Title: The NIHR Global Health Research Group on leveraging improved nutrition preconception, during pregnancy and postpartum in SubSaharan Africa through novel intervention models, Southampton 1000 DaysPlus Global Nutrition, at the University of Southampton
Funder: Department of Health and Social Care

Abstract: Our NIHR Southampton 1000 DaysPlus Global Nutrition Research Group (GNRG) represents a partnership between University of Southampton (UoS), NIHR Southampton Biomedical Research Centre, INDEPTH and South African Medical Research Council (SAMRC). UoS At the University of Southampton (UoS), a world-class research-intensive University, &founder member of the Worldwide Universities Network, global perspectives are high priority (notably Ghana and South Africa). UoS employs ~750 biomedical and translational researchers in strong partnership with University Hospital Southampton NHS Foundation Trust (UHS), with >220 clinical academics. UoS is known globally for DOHaD, nutrition, maternal and child health, social statistics, and behaviour change research. The UoS Global Health Research Institute (GHRI), a hub for its Global Health research, aligns with the UoS Global Excellence strategy, encouraging mobility between institutions and support for young scientists. The mature LMIC GHRI collaborations make it well placed to create a world-class NIHR GNRG to define interventions during preconception, pregnancy and early life period to provide the best start in life for vulnerable people in sub-Saharan Africa DAC countries. NIHR BRC Research from the BRC Lifecourse Nutrition, Lifestyle & Health Theme and the MRC Lifecourse Epidemiology Unit (LEU) has established the critical role of nutrition during the 1000 DaysPlus; these insights and infrastructure in nutritional assessment, nutrition/lifestyle RCTs, behaviour change and nutrition eLearning for healthcare professionals and families place us in an excellent position to now apply these for population and societal benefit in sub-Saharan Africa. We have pioneered a novel behaviour change approach for adolescents, LifeLab, promoting health literacy through hands-on engagement in science (‘Me, my health & my children’s health’). Institutional partnerships and strategies Newell has a long-established collaboration with INDEPTH, a network of population-based longitudinal surveillance sites in Africa evaluating health and social interventions; UoS has an active MoU with INDEPTH, which has 49 health and demographic surveillance sites (HDSS) and 43 Research Centres in 19 Countries across 3 Continents. This network will assist us applying and adapting sceintific insights from high-income counties and will form a basis for a strategic NIHR partnership. Godfrey has an established collaboration with the University of West Indies Solutions for Developing Countries (SODECO) Network, through which he engages in nutritional interventions with our partners in Ghana. Hanson chairs the FIGO Adolescent, Preconception and Maternal Nutrition working group, which developed recommendations for improving nutrition in the 1000 days plus and provides direct access to health care professionals and Ministries of Health in 131 member countries worldwide. A strong GHRI partner is the MRC LEU, which has conducted collaborative research for many years through the COHORTS and other consortia. Burkina Faso and Ghana are both part of the INDEPTH network. The Nanoro site (Burkina Faso) is a multidisciplinary group, with expertise in clinical research and community-based interventions targeting adolescents (PaluFer), pregnant women (PregACT, COSMIC) and infants/children (Mal055, RTS,S-SMC). Nanoro is a national champion in evidence-based policy making, and experienced in engaging with stakeholders in various MoH activities involving community-based intervention. Through the INDEPTH network, Nanoro pilots the Comprehensive Health and Epidemiological Surveillance System (CHESS) to improve non hospital health data collection. The Navrongo site (Ghana) has over 25 years’ experience in community research, with multidisciplinary expertise (clinicians, biomedical scientists, health economists, public health specialists, social demographers). Research findings have informed national and international policies, collaborating with the World Bank, World Health Organization, United States Agency for International Development, and European Union. The Centre actively engages with policy makers in the Ghana Health Service and the Ministry of Health. . In Ghana, the established UoS-Kwame Nkrumah University of Science & Technology, Kumasi (Plange-Rhule, Forrester) partnership brings practical expertise in enacting population scale nutritional interventions in urban and rural settings, along with deep knowledge of how to change healthcare systems in the 1000 DaysPlus period. UoS has a long-standing collaboration with the SA MRC Developmental Pathways for Health Research Unit (DPHRU) based at the University of the Witwatersrand, Johannesburg (Wits). As an extramural unit, DPHRU addresses one the SAMRC’s core aims to improve maternal and child health. DPHRU has strong expertise in nutrition epidemiology across the life course with 30 years research experience with cohorts and studying the urban Soweto community where the proposed work will take place. The SAMRC is linked to the South African Department of Health and has well established engagement processes with policy leaders, and understanding which effective interventions can be used to address high burden conditions in South Africa may have considerable impact on population health. A collaborator of DHPRU is PRICELESS (Priority Cost Effective Lessons for System Strengthening South Africa). The aim of PRICELESS SA, a research unit based at Wits University School of Public Health, is to support the development of evidence-based information and tools to determine how best to use existing scarce resources and make better decisions in prioritizing public health interventions We have selected the 3 SSA sites (Nanoro, Navrongo, Soweto) to capture diversity in terms rural and urban contexts (Table), stages within the nutrition transition, and extent of the double burden of nutrition. These three sites have substantial research experience and access to communities, and an interest in improving the health of children from an early age. Several joint studies exist between the Burkina Faso, Ghana and South African teams. Scientific strategy Our NIHR Southampton 1000 DaysPlus GNRG will strategically combine NIHR nutrition expertise and multidisciplinary UoS Global Health interests. This will enable some of the world's leading experts to work with LMIC partners, with existing cohorts and population platforms, to address the global skills and knowledge gaps relating to how to optimise the environment from preconception to the second birthday. The scientific strategy is two-fold: (i) strengthening, and (ii) sustaining capability. The 1000 DaysPlus GNRG will create synergies between existing research resources, maximises site contributions and provide capacity building opportunities for early career researchers,. We anticipate that the combination of the economic case, enhanced research capacity will lead to further grant opportunities and trials across the group, and partnerships with the delivery side (policy leaders; NGOs) will in time lead to implementation and scale-up. All partners have contributed to the proposal development and during the first workshop will finalise protocols and the work plan. In each site, participants in research will be represented on community advisory boards to ensure their views are heard, and taken into account, using our BRC insights on best PPI practice. We will use Mitchell stakeholder typology to identify stakeholders to involve them in a multi-actor panels to drive strategy and co-creation At the second workshop, and based on the qualitative and quantitative research undertaken by the GNRG under the initial objectives, all partners will discuss possible interventions and agree which two to take forward for evaluation.

Lay abstract: Sub-Saharan Africa (SSA) has persistently high rates of intrauterine growth restriction, pre-term birth, low birthweight, underweight and child stunting, but also rapidly increasing rates of overweight and obesity. Further, communities across SSA now have a ‘double burden’ of malnutrition, where undernutrition in infancy is followed by over-nutrition in terms of macronutrients, but with enduring deficiencies in micronutrients (iron, folic acid and other vitamins). Of particular concern is that from Developmental Origins of Health and Disease (DOHaD) research, early life under-nutrition coupled with excessive weight gain in later life significantly increases risk for adult obesity, diabetes and hypertension. Given that non-communicable diseases (NCD) are major causes of death and disability globally and are now increasing most rapidly in low- and middle-income countries (LMICs), optimising the nutritional status of future parents, and thus tackling the double burden of malnutrition may in the short-term improve growth and neurodevelopment of their offspring, and in the longer-term could set up healthier trajectories that reduces the risk for NCDs in later life. To address the double burden of malnutrition we will establish a group of researchers to develop a framework focussing on our 1000 DaysPlus concept (optimise nutrition before, during and after pregnancy). We envisage that implementing supportive “double-duty” nutritional interventions to tackle both aspects of the double burden of malnutrition will require engagement of critical multisectoral stakeholder groups, including target population groups along with policy-makers and health care professionals (HCPs), to co-create opportunities and services to allow vulnerable populations to adopt healthy diets. HCPs have an important role in motivating men and women to change eating behaviours; in LMICs the case for such policy action has not yet been made, and HCPs lack knowledge and skills to assist motivation. Over 3 years, our objectives are to: 1. Establish a multidisciplinary group of researchers across SSA, with UK Southampton 2. Undertake in-depth review of nutrition policy and engagement of health policy-makers and healthcare leaders with the issue, in three different SSA countries, to establish the barriers and the opportunities to instituting a clear 1000 DaysPlus double duty healthy nutrition policy 3. Formulate the economic case for investment in nutrition in the 1000 DaysPlus for optimal health of people and their future offspring 4. Leverage our on-going work in different contexts and with a range of stakeholders to identify the best 1000 DaysPlus nutrition interventions that could be embedded in ongoing reproductive health services, community health worker programmes, community antenatal care clinics, or fiscal measures (for example, sugar sweetened beverage tax) 5. Develop protocols and pilot novel approaches to improve the nutritional status in the 1000 DaysPlus period

Research activity codes: 3.3 NUTRITION AND CHEMOPREVENTION;8.2 HEALTH AND WELFARE ECONOMICS;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: GENERIC HEALTH RELEVANCE;REPRODUCTIVE HEALTH AND CHILDBIRTH