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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., This research was funded by the National Institute for Health Research (NIHR) (GHR: 16/137/34) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Anna Brugulat-Panés is funded by the UKRI Economic Social Research Council Doctor-al Training Program (ESRC DTP), and by the MRC Epidemiology Unit School of Clinical Medicine, University of Cambridge. Amy is supported by the PEAK Urban programme, funded by UKRI’s Global Challenge Research Fund, Grant Ref: ES/P011055/1

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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.

Breast and cervical cancer are leading causes of female cancer morbidity and mortality in Sub-Saharan Africa (SSA). Despite the high burden of disease, women’s knowledge of evidence-based risk factors and symptoms remains low. To adequately address the apparent knowledge deficits, the underlying knowledge in communities needs to be measured, so as to identify important gaps and contextually address them. To date, cancer knowledge in SSA has been measured using either prompted or unprompted question formats, yielding varying knowledge scores. However, there has been little exploration on the impact of using either question format for assessing disease awareness. This study sought to measure the differences in breast and cervical cancer risk factors and symptoms knowledge reported through prompted and unprompted questions, in South Africa (SA) and Uganda (UG). This was a descriptive cross-sectional study drawing on data collected during validation of an interviewer administered questionnaire (African Woman’s Awareness of Cancer - AWACAN) measuring breast and cervical cancer awareness in SSA. The sample included 139 women recruited from public sector primary health care facilities in two urban districts, Gulu (UG) and Cape Town (SA). Descriptive statistics were used to summarize participant’s socio-demographic characteristics and knowledge about breast and cervical cancer. Composite knowledge scores were calculated by adding up the number of correct responses per individual. The Wilcoxon Singed Rank test was used to compare differences between unprompted and prompted knowledge scores. Regression analyses were used to measure the relationship between unprompted and prompted knowledge. The median age of study participants was 42 years. The majority of women had not completed secondary education (57%) and were unemployed (64%). Unprompted knowledge was considerably lower than prompted knowledge for all breast and cervical cancer risk factors and symptoms. Median scores for unprompted knowledge of breast cancer risk factors (0) and symptoms (1) were significantly lower than for prompted at 6 and 14 respectively. Similarly, the median scores for unprompted knowledge of cervical cancer risk factors (0) and symptoms (1) were lower than prompted knowledge at 6 and 9 respectively. The difference between prompted and unprompted knowledge was least for classical breast and cervical cancer symptoms. For instance, the well-known breast cancer symptom ‘lump in the breast’ was recalled by 57% and 96% with unprompted and prompted questioning respectively. Unprompted questioning identified additional risk lay beliefs such as, ‘itching of the breast’. Combined use of unprompted and prompted questions provides more insight on breast and cervical cancer knowledge patterns in SSA. The low unprompted knowledge scores reported here demonstrate the need for health education interventions to improve knowledge of established breast and cervical cancer risk factors and whilst addressing any predominant lay beliefs about the disease in SSA. This dissertation is divided into three parts. Part A consists of the study protocol outlining the rational for undertaking this study as well as the proposed research methodology. Part B is the literature review that gives a summary of existing literature on the use of prompted and unprompted questions in measuring cancer knowledge thereby providing context for this study. Part C is a journal ready manuscript presenting the results and discussion of study findings.

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.

Funder: National Institute for Health Research; Grant(s): GHR:16/137/34, Noncommunicable diseases contribute the greatest to global mortality. Unhealthy diet���a prominent risk factor���is intricately linked to urban built and food environments and requires intersectoral efforts to address. Framings of the noncommunicable disease problem and proposed solutions within global and African regional diet-related policy documents can reveal how amenable the policy landscape is for supporting intersectoral action for health in low-income to middle-income countries. This study applied a document analysis approach to undertake policy analysis on global and African regional policies related to noncommunicable disease and diet. A total of 62 global and 29 African regional policy documents were analysed. Three problem frames relating to noncommunicable disease and diet were identified at the global and regional level, namely evidence-based, development, and socioeconomic frames. Health promotion, intersectoral and multisectoral action, and evidence-based monitoring and assessment underpinned proposed interventions to improve education and awareness, support structural changes, and improve disease surveillance and monitoring. African policies insufficiently considered associations between food security and noncommunicable disease. In order to effectively address the noncommunicable disease burden, a paradigm shift from ���health for development��� to ���development for health��� is required across non-health sectors. Noncommunicable disease considerations should be included within African food security agendas, using malnutrition as a possible intermediary concept to motivate intersectoral action to improve access to nutritious food in African low-income to middle-income countries.