Faith-based leaders' perceptions on the implementation of programs to promote healthy lifestyles in churches in Barbados-a mixed-methods analysis.

Background: There is a high burden of chronic diseases such as hypertension and diabetes in small island developing states (SIDS). SIDS governments have committed to a range of public health, healthcare, and fiscal measures to reduce this burden including community-based health education in collaboration with civil society organizations. We sought to explore perceived acceptability, appropriateness, and feasibility of implementing self-management health programs in 20 faith-based organizations in the small island developing state of Barbados. Methods: This was a concurrent mixed methods study - a quantitative online survey and a qualitative inquiry using semi-structured interviews. Acceptability, appropriateness and feasibility of the intervention were assessed using the following quantitative assessment tools: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Thirteen in-depth interviews were conducted virtually, recorded and transcribed verbatim. Transcripts were analyzed using thematic analysis based on deductive codes from Proctor's implementation outcomes definitions. Results: From the 52 respondents of the survey, the median and interquartile ranges for the AIM, IAM and FIM scales were 16 (15-20), 16 (16-20) and 16 (15-17) (out of 20), respectively. We found high levels of acceptability, 82% (95% CI (69%, 95%)) of leaders indicating that health programs in churches met with their approval; and high levels of appropriateness-90% (95% CI (80%, 100%)) indicating health programs in churches were "fitting" and "a good match". Feasibility scores were lower, with 60% (95% CI (44%, 76%)) indicating that health programs in churches would be easy to use. In interviews, leaders expressed acceptance of healthy lifestyle programs in churches and described their appropriateness through alignment with church doctrines stating, "the body is the temple of God". They felt that economic impacts from COVID-19 were likely to be a barrier to the success of programs. Leaders expressed the need for support from healthcare providers who are sensitive and respectful of church culture. Conclusion: We found that health-based programs in churches align well with church doctrines, but the success of these programs will depend on establishing trust through the engagement of church-based champions, tailoring programming to include a biblical perspective and engaging entire households.

A systematic scoping review evaluating sugar-sweetened beverage taxation from a systems perspective.

Systems thinking can reveal surprising, counterintuitive or unintended reactions to population health interventions (PHIs), yet this lens has rarely been applied to sugar-sweetened beverage (SSB) taxation. Using a systematic scoping review approach, we identified 329 papers concerning SSB taxation, of which 45 considered influences and impacts of SSB taxation jointly, involving methodological approaches that may prove promising for operationalizing a systems informed approach to PHI evaluation. Influences and impacts concerning SSB taxation may be cyclically linked, and studies that consider both enable us to identify implications beyond a predicted linear effect. Only three studies explicitly used systems thinking informed methods. Finally, we developed an illustrative, feedback-oriented conceptual framework, emphasizing the processes that could result in an SSB tax being increased, maintained, eroded or repealed over time. Such a framework could be used to synthesize evidence from non-systems informed evaluations, leading to novel research questions and further policy development.

Understanding the links between human health, ecosystem health, and food systems in Small Island Developing States using stakeholder-informed causal loop diagrams.

Globalized food systems are a major driver of climate change, biodiversity loss, environmental degradation, and the increasing prevalence of overweight and obesity in society. Small Island Developing States (SIDS) are particularly sensitive to the negative effects of rapid environmental change, with many also exhibiting a heavy reliance on food imports and high burdens of nutrition-related disease, resulting in calls to (re)localize their food systems. Such a transition represents a complex challenge, with adaptation interventions in one part of the food system contingent on the success of interventions in other parts. To help address this challenge, we used group model-building techniques from the science of system dynamics to engage food system stakeholders in Caribbean and Pacific SIDS. Our aim was to understand the drivers of unhealthy and unsustainable food systems in SIDS, and the potential role that increased local food production could play in transformative adaptation. We present two causal loop diagrams (CLDs) considered helpful in designing resilience-enhancing interventions in local food systems. These CLDs represent 'dynamic hypotheses' and provide starting points that can be adapted to local contexts for identifying food system factors, understanding the interactions between them, and co-creating and implementing adaptation interventions, particularly in SIDS. The results can help guide understanding of complexity, assist in the co-creation of interventions, and reduce the risk of maladaptive consequences.

Youth perspectives on mental health during COVID-19 lockdown in a Small Island Developing State: implications for emergency response.

Introduction: Evidence exploring the relationship between COVID-19 mitigation measures and mental health has primarily been from quantitative studies in large, developed countries. A qualitative study to explore the knowledge, attitudes and behaviors of young people living in Trinidad and Tobago was conducted to engage and collaborate with youth on matters affecting them during the pandemic. Methods: Ten virtual focus groups were conducted with 64 participants aged 18 to 24 in 2021 when partial lockdown measures were in effect for COVID-19 prevention. Groups were stratified by geographic location and socioeconomic status. The recordings were transcribed and analyzed to explore themes of importance to youth. Results: Negative impacts on mental health emerged as a strong theme. Lack of timelines for restrictions led to wide ranging mental health impacts, conflict and tension existed in home environments, longer restrictions led to erosion of the social culture, and young people experienced stress about the changing face of education and job security due to the pandemic. Discussion: Measures taken to address one serious public health concern, COVID-19, led to the aggravation of another serious public health concern, mental ill-health. Mental health initiatives to help young people navigate issues specific to their generation must be developed. In low resourced Small Island Developing States settings. The increased need for mental health services during and because of the COVID-19 pandemic highlights the need for strengthening the capacity and resilience of these to respond to environmental and health emergencies. Building the resilience of educational and employment services is also needed.

Improving household nutrition security and public health in the CARICOM, 2018-2022.

The Caribbean is experiencing a worsening epidemic of obesity and noncommunicable diseases (NCDs) and it has the worst rates of premature mortality from cardiovascular diseases in the region of the Americas. Creating enabling environments to improve dietary diversity would help reduce obesity and diet-related NCDs. The Improving Household Nutrition Security and Public Health in the CARICOM project aimed to increase dietary diversity in the Caribbean, and to determine and implement effective, gender-sensitive interventions to improve food sovereignty, household food security, and nutrition in CARICOM states. Primary quantitative and qualitative research, scoping reviews, stakeholder engagement, implementation of interventions and dissemination activities were undertaken. This paper describes the overall project design and implementation, discusses challenges and limitations, and presents core achievements to inform further work in Small Island Developing States throughout CARICOM to advance the nutrition agenda in the Caribbean. The results of the project's research activities are presented in other papers published in this special issue on nutrition security in CARICOM states.

El Caribe está registrando un empeoramiento de la epidemia de obesidad y enfermedades no transmisibles (ENT) y presenta las peores tasas de mortalidad prematura por enfermedades cardiovasculares de la Región de las Américas. La creación de entornos propicios para mejorar la diversidad alimentaria contribuiría a reducir la obesidad y las ENT relacionadas con la alimentación. El proyecto "Mejorar la seguridad nutricional de los hogares y la salud pública en CARICOM" tiene por objetivo ampliar la diversidad alimentaria en el Caribe y acordar y ejecutar intervenciones efectivas con perspectiva de género para mejorar la soberanía alimentaria, la seguridad alimentaria de los hogares y la nutrición en los Estados de CARICOM. Se llevaron a cabo investigaciones primarias cuantitativas y cualitativas, revisiones exploratorias, ejecución de intervenciones y actividades de difusión, y se impulsó la participación de las partes interesadas. En este artículo se describen el diseño y la ejecución del proyecto en general, se analizan sus desafíos y limitaciones, y se presentan sus logros básicos para que se tengan en cuenta en la labor adicional que realizan los pequeños Estados insulares en desarrollo de CARICOM con el fin de impulsar la agenda de nutrición en el Caribe. Los resultados de las actividades de investigación del proyecto se presentan en otros documentos publicados en este número especial sobre seguridad nutricional en los Estados de CARICOM.

O Caribe está passando por um agravamento da epidemia de obesidade e doenças não transmissíveis (DNTs) e tem as piores taxas de mortalidade prematura por doenças cardiovasculares na Região das Américas. A criação de ambientes favoráveis para melhorar a diversidade alimentar ajudaria a reduzir a obesidade e as DNTs relacionadas à alimentação. O projeto Improving Household Nutrition Security and Public Health in the CARICOM [Melhoria da segurança nutricional doméstica e da saúde pública na CARICOM] teve como objetivo aumentar a diversidade alimentar no Caribe e determinar e implementar intervenções eficazes e sensíveis ao gênero para melhorar a soberania alimentar, a segurança alimentar doméstica e a nutrição nos estados da CARICOM. Foram realizadas pesquisas quantitativas e qualitativas primárias, revisões de escopo, ações de envolvimento das partes interessadas, implementação de intervenções e atividades de divulgação. Este documento descreve a elaboração e a implementação geral do projeto, analisa seus desafios e limitações e apresenta as principais realizações para informar o trabalho futuro nos pequenos Estados insulares em desenvolvimento em toda a CARICOM, visando a avançar a agenda nutricional no Caribe. Os resultados das atividades de pesquisa do projeto são apresentados em outros artigos publicados neste número especial sobre segurança nutricional nos Estados da CARICOM.

Improving household nutrition security and public health in the CARICOM, 2018–2022

[ABSTRACT]. The Caribbean is experiencing a worsening epidemic of obesity and noncommunicable diseases (NCDs) and it has the worst rates of premature mortality from cardiovascular diseases in the region of the Americas. Creating enabling environments to improve dietary diversity would help reduce obesity and diet-related NCDs. The Improving Household Nutrition Security and Public Health in the CARICOM project aimed to increase dietary diversity in the Caribbean, and to determine and implement effective, gender-sensitive interventions to improve food sovereignty, household food security, and nutrition in CARICOM states. Primary quantitative and qualitative research, scoping reviews, stakeholder engagement, implementation of interventions and dis- semination activities were undertaken. This paper describes the overall project design and implementation, discusses challenges and limitations, and presents core achievements to inform further work in Small Island Developing States throughout CARICOM to advance the nutrition agenda in the Caribbean. The results of the project’s research activities are presented in other papers published in this special issue on nutrition security in CARICOM states.

[RESUMEN]. El Caribe está registrando un empeoramiento de la epidemia de obesidad y enfermedades no transmisibles (ENT) y presenta las peores tasas de mortalidad prematura por enfermedades cardiovasculares de la Región de las Américas. La creación de entornos propicios para mejorar la diversidad alimentaria contribuiría a redu- cir la obesidad y las ENT relacionadas con la alimentación. El proyecto “Mejorar la seguridad nutricional de los hogares y la salud pública en CARICOM” tiene por objetivo ampliar la diversidad alimentaria en el Caribe y acordar y ejecutar intervenciones efectivas con perspectiva de género para mejorar la soberanía alimen- taria, la seguridad alimentaria de los hogares y la nutrición en los Estados de CARICOM. Se llevaron a cabo investigaciones primarias cuantitativas y cualitativas, revisiones exploratorias, ejecución de intervenciones y actividades de difusión, y se impulsó la participación de las partes interesadas. En este artículo se describen el diseño y la ejecución del proyecto en general, se analizan sus desafíos y limitaciones, y se presentan sus logros básicos para que se tengan en cuenta en la labor adicional que realizan los pequeños Estados insu- lares en desarrollo de CARICOM con el fin de impulsar la agenda de nutrición en el Caribe. Los resultados de las actividades de investigación del proyecto se presentan en otros documentos publicados en este número especial sobre seguridad nutricional en los Estados de CARICOM.

[RESUMO]. O Caribe está passando por um agravamento da epidemia de obesidade e doenças não transmissíveis (DNTs) e tem as piores taxas de mortalidade prematura por doenças cardiovasculares na Região das Améri- cas. A criação de ambientes favoráveis para melhorar a diversidade alimentar ajudaria a reduzir a obesidade e as DNTs relacionadas à alimentação. O projeto Improving Household Nutrition Security and Public Health in the CARICOM [Melhoria da segurança nutricional doméstica e da saúde pública na CARICOM] teve como objetivo aumentar a diversidade alimentar no Caribe e determinar e implementar intervenções eficazes e sensíveis ao gênero para melhorar a soberania alimentar, a segurança alimentar doméstica e a nutrição nos estados da CARICOM. Foram realizadas pesquisas quantitativas e qualitativas primárias, revisões de escopo, ações de envolvimento das partes interessadas, implementação de intervenções e atividades de divulgação. Este documento descreve a elaboração e a implementação geral do projeto, analisa seus desafios e lim- itações e apresenta as principais realizações para informar o trabalho futuro nos pequenos Estados insulares em desenvolvimento em toda a CARICOM, visando a avançar a agenda nutricional no Caribe. Os resultados das atividades de pesquisa do projeto são apresentados em outros artigos publicados neste número especial sobre segurança nutricional nos Estados da CARICOM.

Student Satisfaction and Self-Efficacy in a Novel Online Clinical Clerkship Curriculum Delivered During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic has caused significant disruption to medical education and clinical training and resulted in stressors that impede student learning. This study aimed to assess student satisfaction and self-efficacy in a novel online clinical clerkship curriculum delivered during the COVID-19 pandemic. Methods: Fourth- and fifth-year medical students completed an online survey in January 2021 covering the following areas: student satisfaction, self-efficacy, and perceived effectiveness of online versus face-to-face learning. Results: Just over half of students (51%) were satisfied with online clerkship delivery. However, fewer than half of students (46%) believed online learning effectively increased their knowledge, compared to 56% of students who believed face-to-face learning was effective. The perception of the effectiveness of online learning and face-to-face teaching for clinical skills was 18% and 89%, respectively (p < 0.0001). Few students perceived online teaching to be effective for developing social competencies (27%) compared to face-to-face instruction (67%) (p < 0.001). In addition, mean self-efficacy scores were higher for persons who perceived online teaching to be effective for increasing knowledge, improving clinical skills, and developing social competencies. Overall, students' perception of online learning was strongly associated with online self-efficacy. Conclusion: Student satisfaction and perceived self-efficacy in online learning were higher than reported acceptance of online clerkship curriculum.

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis.

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to 'over' nutrition versus 'under' nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review.

Objective: To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods: A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results: A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions: There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review

[ABSTRACT]. Objective. To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods. A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results. A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions. There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

[RESUMEN]. Objetivo. Describir las características de las intervenciones nutricionales realizadas en los pequeños Estados insulares en desarrollo durante los últimos 20 años. Métodos. Se realizó una revisión exploratoria rápida mediante búsquedas en las bases de datos PubMed y Web of Science de las intervenciones realizadas en los pequeños Estados insulares en desarrollo entre los años 2000 y 2019 con el fin de mejorar la nutrición de su población. También se examinó la publicación Monitoreo de avances en materia de las enfermedades no transmisibles 2020 para evaluar las políticas nutricionales en estos Estados. Resultados. Se efectuaron 174 intervenciones en 49 de los 58 pequeños Estados insulares en desarrollo. La mayor parte se llevaron a cabo en el Caribe (75 intervenciones; 43%), en tanto que la región del Pacífico y la región de los océanos Atlántico e Índico y de los mares de China Meridional y Mediterráneo efectuaron aproximadamente un 30% de las intervenciones cada una. Con la ayuda del marco NOURISHING, la mayor parte de las intervenciones (67%) se efectuaron a nivel de la comunidad y a nivel de país o de política utilizando distintos componentes del marco. La mayor parte de las intervenciones (35%) fueron educativas y de concientización. Entre las políticas que se notificaron con más frecuencia estuvieron las restricciones a la disponibilidad física de las bebidas alcohólicas y el aumento de los impuestos al alcohol; entre las menos frecuentes, las restricciones a las grasas. Por lo general, estos resultados fueron uniformes en todas las regiones con pequeños Estados insulares en desarrollo. Conclusiones. Los pequeños Estados insulares en desarrollo tienen pocas políticas nutricionales; esto puede estar relacionado con sus vulnerabilidades sociales, económicas y ambientales. Las intervenciones deberían ampliarse más allá de la educación para así incorporar múltiples componentes del marco NOURISHING, con una inclusión multisectorial que garantice una mayor colaboración y aceptación de las partes interesadas. Se justifica una revisión sistemática que haga uso de una gama más completa de fuentes para evaluar la efectividad de las intervenciones.

[RESUMO]. Objetivo. Descrever as características das intervenções nutricionais implementadas em pequenos Estados insulares em desenvolvimento (PEID) nos 20 últimos anos. Métodos. Uma revisão de escopo rápida foi realizada mediante pesquisa dos bancos de dados PubMed e Web of Science, buscando intervenções para melhoria nutricional da população em PEID no período entre 2000 e 2019. A publicação Noncommunicable Diseases Progress Monitor 2020 também foi consultada para avaliar as políticas nutricionais destes países. Resultados. Foram implementadas 174 intervenções em 49 dos 58 PEID, distribuídas na sua grande maioria na região do Caribe (75, 43%) e nas regiões do Pacífico e AIMS (Atlântico, Índico, Mediterrâneo e Mar do Sul da China) (cerca de 30% cada). Elaboradas a partir do NOURISHING Framework, a maior parte das intervenções (67%) teve implementação ao nível nacional, da comunidade ou de política, englobando os vários componentes deste quadro. Houve predomínio de intervenções educacionais e de sensibilização (35%). Observou-se com maior frequência o cumprimento total ou parcial de políticas de restrição à oferta física de bebidas alcoólicas e aumento de impostos sobre estas. Políticas de restrição à utilização de gorduras em alimentos foram as menos observadas. Em geral, as conclusões foram semelhantes em todas as regiões de PEID. Conclusões. Os PEID carecem de políticas nutricionais, devido a fatores possivelmente associados a vulnerabilidades ambientais e socioeconômicas. Além de educacionais, as intervenções devem ser ampliadas para englobar diversos outros componentes do NOURISHING Framework, com participação multissetorial para assegurar uma maior colaboração e comprometimento das partes envolvidas. Recomenda-se realizar uma revisão sistemática, com pesquisa de um rol mais amplo de fontes de informação, para avaliar a efetividade das intervenções.

Adaptation of a community-based type-2 diabetes mellitus remission intervention during COVID-19: empowering persons living with diabetes to take control.

BACKGROUND: The Barbados Diabetes Remission Study-2 reported that a low-calorie diet for weight loss and diabetes remission implemented within the community and supported by trained community health advocates was both an acceptable implementation strategy and a clinically effective intervention. This study aimed to examine the adaptability of the face-to-face protocol into an online modality. METHODS: The Iterative Decision-making for Evaluation of Adaptations (IDEA) framework guides researchers in examining the necessity of the adaptation and the preservation of core intervention elements during the adaptation process. Adaptation outcomes were documented using the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS). Implementation outcome was determined by fidelity to core elements. Intervention effectiveness was determined from the analysis of clinical data. RESULTS: We decided that an adaptation was needed as COVID-19 control measures prohibited in-person interactions. The core elements-i.e. 12-week intervention duration, daily 840-kcal allowance, and weekly monitoring of weight and blood glucose-could be preserved during the adaptation process. Adaptations were made to the following: (1) the context in which data were collected-participants self-measured at home instead of following the original implementation strategy which involved being measured by community health advocates (CHA) at a community site; (2) the context in which data were entered-participants posted their measurements to a mobile application site which was accessible by CHAs. As with the original protocol, CHAs then entered the measurements into an online database; (3) the formulation of the low-calorie diet-participants substituted the liquid formulation for a solid meal plan of equivalent caloric content. There was non-inferiority in fidelity to attendance with the online format (97.5% visit rate), as compared to the face-to-face modality (95% visit rate). One participant deviated from the calorie allowances citing difficulty in estimating non-exact portion sizes and financial difficulty in procuring meals. Weight change ranged from - 14.3 to 0.4 kg over the 12-week period, and all group members achieved induction of diabetes remission as determined by a FBG of < 7mmol/l and an A1C of < 6.5%. CONCLUSION: The results suggest that this adapted online protocol-which includes changes to both the implementation strategy and the evidence-based practice-is clinically effective whilst maintaining fidelity to key elements. Utilization of the IDEA and FRAME-IS adaptation frameworks add scientific rigour to the research. TRIAL REGISTRATION: ClinicalTrials.gov NCT03536377 . Registered on 24 May 2018.

Improving household nutrition security and public health in the CARICOM, 2018-2022 / Mejorar la seguridad nutricional de los hogares y la salud pública en la Comunidad del Caribe, 2018-2022 / Melhoria da segurança nutricional doméstica e da saúde pública na CARICOM, 2018-2022

ABSTRACT The Caribbean is experiencing a worsening epidemic of obesity and noncommunicable diseases (NCDs) and it has the worst rates of premature mortality from cardiovascular diseases in the region of the Americas. Creating enabling environments to improve dietary diversity would help reduce obesity and diet-related NCDs. The Improving Household Nutrition Security and Public Health in the CARICOM project aimed to increase dietary diversity in the Caribbean, and to determine and implement effective, gender-sensitive interventions to improve food sovereignty, household food security, and nutrition in CARICOM states. Primary quantitative and qualitative research, scoping reviews, stakeholder engagement, implementation of interventions and dissemination activities were undertaken. This paper describes the overall project design and implementation, discusses challenges and limitations, and presents core achievements to inform further work in Small Island Developing States throughout CARICOM to advance the nutrition agenda in the Caribbean. The results of the project's research activities are presented in other papers published in this special issue on nutrition security in CARICOM states.

RESUMEN El Caribe está registrando un empeoramiento de la epidemia de obesidad y enfermedades no transmisibles (ENT) y presenta las peores tasas de mortalidad prematura por enfermedades cardiovasculares de la Región de las Américas. La creación de entornos propicios para mejorar la diversidad alimentaria contribuiría a reducir la obesidad y las ENT relacionadas con la alimentación. El proyecto "Mejorar la seguridad nutricional de los hogares y la salud pública en CARICOM" tiene por objetivo ampliar la diversidad alimentaria en el Caribe y acordar y ejecutar intervenciones efectivas con perspectiva de género para mejorar la soberanía alimentaria, la seguridad alimentaria de los hogares y la nutrición en los Estados de CARICOM. Se llevaron a cabo investigaciones primarias cuantitativas y cualitativas, revisiones exploratorias, ejecución de intervenciones y actividades de difusión, y se impulsó la participación de las partes interesadas. En este artículo se describen el diseño y la ejecución del proyecto en general, se analizan sus desafíos y limitaciones, y se presentan sus logros básicos para que se tengan en cuenta en la labor adicional que realizan los pequeños Estados insulares en desarrollo de CARICOM con el fin de impulsar la agenda de nutrición en el Caribe. Los resultados de las actividades de investigación del proyecto se presentan en otros documentos publicados en este número especial sobre seguridad nutricional en los Estados de CARICOM.

RESUMO O Caribe está passando por um agravamento da epidemia de obesidade e doenças não transmissíveis (DNTs) e tem as piores taxas de mortalidade prematura por doenças cardiovasculares na Região das Américas. A criação de ambientes favoráveis para melhorar a diversidade alimentar ajudaria a reduzir a obesidade e as DNTs relacionadas à alimentação. O projeto Improving Household Nutrition Security and Public Health in the CARICOM [Melhoria da segurança nutricional doméstica e da saúde pública na CARICOM] teve como objetivo aumentar a diversidade alimentar no Caribe e determinar e implementar intervenções eficazes e sensíveis ao gênero para melhorar a soberania alimentar, a segurança alimentar doméstica e a nutrição nos estados da CARICOM. Foram realizadas pesquisas quantitativas e qualitativas primárias, revisões de escopo, ações de envolvimento das partes interessadas, implementação de intervenções e atividades de divulgação. Este documento descreve a elaboração e a implementação geral do projeto, analisa seus desafios e limitações e apresenta as principais realizações para informar o trabalho futuro nos pequenos Estados insulares em desenvolvimento em toda a CARICOM, visando a avançar a agenda nutricional no Caribe. Os resultados das atividades de pesquisa do projeto são apresentados em outros artigos publicados neste número especial sobre segurança nutricional nos Estados da CARICOM.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review / Intervenciones y políticas orientadas a mejorar la nutrición en los pequeños Estados insulares en desarrollo: una revisión rápida / Intervenções e políticas para melhoria da nutrição em pequenos Estados insulares em desenvolvimento: revisão rápida

ABSTRACT Objective. To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods. A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results. A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions. There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

RESUMEN Objetivo. Describir las características de las intervenciones nutricionales realizadas en los pequeños Estados insulares en desarrollo durante los últimos 20 años. Métodos. Se realizó una revisión exploratoria rápida mediante búsquedas en las bases de datos PubMed y Web of Science de las intervenciones realizadas en los pequeños Estados insulares en desarrollo entre los años 2000 y 2019 con el fin de mejorar la nutrición de su población. También se examinó la publicación Monitoreo de avances en materia de las enfermedades no transmisibles 2020 para evaluar las políticas nutricionales en estos Estados. Resultados. Se efectuaron 174 intervenciones en 49 de los 58 pequeños Estados insulares en desarrollo. La mayor parte se llevaron a cabo en el Caribe (75 intervenciones; 43%), en tanto que la región del Pacífico y la región de los océanos Atlántico e Índico y de los mares de China Meridional y Mediterráneo efectuaron aproximadamente un 30% de las intervenciones cada una. Con la ayuda del marco NOURISHING, la mayor parte de las intervenciones (67%) se efectuaron a nivel de la comunidad y a nivel de país o de política utilizando distintos componentes del marco. La mayor parte de las intervenciones (35%) fueron educativas y de concientización. Entre las políticas que se notificaron con más frecuencia estuvieron las restricciones a la disponibilidad física de las bebidas alcohólicas y el aumento de los impuestos al alcohol; entre las menos frecuentes, las restricciones a las grasas. Por lo general, estos resultados fueron uniformes en todas las regiones con pequeños Estados insulares en desarrollo. Conclusiones. Los pequeños Estados insulares en desarrollo tienen pocas políticas nutricionales; esto puede estar relacionado con sus vulnerabilidades sociales, económicas y ambientales. Las intervenciones deberían ampliarse más allá de la educación para así incorporar múltiples componentes del marco NOURISHING, con una inclusión multisectorial que garantice una mayor colaboración y aceptación de las partes interesadas. Se justifica una revisión sistemática que haga uso de una gama más completa de fuentes para evaluar la efectividad de las intervenciones.

RESUMO Objetivo. Descrever as características das intervenções nutricionais implementadas em pequenos Estados insulares em desenvolvimento (PEID) nos 20 últimos anos. Métodos. Uma revisão de escopo rápida foi realizada mediante pesquisa dos bancos de dados PubMed e Web of Science, buscando intervenções para melhoria nutricional da população em PEID no período entre 2000 e 2019. A publicação Noncommunicable Diseases Progress Monitor 2020 também foi consultada para avaliar as políticas nutricionais destes países. Resultados. Foram implementadas 174 intervenções em 49 dos 58 PEID, distribuídas na sua grande maioria na região do Caribe (75, 43%) e nas regiões do Pacífico e AIMS (Atlântico, Índico, Mediterrâneo e Mar do Sul da China) (cerca de 30% cada). Elaboradas a partir do NOURISHING Framework, a maior parte das intervenções (67%) teve implementação ao nível nacional, da comunidade ou de política, englobando os vários componentes deste quadro. Houve predomínio de intervenções educacionais e de sensibilização (35%). Observou-se com maior frequência o cumprimento total ou parcial de políticas de restrição à oferta física de bebidas alcoólicas e aumento de impostos sobre estas. Políticas de restrição à utilização de gorduras em alimentos foram as menos observadas. Em geral, as conclusões foram semelhantes em todas as regiões de PEID. Conclusões. Os PEID carecem de políticas nutricionais, devido a fatores possivelmente associados a vulnerabilidades ambientais e socioeconômicas. Além de educacionais, as intervenções devem ser ampliadas para englobar diversos outros componentes do NOURISHING Framework, com participação multissetorial para assegurar uma maior colaboração e comprometimento das partes envolvidas. Recomenda-se realizar uma revisão sistemática, com pesquisa de um rol mais amplo de fontes de informação, para avaliar a efetividade das intervenções.

Evidence of a health risk 'signalling effect' following the introduction of a sugar-sweetened beverage tax.

Consuming sugar-sweetened beverages (SSBs) has been associated with increased rates of obesity and type 2 diabetes, making SSBs an increasingly popular target for taxation. In addition to changing prices, the introduction of an SSB tax may convey information about the health risks of SSBs (a signalling effect). If SSB taxation operates in part by producing a health risk signal, there may be important opportunities to amplify this effect. Our aim was to assess whether there is evidence of a risk signalling effect following the introduction of the Barbados SSB tax. We used process tracing to assess the existence of a signalling effect around sodas and sugar-sweetened juices (juice drinks). We used three data sources: 611 archived transcripts of local television news, 30 interviews with members of the public, and electronic point of sales data (46 months) from a major grocery store chain. We used directed content analysis to assess the qualitative data and an interrupted time series analysis to assess the quantitative data. We found evidence consistent with a risk signalling effect following the introduction of the SSB tax for sodas but not for juice drinks. Consistent with risk signalling theory, the findings suggest that consumers were aware of the tax, believed in a health rationale for the tax, understood that sodas were taxed and perceived that sodas and juice drinks were unhealthy. However consumers appear not to have understood that juice drinks were taxed, potentially reducing tax effectiveness from a health perspective. In addition, the tax may have incentivised companies to increase advertising around juice drinks (undermining any signalling effect) and to introduce low-cost SSB product lines. Policymakers can maximize the impact of risk signals by being clear about the definition of taxed SSBs, emphasizing the health rationale for introducing such a policy, and introducing co-interventions (e.g. marketing restrictions) that reduce opportunities for industry countersignals. These actions may amplify the impact of an SSB tax.

Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis.

BACKGROUND: Only three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region's children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators. METHODS: A documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool-school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12. RESULTS: School administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices. CONCLUSION: School administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

A COVID-19 opportunity: Applying a systems approach to food security and noncommunicable diseases

[Extract]. To the Editor, Small Island Developing States (SIDS) are highly dependent on food imports from larger nations, with the Caribbean Community (CARICOM) and Pacific islands combined importing almost $5 billion in food in 2018, and more than half of SIDS countries importing more than 80% of their food, much of it nutritionally poor and highly processed. This has been an important driver of high levels of obesity (>30% of adults), food insecurity, and noncommunicable diseases (NCDs) (between 10-30% of adults) in these countries. The susceptibility of the SIDS food system to shocks in the supply chain of imported foods has been dramatically exposed in recent weeks through the growing COVID-19 pandemic with discussions focused on food security and vulnerability to climate change. The current crisis has accelerated the discourse on increasing food security, particularly in the CARICOM, as the region–which consists of 15 nations with a combined population of over 18 million–braces for a disruption in food imports from larger economies, and also due to border closures. Food security in the context on COVID-19 was high on the agenda at the Ninth Special Emergency Meeting of the Conference of Heads of Government of CARICOM on April 15, 2020, focusing on a regional approach instead of individual country approaches.

Using Group Model Building to Describe the System Driving Unhealthy Eating and Identify Intervention Points: A Participatory, Stakeholder Engagement Approach in the Caribbean.

Many Small Island Developing States of the Caribbean experience a triple burden of malnutrition with high rates of obesity, undernutrition in children, and iron deficiency anemia in women of reproductive age, driven by an inadequate, unhealthy diet. This study aimed to map the complex dynamic systems driving unhealthy eating and to identify potential points for intervention in three dissimilar countries. Stakeholders from across the food system in Jamaica (n = 16), St. Kitts and Nevis (n = 19), and St. Vincent and the Grenadines (n = 6) engaged with researchers in two group model building (GMB) workshops in 2018. Participants described and mapped the system driving unhealthy eating, identified points of intervention, and created a prioritized list of intervention strategies. Stakeholders were also interviewed before and after the workshops to provide their perspectives on the utility of this approach. Stakeholders described similar underlying systems driving unhealthy eating across the three countries, with a series of dominant feedback loops identified at multiple levels. Participants emphasized the importance of the relative availability and price of unhealthy foods, shifting cultural norms on eating, and aggressive advertising from the food industry as dominant drivers. They saw opportunities for governments to better regulate advertising, disincentivize unhealthy food options, and bolster the local agricultural sector to promote food sovereignty. They also identified the need for better coordinated policy making across multiple sectors at national and regional levels to deliver more integrated approaches to improving nutrition. GMB proved to be an effective tool for engaging a highly diverse group of stakeholders in better collective understanding of a complex problem and potential interventions.

Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study.

BACKGROUND: The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax. METHODS: We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks. RESULTS: We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs. CONCLUSIONS: This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes.