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

Barriers to consumption of fruits and vegetables and strategies to overcome them in low- and middle-income countries: a narrative review

This review provides an overview of the barriers to the consumption of fruits and vegetables (FVs) as well as strategies to improve the intake of FVs in low- and middle-income countries (LMICs). The importance of the consumption of FVs and its role in disease prevention are discussed briefly. Trends in the consumption of FVs in LMICs are also summarised. The WHO recommends that every individual should consume at least five servings or 400 grams of FVs per day. Epidemiological and clinical investigations have demonstrated that FVs contain numerous bioactive compounds with health-protecting activities. Despite their health benefits, the intake of FVs in LMICs remains low. Major barriers identified were socio-demographic factors, environmental conditions, individual and cultural factors, and macrosystem influences. These barriers may be lowered at the household, school, community, and national level through multi-component interventions including behaviour change communication (BCC) initiatives, nutrition education (NE), gardening initiatives, farm to institution programs (FIPs), food baskets, cash transfers, nutrition-agriculture policy and program linkages, and food-market environment-based strategies. This review has research implications due to the positive outcomes of strategies that lower such barriers and boost consumption of FVs in LMICs.

Revising primary and secondary school curricula in the Caribbean to enhance education on the risks for noncommunicable diseases

In the English-speaking Caribbean, an estimated 46% of men and 61% of women are currently overweight or obese, and 8% of children younger than 5 years are also overweight. To combat this worsening epidemic, driven by unhealthy dietary patterns, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, which included mandates on the provision of healthy school meals, promotion of healthy dietary patterns, and reintroduction of physical education in schools. These mandates are aligned with evidence-based approaches used in childhood obesity prevention programs. School-based interventions, including curriculum revisions, are part of a multipronged approach to improve nutrition in children and are designed to complement and reinforce other interventions in schools. However, formal evaluation of the Port-of-Spain Declaration showed that most CARICOM member countries had difficulty implementing the mandates related to schools and diet. The Improving Household Nutrition Security and Public Health in the CARICOM project, in collaboration with regional institutions, the CARICOM Secretariat, and the Caribbean Examinations Council, sought to enhance nutrition education through revision of region-wide primary and secondary school curricula to increase the focus on prevention of noncommunicable diseases. This paper describes the process of revising the Caribbean Examinations Council's Human and Social Biology syllabus for secondary schools and the CARICOM Health and Family Life Education Regional Curriculum Framework for primary schools, which was achieved through multisectoral collaboration. We used the Framework for Reporting Adaptations and Modifications-Enhanced model to describe the process through which the modifications were made.

Barriers and facilitators to implementation of nutrition-related actions in school settings in low- and middle-income countries (LMICs): a qualitative systematic review using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Low- and middle-income countries (LMICs) are particularly vulnerable to the double burden of malnutrition: co-existence of underweight, overweight, obesity, and/or diet-related non-communicable diseases. Nutrition-related double-duty actions in school settings have been identified as one of the ways to address this challenge. However, to be able to take full advantage of the potential impact, it is important to understand their implementation as well. The aim of this paper is to systematically review qualitative research on barriers and facilitators to the implementation of nutrition-related actions in the school settings in LMICs.

METHODS

The following databases were searched: EMBASE, ERIC, MEDLINE, Global Health and PsycInfo (all on Ovid), Scopus (Elsevier), the Web of Science Social Sciences Citation Index, and Global Index Medicus from the World Health Organization. Of the 4253 identified records, 4030 were excluded after the abstract and title screen, leaving 223 for the full-text screen. A final 36 papers were included in this review. The consolidated framework for implementation research (CFIR) was used in the analysis.

RESULTS

We identified barriers and facilitators to implementation linked to the following CFIR constructs/sub-constructs: design quality and packaging, cost (intervention characteristics); target group needs and resources, cosmopolitanism, external policy and incentives (outer setting); structural characteristics, readiness for implementation (inner setting); knowledge and beliefs (characteristics of individuals) and engaging, executing (process). All identified constructs apart from target group needs and resources, knowledge and beliefs, and engaging were predominantly barriers. Available resources were the most prevalent barriers across studies.

CONCLUSION

This review identified barriers and facilitators to the implementation of nutrition-related actions based on qualitative articles in the school setting in LMICs, using the CFIR. Schools face continuous challenges in regard to funding and the government sector may have a role to play not only by offering financial assistance, but also through policy-making that would support healthy eating practices on school grounds.

REGISTRATION

PROSPERO ID: CRD42022296159.

Review: Evaluating existing policies to address overweight and obesity in the Anglophone Caribbean: A narrative review of Barbados, Grenada, St. Lucia, and Trinidad & Tobago

Overweight and obesity continues to be a burden to the health and well-being of Caribbean residents. The rise of childhood obesity and non-communicable diseases within the Caribbean is a major public health challenge for policymakers, educators and health professionals. These alarming rates of obesity also pose a threat to the sustainability of existing health systems particularly in small island developing states like the Caribbean. Therefore, it is crucial to evaluate existing policies and create policy solutions to address these problems and reduce the potential impact later on. This systematic review explored existing policies among countries within the Anglophone Caribbean to identify trends within the region. The literature search focused on the following themes: (i) national policies (ii) school nutrition policies and programs (iii) physical activity among youth, and (iv) food import bill and food security. An analysis was conducted on literature from national, regional and international institutions including but not limited to the World Health Organization, Ministries of Health and the Healthy Caribbean Coalition. Countries throughout the region has acknowledged the challenges with overweight and obesity in the region. Collectively decisions have been made to address food insecurity and promote healthy lifestyle behaviours through policy changes. There's still a need for Caribbean countries to work together to create effective policy solutions in collaboration with community service organizations and other stakeholders. As small island developing states grappling with the same issues, pooling resources to create effective regional policies can help to address this public health crisis.

The whole-of-society approach of mass COVID-19 vaccination in China: a qualitative study

BACKGROUND

Many countries have an inefficient vaccination system, which hinders global exit from the COVID-19 pandemic. It is vital to summarize COVID-19 vaccination practices in countries with high vaccination coverage and provide implications for other countries. This study aimed to investigate China's COVID-19 vaccination system and to summarize its implementation experience from a health system perspective.

METHODS

We conducted key informant interviews in five representative cities of China in late 2021. Guided by the health systems framework proposed by WHO, we developed our interview guidelines which included seven building blocks-leadership and governance, health workforce, vaccination service delivery, vaccination mobilization and communication, financing, access to vaccines, and information systems. Semi-structured interviews and COVID-19 vaccination policy documents were collected and coded using a thematic analysis approach.

RESULTS

A total of 61 participants (nine vaccination programme directors of the local Center for Disease Control and Prevention, four government staff and 48 vaccination service workers) were interviewed. We found that China adopted a whole-of-society approach with adequate government engagement and linked health and non-health sectors to promote COVID-19 vaccination. Key measures included the collaboration of multiple systems and departments from a governance perspective, allocating sufficient health workers and resources, large-scale vaccination mobilization and communication, expansion of vaccine financing channels, localized production and digital information systems. With the vaccination system strengthening, the two-doses vaccination coverage reached 89.5% for the total population but relatively lower coverage for older adults as of July 2022.

CONCLUSIONS

Our study highlights the importance of a government-led whole-of-society approach to promote mass vaccination. The low vaccination coverage among older adults should be paid the greatest attention to. The experiences and lessons from China may serve as a reference for other countries.

Perceptions of the local food environment and fruit and vegetable intake in the Eastern Caribbean Health Outcomes research Network (ECHORN) Cohort study

INTRODUCTION

Studies conducted in the US and other high-income countries show that the local food environment influences dietary intakes that are protective for cardiovascular health.However, few studies have examined this relationship in the Caribbean. This study aimed to determine whether perceptions of the local food environment were associated with fruit and vegetable (FV) intake in the Eastern Caribbean, where daily FV intake remains below recommended levels.

METHODS

Cross-sectional analysis of Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS) baseline data (2013-2016) from Barbados, Puerto Rico, Trinidad and Tobago, and US Virgin Islands was conducted in 2020. The National Cancer Institute Dietary Screener Questionnaire was adapted to measure daily servings of FV. Existing scales were used to assess participant perceptions of the food environment (availability, affordability, and quality). Chi-square tests and Poisson regression were used for analyses.

RESULTS

Participants reported eating one mean daily serving of FV. Mean daily intake was higher among those who perceived FV as usually/always affordable, available, and high quality. Multivariate results showed statistically significant associations between FV and affordability. Persons who perceived FV as affordable had 0.10 more daily servings of FV compared to those who reported FV as not always affordable (p = 0.02). Food insecurity modified the association between affordability and FV intake.

CONCLUSIONS

This study highlights the importance of affordability in consumption of FV in the Eastern Caribbean, and how this relationship may be modified by food insecurity.