unexposed to maternal HFDP. Fine and gross motor skills were secondary outcomes. Ordinal regression analysis with known confounders was performed for children born at-term.

RESULTS

Of children exposed to HFDP born at-term, 24.3% scored 'high' and 25.7% scored 'low' in the cognitive subsection of the test, as opposed to 37.7% and 12.9% in the HFDP-unexposed group, respectively. In ordinal regression, exposed participants had a significantly lower odds of scoring in a higher cognitive category when adjusting for maternal confounders and socio-economic status (OR 0.33, 95% CI 0.15-0.74, p = 0.007). No difference was found in gross motor development between the two groups; differences in fine motor development were attenuated after adjustment for maternal pregnancy factors and household socioeconomic status (OR 0.62, 95% CI 0.28-1.37, p = 0.239).

CONCLUSIONS FOR PRACTICE

Exposure to HFDP was negatively associated with cognitive development at preschool age. Optimising maternal (preconception) health and early childhood cognitive stimulation could help more children reach their developmental potential.

A collaborative approach to adopting/adapting guidelines. The Australian 24-hour movement guidelines for children (5-12 years) and young people (13-17 years): An integration of physical activity, sedentary behaviour, and sleep

Abstract

Background

In 2018, the Australian Government updated the Australian Physical Activity and Sedentary Behaviour Guidelines for Children and Young People. A requirement of this update was the incorporation of a 24-hour approach to movement, recognising the importance of adequate sleep. The purpose of this paper was to describe how the updated Australian 24-Hour Movement Guidelines for Children and Young People (5 to 17 years): an integration of physical activity, sedentary behaviour and sleep were developed and the outcomes from this process.

Methods

The GRADE-ADOLOPMENT approach was used to develop the guidelines. A Leadership Group was formed, who identified existing credible guidelines. The Canadian 24-Hour Movement Guidelines for Children and Youth best met the criteria established by the Leadership Group. These guidelines were evaluated based on the evidence in the GRADE tables, summaries of findings tables and recommendations from the Canadian Guidelines. We conducted updates to each of the Canadian systematic reviews. A Guideline Development Group reviewed, separately and in combination, the evidence for each behaviour. A choice was then made to adopt or adapt the Canadian recommendations for each behaviour or create de novo recommendations. We then conducted an online survey (n=237) along with three focus groups (n=11 in total) and 13 key informant interviews. Stakeholders used these to provide feedback on the draft guidelines.

Results

Based on the evidence from the Canadian systematic reviews and the updated systematic reviews in Australia, the Guideline Development Group agreed to adopt the Canadian recommendations and, apart from some minor changes to the wording of good practice statements, maintain the wording of the guidelines, preamble, and title of the Canadian Guidelines. The Australian Guidelines provide evidence-informed recommendations for a healthy day (24-hours), integrating physical activity, sedentary behaviour (including limits to screen time), and sleep for children (5-12 years) and young people (13-17 years).

Conclusions

To our knowledge, this is only the second time the GRADE-ADOLOPMENT approach has been used to develop movement behaviour guidelines. The judgments of the Australian Guideline Development Group did not differ sufficiently to change the directions and strength of the recommendations and as such, the Canadian Guidelines were adopted with only very minor alterations. This allowed the Australian Guidelines to be developed in a shorter time frame and at a lower cost. We recommend the GRADE-ADOLOPMENT approach, especially if a credible set of guidelines that was developed using the GRADE approach is available with all supporting materials. Other countries may consider this approach when developing and/or revising national movement guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01236-2.

Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa

The prevalence of anaemia among South African women of reproductive age (WRA) remains high at 39%. Multiple micronutrient supplementation (MMS) may be an effective strategy in the prevention and management of anaemia. Our aim was to understand facilitators and barriers to preconception MMS adherence and to explore perceptions and beliefs of MMS in the prevention and treatment of anaemia among non-pregnant WRA. This qualitative study was embedded in a preconception MMS intervention trial of WRA and was conducted in two phases. Phase one assessed the barriers and facilitators of MMS adherence. Individual interviews were conducted with the community health workers (n = 7) administering MMS, and with non-pregnant WRA (n = 25) participating in the trial. Phase two included four focus groups with participating WRA (n = 26), which further explored participants' perceptions and beliefs of MMS provision and adherence, and strategies to improve adherence. The reported facilitators to supplementation were family support, interaction with the community health workers, easy access to MMS, and experienced benefits of MMS. Barriers to preconception supplementation included the lack of family support, the link of supplements to antenatal care, and the perceived lack of benefits of MMS. Participants reported negative associations of supplements with medication, individual and societal stigma around medication and challenges around the supplementation schedule. For successful preconception MMS interventions, young women, their families, and communities need to be convinced of the value of supplementation. Public health interventions utilising preconception supplementation will require specialised training for health care providers, targeted counselling materials and community household support.

24 hour movement behaviours and the health and development of pre-school children from Zimbabwean settings: the SUNRISE pilot study

Background

In 2019, the World Health Organization (WHO) released global guidelines for physical activity, sedentary behaviour and sleep for the early years. The International Study of Movement Behaviours in the Early Years, SUNRISE, aimed to assess the extent to which children aged three and four years meet the WHO global guidelines and its association with health and development.

Objectives

To assess movement behaviours in pre-school children from low-income settings in Zimbabwe and to establish associations between these movement behaviours and adiposity, motor skills and executive function.

Methods

Pre-school children/caregivers were recruited from two urban and two rural public schools respectively in Zimbabwe. The caregivers answered questions on the children's physical activity, screen time, sedentary behaviour and sleep patterns. Children's movement behaviours were objectively measured using accelerometers. Gross and fine motor skills and executive function were assessed using the Ages and Stages Questionnaire-3 and Early Years Toolbox, respectively. Focus group discussions were carried out with caregivers and teachers on the acceptability and feasibility of the study.

Results

Eighty-one children participated in the study. The proportions of children meeting the guidelines were physical activity 92%, sedentary behaviour 70%, and sleep 86%, and all guidelines combined 24%. Boys and girls were similar (p>0.05 for all variables) for all executive function variables, but rural children had significantly lower inhibition scores (p=0.026) than urban children.

Conclusion

The study adds to the growing literature on movement behaviours and associated risk factors in low-resourced settings. Further investigations of movement behaviours in this age group in Zimbabwe are recommended.

Cross-sectional examination of 24-hour movement behaviours among 3- and 4-year-old children in urban and rural settings in low-income, middle-income and high-income countries: the SUNRISE study protocol

INTRODUCTION

24-hour movement behaviours (physical activity, sedentary behaviour and sleep) during the early years are associated with health and developmental outcomes, prompting the WHO to develop Global guidelines for physical activity, sedentary behaviour and sleep for children under 5 years of age. Prevalence data on 24-hour movement behaviours is lacking, particularly in low-income and middle-income countries (LMICs). This paper describes the development of the SUNRISE International Study of Movement Behaviours in the Early Years protocol, designed to address this gap.

METHODS AND ANALYSIS

SUNRISE is the first international cross-sectional study that aims to determine the proportion of 3- and 4-year-old children who meet the WHO Global guidelines. The study will assess if proportions differ by gender, urban/rural location and/or socioeconomic status. Executive function, motor skills and adiposity will be assessed and potential correlates of 24-hour movement behaviours examined. Pilot research from 24 countries (14 LMICs) informed the study design and protocol. Data are collected locally by research staff from partnering institutions who are trained throughout the research process. Piloting of all measures to determine protocol acceptability and feasibility was interrupted by COVID-19 but is nearing completion. At the time of publication 41 countries are participating in the SUNRISE study.

ETHICS AND DISSEMINATION

The SUNRISE protocol has received ethics approved from the University of Wollongong, Australia, and in each country by the applicable ethics committees. Approval is also sought from any relevant government departments or organisations. The results will inform global efforts to prevent childhood obesity and ensure young children reach their health and developmental potential. Findings on the correlates of movement behaviours can guide future interventions to improve the movement behaviours in culturally specific ways. Study findings will be disseminated via publications, conference presentations and may contribute to the development of local guidelines and public health interventions.

Pharmaceutical workers' perceptions of physical activity and healthy eating: a qualitative study

Objective

The public health message ‘move for health’ is relevant given the high prevalence of insufficient physical activity, particularly in African countries. The call for behaviour modification including limiting unhealthy dietary patterns in these settings is therefore critical; however, there is limited knowledge on the adoption of health promotion strategies in the workplace. This study aimed to investigate workers’ perceptions of physical activity and healthy eating.

Results

Five focus groups were conducted with 28 participants employed in a South African pharmaceutical manufacturing company to explore perceptions of physical activity and healthy eating. Results showed that two categories emerged: physical activity and unhealthy behaviours. Participants recognised the importance of obtaining sufficient physical activity in various domains, however believed that contemporary lifestyle limited opportunities for movement. Likewise, participants viewed healthy eating as unrealistic due to financial constraints. There was however agreement that total physical activity time could be increased during recreational pursuits outside of vocational time and may include intermittent walking for travel. These findings are important for workplace interventions and provide a more robust understanding of workers’ perceptions of physical activity and healthy eating.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05765-8.

Engaging communities in non-communicable disease research and interventions in low- and middle-income countries: a realist review protocol

INTRODUCTION

Engaging communities and intended beneficiaries at various stages of health research is a recommended practice. The contribution of community engagement to non-communicable disease research in low- and middle-income countries has not yet been extensively studied or synthesised. This protocol describes the steps towards generating an understanding of community engagement in the context of non-communicable disease research, prevention and health promotion using a realist review approach. A realist lens enables a rich explanatory approach to causation while capturing complexity, and an openness to multiple outcomes, including unintended consequences. The review will thus develop an understanding of community engagement without assuming that such practices result in more ethical research or effective interventions.

METHODS AND ANALYSIS

We propose a realist approach aiming to examine how, why, under what circumstances and for whom community engagement works or does not work. The iterative review steps include clarifying the review scope; searching for evidence; appraising studies and extracting data; synthesising evidence and drawing conclusions; and disseminating, implementing and evaluating the findings. Principles of meta-narrative review (pragmatism, pluralism, historicity, contestation, reflexivity and peer review) are employed to ensure practicable and contextualised review outputs. The proposed review will draw on theoretical and empirical literature beyond specific diseases or settings, but with a focus on informing non-communicable disease research and interventions in low- and middle-income countries. The synthesis of existing literature will be complemented by qualitative realist interviews and stakeholder consultation. Through drawing on multiple types of evidence and input from both experts and intended beneficiaries, the review will provide critical and pragmatic insights for research and community engagement in low- and middle-income countries.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of the Witwatersrand. Dissemination will include traditional academic channels, institutional communications, social media and discussions with a wide range of stakeholders.

Global effect of COVID-19 pandemic on physical activity, sedentary behaviour and sleep among 3- to 5-year-old children: a longitudinal study of 14 countries

BACKGROUND

The restrictions associated with the 2020 COVID-19 pandemic has resulted in changes to young children's daily routines and habits. The impact on their participation in movement behaviours (physical activity, sedentary screen time and sleep) is unknown. This international longitudinal study compared young children's movement behaviours before and during the COVID-19 pandemic.

METHODS

Parents of children aged 3-5 years, from 14 countries (8 low- and middle-income countries, LMICs) completed surveys to assess changes in movement behaviours and how these changes were associated with the COVID-19 pandemic. Surveys were completed in the 12 months up to March 2020 and again between May and June 2020 (at the height of restrictions). Physical activity (PA), sedentary screen time (SST) and sleep were assessed via parent survey. At Time 2, COVID-19 factors including level of restriction, environmental conditions, and parental stress were measured. Compliance with the World Health Organizations (WHO) Global guidelines for PA (180 min/day [≥60 min moderate- vigorous PA]), SST (≤1 h/day) and sleep (10-13 h/day) for children under 5 years of age, was determined.

RESULTS

Nine hundred- forty-eight parents completed the survey at both time points. Children from LMICs were more likely to meet the PA (Adjusted Odds Ratio [AdjOR] = 2.0, 95%Confidence Interval [CI] 1.0,3.8) and SST (AdjOR = 2.2, 95%CI 1.2,3.9) guidelines than their high-income country (HIC) counterparts. Children who could go outside during COVID-19 were more likely to meet all WHO Global guidelines (AdjOR = 3.3, 95%CI 1.1,9.8) than those who were not. Children of parents with higher compared to lower stress were less likely to meet all three guidelines (AdjOR = 0.5, 95%CI 0.3,0.9).

CONCLUSION

PA and SST levels of children from LMICs have been less impacted by COVID-19 than in HICs. Ensuring children can access an outdoor space, and supporting parents' mental health are important prerequisites for enabling pre-schoolers to practice healthy movement behaviours and meet the Global guidelines.

Young women's perceptions of life in urban South Africa: Contextualising the preconception knowledge gap

Raising awareness to support improved health and well-being of young women in sub-Saharan Africa is critical, particularly in the preconception period in order to achieve improved health for multiple generations. To inform messaging campaign on preconception health, we conducted eight focus group discussions (FGDs) with young women in Soweto to understand their perceptions and access to health messages. Preconception health was generally not a familiar topic for young women. Participants prioritised information seeking for other pressing challenges they faced such as poverty and unemployment. Within this context, mental health was viewed as important, while physical health only gained importance when illness was present or during pregnancy. Television, radio and community health workers were all viewed as useful communication channels for health messaging. Understanding the importance of preconception health of young adults to benefit from the triple dividend of better health now, better health for the future and for children is a critical knowledge gap for young women. Messages aimed to improve preconception physical and mental health could leverage significant health gains. Health messages should be contextualised within the experiences that young women face and should offer information to help young women cope with their challenges.

Sleep and BMI in South African urban and rural, high and low-income preschool children

BACKGROUND

The extent to which income setting or rural and urban environments modify the association between sleep and obesity in young children is unclear. The aims of this cross-sectional observational study were to (i) describe and compare sleep in South African preschool children from rural low-income (RL), urban low-income (UL) and urban high-income (UH) settings; and (ii) test for associations between sleep parameters and body mass index (BMI).

METHODS

Participants were preschoolers (5.2 ± 0.7y, 49.5% boys) from RL (n = 111), UL (n = 65) and UH (n = 22) settings. Height and weight were measured. Sleep, sedentary behaviour and physical activity were assessed using accelerometery.

RESULTS

UL children had higher BMI z-scores (median: 0.39; interquartile range: - 0.27, 0.99) than the UH (- 0.38; - 0.88, 0.11) and RL (- 0.08; - 0.83, 0.53) children (p = 0.001). The UL children had later bedtimes (p < 0.001) and wake-up times (p < 0.001) and shorter 24 h (p < 0.001) and nocturnal (p < 0.001) sleep durations than the RL and UH children. After adjusting for age, sex, setting, SB and PA, for every hour less sleep obtained (24 h and nocturnal), children were 2.28 (95% CI: 1.28-4.35) and 2.22 (95% CI: 1.27-3.85) more likely, respectively, to belong to a higher BMI z-score quartile.

CONCLUSIONS

Shorter sleep is associated with a higher BMI z-score in South African preschoolers, despite high levels of PA, with UL children appearing to be particularly vulnerable.

Evaluation of the Dissemination of the South African 24-Hour Movement Guidelines for Birth to 5 Years

South Africa (SA) launched their 24-h movement guidelines for birth to five years in December 2018. The guideline dissemination plan adopted a “train-the-trainer” strategy through dissemination workshops with community-based organisations (CBOs) working in early childhood development. The aim of this paper is to: (1) document this dissemination process; and (2) report on the feasibility of implementing the dissemination workshops, the acceptability of the workshops (and guidelines) for different end-user groups, and the extent to which CBO representatives disseminated the guidelines to end-users. Fifteen workshops were held in seven of SA’s nine provinces with a total of 323 attendees. Quantitative and qualitative findings (n = 281) indicate that these workshops were feasible for community-based dissemination of the guidelines and that this method of dissemination was acceptable to CBOs and end-users. Findings from follow-up focus groups (6 groups, n = 28 participants) indicate that the guidelines were shared with end-users of CBOs who participated in the focus groups. An additional musical storytelling resource, the “Woza, Mntwana” song, was well-received by participants; sharing via WhatsApp was believed to be the most effective way to disseminate this song. These findings confirm the feasibility and acceptability of culturally appropriate and context-specific community-based dissemination of behavioural guidelines in low-income settings.

Can public sector community health workers deliver a nurturing care intervention in South Africa? The Amagugu Asakhula feasibility study

Background

Nurturing care interventions have the potential to promote health and development in early childhood. Amagugu Asakhula was designed to promote developmentally important dietary and movement behaviours among children of preschool age (3–5 years) in South Africa. An initial formative study in Cape Town found the intervention to be feasible and acceptable when delivered by community health workers (CHWs) linked to a community-based organisation. This study evaluated the delivery of the Amagugu Asakhula intervention by CHWs linked to a public sector primary health care facility in Soweto, as this mode of delivery could have more potential for sustainability and scalability.

Methods

A qualitative design was utilised to assess feasibility, acceptability, adoption, appropriateness, implementation, fidelity and context. CHWs (n = 14) delivered the intervention to caregivers (n = 23) of preschool-age children in Soweto over 6 weeks. Following the completion of the intervention, focus group discussions were held with CHWs and caregivers. Further data were obtained through observations, study records and key informant interviews (n = 5). Data were analysed using deductive thematic analysis guided by a process evaluation framework.

Results

The delivery of the Amagugu Asakhula intervention through CHWs linked to a primary health care facility in Soweto was not found to be feasible due to contextual challenges such as late payment of salaries influencing CHW performance and willingness to deliver the intervention. CHWs expressed dissatisfaction with their general working conditions and were thus reluctant to take on new tasks. Despite barriers to successful delivery, the intervention was well received by both CHWs and caregivers and was considered a good fit with the CHWs’ scope of work.

Conclusions

Based on these findings, delivery of the Amagugu Asakhula intervention is not recommended through public sector CHWs in South Africa. This feasibility study informs the optimisation of implementation and supports further testing of the intervention’s effectiveness when delivered by CHWs linked to community-based organisations. The present study further demonstrates how implementation challenges can be identified through qualitative feasibility studies and subsequently addressed prior to large-scale trials, avoiding the wasting of research and resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00802-6.

Screen Time and Sleep of Rural and Urban South African Preschool Children

This study aimed to investigate the extent to which preschool children meet guidelines for screen time (<1 h/day) and sleep (10-13 h/24-h) and explored home factors that affect these behaviors. Parents of preschoolers across income settings in South Africa (urban high-income n = 27, urban low-income n = 96 and rural low-income n = 142) completed a questionnaire. Urban high-income children had higher rates of exceeding screen time guidelines (67.0%) than children from urban low-income (26.0%) and rural low-income (3.5%) settings. Most children (81.0%) met sleep guidelines on weekdays and on weekends (75.0%). More urban high-income children met the sleep guideline, in comparison to both low-income settings. Fewer urban high-income parents (50.0%) thought that screen time would not affect their preschooler's health, compared to urban low-income (90.4%) and rural low-income (81.7%) parents. Weeknight bedtime was positively correlated with both weekday screen time (p = 0.001) and weekday TV time (p = 0.005), indicating that more time on screens correlated with later bedtimes. Meeting screen time and sleep guidelines differs across income settings, but it is evident that parents of preschoolers across all income settings would benefit from greater awareness about guidelines.

Pilot implementation of Bukhali: A preconception health trial in South Africa

Objectives

This article describes the learnings from the pilot phase of the Healthy Life Trajectories Initiative, a preconception health trial for 18- to 25-year-old women in Soweto, South Africa.

Methods

The study compares two arms focussed on either physical and mental health (intervention; delivered by community health workers - 'Health Helpers') or standard of care plus (control; standard access to healthcare plus additional telephonic input on 'life skills'; delivered by call centre assistants). These are collectively referred to as Bukhali. Data on the pilot implementation of the Bukhali trial (n = 1655) were collected from (1) weekly team meetings, (2) two focus groups (one with the intervention team Health Helpers, n = 7; one with intervention participants, n = 8) and one paired interview with control call centre assistants (n = 2), (3) notes from eight debrief sessions with Health Helpers and (4) quantitative trial monitoring data. Qualitative data were thematically analysed.

Results

The findings clustered within three themes: (1) challenges for young women in Soweto, (2) priorities for young women in Soweto and (3) implementation challenges and perceptions of the intervention. Challenges were mostly related to tough socioeconomic circumstances and less prioritisation of living a healthier life. The priorities of employment and educational opportunities reflected the socioeconomic challenges, where health was not recognised as priority. The main challenge to participation and compliance with the trial was that young women in Soweto generally wanted a tangible and preferably financial and immediate benefit. Community peer sessions, despite being recommended by young women as part of the intervention development, were not successful. Many women also moved between multiple households within Soweto, which flagged concerns for a cluster trial and risk of contamination.

Conclusion

Preconception health trials should consider socioeconomic challenges present in urban poor contexts. Learnings from the pilot phase significantly affected the design and implementation of the main Bukhali trial.

"The thing is, kids don't grow the same": Parent perspectives on preschoolers' weight and size in Soweto, South Africa

The prevalence of overweight and obesity is high among preschool age (3-5 years) children in South Africa, and children in urban low-income settings are particularly at risk. A better understanding of how parents or caregivers of young children perceive children's weight and size, as well as contextual factors influencing perceptions, is needed to inform interventions. The aim of this study was to examine how parents of preschool children in Soweto, South Africa, view childhood obesity, and to situate these perspectives in the context of the home environment in which preschool age children in Soweto live. Semi-structured in-depth interviews were conducted with 16 parents in four neighbourhoods of Soweto. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis following a contextualist approach. Three themes were developed: growing differently, the 'right' way to be, and weight is not health. These themes capture parents' views on complex and reportedly inevitable causes of obesity, ideas about acceptable and preferred body sizes, and the low priority of weight per se compared to health. The findings suggest that childhood obesity prevention in South Africa needs to be done in a non-stigmatising way that recognises environmental and contextual factors, such as parents' limited sense of agency in relation to their children's health and weight, and concrete resource constraints. Environmental barriers to healthy behaviours need to be addressed in order to overcome the coexisting challenges of childhood undernutrition and obesity in urban low-income South African settings.