A discussion on: - Achieving SDG 3 (health) as a complex challenge - Spotlighting the complex challenge of addressing non-communicable disease (NCD) prevention in African cities - Evidence as a strategic tool for facilitating and sustaining impact - Brainstorm on the evidence, actors in addressing case studies presented - Examples from recent work

1. The role of evidence in
influencing upstream action on
health challenges
Dr. Ebele R.I. Mọgọ
Guest Lecture, Public Policy and Knowledge Translation
McGill University

2. What we will discuss
• Achieving SDG 3 (health) as a complex challenge
• Spotlighting the complex challenge of addressing non-
communicable disease (NCD) prevention in African cities
• Evidence as a strategic tool for facilitating and sustaining
impact
• Brainstorm on the evidence, actors in addressing case studies
presented
• Examples from recent work

3. Some characteristics of complex challenges
• Multifaceted causes which are themselves symptoms of broader
problems
• Cause and effect are not simplistically linked
• Requires both technical and social and contextual know how
• Often differing perspectives about how to achieve impact even if
there is agreement on the science given the need to weigh
feasibility, values, multiple actors etc.

4. Examples: NCDs in rapidly
urbanizing African cities
• Examples include diabetes, cardiovascular
disease, cancer etc
• Responsible for approximately 71% of deaths
globally, with most occurring in low and
middle-income countries (LMICs)
• Multiplied by the ongoing urban transition
which affects access to clean air, healthy food,
access to transport, housing etc.
• Half of the world’s population growth
between 2015 and 2050 will occur in Africa
and by 2050, the continent will house 30–40%
of the worlds’ youth
• What does upstream impact look like in a
setting where cities are primarily informal?

5. Reflect: What upstream action is needed to
improve Miremba’s health?
Miremba grew up in Tororo, Uganda and had always dreamt of moving to
the big city and being a successful lawyer with international firms. She
worked so hard as a child, and eventually, after she got her law degree, her
dream came true – she got a job with a law firm in Kampala; she was so
happy and has been living in Kampala for five years now. She makes good
money in the city, but as the city grows, she is finding herself spending a lot
of time in traffic. Sometimes, she spends up to two hours in traffic to and
from work. Coupled with her busy job, it is very stressful for her. The other
day she went to the hospital, and the doctor told her that her blood
pressure was high. It surprised her, because she is not even forty yet. The
doctor recommended that she exercise more and eat healthily but it’s
difficult to do that because the roads are not good. Whenever she went for
a run, she had to keep looking out for cars as she was running on the main
road. She also inhaled a lot of smoke and exhaust fumes, which wasn’t very
enjoyable. Also, men kept calling out to her on the street, which made her
feel unsafe. She would go to the gym more often, but after dealing with the
traffic to and from work, she doesn’t have much time or energy left to drive
to the gym. That is also why she doesn’t cook as often as she wanted. Most
times, she ends up going to the food court of the new mall near their office
to buy fries and coke – her comfort foods of choice.

6. Example 2: What of Lebo’s health?
Lebo has been living in the informal settlement, Khayelitsha, South
Africa for 10 years now with her four children who are 13, 10, 8 and 5
years old. She is grateful that she can afford to feed her children and
often needs to cook with a stove indoors, which seems to worsen her
daughter’s asthma. She tends to buy snacks, sachet noodles and coke
for her children, because she does not have enough space and
electricity to store foods. The tap water is not very clean, and she tends
to use sachet water for cooking, which is expensive, so she tries not to
buy foods that need washing and refrigerating, though she wishes that
her children could enjoy fresh fruits as much as she did when she was
growing up in the village. Lebogang is worried that her children must
walk long distances at night to use the bathrooms. Even though she asks
them to go in twos she is always afraid something may happen to them
– one of her neighbours was recently shot by a stray bullet that came
from a confrontation between two gangs. The toilets are also not very
clean. Every now and then she has a urinary infection as a result. She
hopes that one day she can give her children the better life she has been
working so hard for. She works very hard to save so that they can move
to a new neighbourhood, but it is a bit difficult doing so as a single
parent and with her job as a cleaner. She is happy at least, that she can
send her children to school and hopes it will be their way to a better life.

7. The role of evidence
• Understanding the causes of the causes
• Exploring the ecosystem of actors and
ongoing activities and needs
• Understanding promising initiatives
• Aligning strategies across actors with goals
for public health
• Understanding and iterating on initiatives

8. Understanding the causes of the causes
Questions that may need to be answered:
• What is the risk and disease profile of the population?
• What environmental and social factors are related to the
spread of risks and outcomes?
• What knowledge already exists?
• What extra evidence do we need to inform action?

9. Example: Odunitan-Wayas, F. A., Wadende, P., Mogo, E. R., Brugulat-Panés, A., Micklesfield,
L. K., Govia, I., ... & Oni, T. (2021). Adolescent Levers for a Diet and Physical Activity
Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica:
Mixed Methods Study Protocol. JMIR Research Protocols, 10(7), e26739.
• Aiming to understand the multilevel system of factors that can be leveraged through upstream
and downstream strategies and interventions to improve health outcomes.
• Recruited male and female adolescents from selected high schools or households in Kenya,
Cameroon, Jamaica and South Africa
• Used self-reported questionnaires to collect data on anthropometric measures, food intake, and
physical activity knowledge and behavior will be collected using self-report questionnaires.
• Selected a small number of students to be citizen scientists, capturing 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 application and for objective PA measurements.
• Conducted in-depth interviews with the citizen scientists and their caregivers to explore
household experiences and determinants of food intake and foodways, as well as the physical
activity of household members.

10. Reflect: Who are the stakeholders at play
in improving Lebo’s health? What
evidence may they need?
Lebo has been living in the informal settlement, Khayelitsha, South Africa
for 10 years now with her four children who are 13, 10, 8 and 5 years old.
She is grateful that she can afford to feed her children and often needs to
cook with a stove indoors, which seems to worsen her daughter’s asthma.
She tends to buy snacks, sachet noodles and coke for her children, because
she does not have enough space and electricity to store foods. The tap
water is not very clean, and she tends to use sachet water for cooking,
which is expensive, so she tries not to buy foods that need washing and
refrigerating, though she wishes that her children could enjoy fresh fruits
as much as she did when she was growing up in the village. Lebogang is
worried that her children must walk long distances at night to use the
bathrooms. Even though she asks them to go in twos she is always afraid
something may happen to them – one of her neighbours was recently shot
by a stray bullet that came from a confrontation between two gangs. The
toilets are also not very clean. Every now and then she has a urinary
infection as a result. She hopes that one day she can give her children the
better life she has been working so hard for. She works very hard to save so
that they can move to a new neighbourhood, but it is a bit difficult doing so
as a single parent and with her job as a cleaner. She is happy at least, that
she can send her children to school and hopes it will be their way to a
better life.

11. Understanding promising initiatives
Questions that may need to be answered:
• What are the key components of initiatives have been carried out
in similar populations?
• Which partners are necessary to implement and sustain evidence-
based interventions?

12. Example: Ebele Mogo, Louise Foley, Rod Jones, Lia Chatzidiakou, Taibat Lawanson,
Felix Assah, Rose Alani, Tolu Oni. A systematic review of opportunities for health
promotion via public space activities in African cities.
• Synthesizing peer-reviewed literature on initiatives to address NCDs through public space
initiatives
Aimed to answer the following questions:
• How are public spaces in African cities being used for activities that influence physical and
mental health?
• What components, funders, partners and outcomes are associated with such initiatives?
• How might the initiatives and governance of these spaces be harnessed for health and
wellbeing?

13. Reflect: how would you understand promising
initiatives for addressing Miremba’s health risks?
Miremba grew up in Tororo, Uganda and had always dreamt of moving to
the big city and being a successful lawyer with international firms. She
worked so hard as a child, and eventually, after she got her law degree, her
dream came true – she got a job with a law firm in Kampala; she was so
happy and has been living in Kampala for five years now. She makes good
money in the city, but as the city grows, she is finding herself spending a lot
of time in traffic. Sometimes, she spends up to two hours in traffic to and
from work. Coupled with her busy job, it is very stressful for her. The other
day she went to the hospital, and the doctor told her that her blood
pressure was high. It surprised her, because she is not even forty yet. The
doctor recommended that she exercise more and eat healthily but it’s
difficult to do that because the roads are not good. Whenever she went for
a run, she had to keep looking out for cars as she was running on the main
road. She also inhaled a lot of smoke and exhaust fumes, which wasn’t very
enjoyable. Also, men kept calling out to her on the street, which made her
feel unsafe. She would go to the gym more often, but after dealing with the
traffic to and from work, she doesn’t have much time or energy left to drive
to the gym. That is also why she doesn’t cook as often as she wanted. Most
times, she ends up going to the food court of the new mall near their office
to buy fries and coke – her comfort foods of choice.

14. Understanding leverage points for
ecosystem shifts
Questions that may need to be answered:
• What are the demand side factors (policies, investments etc.) affecting the
health issues
• What are the supply side factors (initiatives, tools etc.) responsible for
access to health determinants
• Who are the critical actors responsible for the demand and supply side
factors identified?
• How can they supported to align incentives and activities for improved
health?
• What cost-effective options will yield the biggest impacts?

15. Mogo, E. R., Wesonga, J. M., Gichuyia, L. N., & Shuckburgh, E. (2021). COP26
Futures We Want-Kenya Country Profile
• Ahead of COP26 deliberations aimed to create a brief on desirable net-zero visions for
Kenya
• Partnered with Kenyan academics to aggregate peer-reviewed and grey literature on
climate change impacts on the Kenyan economy across multiple sectors including
agriculture, health, transport
• Created a country brief used as to stimulate in-country workshops and creative
translational approaches that will develop a plausible vision for each country. This
document provides a selection of relevant evidence for the sectors and themes identified
through the scoping exercise.
• Cross-section of the Kenyan public including government, civil society and business, young
people, and residents of informal settlements.
• Citizens provided perspectives on the briefs, visions and solutions they hope for based on
the information
• Used to inform leaders and policymakers on the question: what could a desirable future for
Kenya look like in a climate resilient, net-zero world?

16. Reflect: how would you understand the
leverage points to improve Lebo’s
health?
Lebo has been living in the informal settlement, Khayelitsha, South Africa
for 10 years now with her four children who are 13, 10, 8 and 5 years old.
She is grateful that she can afford to feed her children and often needs to
cook with a stove indoors, which seems to worsen her daughter’s asthma.
She tends to buy snacks, sachet noodles and coke for her children, because
she does not have enough space and electricity to store foods. The tap
water is not very clean, and she tends to use sachet water for cooking,
which is expensive, so she tries not to buy foods that need washing and
refrigerating, though she wishes that her children could enjoy fresh fruits
as much as she did when she was growing up in the village. Lebogang is
worried that her children must walk long distances at night to use the
bathrooms. Even though she asks them to go in twos she is always afraid
something may happen to them – one of her neighbours was recently shot
by a stray bullet that came from a confrontation between two gangs. The
toilets are also not very clean. Every now and then she has a urinary
infection as a result. She hopes that one day she can give her children the
better life she has been working so hard for. She works very hard to save so
that they can move to a new neighbourhood, but it is a bit difficult doing so
as a single parent and with her job as a cleaner. She is happy at least, that
she can send her children to school and hopes it will be their way to a
better life.

17. Aligning strategy with goals for public health
Questions that may need to be answered:
• What initiatives need to be implemented and scaled up to address NCDs?
• What initiatives need to be divested from for a coherent response?
• How do we enable funding for multi-sectoral action on NCDs?
• How do we work with grassroots organizations and private sector partners to fill service
gaps?
• How do we create an aligned strategy for urban development that leads to improved
health?

18. Example: WHO Urban Health Research
Agenda
• Scoping review on urban health research in different WHO regions
• Big data analysis of key priorities, actors in urban health research
• Survey of urban health researchers
• In-house mapping of urban health activities within the WHO
• Expert Meeting on Urban Health to provide guidance on the way forward
• Drafting of the UHRA
• Stakeholder Consultation with communities, cities, international organizations, citizen
groups, and national authorities to provide feedback and strategies for implementation
for the draft UHRA priorities
• Preparation of a final UHRA to push for evidence-based solutions in urban environments.

19. Reflect: how would you create a strategy to
address Miremba’s health risks?
Miremba grew up in Tororo, Uganda and had always dreamt of moving to
the big city and being a successful lawyer with international firms. She
worked so hard as a child, and eventually, after she got her law degree, her
dream came true – she got a job with a law firm in Kampala; she was so
happy and has been living in Kampala for five years now. She makes good
money in the city, but as the city grows, she is finding herself spending a lot
of time in traffic. Sometimes, she spends up to two hours in traffic to and
from work. Coupled with her busy job, it is very stressful for her. The other
day she went to the hospital, and the doctor told her that her blood
pressure was high. It surprised her, because she is not even forty yet. The
doctor recommended that she exercise more and eat healthily but it’s
difficult to do that because the roads are not good. Whenever she went for
a run, she had to keep looking out for cars as she was running on the main
road. She also inhaled a lot of smoke and exhaust fumes, which wasn’t very
enjoyable. Also, men kept calling out to her on the street, which made her
feel unsafe. She would go to the gym more often, but after dealing with the
traffic to and from work, she doesn’t have much time or energy left to drive
to the gym. That is also why she doesn’t cook as often as she wanted. Most
times, she ends up going to the food court of the new mall near their office
to buy fries and coke – her comfort foods of choice.

20. Understanding the impact of initiatives
Questions that may need to be answered:
• What was the impact of an intervention on the population?
• What was the impact on sub-populations?
• Were they any positive or negative externalities?
• What lessons were learnt?
• How can the intervention be replicated in similar settings?

21. Example: The Potential of Social Media Insights to Inform Emergency
Responses in Cities: A Case Study of Nigeria’s COVID-19 Lockdowns (Mogo
et al. (2021) (under consideration)
• Understanding how members of the Nigerian
public were responding to COVID-19 pandemic
control measures
• Used social media analytics to fill the gap in data
collection during lockdown
• Analysed data from January to August 2020 to see
how conversations around NCD risk factors evolved
along with changing COVID-19 control and
mitigation measures
• Used to identify key public concerns in order to
inform future public health messaging

22. Reflect: what evidence would you use to
understand the impact of initiatives to
improve Lebo’s health?
Lebo has been living in the informal settlement, Khayelitsha, South
Africa for 10 years now with her four children who are 13, 10, 8 and 5
years old. She is grateful that she can afford to feed her children and
often needs to cook with a stove indoors, which seems to worsen her
daughter’s asthma. She tends to buy snacks, sachet noodles and coke
for her children, because she does not have enough space and
electricity to store foods. The tap water is not very clean, and she tends
to use sachet water for cooking, which is expensive, so she tries not to
buy foods that need washing and refrigerating, though she wishes that
her children could enjoy fresh fruits as much as she did when she was
growing up in the village. Lebogang is worried that her children must
walk long distances at night to use the bathrooms. Even though she asks
them to go in twos she is always afraid something may happen to them
– one of her neighbours was recently shot by a stray bullet that came
from a confrontation between two gangs. The toilets are also not very
clean. Every now and then she has a urinary infection as a result. She
hopes that one day she can give her children the better life she has been
working so hard for. She works very hard to save so that they can move
to a new neighbourhood, but it is a bit difficult doing so as a single
parent and with her job as a cleaner. She is happy at least, that she can
send her children to school and hopes it will be their way to a better life.

23. Reflections
• What have you learnt about the role of evidence in influencing health
issues?
• How would you apply this perspective to health challenges in your
community?