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

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

Integrating Health Technology Assessment and the Right to Health in South Africa: A Qualitative Content Analysis of Substantive Values in Landmark Judicial Decisions.

The World Health Assembly has encouraged WHO member-states to establish capacity in health technology assessment (HTA) as a support for achieving universal health coverage (UHC). Simultaneously, the WHO has stated that UHC is "a practical expression of the concern for health equity and the right to health." This has prompted questions about potential tensions between priority-setting efforts and the right to health on the road to UHC. South Africa (SA) is an ideal setting in which to explore how the priority-setting work of an HTA body may be integrated with an existing rights framework.

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

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

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

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

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

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

A realist review of voluntary actions by the food and beverage industry and implications for public health and policy in low- and middle-income countries.

The increasing availability of unhealthy processed food products is linked to rising rates of non-communicable diseases and obesity in low- and middle-income countries. Voluntary actions (VAs) are often adopted in lieu of regulating the composition, production, marketing and sale of unhealthy commodities, but their effectiveness is unclear. This realist review examines VAs adopted by the food and beverage industry in low- and middle-income countries. We developed a conceptual framework and followed a three-stage search to identify literature and VAs and, adhering to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines, we produced a synthesized analysis of VAs. VAs, often initiated in response to governments' efforts to introduce regulations, were difficult to evaluate due to vague language and a lack of enforcement mechanisms. The review found no evidence indicating that VAs are effective in safeguarding public health. Yet their implementation has resulted in weaker responses and policy substitution, and so we suggest that VAs have the potential to negatively influence public health and policy. The United Nations should rescind their endorsement of industry involvement and mandatory measures should be favoured over VAs.