A qualitative analysis of perceptions of various stakeholders on nutrition-sensitive agricultural interventions, including the taxation on sugar-sweetened beverages (SSBs), to improve overall health and nutrition in South Africa

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

Background

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

Methods

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

Results

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

Conclusions

The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00899-y.

The 'sugar tax' in Bermuda: a mixed methods study of general population and key stakeholder perceptions

Background

Taxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018–2019, the Bermuda government introduced a phased tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar, and eliminated import duties on select healthy food items. The aim of this study was to conduct an mixed methods evaluation of perceptions of the tax among the general population and key stakeholders.

Methods

We conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Survey data was analysed using thematic analysis, summary statistics, and Chi-squared tests. Key informant interviews were analysed using the framework method.

Results

General population respondents had high awareness of the sugar tax (94%) but low awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption due to beliefs the tax would not be effective (44%), and because of the high price of healthy food (20%). However, nearly half (48%) reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness but limited understanding of the tax policy. Informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The lack of clear price differentiation between taxed and un-taxed products and the absence of accompanying health education were key factors believed to affect the impact of the tax. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed to other priorities after implementation.

Conclusions

There was high awareness, but limited acceptability of the Bermuda sugar tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13945-9.

Cost-effectiveness and efficacy of fluoride varnish for caries prevention in South African children: A cluster-randomized controlled community trial

OBJECTIVES

This cluster-randomized controlled community trial aimed to assess the efficacy and costs of fluoride varnish (FV) application for caries prevention in a high-risk population in South Africa.

METHODS

513 children aged 4-8 years from two schools in a township in South Africa were randomly allocated by class to the FV or Control (CO) groups. In addition to supervised toothbrushing with fluoridated toothpaste in both groups, FV was applied in 3-month intervals by trained local non-professional assistants. Intraoral examinations were conducted at baseline, 12, 21 and 24 months. Primary outcome was the increment of teeth with cavitated lesions (i.e. newly developed or progressed, formerly non-cavitated lesions), requiring restoration or extraction over the study period. Additionally, treatment and re-treatment costs were analyzed.

RESULTS

513 children (d_1-4 mft 5.9 ± 4.3 (mean ± SD)) were randomly allocated to FV (n = 287) or CO (n = 226). 10.2% FV and CO teeth received or required a restoration; 3.9% FV and 4.1% CO teeth were extracted, without significant differences between groups. While FV generated high initial costs, follow-up costs were comparable in both groups, resulting in FV being significantly more expensive than CO (1667 ± 1055 ZAR vs. 950 ± 943 ZAR, p < .001).

CONCLUSIONS

Regular FV application, in addition to daily supervised toothbrushing, had no significant caries-preventive effect and was not cost-effective in a primary school setting within a peri-urban, high-risk community in South Africa. Alternative interventions on community or public health level should be considered to reduce the caries burden in high-risk communities.

Community Perceptions in New York City: Sugar-Sweetened Beverage Policies and Programs in the First 1000 Days

Objectives

To examine perceptions of Sugar-sweetened beverage (SSB) policies and programs focused on the first 1000 days—gestation through age 2 years—among community stakeholders in Washington Heights and the South Bronx, two neighborhoods in New York City with disproportionately high prevalence of childhood obesity.

Methods

A multilevel framework informed interview guide development. Using purposeful sampling, we recruited study participants who were (1) able to speak English or Spanish and (2) resided or employed in Washington Heights or the South Bronx. Participants included community leaders (local government officials, community board members, and employees from community- and faith-based organizations) as well as community members. Trained research staff conducted semi-structured in-depth interviews. Using immersion/crystallization and template style coding, the study team performed thematic analysis until no new relevant themes emerged.

Results

Among the 19 female study participants, perceived facilitators to SSB policy and program implementation included sustained partnerships with broad coalitions; continual education and clear messaging; and increased accessibility to healthier beverages. Perceived barriers included systems-level challenges accessing programs that support healthy beverage options, and individual-level lack of access to affordable healthy beverages. Acceptable potential intervention strategies included messaging that emphasizes health in pregnancy and infancy; policies that require healthy beverages as the default option in restaurants; and policies that remove SSBs from childcare settings. Some strongly favored SSB excise taxes while others opposed them, but all participants supported reinvestment of SSB tax revenue into health resources among marginalized communities.

Conclusions

A multi-pronged approach that incorporates engagement, access, equitable reinvestment of revenue, and continual clear messaging may facilitate implementation of policies and programs to reduce SSB consumption in the first 1000 days.