Socioeconomic and gendered inequities in travel behaviour in Africa: Mixed-method systematic review and meta-ethnography

Multisectoral interventions for urban health in Africa: a mixed-methods systematic review

Increasing evidence suggests that urban health objectives are best achieved through a multisectoral approach. This approach requires multiple sectors to consider health and well-being as a central aspect of their policy development and implementation, recognising that numerous determinants of health lie outside (or beyond the confines of) the health sector. However, collaboration across sectors remains scarce and multisectoral interventions to support health are lacking in Africa. To address this gap in research, we conducted a mixed-method systematic review of multisectoral interventions aimed at enhancing health, with a particular focus on non-communicable diseases in urban African settings. Africa is the world's fastest urbanising region, making it a critical context in which to examine the impact of multisectoral approaches to improve health. This systematic review provides a valuable overview of current knowledge on multisectoral urban health interventions and enables the identification of existing knowledge gaps, and consequently, avenues for future research. We searched four academic databases (PubMed, Scopus, Web of Science, Global Health) for evidence dated 1989-2019 and identified grey literature from expert input. We identified 53 articles (17 quantitative, 20 qualitative, 12 mixed methods) involving collaborations across 22 sectors and 16 African countries. The principle guiding the majority of the multisectoral interventions was community health equity (39.6%), followed by healthy cities and healthy urban governance principles (32.1%). Targeted health outcomes were diverse, spanning behaviour, environmental and active participation from communities. With only 2% of all studies focusing on health equity as an outcome and with 47% of studies published by first authors located outside Africa, this review underlines the need for future research to prioritise equity both in terms of research outcomes and processes. A synthesised framework of seven interconnected components showcases an ecosystem on multisectoral interventions for urban health that can be examined in the future research in African urban settings that can benefit the health of people and the planet.Paper ContextMain findings: Multisectoral interventions were identified in 27.8% of African countries in the African Union, targeted at major cities with five sectors present at all intervention stages: academia or research, agriculture, government, health, and non-governmental.Added knowledge: We propose a synthesised framework showcasing an ecosystem on multisectoral interventions for urban health that can guide future research in African urban settings.Global health impact for policy and action: This study reveals a crucial gap in evidence on evaluating the long-term impact of multisectoral interventions and calls for partnerships involving various sectors and robust community engagement to effectively deliver and sustain health-promoting policies and actions.

Young drivers' early access to their own car and crash risk into early adulthood: Findings from the DRIVE study

INTRODUCTION

Car ownership at early licensure for young drivers has been identified as a crash risk factor, but for how long this risk persists is unknown. This study examined crash hazard rates between young drivers with their own vehicle and those who shared a family vehicle at early licensure over 13 years.

METHODS

The DRIVE study, a 2003/04 survey of 20,806 young novice drivers in New South Wales, Australia was used to link to police crash, hospital and death records up to 2016. The first police-reported crash and crash resulting in hospitalisation/death was modelled via flexible parametric survival analysis by type of vehicle access at baseline (own vs. shared family vehicle).

RESULTS

After adjusting for covariates, drivers with their own vehicle at early licensure had an almost 30 % increased hazard rate for any crash after one year (95 % CI:1.16-1.42) compared with those who only had access to a family car and this attenuated but remained significantly higher until year 7 (HR: 1.1, 95 % CI: >1.00-1.20). For crashes resulting in hospitalisation or death, an almost 15-times higher hazard (95 % CI: 1.40-158.17) was observed at the start of follow up, remaining 50 % to year 3 (95 % CI:1.01-2.18).

CONCLUSIONS

Parents and young drivers should be aware of the increased risks involved in car ownership at early licensure. Development of poorer driving habits has been associated with less parental monitoring at this time. Graduated Driving Licensing educators, researchers and stakeholders should seek to address this and to identify improved safety management options.

An Overview of Physical Activity Research Evolution in Africa: The Global Observatory for Physical Activity-GoPA!

OBJECTIVE

To describe the evolution of physical activity (PA) research in Africa, examine income and gender inequalities, and discuss future possibilities.

METHODS

A secondary analyses of the Global Observatory for Physical Activity data on PA research in Africa (1950-2019).

RESULTS

We identified 514 PA articles from 47 African countries in the past 70 years. Majority (83.1%) of the articles were published between 2012 and 2019. Fifteen countries had no publications. Six countries (South Africa [n = 156], Nigeria [n = 85], Ethiopia [n = 44], Ghana [n = 41], Kenya [n = 39], and Cameroon [n = 20]) accounted for about 75% of the publications. Most articles were observational (92.4%), single-country studies (78.4%), with male first (58.4%) and last authors (68%), and were classified as surveillance studies (45.1%). Few studies addressed interventions (5.8%) and policy (3.5%) or used device-based PA measurement (14.0%). The number of articles per country was positively related to human population level (r = .552, P = .000) and gross domestic product % spent on research and development (r = .301, P = .040). The publication rate per 100,000 people was positively related with the human development index (r = .349, P = .016) and negatively with the gender inequality index (r = -.360, P = .019).

CONCLUSIONS

Our results provide an overview and status of PA research in Africa, highlighting country differences and gender inequalities in authorship. The findings may be used to benchmark the evolution of research in the region and to inform areas for improvement. There is an urgent need for more PA interventions and policy studies in Africa.

Changing mobility practices. Can meta-ethnography inform transferable and policy-relevant theory?

Social practice theories have attracted attention for their potential insights into how to change transport systems towards "healthier" states. However, most evidence is from small-scale qualitative case studies. We explored whether a synthesis of qualitative evidence on mobility practices in one country, informed by meta-ethnography and a Bourdieusian approach to practice, could produce theory that is of sufficient abstraction to be transferable, yet also capable of informing intervention planning. The synthesis identified three third order constructs: mobility practices result from habitus plus capital in fields; specific configurations of local mobility practices are shaped, but not determined, by material infrastructures and social structures; and changes in practice happen across a number of scales and temporalities. This body of evidence as a whole was then interpreted as an integrative "storyline": Mobility systems are complex, in that outcomes from interventions are neither unilinear nor necessarily predictable from aggregations of individual practice changes. Infrastructure changes may be a necessary, but not sufficient, condition for change. Moving systems towards "healthier" states requires changing habitus such that "healthier" practices align with fields, and that interventions take sufficient account of the power relations that materially and symbolically constrain or enable attachments to and changes in mobility practices. Meta-ethnography is a useful approach for integrating qualitative evidence for informing policy.

Comparing travel behaviour characteristics and correlates between large and small Kenyan cities (Nairobi versus Kisumu)

Understanding urban travel behaviour is crucial for planning healthy and sustainable cities. Africa is urbanising at one of the fastest rates in the world and urgently needs this knowledge. However, the data and literature on urban travel behaviour, their correlates, and their variation across African cities are limited. We aimed to describe and compare travel behaviour characteristics and correlates of two Kenyan cities (Nairobi and Kisumu). We analysed data from 16,793 participants (10,000 households) in a 2013 Japan International Cooperation Agency (JICA) household travel survey in Nairobi and 5790 participants (2760 households) in a 2016 Institute for Transportation and Development Policy (ITDP) household travel survey in Kisumu. We used the Heckman selection model to explore correlations of travel duration by trip mode. The proportion of individuals reporting no trips was far higher in Kisumu (47% vs 5%). For participants with trips, the mean number [lower - upper quartiles] of daily trips was similar (Kisumu (2.2 [2-2] versus 2.4 [2-2] trips), but total daily travel durations were lower in Kisumu (65 [30-80] versus 116 [60-150] minutes). Walking was the most common trip mode in both cities (61% in Kisumu and 42% in Nairobi), followed by motorcycles (17%), matatus (minibuses) (11%), and cars (5%) in Kisumu; and matatus (28%), cars (12%) and buses (12%) in Nairobi. In both cities, females were less likely to make trips, and when they did, they travelled for shorter durations; people living in households with higher incomes were more likely to travel and did so for longer durations. Gender, income, occupation, and household vehicle ownership were associated differently with trip making, use of transport modes and daily travel times in cities. These findings illustrate marked differences in reported travel behaviour characteristics and correlates within the same country, indicating setting-dependent influences on travel behaviour. More sub-national data collection and harmonisation are needed to build a more nuanced understanding of patterns and drivers of travel behaviour in African cities.

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

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

Making integration foundational in population health intervention research: why we need 'Work Package Zero'

OBJECTIVES

We aimed to identify when and how integration should take place within evaluations of complex population health interventions (PHIs).

STUDY DESIGN

Descriptive analytical approach.

METHODS

We draw on conceptual insights that emerged through (1) a working group on integration and (2) a diverse range of literature on case studies, small-n evaluations and mixed methods evaluation studies.

RESULTS

We initially sought techniques to integrate analyses at the end of a complex PHI evaluation. However, this conceptualization of integration proved limiting. Instead, we found value in conceptualizing integration as a process that commences at the beginning of an evaluation and continues throughout. Many methods can be used for this type of integration, including process tracing, realist evaluation, congruence analysis, general elimination methodology/modus operandi, pattern matching and contribution analysis. Clearly signposting when integrative methods should commence within an evaluation should be of value to the PHI evaluation community, as well as to funders and related stakeholders.

CONCLUSIONS

Rather than being a tool used at the end of an evaluation, we propose that integration is more usefully conceived as a process that commences at the start of an evaluation and continues throughout. To emphasize the importance of this timing, integration can be described as comprising 'Work Package Zero' within evaluations of complex PHIs.

Travel Behaviour and Barriers to Active Travel among Adults in Yaoundé, Cameroon

The literature on urban travel behaviour in Africa is sparse, limiting our understanding of how urban transport policies respond to human and planetary needs. We conducted a cross-sectional household telephone survey on 1334 participants, using a 24 h time-use diary, to investigate travel behaviour and barriers to active travel (walking and cycling) in Yaoundé, Cameroon. We found that two-thirds of all participants reported at least one trip; the median (IQR) numbers of trips per capita and per participant with trips were 2 (0–3) and 2 (2–3), respectively. The main trip modes were shared taxi (46%), walking (27%), private cars (11%), and motorcycle taxis (10%), with 25%, 56%, and 45% of all participants reporting the use of active, motorised, and public transport, respectively. The mean (IQR) trip duration was 48 (30–60) min; for participants who reported trips, the daily overall and active travel durations were 121 (60–150) and 28 (0–45) min, respectively. Women were less likely to travel, making fewer and shorter trips when they did. Participants in less wealthy households were more likely to travel. The primary barriers to both walking and cycling were the fear of road traffic injuries and the inconvenience of active travel modes. Therefore, local urban transport authorities need to improve the safety and convenience of active mobility and promote gender equity in transport. Restrictions to movements during the COVID-19 pandemic and the relatively small survey sample might have biased our results; thus, a representative travel survey could improve current estimates. More generally, high-quality research on travel behaviours and their correlates is needed in low-resource settings.

Physical Activity Behaviour and Comparison of GPAQ and Travel Diary Transport-Related Physical Activity in Accra, Ghana

There is a lack of data on physical activity (PA), active travel, and the comparison of measurement instruments in low-resource settings. The objective of this paper is to describe PA behaviour and the agreement of walking estimates from the Global Physical Activity Questionnaire (GPAQ) and the travel diary in a low-resource setting. We used a cross-sectional survey design to capture data from the residents of Accra (Ghana) between May 2020 and March 2021. Of the 863 participants aged 15+ years, 65% were females, and 86% reported PA. The median weekly PA was 18 (interquartile range: 5-75) metabolic equivalent of task hours, with 50% of females and 37% of males achieving low PA levels. In the GPAQ, 80% of participants reported weekly walking; the mean number of days walked was 3.8 (standard deviation (SD): 2.5); hence, 54% of participants reported walking on any day, and the mean daily walking duration was 51 (SD: 82) minutes. In the diary, 56% of participants reported walking for over 24 h, with a mean walking duration of 31 (SD: 65) minutes. The correlation of walking duration between instruments was weak (rho: 0.31; 95% Confidence Interval: 0.25-0.37); the mean bias was 20 min, with GPAQ estimates being 0.1 to 9 times higher than diary estimates. We concluded that low PA is prevalent in Accra, and while the travel diary and GPAQ estimate similar walking prevalence, their walking duration agreement is poor. We recommend accompanying PA questionnaires with objective measures for calibration.

Geographic accessibility to health facilities predicts uptake of community-based tuberculosis screening in an urban setting

Objectives:

Annually, more than 30% of individuals with tuberculosis (TB) remain undiagnosed. We aimed to assess whether geographic accessibility measures can identify neighborhoods that would benefit from TB screening services targeted toward closing the diagnosis gap.

Methods:

We used data from a community-based mobile TB screening program in Carabayllo district, Lima, Peru. We constructed four accessibility measures from the geographic center of neighborhoods to health facilities. We used logistic regression to assess the association between these measures and screening uptake in one’s residential neighborhood versus elsewhere, with quasi-information criterion values to assess the association.

Results:

We analyzed the screening locations for 25,000 Carabayllo residents from 49 neighborhoods. Pedestrian walk time was preferable to Euclidean distance or vehicular time in our models. For each additional 12 minutes walking time between the neighborhood and the health facility, the odds of residents using TB screening units located in their neighborhoods increased by 50% (95% CI: 26%–78%). Females had 9% (95% CI: 3%–16%) increased odds versus males of using a screening unit in their own neighborhood.

Conclusion:

Placing mobile TB screening units in neighborhoods with longer pedestrian time to access health facilities could benefit individuals who face more acute access barriers to health care.

A Systematic Review Protocol of Opportunities for Noncommunicable Disease Prevention via Public Space Initiatives in African Cities

Public spaces have the potential to produce equitable improvements in population health. This mixed-methods systematic review aims to understand the components of, determinants, risks, and outcomes associated with public space initiatives in African cities. This study will include quantitative and qualitative study designs that describe public space initiatives in African cities with implications for promoting health and wellbeing, particularly through the prevention of noncommunicable diseases. Only studies published after 1990 and that contain primary or secondary data will be included in the review. Literature search strategies will be developed with a medical librarian. We will search PubMed, using both text words and medical subject headings. We will adapt this search to Scopus, Global Health, and Web of Science. This systematic review will adopt a mixed methods analytical approach. Mixing will occur in extracting both qualitative and quantitative findings; in synthesizing findings; and in the analysis where we will integrate the qualitative and quantitative strands. The learnings from this study will contribute to advancing knowledge on noncommunicable disease prevention through public space initiatives in African cities.

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

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