Challenges with implementation of nutrition interventions aimed at non-communicable diseases among black urban South Africans

Abstract

AIM - To investigate challenges to the implementation of nutrition interventions aimed at chronic non-communicable diseases (CNCDs) at government, community and individual levels in the Langa PURE study site in Cape Town, South Africa. METHODS - This cross-sectional study was embedded in the Prospective Urban and Rural Epidemiological (PURE) Study. The PURE study is a large-scale worldwide epidemiological cohort study. The PURE study aimed to recruit approximately 150,000 participants aged between 35 and 70 years living in more than 600 communities in 17 low-, middle- and high-income countries around the world. The participating countries’ selection were based on representativeness of different economic levels and the study sites included were based on the commitment of investigators to collect good quality data over the planned 10-year period. The University of the Western Cape’s (UWC) School of Public Health (SoPH) committed itself to carry out data collection in Langa (urban community) in the Western Cape Province and Mount Frere (rural community) in the Eastern Cape Province. The current study was conducted in the urban study site (Langa). For phase 1 of the study existing baseline information (demographic, dietary, anthropometric and blood pressure (BP)) was used for secondary data analysis, 300 participants were randomly selected. For phase 2 DoH officials were identified and interviewed using the multicriteria mapping (MCM) interviewing method. For phase 3, 47 participants were selected to participate in FDGs. Data were collected at baseline from the existing PURE Western Cape Province cohort for cross-sectional analysis. For the second part of this study, 300 male and female participants aged between 35 and 70 years, from the urban community were included. Structured interviews on challenges to the implementation of nutrition interventions aimed at chronic non-communicable diseases (CNCDs) with the study participants were conducted, using a questionnaire. The multi-criteria mapping (MCM) interviewing method was used to conduct interviews with key officers from the Department of Health (DoH), to explore best courses of action to address CNCDs. Structured interviews were also conducted with DoH officials to determine challenges to the implementation of exisiting nutrition interventions aimed at CNCDs, as well as to determine their awareness of existing CNCDs policies. The third part of the study was a qualitative analysis of focus group discussions with a subsample of the PURE participants to explore challenges and barriers to the implementation of, and adherence to, CNCDs interventions. Medians and frequencies were calculated for demographic data, anthropometric measurements, smoking habits, alcohol use and BP of men and women. The dietary data was analysed using the MRC Foodfinder III software package. Furthermore, diet adherence was determined by calculating a dietary adherence score which was based on a combination of the Dietary Approaches to Stop Hypertension (DASH) guidelines and the South African Food-Based Dietary Guidelines (SAFBDG). The dietary adherence score was calculated using an adaptation of the DASH score. Correlations were calculated between continuous variables (dietary intakes, anthropometric variables and BP) for men and women. A comparison between anthropometric variables and BP, by diet quality (adherence group) was determined using the Mann-Whitney U test. The presence of associations between diet adherence category and body mass index (BMI) (overweight/obese vs normal weight), waist-height ratio (WtHR) (</>0.5), waist-hip ratio (WHR) and waist circumference (WC) (</> cut-points), were determined by means of the chi square test (two-by-two tables). Logistic regression and odds ratios were used to determine associations between BP as the dependent variable and dietary adherence score, age, smoking and physical activity as covariates. Data analysis was done using the Statistical Package for Social Studies (SPSS) version 23 (SPSS Inc., Chicago, IL, USA) software programme. The MCM data was analysed using the MCM software package 2016 version (University of Sussex). The responses of the participants to the structured interviews were presented as frequencies. The results of the MCM interviews were summarised. The focus group discussions were analysed using content analysis. RESULTS AND CONCLUSION OF MANUSCRIPTS - Three manuscripts were written to meet the aims of this thesis. In the first manuscript, the association between dietary adherence score and blood pressure, as well as anthropometric measurements were investigated. Positive relationships were found between age, for both men and women and systolic and diastolic BP. A significant positive relationship between added sugar intake and systolic blood pressure (SBP) was only present in the women’s group. A significant positive relationship was found between SBP, diastolic blood pressure (DBP) and BMI for men only. No significant differences existed between blood pressure of men or women in the lowest and top tertile groups, according to dietary adherence score, but a significant inverse correlation between the dietary adherence score and SBP in women was found. The findings revealed that there were no significant differences between anthropometric measurements or blood pressure in the three groups according to dietary adherence, but women with the highest adherence scores had the lowest SBP. In the second manuscript, the aim was to determine the challenges that participants had regarding CNCDs interventions and their needs from intervention programmes were explored. In addition, the strategies that the Department of Health officials viewed as the best options to address the CNCDs epidemic were also investigated. Participants sought education on foods associated with weight gain, what food and drinks to purchase and how to prepare healthy food and recipes as part of CNCDs intervention programmes. Department of Health officials regarded the integration of health services, community participation, improved inter-sectoral partnerships and food taxation as the most favourable options to address the CNCDs epidemic. The findings revealed that current CNCDs interventions should be adapted to include context-based needs of community members. In the third manuscript, perceived challenges with the implementation of, and adherence to, CNCDs intervention health messages were explored. The study attempted to gain an understanding of participants’ expectations of CNCDs intervention programmes and explored the acceptability and preference of health message dissemination. In addition, preferred modes of health message dissemination were explored. Four themes emerged from the data analysis: practical aspects of implementation and adherence to intervention programmes; participants’ expectations of intervention programmes; aspects influencing participants’ acceptance of interventions and their preferences for health message dissemination. The findings revealed that, although participants found current methods of health message dissemination in CNCD interventions acceptable, they faced real challenges with implementing and adhering to these messages. GENERAL CONCLUSION - The study revealed that the challenges faced with the implementation of and adherence to CNCDs health messages are multifactorial and that current CNCDs intervention programmes do not necessarily meet participants’ expectations and perceived needs. This indicates the need for culturally-sensitive health messages and dietary recommendations that are context-based. By including the community members from the onset when planning CNCDs intervention programmes, possible gaps between the planned interventions of the Department of Health and the expectations about intervention programmes of target groups could be addressed