The challenges in protecting public health interests in multisectoral governance in the context of small island developing states: the case of tobacco control in Fiji and Vanuatu.

BACKGROUND: The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. Despite existing recommendations to strengthen institutional structures, protecting public health interests can be challenging amidst industry interference and conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH because their unique socioeconomic, political, and geographic vulnerabilities may weaken institutional conditions that could aid health sector actors in protecting health interests. This study aims to explore the institutional conditions that shape health sector actors' capability to protect public health interests in tobacco governance in Fiji and Vanuatu. METHODS: We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019. RESULTS: The findings show that the protection of health interests in tobacco governance were not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensured a level playing field between actors, policies were often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests were not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contributed to the politicisation of government in both states, resulting in high-level government officials' questionable commitment to protect public health interests. The system of checks and balances usually embedded into democratic governments appeared to be muted, and policymakers had limited bureaucratic autonomy to elevate health interests in multisectoral policymaking amidst high-level government officials' frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impacted health sector actors' capability to analyse policy alternatives. CONCLUSIONS: Health sector actors in Fiji and Vanuatu were not supported by institutional conditions that could help them protect public health interests in multisectoral governance to regulate CDoH originating from the tobacco industry. Institutional conditions in these states were shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.

Teaching strategies are shaped by experience with formal education: Experimental evidence from caregiver-child dyads in two Tannese communities.

Humans are extraordinary in the extent to which we rely on cumulative culture to act upon and make sense of our environment. Teaching is one social learning process thought to be fundamental to the evolution of cumulative culture as a means of adaptation in our species. However, the frequency of teaching and how we teach are known to vary across human sociocultural contexts. Understanding this variation adds to our understanding of the complex interplay between cognition and culture in shaping learning behavior but also contributes to theory around the costs and benefits of different social learning processes. Here, we examined how prior experience with formal education is related to the frequency and diversity of teaching behaviors in an experimental paradigm where caregivers were motivated (but not instructed) to teach a simple skill to a child (7-10 years old). We identified and coded a suite of subtle nonverbal behaviors that could be construed as facilitating learning. Dyads (n = 64) were recruited from two communities on Tanna Island that differ in their experience with formal schooling and their acceptance of Western institutions. We found evidence for parallel teaching strategies in both communities. However, the rate and diversity of teaching behaviors were positively associated with caregiver's experience with formal schooling and independently and negatively associated with being from a village that rejects Western-derived institutions. These results further our understanding of how multiple cultural processes influence social learning and highlights the powerful influence of formal schooling on the cultural evolution of teaching in humans.

'They're not as MSM, they're a bufta': using the categories 'men who have sex with men' and 'transgender' as technologies in Vanuatu.

In Vanuatu, the use of the terms such as 'men who have sex with men' (MSM) and 'transgender' has increased over the past decade. This paper draws on twenty months ethnographic research in Port Vila, the country's capital, to analyse what happens on the ground when MSM and transgender categories are taken up to identify people or to narrate the self. The focus is on who uses these terms, in what ways they are experienced, and what is rendered visible (or not) by their use. This research departs from approaches framing 'non-heteronormative' categories as related solely to gender and sexuality. It argues that MSM and transgender categories are used in various ways to refer not only to sexual practices and/or gender identity, but also to health risk behaviours, transactional sex and LGBT rights advocacy. The analysis offered suggests we view MSM and transgender categories as technologies that, depending on the interactional context, contribute to bureaucratic tasks or to maintaining or, on the contrary, changing established socio-political relations.

Humanitarian aid and local responses: the aftermath of the rebuilding effort on Tongoa island, Vanuatu.

Cyclone Pam swept through the archipelago of Vanuatu on 13-14 March 2015, with wind speeds exceeding those recorded anywhere in the South Pacific since the 1980s. Southern and central parts of the country were particularly affected. Material damage on Tongoa, one of the most afflicted islands, was extensive, but no deaths were reported. During the storm, villagers found shelter in their kitchen, in what is considered locally as a 'lifeboat'. The aftermath was managed and mitigated by international aid organisations. On Tongoa, this included a 'Shelter Cluster' programme, under which villagers were given house rebuilding kits. Elaborating upon extensive ethnographic investigations on site between 2011 and 2018, this paper explores and reveals the ways in which this aid generated confusion among the local population. In a larger context of regular disasters triggered by natural hazards, locals have found endogenous ways of dealing with such extreme climatic events, for the most part without any external assistance.

Mathematical Modeling for Removing Border Entry and Quarantine Requirements for COVID-19, Vanuatu.

The Pacific Island country of Vanuatu is considering strategies to remove border restrictions implemented during 2020 to prevent imported coronavirus disease. We performed mathematical modeling to estimate the number of infectious travelers who had different entry scenarios and testing strategies. Travel bubbles and testing on entry have the greatest importation risk reduction.

A qualitative study of patient perspectives of diabetes and diabetic retinopathy services in Vanuatu.

ISSUE ADDRESSED: Diabetes mellitus is an increasing global health problem, particularly in Vanuatu, where it poses a major health burden. There is paucity of information on how patients in Vanuatu perceive diabetes, diabetic retinopathy, access to services and management, health promotion and intervention services to alleviate the issues. This study aimed to explore the perceptions of diabetic patients in Vanuatu on these issues, to help inform the design of health promotion materials and community activities to empower people to self-manage and shape diabetic services that are integrated and people-centred. METHODS: Qualitative Talanga and Kakala Pacific research methodologies were applied. Participants were diabetic patients from both urban locations and rural villages in Vanuatu. Data were collected from four (two male, two female) focus group interviews and thematically analysed. RESULTS: There were 26 participants. System failures became apparent, including the inability of the health care services to meet the complex needs of patients with diabetes. The protective factors to reduce the risk and increasing incidence of diabetes and diabetic retinopathy included comprehensive village-based health promotion and community development programmes at the primary prevention level. CONCLUSION: This study described patients' experiences of their diabetic care and identified key barriers and facilitators of service delivery pathways. SO WHAT?: Vanuatu needs to expand nationwide health promotion and education programmes on nutrition and exercise, food insecurity and access through trade agreements and provide well-trained nursing and medical specialists for early diagnosis and adequate management of diabetes that all people can access and afford.

'Most nurses in the rural or remote health clinics run away from their job due to no remote allowances and poor working equipment and environment'. Health professional leaders' perception of shortages in the nursing workforce in underserved areas in Vanuatu.

INTRODUCTION: Health professional leaders are key informants working at senior levels in various health facilities in the areas of policies and planning processes, and human resources. This study explores the factors affecting the nursing shortage in Vanuatu and recommends measures and interventions to resolve the shortage. METHODS: A qualitative study was used to collect data from 12 health professional leaders using focus group discussion in three randomly selected hospitals in Vanuatu. The qualitative data were collected using a semi-structured, open-ended questionnaire and were audio-recorded. The data were translated and transcribed, and then analysed using thematic analysis. RESULTS: Four themes were identified: inadequate planning, increased population growth, nurse turnover and proposed strategies to resolve nursing shortages. Subthemes for inadequate planning were inadequate policy and human resources planning, and inadequate enrolment. Subthemes for increased population growth were demographics and burden of disease. Subthemes for nurse turnover were job dissatisfaction, absenteeism and increased medical problems. Subthemes for proposed strategies to resolve the nursing shortage were increased enrolment, infrastructure and capacity building. CONCLUSION: The present study identified key factors affecting current nursing workforce shortages and the recommended measures and interventions to resolve nursing shortages. The findings will assist policymakers to refine and develop relevant policies to address and strengthen the Vanuatu Ministry of Health nursing workforce.

Development and implementation of the Bachelor of Nursing (Conversion) course in Vanuatu.

CONTEXT: Vanuatu, a Pacific Island nation in the Western Pacific region, has to date educated its nurses by diploma program. Research evidence in developed countries has consistently shown that nurses educated by bachelor degree improve patient health outcomes and reduce hospital length of stay. In seeking to improve health outcomes, the Vanuatu Ministry of Health decided to introduce a new Bachelor of Nursing degree to provide a skilled, safe nursing workforce for the provision of health care to its peoples{1-3}. The curriculum for this degree was to be developed by Ni-Vanuatu nurse educators with the collaboration of educators from the WHO Collaborating Centre, University of Technology Sydney. However, it was first necessary to upgrade (from diploma to bachelor level) the qualifications of teachers and senior nursing practitioners who would lead the new degree course by introducing a Bachelor of Nursing (Conversion) course. ISSUES: In order to design and implement a Bachelor of Nursing (Conversion) course that would be relevant for the educational and healthcare context in Vanuatu and that would meet qualification requirements of the local regulatory bodies, it was essential to build collaborative relationships with key stakeholders in Vanuatu. A second key concern was to design a program that would cater for participants who were working full time, who were not all living in the same physical location, and who had limited access to internet technology and resources. The course also needed to take into account that participants were multilingual, and that English was not their first language. LESSONS LEARNED: Lessons learned included the importance of coming to understand the sociocultural nexus within which this course was developed and implemented, as well as appreciating the constraints that affect nursing education within the Pacific.

Scale-Dependent Influences of Distance and Vegetation on the Composition of Aboveground and Belowground Tropical Fungal Communities.

Fungi provide essential ecosystem services and engage in a variety of symbiotic relationships with trees. In this study, we investigate the spatial relationship of trees and fungi at a community level. We characterized the spatial dynamics for above- and belowground fungi using a series of forest monitoring plots, at nested spatial scales, located in the tropical South Pacific, in Vanuatu. Fungal communities from different habitats were sampled using metagenomic analysis of the nuclear ribosomal ITS1 region. Fungal communities exhibited strong distance-decay of similarity across our entire sampling range (3-110,000 m) and also at small spatial scales (< 50 m). Unexpectedly, this pattern was inverted at an intermediate scale (3.7-26 km). At large scales (80-110 km), belowground and aboveground fungal communities responded inversely to increasing geographic distance. Aboveground fungal community turnover (beta diversity) was best explained, at all scales, by geographic distance. In contrast, belowground fungal community turnover was best explained by geographic distance at small scales and tree community composition at large scales. Fungal communities from various habitats respond differently to the influences of habitat and geographic distance. At large geographic distances (80-110 km), community turnover for aboveground fungi is better explained by spatial distance, whereas community turnover for belowground fungi is better explained by plant community turnover. Future syntheses of spatial dynamics among fungal communities must explicitly consider geographic scale to appropriately contextualize community turnover.

Analysing the impact of trade agreements on national food environments: the case of Vanuatu.

BACKGROUND: A large body of literature exists on trade liberalisation and the ways in which trade agreements can affect food systems. However, the systematic and objective monitoring of these and their impact on national food environments has been limited. Using a case study, this paper undertakes a systematic analysis of how Vanuatu's obligations under WTO agreements has impacted its food environment. RESULTS: Data collection was guided by the INFORMAS trade monitoring framework's minimal approach and seven selected indicators outlined in three domains: trade in goods, trade in services and FDI, and policy space. Strong associations between trade liberalisation and imported foods, especially ultra-processed foods were evident in measured indicators as follows: (i) food trade with 32 WTO countries showing high levels of import volumes; (ii) a marked increase in 'less healthy' focus food imports namely fatty and other selected meat products, sugar, savoury snacks, ice-cream and edible ices and energy-dense beverages; (iii) actual and bound tariff rates impacting import trends of ice-cream and edible ices, bakery products and confectionary; and in other instances, a sharp increase in import of crisps, snacks and noodles despite tariff rates remaining unchanged from 2008 to 2019; (iv) policies regulating food marketing, composition, labelling and trade in the domestic space with relatively limited safeguard measures; (v) 49 foreign-owned food-related companies involved in food manufacturing and processing and the production of coffee, bakery products, confectionary, food preservatives, fish, local food products and meat, and the manufacturing, processing and packaging of palm oil, coconut oil, cooking oil, water, cordial juice, flavoured juices, soft drinks and alcoholic beverages. These were largely produced for local consumption; (vi) 32 domestic industries engaged in food and beverage production; and (vii) an assessment of WTO provisions relating to domestic policy space and governance showing that the current legal and regulatory environment for food in Vanuatu remains fragmented. CONCLUSIONS: The analysis presented in this paper suggest that Vanuatu's commitments to WTO agreements do play an important role in shaping their food environment and the availability, nutritional quality, and accessibility of foods.

Assessing Women's Health Needs in the Underserved Island Communities of Vanuatu.

INTRODUCTION: Vanuatu is a South Pacific island nation with limited resources and dispersed communities. Healthcare provision and population health data is lacking; and women have been an historically undervalued, underserved group. This needs assessment was completed by mothers in the area surrounding a health clinic in Vanuatu to better inform the clinic's service expansion. METHODS: In a period of six weeks, 60 parous women, between 17 and 66 years old, were interviewed in their native language (Bislama). Participants provided verbal responses to 29 questions targeting family health needs and pregnancy experiences. The questionnaire was constructed from WHO and UNICEF surveys. Descriptive statistics were calculated. RESULTS: Primary care complaints were the most common health concerns reported by participants. Few women (43.3%, 26/60) knew what a sexually transmitted infection was, and 38.3% (23/60) knew a place offering HIV testing. Thirty percent (18/60) never had a pelvic exam. During their last pregnancies, 98.3% (59/60) received prenatal care with a median of five visits and variable health education. Injectable (65.2%, 15/23) and oral contraception (21.7%, 5/23) were the most utilized family planning methods; one person used condoms (4.3%, 1/23). Eighty-seven percent (52/60) felt unsafe walking through their neighborhoods at night. DISCUSSION: General knowledge and utilization of women's health resources were limited in this group. The community-based primary care setting could be an important site for future provision of women's health services. Future studies and interventions in family planning, sexual health, and prenatal care could aid this community.

Medical pluralism, sorcery belief and health seeking in Vanuatu: a quantitative and descriptive study.

Set in Espiritu Santo, Vanuatu, this study explores the relationship between cultural knowledge and beliefs concerning illness and health-seeking behaviour within the context of medical pluralism. Concentrating on the nation's high rates of diabetes and non-communicable disease (NCD) risk factors, this research analyses the way in which understandings of disease aetiology and healing efficacy impact upon treatment-related decisions. Data were obtained through a mixed-methods community survey of 313 adult respondents developed in collaboration with ni-Vanuatu health experts, community leaders and survey enumerators, and comprised of open and closed-ended questions. As the results demonstrate, framed by cultural and religious beliefs, multifaceted indigenous conceptualizations of health and illness in Vanuatu are directly linked to pluralist health seeking practices, including the concurrent use of formal and informal health services. The interwoven identification of sociocultural, physical and clinical determinants of disease highlights the complex manner in which health is understood and maintained by ni-Vanuatu. In successfully addressing the rising burden of NCDs, it is integral that health interventions and service providers acknowledge the complex conceptualization of disease and ensure the provision of holistic care that embraces rather than ignores the steadfast role of local systems of belief, and of traditional, religious and other informal forms of healthcare provision.

Metapopulation Vicariance, Age of Island Taxa and Dispersal: A Case Study Using the Pacific Plant Genus Planchonella (Sapotaceae).

Oceanic islands originate from volcanism or tectonic activity without connections to continental landmasses, are colonized by organisms, and eventually vanish due to erosion and subsidence. Colonization of oceanic islands occurs through long-distance dispersals (LDDs) or metapopulation vicariance, the latter resulting in lineages being older than the islands they inhabit. If metapopulation vicariance is valid, island ages cannot be reliably used to provide maximum age constraints for molecular dating. We explore the relationships between the ages of members of a widespread plant genus (Planchonella, Sapotaceae) and their host islands across the Pacific to test various assumptions of dispersal and metapopulation vicariance. We sampled three nuclear DNA markers from 156 accessions representing some 100 Sapotaceae taxa, and analyzed these in BEAST with a relaxed clock to estimate divergence times and with a phylogeographic diffusion model to estimate range expansions over time. The phylogeny was calibrated with a secondary point (the root) and fossils from New Zealand. The dated phylogeny reveals that the ages of Planchonella species are, in most cases, consistent with the ages of the islands they inhabit. Planchonella is inferred to have originated in the Sahul Shelf region, to which it back-dispersed multiple times. Fiji has been an important source for range expansion in the Pacific for the past 23 myr. Our analyses reject metapopulation vicariance in all cases tested, including between oceanic islands, evolution of an endemic Fiji-Vanuatu flora, and westward rollback vicariance between Vanuatu and the Loyalty Islands. Repeated dispersal is the only mechanism able to explain the empirical data. The longest (8900 km) identified dispersal is between Palau in the Pacific and the Seychelles in the Indian Ocean, estimated at 2.2 Ma (0.4-4.8 Ma). The first split in a Hawaiian lineage (P. sandwicensis) matches the age of Necker Island (11.0 Ma), when its ancestor diverged into two species that are distinguished by purple and yellow fruits. Subsequent establishment across the Hawaiian archipelago supports, in part, progression rule colonization. In summary, we found no explanatory power in metapopulation vicariance and conclude that Planchonella has expanded its range across the Pacific by LDD. We contend that this will be seen in many other groups when analyzed in detail.

Betel Nut Use in Vanuatu: Investigating Opportunities to Reduce Harms to Health.

Background: Betel nut chewing is a public health concern in the Asia-Pacific region and is an emerging issue in Vanuatu. Despite the significant health risks associated with betel nut chewing, few interventions have been undertaken to reduce its harm. Objectives: To investigate betel nut use in Vanuatu and to identify opportunities to reduce its harm and possible interventions, framing the responses using the World Health Organization's MPOWER tobacco control model. Method: Qualitative research design, in the form of semi-structured interviews with ten participants with expertise in health, agriculture, education or non-communicable disease in Port Vila, Vanuatu during June 2017. Recorded interviews were transcribed verbatim, and a general inductive approach was used to identify key themes. Results: Participants reported a recent increase in betel nut use in Vanuatu due to the influence from Papua New Guinea and the Solomon Islands. To reduce the harm of betel nut use in Vanuatu, participants suggested policies and strategies that aligned with the MPOWER framework that could be adopted for betel nut control, including restricting cultivation and sale of betel nut in Vanuatu and using radio and existing community networks to reach people with messages about the dangers of betel nut use. Conclusion: Betel nut use may be growing in popularity in Vanuatu, where there are potential policy options to minimize harm. The MPOWER model for tobacco control may be a useful framework to help the Vanuatu government to deliver a comprehensive approach to reducing harm from betel nut use.

Scaring Nemo: Contrasting effects of observer presence on two anemonefish species.

Behaviours of Clark's anemonefish Amphiprion clarkii and the dusky anemonefish Amphiprion melanopus were studied in Vanuatu. Six anemones and their resident fish were observed for typical behaviours (hiding, watching, roaming, inter-, and intraspecific behaviour) with and without the presence of a snorkelling observer. Observer presence had significant but contrasting effects on hiding behaviour in A. clarkii and A. melanopus. Bolder anemonefish species may be able to outcompete other species in areas with high human presence.

Vanuatu Psychiatry Mentorship Programme: a case illustrating cultural and clinical considerations.

OBJECTIVES: The objectives of this article are to describe a case highlighting challenges in managing an acute psychiatric presentation, the process of mentorship and the significance of cultural matters influencing family engagement in Vanuatu. METHOD: Case description. RESULTS: This case highlights resourcing constraints facing a small mental health team in the Pacific, the clinical significance of the concept of tabu in a ni-Vanuatu context and the importance of family decision making processes in ni-Vanuatu culture. CONCLUSION: A structured mentoring programme to foster mental health capacity development in Vanuatu can support psychiatric decision-making in complex cases, reflection on the role of culture in formulation and family engagement, and mutual learning.

The Vanuatu Psychiatry Mentorship Programme: supporting the development of a fledgling mental health service in the Pacific.

OBJECTIVE: To describe the Vanuatu Psychiatry Mentorship Programme (VPMP) set up to support the sole mental health doctor and local nurses developing mental health service capacity in Vanuatu. METHOD: Following a request from Vanuatu, the VPMP was set up under the auspices of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (the College) with three components: regular online supervision, yearly onsite visits and advice over the Internet on an as-required basis. RESULTS: Onsite visits undertaken by three VPMP psychiatrists provided opportunities for mentoring and teaching activities related to clinical psychiatry, community liaison, social and ethical considerations and mental health policy matters. Online supervision sessions were initially hampered by technology difficulties. Ad hoc advice over the Internet allowed more rapid responses in complex acute psychiatry cases. CONCLUSIONS: Structured mentoring programmes can play a role in supporting the development of mental health capacity in low-resourced Pacific nations. Such programmes are likely to be more useful for Pacific participants if they are flexible, ongoing, sustained by support from the College and reviewed regularly.

COVID-19 restrictions amidst cyclones and volcanoes: A rapid assessment of early impacts on livelihoods and food security in coastal communities in Vanuatu.

Coastal communities in regions like the Pacific have been impacted by COVID-19 related public health measures that limit the movement of people, trade and access to resources. In disaster-prone countries, like Vanuatu, such measures add to existing pressures on coastal communities' adaptive capacity. To understand how coastal communities in Vanuatu were impacted in the immediate period after COVID-19 measures were placed, and how people responded to the changing circumstances, a rapid appraisal survey was carried out following a nationally declared state of emergency in March 2020. Results reveal changes in village population, loss of cash income, difficulties in accessing food and shifting pressures on particular resources and habitats. The findings provide insights into the ways local adaptive capacity to satisfy livelihood and food security needs differed among rural contexts. From this we argue that broad quantitative impact assessments are important in guiding strategic and longer term responses and adaptations, but that these are made more useful when complemented with qualitative insights on people and place in the short-term.

Infant gaze following depends on communicative signals: An eye-tracking study of 5- to 7-month-olds in Vanuatu.

Gaze is considered a crucial component of early communication between an infant and her caregiver. When communicatively addressed, infants respond aptly to others' gaze by following its direction. However, experience with face-to-face contact varies across cultures, begging the question whether infants' competencies in receiving others' communicative gaze signals are universal or culturally specific . We used eye-tracking to assess gaze-following responses of 5- to 7-month olds in Vanuatu, where face-to-face parent-infant interactions are less prevalent than in Western populations. We found that-just like Western 6-month-olds studied previously-5- to -7-month-olds living in Vanuatu followed gaze only, when communicatively addressed. That is, if presented gaze shifts were preceded by infant-directed speech, but not if they were preceded by adult-directed speech. These results are consistent with the notion that early infant gaze following is tied to infants' early emerging communicative competencies and rooted in universal mechanisms rather than being dependent on cultural specificities of early socialization.

Cross-cultural variation in the development of folk ecological reasoning.

Two studies examined children's reasoning about biological kinds in populations that vary in formal education and direct experience with the natural world, a Western (urban U.S.) and a Non-Western population (Tanna, Vanuatu). Study 1 examined children's concepts of ecological relatedness between species (N = 97, 5-13- year-olds). U.S. children provided more taxonomic explanations than Ni-Vanuatu children, who provided more ecological, physiological, and utility explanations than U.S. children. Ecological explanations were most common overall and more common among older than younger children across cultures. In Study 2, children (N=106, 6-11-year-olds) sorted pictures of natural kinds into groups. U.S. children were more likely than Ni-Vanuatu children to categorize a human as an animal and the tendency to group a human with other animals increased with age in the U.S. Despite substantial differences in cultural, educational, and ecological input, children in both populations privileged ecological reasoning. In contrast, taxonomic reasoning was more variable between populations, which may reflect differences in experience with formal education.