Travel has individual, societal and planetary health implications. We explored socioeconomic and gendered differences in travel behaviour in Africa, to develop an understanding of travel-related inequity. We conducted a mixed-methods systematic review (PROSPERO CRD42019124802). In 2019, we searched MEDLINE, TRID, SCOPUS, Web of Science, LILACS, SciELO, Global Health, Africa Index Medicus, CINAHL and MediCarib for studies examining travel behaviour by socioeconomic status and gender in Africa. We appraised study quality using Critical Appraisal Skills Programme checklists. We synthesised qualitative data using meta-ethnography, followed by a narrative synthesis of quantitative data, and integrated qualitative and quantitative strands using pattern matching principles. We retrieved 103 studies (20 qualitative, 24 mixed-methods, 59 quantitative). From the meta-ethnography, we observed that travel is: intertwined with social mobility; necessary to access resources; associated with cost and safety barriers; typified by long distances and slow modes; and dictated by gendered social expectations. We also observed that: motorised transport is needed in cities; walking is an unsafe, ‘captive’ mode; and urban and transport planning are uncoordinated. From these observations, we derived hypothesised patterns that were tested using the quantitative data, and found support for these overall. In lower socioeconomic individuals, travel inequity entailed reliance on walking and paratransit (informal public transport), being unable to afford travel, travelling less overall, and travelling long distances in hazardous conditions. In women and girls, travel inequity entailed reliance on walking and lack of access to private vehicles, risk of personal violence, societally-imposed travel constraints, and household duties shaping travel. Limitations included lack of analytical rigour in qualitative studies and a preponderance of cross-sectional quantitative studies (offering a static view of an evolving process). Overall, we found that travel inequity in Africa perpetuates socioeconomic and gendered disadvantage. Proposed solutions focus on improving the safety, efficiency and affordability of public transport and walking.

Small Island Developing States (SIDS) have high and increasing rates of diet-related diseases. This situation is associated with a loss of food sovereignty and an increasing reliance on nutritionally poor food imports. A policy goal, therefore, is to improve local diets through improved local production of nutritious foods. Our aim in this study was to develop methods and collect preliminary data on the relationships between where people source their food, their socio-demographic characteristics and dietary quality in Fiji and Saint Vincent and the Grenadines (SVG) in order to inform further work towards this policy goal. We developed a toolkit of methods to collect individual-level data, including measures of dietary intake, food sources, socio-demographic and health indicators. Individuals aged ≥15 years were eligible to participate. From purposively sampled urban and rural areas, we recruited 186 individuals from 95 households in Fiji, and 147 individuals from 86 households in SVG. Descriptive statistics and multiple linear regression were used to investigate associations. The mean dietary diversity score, out of 10, was 3.7 (SD1.4) in Fiji and 3.8 (SD1.5) in SVG. In both settings, purchasing was the most common way of sourcing food. However, 68% (Fiji) and 45% (SVG) of participants regularly (>weekly) consumed their own produce, and 5% (Fiji) and 33% (SVG) regularly consumed borrowed/exchanged/bartered food. In regression models, independent positive associations with dietary diversity (DD) were: borrowing/exchanging/bartering food (β = 0.73 (0.21, 1.25)); age (0.01 (0.00, 0.03)); and greater than primary education (0.44 (0.06, 0.82)). DD was negatively associated with small shop purchasing (−0.52 (95% CIs −0.91, −0.12)) and rural residence (−0.46 (−0.92, 0.00)). The findings highlight associations between dietary diversity and food sources and indicate avenues for further research to inform policy actions aimed at improving local food production and diet.

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.

Background: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. Objective: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. Methods: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. Results: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. Conclusions: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. International Registered Report Identifier (IRRID): DERR1-10.2196/26739

The Human Mobility Transition model describes shifts in mobility dynamics and transport systems. The aspirational stage, ‘human urbanism’, is characterised by high active travel, universal public transport, low private vehicle use and equitable access to transport. We explored factors associated with travel behaviour in Africa and the Caribbean, investigating the potential to realise ‘human urbanism’ in this context. We conducted a mixed-methods systematic review of ten databases and grey literature for articles published between January 2008 and February 2019. We appraised study quality using Critical Appraisal Skills Programme checklists. We narratively synthesized qualitative and quantitative data, using meta-study principles to integrate the findings. We identified 39,404 studies through database searching, mining reviews, reference screening, and topic experts’ consultation. We included 129 studies (78 quantitative, 28 mixed-methods, 23 qualitative) and 33 grey literature documents. In marginalised groups, including the poor, people living rurally or peripheral to cities, women and girls, and the elderly, transport was poorly accessible, travel was characterised by high levels of walking and paratransit (informal public transport) use, and low private vehicle use. Poorly controlled urban growth (density) and sprawl (expansion), with associated informality, was a salient aspect of this context, resulting in long travel distances and the necessity of motorised transportation. There were existing population-level assets in relation to ‘human urbanism’ (high levels of active travel, good paratransit coverage, low private vehicle use) as well as core challenges (urban sprawl and informality, socioeconomic and gendered barriers to travel, poor transport accessibility). Ineffective mobility systems were a product of uncoordinated urban planning, unregulated land use and subsequent land use conflict. To realise ‘human urbanism’, integrated planning policies recognising the linkages between health, transport and equity are needed. A shift in priority from economic growth to a focus on broader population needs and the rights and wellbeing of ordinary people is required. Policymakers should focus attention on transport accessibility for the most vulnerable.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations—women, girls, and adolescents—requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.