Citation: Lachat C, Nago E, Roberfroid D, Holdsworth M, Smit K, Kinabo J, et al. (2014) Developing a Sustainable Nutrition Research Agenda in Sub-Saharan Africa—Findings from the SUNRAY Project. PLoS Med 11(1): e1001593. doi:10.1371/journal.pmed.1001593
Published: January 28, 2014
Copyright: © 2014 Lachat et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: SUNRAY was funded by the European Commission under the 7th Framework Programme Grant Agreement nr. 266080. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: HTA, health technology assessment; IUNS, International Union of Nutritional Sciences; NGO, non-governmental organization; SSA, sub-Saharan Africa; UN, United Nations
Provenance: Not commissioned; externally peer reviewed.
- Here we present the findings of a collaborative effort by stakeholders in sub-Saharan Africa (SSA) to identify priorities for nutrition research and actions to create an enabling research environment.
- 117 stakeholders from 40 countries in SSA defined priorities using participatory approaches.
- The priority areas for nutrition research were (i) community interventions to improve nutritional status, (ii) behavioral strategies to improve nutritional status, and (iii) food security interventions to improve nutrition.
- The priority actions for creating an enabling nutrition research environment were (i) better governance of nutrition research, (ii) alignment of nutrition research funding with priorities identified within SSA, (iii) increased capacity development for nutrition research competencies, and (iv) enhanced information sharing and communication of nutrition research findings.
- We propose a new approach for nutrition research in SSA that stimulates a demand from SSA policy makers for research in SSA and holds them accountable for incorporating research into policy and practice.
Nutrition in Sub-Saharan Africa
Despite considerable economic growth in sub-Saharan Africa (SSA) , undernutrition rates have not improved compared to other parts of the world . In addition, diet-related noncommunicable diseases have emerged as a public health issue in SSA . Emerging threats, including climatic and demographic changes, affect the nutritional status of populations in SSA and will require effective and innovative mitigation measures . At the same time, there are concerns that scarce resources for actions to improve nutrition are not focused on the interventions with the highest effectiveness .
International commitment to address malnutrition has increased, partly because of global food insecurity concerns, academic consensus on effective actions, and the inclusion of nutritional indicators in the Millennium Development Goals . In 2010, the European Commission called for projects to help establish research priorities, strengthen commitment, and identify resource needs, synergies, and coordinated research efforts on a European and global level to tackle malnutrition. The SUNRAY (Sustainable Nutrition Research for Africa in the Years to come) project was selected for funding. SUNRAY took a consultative approach to define priorities for research themes and actions to create an enabling research environment from the perspective of stakeholders in nutrition in SSA. SUNRAY had no a priori focus and considered malnutrition in all its forms and both preventive and curative aspects.
SUNRAY was led by the SUNRAY consortium: academics from four European institutions, academics from four universities in SSA, an international non-governmental organization (NGO), and an organization that funds research in SSA. SUNRAY was organized in three stages (Figure 1). First the SUNRAY consortium analyzed the nutrition research landscape in SSA through a review of institutions publishing nutrition research and type of nutrition research published between 2000 and 2010, an analysis of the perceptions of nutrition researchers regarding nutrition research , an assessment of the nutrition research priorities of stakeholders, and the identification of research needs for environmental challenges .
In stage 2, three regional workshops in Africa were organized to set priorities. Attendance at these workshops was by invitation only. We circulated invitation letters clarifying the objective of the workshop to researchers and policy makers in SSA selected for their decision-making authority at their institutions. Care was taken to balance the representation of research groups within a country. We aimed for one representative from government and one from academia per country. Selection was primarily based on consultation of three networks—the United Nations (UN) University Food and Nutrition Programme, the International Union of Nutritional Sciences (IUNS), and the Federation of African Nutrition Societies—and those affiliated with dedicated agencies of the UN in the region.
At the workshops, the findings of stage 1 were presented to set the scene (Figure 2). Next, participants worked in small groups of about eight participants. The groups listed priorities for research and actions for an enabling environment, with criteria to rank them. Next, priorities were ranked by scoring them against the criteria. This approach was used to reach a consensus and allowed a transparent process that considered various criteria . Agreement on the priorities was reached through consensus. Dissenting views were aired and considered within both the working groups as well as the plenary. Each step of the ranking was accompanied by a plenary discussion to enable group understanding and benchmarking. The plenary discussions allowed clarification and consensus building about the emerging priorities. On the last day, external stakeholders (i.e., government officials, UN agencies, NGOs, bilateral donors, and the private sector) were invited to comment on the priorities and helped define the actions needed to implement them (Table S1). No changes to the priorities were made at this point.
The contribution of the SUNRAY consortium was limited to the introductory presentation and feedback on the findings. The moderator essentially facilitated group interactions and free expression.
In stage 3, SUNRAY organized the findings of the regional workshops into priorities for SSA. All priorities emerging from the regional workshop were allocated, and there was no further ranking or analysis afterwards. This report was circulated for consultation and approval by workshop participants from October–November 2012.
Next, SUNRAY prepared a roadmap document with the conclusions and recommendations. During a second consultation round, this document was circulated to the participants and a wider group of 56 international stakeholders, mainly based outside of SSA (two originated from Africa), i.e., academia, multilateral and bilateral donors, the UN, NGOs, IUNS, and representatives of projects in nutrition selected for their excellence or mandate for nutrition in SSA. In addition, face-to-face meetings were organized with the Department for International Development (UK), with the European Commission, and during a national workshop in Benin for Beninese and Togolese stakeholders.
The results of stage 1 are presented elsewhere ,. In total, 117 participants from 40 countries in SSA attended the workshops of stage 2 (Table S1); 34 invitees declined to participate, mainly because of prior engagements (n = 19). No response was obtained from ten invitees; three invitees provided replacement by colleagues, and two declined but gave no explanation for declining (n = 2). Participants were principally senior researchers (52%) and policy makers (30%) in nutrition. The remaining particpants (18%) were external stakeholders.
Priority Areas for Nutrition Research
Evaluate the impact of community interventions.
Participants emphasized that interventions for malnutrition have focused on curative aspects. Community-based initiatives that create an environment to prevent malnutrition using locally available approaches and resources, i.e., nutrition-sensitive approaches from areas such as agriculture, education, family planning, environmental sanitation, and rural development should be evaluated for their effectiveness.
Effectiveness of behavioral strategies.
Although some approaches have been tested in SSA, participants suggested that more understanding of the drivers of eating and child feeding behavior in SSA is needed to design effective interventions. Such research would require the propagation of multidisciplinary research across the continent that includes disciplines such as psychology and the social sciences.
Exploit the potential of food security interventions.
Sustainability and the potential to mitigate the effect of environmental challenges on nutritional status should be assessed for social safety nets, e.g., conditional/unconditional cash transfers (see ), and for food security interventions, e.g., the promotion of traditional foods, food systems, and local adaptation and mitigation strategies for environmental challenges.
Priority Actions for Creating an Enabling Research Environment
The priority actions for creating an enabling nutrition research environment were organized into four actions for SSA (Table S3).
Better governance of nutrition research.
Better governance and uptake of nutrition research is needed to ensure the practical relevance of findings, so that efforts can be targeted towards the priorities for action. A clear integration of nutrition research in the development agenda, with an explicit articulation of priorities for nutrition research in policies in SSA was highlighted.
Alignment of nutrition research funding with priorities in SSA.
The current nutrition research agenda was perceived to be driven by high-income countries, while the capacity to attract international competitive funding for most researchers in SSA was considered limited. There is a need to align funding for nutrition in SSA with the priorities identified by stakeholders from SSA.
Increased capacity development for nutrition research.
Efforts to increase regional networking and mobility within SSA, re-entry grants for promising scientists, and various specific courses are needed to capitalize on the existing nutrition research capacity in SSA. Scholarship programs from donor countries might need revision to favor local PhD programs and exchange programs where students carry out research at universities within SSA.
Enhanced information sharing and communication of research.
A new approach is needed to rationalize the communication of nutrition research findings with relevance for SSA. Mass-distributed reports or guidelines from various stakeholders in nutrition in SSA need to be organized systematically, with a transparent appraisal of quality. Local research findings should be communicated effectively to decision makers in SSA.
Regarding stage 3, 39 workshop participants commented on the report and endorsed it. A response rate of 27% (15/56) for international stakeholders was obtained. The feedback received was overall positive and highlighted the global significance of the SUNRAY findings.
Our priorities for nutrition research focus on the prevention of malnutrition in all its forms and deviate substantially from previous initiatives , that listed micronutrient supplementation or fortification as top priorities for research or investment. The participants expressed concerns regarding the sustainability of technological and curative approaches and prioritized research to prevent malnutrition. Most of the identified priorities called for multidisciplinary research and corresponded with those of a global nutrition research agenda .
Our findings reiterate previous concerns and illustrate that the prioritizing of nutrition research topics must be accompanied by a better environment and translation of research into action ,,. Recent research priority-setting exercises for SSA ,– emphasize that motivating and educating policy makers in SSA is critical to improve health . A critical challenge for scaling up efforts for nutrition in SSA is integrating nutrition research findings in programs and policies. Our findings illustrate the need to integrate different levels of nutrition research. They respond to an earlier call for new frameworks for the production and use of nutrition knowledge to enhance its practical utility for stakeholders and societal benefit .
Systematic reviews have gained ground in nutrition ,. A renewed approach for nutrition research needs to foster specific mechanisms to translate this evidence into context-specific recommendations for decision makers in SSA. Similar to health research , developing a nutrition research agenda should be an inclusive process initiated by decision makers in SSA in collaboration with other stakeholders. Much like health technology assessment (HTA), such a process should follow transparent and well-established procedures to ensure an objective outcome. Experiences with HTA are limited in SSA .
An important condition for the success of HTA for nutrition is the presence of a strong research community. In many countries of SSA the nutrition research community is weak and fragmented , and adequate capacity to govern nutrition research  together with policy commitment and funding is required.
Following SUNRAY, we have piloted an annual course on evidence-based nutrition and initiated the development of a knowledge network for evidence-based nutrition in Africa. This network will focus on the use and adaptation of existing evidence in policy and programming in Africa and on developing appropriate tools for decision makers. Facilitating evidence-based decisions is expected to improve the effectiveness of nutrition actions in SSA. Under its African presidency, the IUNS requires support, together with the Federation of African Nutrition Societies and national nutrition societies, to drive the development of a revised approach to nutrition research in SSA. The knowledge network will be able to support this process.
Setting a nutrition research agenda is also a normative process. SUNRAY went beyond international research guidelines , as it involved the integration of values and concerns of stakeholders in SSA. As such, our process also aligned with the principles of the Busan declaration .
A review of priority setting exercises in low- and middle-income countries illustrates the current lack of both systematic approaches and the involvement of stakeholders . SUNRAY successfully provided a forum for stakeholders from SSA, including countries where nutrition research is poorly developed. Previous exercises for priority setting for research in low- and middle-income countries ,,–, did not focus on creating momentum within the research community or on enhancing the research environment. We acknowledge a large heterogeneity of participants. Not all participants were able to make equally informed decisions on priorities across all issues. Another limitation was the low response rate of the consultation round with international stakeholders, which we attribute to the short duration of the consultation round and the high-level profile of those contacted. Clearly, the relative importance of our findings differs by region and country. Although the prioritization process was based on a comprehensive assessment of literature and a broad-based consultation process in SSA, we acknowledge a potential selection bias. We limited workshop participants per country to enable mutual dialogue and interactions in smaller groups.
International commitments such as Scaling Up Nutrition will require actions at the country level to yield success on the ground. A crucial condition for this success is to build and strengthen national research capacity that can engage effectively with policy makers. Our findings call for a nutrition research system that stimulates a demand from policy makers from SSA for research in SSA and holds them accountable for incorporating research into policy.
Participants of the regional workshops.
Ranking criteria and priorities for nutrition research in sub-Saharan Africa, organized by regional workshop.
Ranking criteria and priority actions for establishing an enabling environment for nutrition research in sub-Saharan Africa, organized by regional workshop.
The SUNRAY consortium (http://sunrayafrica.co.za/) was composed of the Institute of Tropical Medicine, Belgium (coordinator); Wageningen University, The Netherlands; Institut de Recherche pour le Développement, France; University of Sheffield, United Kingdom; Intermon Oxfam, Spain; the International Foundation for Science, Sweden; Université de Abomey-Calavi, Benin; Makarere Institute, Uganda; Sokoine University, Tanzania; and North-West University, South Africa.
The following members of the SUNRAY consortium provided guidance for the project: Waliou Amoussa Hounkpatin, Yves Kameli, Paula San Pedro, Teresa Cavero, Nathalie Persson Andrianasitera, Christopher Garimoi Orach, and Fre Pepping. We especially extend our appreciation to Prof. Romain Dossa (Benin) who unfortunately passed away during the project. We thank the SUNRAY Advisory Committee members for their input: Anna Taylor, Stuart Gillespie, Myriam Ait Aissa, Félicité Tchibindat, and Mathurin Coffi Nago. We thank Anna Lartey, Claire Chastre, Gerasimos Apostolatos, Nathalie Persson, Lawrence Haddad, Bruce Cogill, Barrie Margetts, Félicité Tchibindat, Jessica Fanzo, Myriam Ait Aissa, Irmgard Jordan, Martinus Desmet, and Lina Mahy for their contributions during the consultation round of the workshops' findings. We thank the workshop participants from SSA for sharing their precious time with us. Their work provides the basis for this manuscript.
Conceived and designed the experiments: CL EN DR MH KS JK AK PK. Performed the experiments: CL EN DR MH KS JK AK PK. Analyzed the data: CL EN DR MH KS JK WP AK PK. Wrote the first draft of the manuscript: CL EN. Contributed to the writing of the manuscript: CL EN DR MH KS JK WP AK PK. ICMJE criteria for authorship read and met: CL EN DR MH KS JK WP AK PK. Agree with manuscript results and conclusions: CL EN DR MH KS JK WP AK PK.
- 1. United Nations Development Programme (2012) Africa human development report: towards a food secure future. Washington (District of Columbia): United Nations Development Programme.
- 2. Stevens GA, Finucane MM, Paciorek CJ, Flaxman SR, White RA, et al. (2012) Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data. Lancet 380: 824–834. doi: 10.1016/s0140-6736(12)60647-3
- 3. Kelly T, Yang W, Chen CS, Reynolds K, He J (2008) Global burden of obesity in 2005 and projections to 2030. Int J Obes (Lond) 32: 1431–1437. doi: 10.1038/ijo.2008.102
- 4. Morris SS, Cogill B, Uauy R (2008) Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet 371: 608–621 doi:10.1016/S0140-6736(07)61695-X.
- 5. Gillespie S, Haddad L, Mannar V, Menon P, Nisbett N (2013) The politics of reducing malnutrition: building commitment and accelerating progress. Lancet 382: 552–569 doi:10.1016/S0140-6736(13)60842-9.
- 6. van Royen K, Lachat C, Holdsworth M, Smit K, Kinabo J, et al. (2013) How can the operating environment for nutrition research be improved in sub-Saharan Africa? The views of African researchers. PLoS ONE 8: e66355 doi:10.1371/journal.pone.0066355.
- 7. SUNRAY (2012) Challenges for nutrition in sub-Saharan Africa: background documents for the SUNRAY regional workshops. Available: http://sunrayafrica.co.za/sunray_cms/downloads/dynamic/compound_text_content/sunray_background_papers_english_0d1fe7c4b9d1c53e38a94f6ea689eb07.pdf. Accessed 19 December 2013.
- 8. Baltussen R, Niessen L (2006) Priority setting of health interventions: the need for multi-criteria decision analysis. Cost Eff Resour Alloc 4: 14 doi:10.1186/1478-7547-4-14.
- 9. Ruel MT, Alderman H (2013) Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet 382: 536–551 doi:10.1016/S0140-6736(13)60843-0.
- 10. Copenhagen Consensus 2012 (2012) Nobel Laureates: more should be spent on hunger, health. Available: http://www.copenhagenconsensus.com/sites/default/files/CC12%2BResults%2BPress%2BRelease%2BFinal_0.pdf. Accessed 19 December 2013.
- 11. Brown KH, Hess SY, Boy E, Gibson RS, Horton S, et al. (2009) Setting priorities for zinc-related health research to reduce children's disease burden worldwide: an application of the Child Health and Nutrition Research Initiative's research priority-setting method. Public Health Nutr 12: 389–396 doi:10.1017/S1368980008002188.
- 12. The Sackler Institute for Nutrition Science (2013) A global agenda for nutrition science. Outcome of a collaborative process between academic and non-profit researchers and the World Health Organization. Available: http://www.nutritionresearchagenda.org/pdf/Sackler-Agenda-121313-WEB.pdf. Accessed 19 December 2013.
- 13. Berg A (1993) Sliding toward nutrition malpractice: time to reconsider and redeploy. Am J Clin Nutr 57: 3–7. doi: 10.1146/annurev.nu.13.070193.000245
- 14. Berg A, Levinson F, Moorthy D (2008) Reflections from the front lines: swimming upstream with optimism. SCN News 36: 44–50 Available: http://www.unscn.org/layout/modules/resources/files/scnnews36.pdf. Accessed 19 December 2013.
- 15. Rudan I, Kapiriri L, Tomlinson M, Balliet M, Cohen B, et al. (2010) Evidence-based priority setting for health care and research: tools to support policy in maternal, neonatal, and child health in Africa. PLoS Med 7: e1000308 doi:10.1371/journal.pmed.1000308.
- 16. Swingler GH, Irlam JH, Macharia WM, Tietche F, Meremikwu MM (2005) A systematic review of existing national priorities for child health research in sub-Saharan Africa. Health Res Policy Syst 3: 7 doi:10.1186/1478-4505-3-7.
- 17. Tomlinson M, Chopra M, Sanders D, Bradshaw D, Hendricks M, et al. (2007) Setting priorities in child health research investments for South Africa. PLoS Med 4: 1293–1298. doi: 10.1371/journal.pmed.0040259
- 18. Wazny K, Zipursky A, Black R, Curtis V, Duggan C, et al. (2013) Setting research priorities to reduce mortality and morbidity of childhood diarrhoeal disease in the next 15 years. PLoS Med 10: e1001446 doi:10.1371/journal.pmed.1001446.
- 19. Pelletier DL, Porter CM, Aarons GA, Wuehler SE, Neufeld LM (2013) Expanding the frontiers of population nutrition research: new questions, new methods, and new approaches. Adv Nutr 4: 92–114 doi:10.3945/an.112.003160.
- 20. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, et al. (2008) What works? Interventions for maternal and child undernutrition and survival. Lancet 371: 417–440. doi: 10.1016/s0140-6736(07)61693-6
- 21. World Health Organization (2013) E-library of Evidence for Nutrition Actions (eLENA). Available: http://www.who.int/elena/en/ [database]. Accessed 19 December 2013.
- 22. Mckee M, Stuckler D, Basu S (2012) Where there is no health research: what can be done to fill the global gaps in health research? PLoS Med 9: e1001209. doi: 10.1371/journal.pmed.1001209
- 23. International Network of Agencies for Health Technology Assessment (2012) Members. Available: http://www.inahta.org/Members/. Accessed 19 December 2013.
- 24. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 310: 2191–2194 doi:10.1001/jama.2013.281053.
- 25. (2011) Busan partnership for effective development co-operation. 4th High Level Forum on Aid Effectiveness; 29 Nov–1 Dec 2011; Busan, Korea. Available: http://effectivecooperation.org/files/OUTCOME_DOCUMENT_-_FINAL_EN.pdf. Accessed 19 December 2013.
- 26. Tomlinson M, Chopra M, Hoosain N, Rudan I (2011) A review of selected research priority setting processes at national level in low and middle income countries: towards fair and legitimate priority setting. Health Res Policy Syst 9: 19 doi:10.1186/1478-4505-9-19.
- 27. Costello A, Filippi V, Kubba T, Horton R (2007) Research challenges to improve maternal and child survival. Lancet 369: 1240–1243 doi:10.1016/S0140-6736(07)60574-1.