Developing a sustainable nutrition research agenda in sub-Saharan Africa--findings from the SUNRAY project

La pérennité d’un projet de prévention et de prise en charge de la malnutrition au Niger

OBJECTIVE

This article is a case study of a capacity-building project to reduce malnutrition, implemented by a non-governmental organization (NGO) in Niger. It aims to generate a set of lessons learned on the processes of sustaining health interventions in vulnerable contexts.

METHODS

Using a theoretical framework on sustainability, we carried out a thematic analysis on semi-structured individual interviews (n = 124) collected, between 2016 and 2017, during the evaluative research of the NGO project.

RESULTS

The data analysis revealed several risks and opportunities to sustain the project activities, classified according to the characteristics of a routine identified in the theoretical framework: memory, routines, values, and rules. Our findings show a low level of sustainability of the project. Several activities were stopped at the end of the project and others may not continue in the long term. Indeed, local realities-poverty and political fragility-combined with the 'short-term' and vertical logics of the project's implementation have hindered the project activities' sustainability.

CONCLUSION

In vulnerable environments, sustainability should not simply be seen as an outcome to be achieved at the end of the project. The sustainability process must be activated by key stakeholders, focusing not only on the resources stabilizing but also on the resilience of the structures and systems in which interventions are embedded.

Seasonal Variations in Dietary Diversity and Nutrient Intakes of Women and Their Children (6-23 Months) in Western Kenya

Seasonal variations in food availability and access contributes to inadequate nutrient intakes, particularly in low income countries. This study assessed the effect of seasonality on dietary diversity (DD) and nutrient intakes of women and children aged 6–23 months in a rural setting in Western Kenya. A longitudinal study was conducted among 426 mother-child pairs during the harvest and post-harvest seasons in 2012. Dietary intakes were assessed using 24-h dietary recalls and dietary diversity scores (DDS) and nutrient intakes calculated for both seasons. Effect of seasonality on women dietary diversity scores (WDDS) and children's dietary diversity scores (CDDS) were assessed using generalised linear mixed models (GLMM). The proportion of women consuming diets with high DDS (>4 out of 9 food groups) increased from 36.4 to 52.4% between the two seasons, with mean WDDS being significantly higher in November compared to July/August (4.62 ± 1.43 vs. 4.16 ± 1.14, P < 0.001). A significantly higher proportion of children consumed foods from ≥4 out of 7 food groups in November compared to July/August (62.4 vs. 52.6%, P = 0.004). Mean CDDS (3.91 vs. 3.61, P = 0.004) was low but significantly higher in November compared to July/August. Estimated marginal mean WDDS increased from 4.17 to 4.38, and decreased for CDDS from 3.73 to 3.60 between the seasons. Seasonality had a small but significant effect on WDDS, P = 0.008 but not on CDDS, P = 0.293. Increase in CDDS in November was due to age and not seasonal effect. Higher women education and household food security were associated with higher WDDS and CDDS. Intakes of iron, calcium and vitamin E were higher among women in November and significantly different between the seasons. Agro-ecological zone, ethnic group and home gardening influenced nutrient intakes of the women. Seasonality had an effect on the DD of women but not of children, thus other factors apart from food availability influence the quality of children's diets during the complementary feeding period. With increasing age and transition to family foods, children's DD is expected to be affected by seasonality. Integrated interventions to alleviate seasonal food insecurity and strengthen rural households' resilience against seasonal deterioration in diet quality are recommended.

A research vision for food systems in the 2020s: Defying the status quo

•Research and science should not only inform food and environmental policy but should be adopted and mainstreamed into actions at all levels.•Food systems are faced with grander and interconnected challenges and constraints that bring about new research questions.•Research has a vital role in charting a positive and sustainable direction for global food security, nutrition, and health.•The status quo must be challenged to shape food systems transformation to deliver sustainable, healthier diets.• Global Food Security provides a platform where evidence is shared in an accessible manner for those who need to act on it.

Uptake and impact of priority setting exercises in nutrition research publications

OBJECTIVE

To assess how priority setting exercises for nutrition research are considered in publication.

DESIGN

Cross-sectional design.

SETTINGS

First, a citation analysis of priority setting exercises found in nutrition research until 2019 was conducted. The reasons for citation were extracted from the text of citing papers and the reasons were defined as: (i) acting on the research questions identified as priorities, (ii) acknowledging the priority setting exercise, (iii) using the same method, or (iv) previous knowledge to support evidence. Second, a survey with authors of the priority setting exercises was done to understand priority setters' perspectives on the impact and satisfaction of their work.

PARTICIPANTS

Twenty-one priority setting exercise papers were included. In all, 434 citing papers were found, of which 338 were considered in the citation analysis. A sample of 17 authors representing 13 priority setting exercise papers completed the impact and satisfaction survey.

RESULTS

Half of the priority setting exercise papers were published by 2013. After excluding self-citations (n = 60), the priority setting papers had on average 18 citations. Priority setting exercises had a median of 1 (IQR = 0-1) citing manuscript that acted on the recommendations produced from priority setting exercises. Authors of the priority setting exercises expressed a desire for increased uptake of the results of the priority setting exercises by funding agencies. Key barriers for uptake were identified as challenges in involving stakeholders and the general public for participation in the priority setting exercise.

CONCLUSIONS

Priority settings exercises are important efforts to guide nutrition research toward effective allocation of resources. However, there seems to be a limited consideration of these priority setting exercises in research papers.

Reducing waste in nutritional epidemiology: review and perspectives

We discuss efforts in improving the value of nutrition research. We organised the paper in five research stages: Stage 1: research priority setting; Stage 2: research design, conduct and analysis; Stage 3: research regulation and management; Stage 4: research accessibility and Stage 5: research reporting and publishing. Along the stages of the research cycle, varied initiatives exist to improve the quality and added value of nutrition research. However, efforts are focused on single stages of the research cycle without vision of the research system as a whole. Although research on nutrition research has been limited, it has potential to improve the quality of nutrition research and develop new tools and instruments for this purpose. A comprehensive assessment of the magnitude of research waste in nutrition and consensus on priority actions is needed. The nutrition research community at large needs to have open discussions on the usefulness of these tools and lead suitable efforts to enhance nutrition research across the stages of the research cycle. Capacity building is essential and considerations of nutrition research quality are vital to be integrated in training efforts of nutrition researchers.

Lessons learned from Evidence-Informed Decision-Making in Nutrition & Health (EVIDENT) in Africa: a project evaluation

Background

Evidence-informed Decision-making in Nutrition and Health (EVIDENT) is an international partnership that seeks to identify information needs in nutrition and health in Africa and build local capacity in knowledge management to help translate the best available evidence into context-appropriate recommendations aligned to the priorities of decision-makers. This study evaluates the extent to which EVIDENT achieved its intended activities, documents the lessons learned and draws on these lessons learned to inform future activities of EVIDENT, as well as in evidence-informed decision-making (EIDM) in nutrition overall.

Methods

Purposive and snowball sampling were used to identify participants that were either directly or indirectly involved with EVIDENT. An analytical framework of five key elements was developed to guide data collection from EVIDENT’s documentation, in-depth interviews (n = 20), online surveys (n = 26) and a participatory discussion. Interviews were transcribed verbatim and coded in NVivo 11, using deductive thematic content analysis and a phenomenological approach. Online surveys were analysed using Stata 14. Data were triangulated to address both objectives under each element of the analytical framework.

Results

EVIDENT succeeded in establishing a collaborative partnership, within which it delivered four short courses in EIDM. This capacity complemented case study activities in four partner African countries where EIDM processes were implemented and assessed. Identified barriers to these processes included little experience in EIDM, difficulties in engaging stakeholders, challenging local environments (e.g. donor influence, bureaucracy, inaccessibility to scientific research, poor internet connectivity), and limited time and funding. However, EVIDENT activities were driven by a local need for EIDM, a sheer interest and commitment to the cause, and the opportunity for the Global North and South to work together and build relationships. Future activities of EVIDENT, and EIDM in nutrition overall, should focus on sustained capacity-building in EIDM processes, leadership and functional skills across the Global South, investment in stakeholder engagement, context-specific EIDM, enhanced communication and linking, and strengthening relationships with existing stakeholder organisations.

Conclusions

In its first 3 years, EVIDENT developed and strengthened partnership, capacity and visibility on EIDM in Africa. Innovative and long-term capacity-building, dedicated leadership, further stakeholder engagement and sustainable financing, are needed for future activities of EVIDENT and EIDM in nutrition.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0413-6) contains supplementary material, which is available to authorized users.

Urban food environments in Africa: implications for policy and research

Africa is currently experiencing rapid urbanisation impacting on people's food environments and dietary habits. Such changes are associated with higher prevalence of obesity coexisting with undernutrition. The present paper provides an overview of the healthiness of African urban food environments. We discuss the ways that food environments can be characterised and summarise the methods that can be used to investigate and intervene in the food environment. Data for Africa over a 50-year period (1961–2013) suggest an increasing availability of energy, animal products, fruit and vegetables, vegetable oils, sugar and sweeteners but a decrease in animal fats. There is a lack of evidence about how social, physical and macro-environments drive dietary habits in urban Africa, as most research has focused on the individual level. Examining how food consumption is embedded in everyday life, by investigating social environments is crucial to developing effective interventions. The informal food sector plays an important role in the retail food environment. Macro-level food price changes are an important factor influencing nutritional quality of African diets. The rapid expansion of food/beverages advertising in Africa threatens traditional food habits. Liberalisation of food trade is already impacting on the nutritional quality of food available. Improving African food environments represents a pressing public health concern and has the potential to prevent all forms of malnutrition. Hence, by conducting research into the role of urban social, physical and macro-environments, emerging interventions and policies are likely to positively impact on nutritional status, thereby enhancing social and economic development.

Perspective: Consideration of Values When Setting Priorities in Nutrition Research: Guidance for Transparency

Nutrition research can guide interventions to tackle the burden of diet-related diseases. Setting priorities in nutrition research, however, requires the engagement of various stakeholders with diverse insights. Consideration of what matters most in research from a scientific, social, and ethical perspective is therefore not an automatic process. Systematic ways to explicitly define and consider relevant values are largely lacking. Here, we review existing nutrition research priority-setting exercises, analyze how values are reported, and provide guidance for transparent consideration of values while setting priorities in nutrition research. Of the 27 (n = 22 peer-reviewed manuscripts and 5 grey literature documents) studies reviewed, 40.7% used a combination of different methods, 59.3% described the represented stakeholders, and 49.1% reported on follow-up activities. All priority-setting exercises were led by research groups based in high-income countries. Via an iterative qualitative content analysis, reported values were identified (n = 22 manuscripts). Three clusters of values (i.e., those related to impact, feasibility, and accountability) were identified. These values were organized in a tool to help those involved in setting research priorities systematically consider and report values. The tool was finalized through an online consultation with 7 international stakeholders. The value-oriented tool for priority setting in nutrition research identifies and presents values that are already implicitly and explicitly represented in priority-setting exercises. It provides guidance to enable explicit deliberation on research priorities from an ethical perspective. In addition, it can serve as a reporting tool to document how value-laden choices are made during priority setting and help foster the accountability of stakeholders involved.

Ethical issues in the development and implementation of nutrition-related public health policies and interventions: A scoping review

BACKGROUND

The limited integration of ethics in nutrition-related public health policies and interventions is one major concern for those who have the task of implementing them. Ethical challenges that are overlooked during the development of such interventions could raise serious ethical issues during their implementation and even after. As a result, these decision makers need technical support and ethical guidance for adaptation of interventions to local (cultural, social, economic, etc.) contexts.

AIM

The goal of this scoping review is to delineate and "map" the range of ethical issues in nutrition-related public health interventions, as well as the range of the various fields in which they may arise.

METHODS

A scoping review of empirical research and conceptual literature was conducted following the framework of Arksey and O'Malley. Searches using PubMed with Medical Subject Headings (MeSH) categories and Advanced Search Builder as well as in the Global Health Library were performed. The final sample consists of 169 publications.

RESULTS

The ethics of public health prevention or treatment of obesity and non-communicable diseases is the most explicitly and frequently discussed subject. In comparison, ethical issues raised by public health interventions in the fields of undernutrition, breastfeeding, vitamin/mineral supplementation and food fortification, food security, food sustainability and food safety are addressed in a lower proportion of the sample. The results illustrate the various natures, types, and scopes of existing public health nutrition-related interventions, and the various ethical issues that may be raised by these interventions, in addition to the numerous and different contexts in which they may be implemented.

DISCUSSION

The ethical issues faced in the development and implementation of nutrition-related public health interventions are varied and cannot be equated with, nor generalized about, when dealing with specific activities in this field. More importantly, these ethical issues cannot be managed without a careful consideration for the complexity of contexts in which nutrition-related interventions are expected to be implemented. These interventions engage a variety of actors with diverse perspectives and interests. We discuss these challenges and also comment on the importance of considering ethical impacts in the monitoring and evaluation of such interventions.

CONCLUSION

General ethical frameworks or recommendations-although useful-cannot be expected to provide policy makers, implementators and other public health personnel with sufficient practical ethical guidance as they cannot consider and anticipate the particularities of all specific nutrition-related public health interventions and the complexity of the contexts in which they are implemented. Further research is needed in order to develop more targeted ethical frameworks.

Evidence-informed decision making for nutrition: African experiences and way forward

Although substantial amount of nutrition research is conducted in Africa, the research agenda is mainly donor-driven. There is a clear need for a revised research agenda in Africa which is both driven by and responding to local priorities. The present paper summarises proceedings of a symposium on how evidence can guide decision makers towards context-appropriate priorities and decisions in nutrition. The paper focuses on lessons learnt from case studies by the Evidence Informed Decision Making in Nutrition and Health Network implemented between 2015 and 2016 in Benin, Ghana and South Africa. Activities within these countries were organised around problem-oriented evidence-informed decision-making (EIDM), capacity strengthening and leadership and horizontal collaboration. Using a combination of desk-reviews, stakeholder influence-mapping, semi-structured interviews and convening platforms, these country-level studies demonstrated strong interest for partnership between researchers and decision makers, and use of research evidence for prioritisation and decision making in nutrition. Identified capacity gaps were addressed through training workshops on EIDM, systematic reviews, cost-benefit evaluations and evidence contextualisation. Investing in knowledge partnerships and development of capacity and leadership are key to drive appropriate use of evidence in nutrition policy and programming in Africa.

Gaps and opportunities for nutrition research in relation to non-communicable diseases in Arab countries: Call for an informed research agenda

Effective public health nutrition interventions are needed to curb the escalating prevalence of non-communicable diseases (NCDs) in many Arab countries. In order to generate the scientific evidence needed for the success of these interventions, an informed research agenda should be developed. The purpose of this review is to identify gaps and opportunities for research on nutrition and NCDs among Arab countries, which is an important step towards the formulation of this research agenda. Published papers that addressed nutrition and NCDs in Arab countries between the years 2006 and 2015 were reviewed (n=824). The main gaps identified were related to the predominance of laboratory-based studies with few cohort and intervention studies, and the small percentage of articles examining dietary patterns. While food frequency questionnaires were the main dietary assessment method used, only 35% were validated. Very few studies included children and the majority considered nutrition in isolation, excluding other environmental factors. Opportunities identified included the promising momentum in studying nutrition and NCDs among Arab countries, evidenced by an increasing number of articles published over the years, that may be guided in future nutrition research to fill the identified gaps. In addition, the higher number of articles in high-income countries coupled with the impact of papers in middle-income countries suggests an opportunity of synergistic collaboration among these countries. The identified gaps and opportunities in this review may serve as basis for Arab countries to start developing a research agenda in the area of nutrition and NCDs.

Enabling nutrient security and sustainability through systems research

Human and companion animal health depends upon nutritional quality of foods. Seed varieties, seasonal and local growing conditions, transportation, food processing, and storage, and local food customs can influence the nutrient content of food. A new and intensive area of investigation is emerging that recognizes many factors in these agri-food systems that influence the maintenance of nutrient quality which is fundamental to ensure nutrient security for world populations. Modeling how these systems function requires data from different sectors including agricultural, environmental, social, and economic, but also must incorporate basic nutrition and other biomedical sciences. Improving the agri-food system through advances in pre- and post-harvest processing methods, biofortification, or fortifying processed foods will aid in targeting nutrition for populations and individuals. The challenge to maintain and improve nutrient quality is magnified by the need to produce food locally and globally in a sustainable and consumer-acceptable manner for current and future populations. An unmet requirement for assessing how to improve nutrient quality, however, is the basic knowledge of how to define health. That is, health cannot be maintained or improved by altering nutrient quality without an adequate definition of what health means for individuals and populations. Defining and measuring health therefore becomes a critical objective for basic nutritional and other biomedical sciences.

A decade of nutrition research in Africa: assessment of the evidence base and academic collaboration

OBJECTIVE

Malnutrition in Africa has not improved compared with other regions in the world. Investment in the build-up of a strong African research workforce is essential to provide contextual solutions to the nutritional problems of Africa. To orientate this process, we reviewed nutrition research carried out in Africa and published during the last decade.

DESIGN

We assessed nutrition research from Africa published between 2000 and 2010 from MEDLINE and EMBASE and analysed the study design and type of intervention for studies indexed with major MeSH terms for vitamin A deficiency, protein-energy malnutrition, obesity, breast-feeding, nutritional status and food security. Affiliations of first authors were visualised as a network and power of affiliations was assessed using centrality metrics.

SETTING

Africa.

SUBJECTS

Africans, all age groups.

RESULTS

Most research on the topics was conducted in Southern (36%) and Western Africa (34%). The intervention studies (9%; n 95) mainly tested technological and curative approaches to the nutritional problems. Only for papers on protein-energy malnutrition and obesity did lead authorship from Africa exceed that from non-African affiliations. The 10% most powerfully connected affiliations were situated mainly outside Africa for publications on vitamin A deficiency, breast-feeding, nutritional status and food security.

CONCLUSIONS

The development of the evidence base for nutrition research in Africa is focused on treatment and the potential for cross-African networks to publish nutrition research from Africa remains grossly underutilised. Efforts to build capacity for effective nutrition action in Africa will require forging a true academic partnership between African and non-African research institutions.

How are health research priorities set in low and middle income countries? A systematic review of published reports

BACKGROUND

Priority setting is increasingly recognised as essential for directing finite resources to support research that maximizes public health benefits and drives health equity. Priority setting processes have been undertaken in a number of low- and middle-income country (LMIC) settings, using a variety of methods. We undertook a critical review of reports of these processes.

METHODS AND FINDINGS

We searched electronic databases and online for peer reviewed and non-peer reviewed literature. We found 91 initiatives that met inclusion criteria. The majority took place at the global level (46%). For regional or national initiatives, most focused on Sub Saharan Africa (49%), followed by East Asia and Pacific (20%) and Latin America and the Caribbean (18%). A quarter of initiatives aimed to cover all areas of health research, with a further 20% covering communicable diseases. The most frequently used process was a conference or workshop to determine priorities (24%), followed by the Child Health and Nutrition Initiative (CHNRI) method (18%). The majority were initiated by an international organization or collaboration (46%). Researchers and government were the most frequently represented stakeholders. There was limited evidence of any implementation or follow-up strategies. Challenges in priority setting included engagement with stakeholders, data availability, and capacity constraints.

CONCLUSIONS

Health research priority setting (HRPS) has been undertaken in a variety of LMIC settings. While not consistently used, the application of established methods provides a means of identifying health research priorities in a repeatable and transparent manner. In the absence of published information on implementation or evaluation, it is not possible to assess what the impact and effectiveness of health research priority setting may have been.

African stakeholders' views of research options to improve nutritional status in sub-Saharan Africa

BACKGROUND

Setting research priorities for improving nutrition in Africa is currently ad hoc and there is a need to shift the status quo in the light of slow progress in reducing malnutrition. This study explored African stakeholders' views on research priorities in the context of environmental and socio-demographic changes that will impact on nutritional status in Africa in the coming years.

METHODS

Using Multi-Criteria Mapping, quantitative and qualitative data were gathered from 91 stakeholders representing 6 stakeholder groups (health professionals, food Industry, government, civil society, academics and research funders) in Benin, Mozambique, South Africa, Tanzania, Togo and Uganda. Stakeholders appraised six research options (ecological nutrition, nutritional epidemiology, community nutrition interventions, behavioural nutrition, clinical nutrition and molecular nutrition) for how well they could address malnutrition in Africa.

RESULTS

Impact (28.3%), research efficacy (23.6%) and social acceptability (22.4%) were the criteria chosen the most to evaluate the performance of research options. Research on the effectiveness of community interventions was seen as a priority by stakeholders because they were perceived as likely to have an impact relatively quickly, were inexpensive and cost-effective, involved communities and provided direct evidence of what works. Behavioural nutrition research was also highly appraised. Many stakeholders, particularly academics and government were optimistic about the value of ecological nutrition research (the impact of environmental change on nutritional status). Research funders did not share this enthusiasm. Molecular nutrition was least preferred, considered expensive, slow to have an impact and requiring infrastructure. South Africa ranked clinical and molecular nutrition the highest of all countries.

CONCLUSION

Research funders should redirect research funds in Africa towards the priorities identified by giving precedence to develop the evidence for effective community nutrition interventions. Expanding research funding in behavioural and ecological nutrition was also valued and require multi-disciplinary collaborations between nutritionists, social scientists, agricultural and climate change scientists.