There have been many calls for systems-informed approaches to evaluation. Population health interventions, which often focus on improving the upstream determinants of health through large-scale change, seem well-suited to systems-informed approaches to evaluation. The purported benefits and appropriateness of taking a systems-based approach to population health intervention evaluation have been extensively discussed, and there is a growing, but still limited, number of applied case studies that operationalised these calls. Here, we reflect on insights gained from recent experiences across three evaluation case studies of: a late-night levy to support local policing (UK), the tiered soft drinks industry levy (UK) and a value-based tax on sugar-sweetened beverages (Barbados). Building on theoretical work in this area, we illustrate through applied examples how a systems-informed approach can help to cast a wider net for potential impacts, be integrated with an effectiveness perspective to produce deeper insights and support greater engagement with non-linearity.

Small island countries of the Caribbean, South-east Asia, and the Pacific are increasingly dependent on food imports, typically of low nutritional quality. This dependence is associated with a decline in local food production and a high burden of nutrition related non-communicable diseases. This paper outlines the rationale, settings, methodology, and theories of change (ToC) of the Global Community Food and Health Project. The project has partnered with communities and stakeholders in Fiji, Palawan (Philippines), St. Vincent and the Grenadines, and St. Lucia to address the question: how can promoting increased community-based food production (CFP) based on agroecological principles improve household diets, nutrition, and food security, while also reducing the incidence of nutrition-related diseases? A further key question being addressed is: what is the environmental, economic and social sustainability of this approach? Our approach engages local stakeholders in food system mapping and co-creation, with “Living Labs” in which setting-specific interventions and ToC with measurable outcomes are designed in each of the four settings. Stakeholders are from local communities, government, local businesses, and civil society. Systematic evidence reviews were conducted and baseline data on household diet and growing practices were collected with locally adapted quantitative and qualitative tools. Interventions, now being implemented, promote environmentally sustainable, and resilient food production based on agroecological principles, while also providing communities with the knowledge and skills to better use local produce. Interventions also include the processing and marketing of produce. The interventions are being evaluated using mixed methods, including an assessment of participant engagement. Our interdisciplinary project provides approaches to engaging with communities and stakeholders to co-create system-wide and complementary interventions that navigate the challenges of improving both population nutrition and sustainable food production. Key to the future success of this work will be learning from and responding to the evaluation of the current interventions, in particular understanding where there are synergies and trade-offs and their implications for ensuring the continuing engagement of, and ownership by, local communities and stakeholders.

Food sharing is an important part of food practices in many settings and contributes to food access and diversity. Food sharing has long been embedded in Caribbean culture, reflecting values of community, care, and social cohesion. These practices are undergoing shifts influenced by various socio-political, economic, and environmental factors. Contemporary trends suggest a decline in food sharing, with increased sharing of convenienceoriented foods, and reduced sharing of food from backyard gardens and fishing, aligning with the ongoing nutrition transition. To examine these trends, we applied systems-thinking lens to map relationships between food sharing and wider social and food systems. We drew on data from qualitative interviews with intergenerational dyads and secondary data from an evidence review covering 13 Caribbean countries. We developed three causal loop diagrams (CLDs) focusing on systems determining (1) frequency of engagement in food sharing, (2) healthiness of shared foods, and (3) use of locally produced shared foods. We refined the CLDs with stakeholders from health, food, and youth sectors across the region. We formulated system thinking-informed hypotheses about drivers of food sharing using systems archetypes. Our aim was to support the value of food sharing practices and propose ways to enhance their role in addressing non-communicable diseases (NCDs), including mental health and well-being. We found that food sharing can enrich social lives, strengthen community bonds, and improve food access and availability, particularly during periods of hardship. Our findings serve as a conceptual model for future systems-informed research, guiding interventions to improve NCD outcomes in the Caribbean.

Background/Objectives: Diet is implicated in the high burden of mental health on society, and research examining associations between these two fields is growing. However, qualitative explorations are lacking, especially within culturally diverse settings. This study aims to explore the beliefs on the mechanisms of the relationship between diet, food systems, and mental health, and the lived experience of such, through a case study of one Caribbean Small Island Developing State, to inform culturally grounded public health strategies that integrate nutritional and psychological well-being. Methods: Fifteen interviews with food system stakeholders and five focus groups with the general public were conducted. Transcripts were analyzed using a grounded theory approach with a critical realist epistemological stance. Results: Four major categories centered on beliefs of mechanistic effects of diet on mental health, as well as broader perspectives of the relationship between food systems, food experiences, and mental health. Participants believed that (1) unhealthy diets of processed and chemically treated foods contribute to poor mental health and that (2) food insecurity is a key threat to mental health, but they also believed that (3) consumption of locally produced foods and (4) residing in agricultural communities can be beneficial to mental health. Conclusions: Participants recognize that diet influences mental health through physiological, social, and structural pathways, but this connection is threatened by rising dependence on imported, processed foods. Along with complementary quantitative research, the findings highlight the potential of expanding nutritional health literacy and clinical guidance and strengthening local food systems and traditional diets for mental well-being among Caribbean Small Island Developing States.

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.

IntroductionFood system transformation is required for planetary health. Localizing food systems and applying agroecological principles to food production and supply have been suggested to support a resilient and sustainable food system. This scoping review aimed to map the implementation of interventions designed to promote the consumption of locally produced food, their application of agroecological principles and the outcomes evaluated, across Global North and Global South countries.MethodsSearches were conducted systematically in 15 databases. Screening was conducted against criteria to identify eligible studies and data extracted in REDCap and EPPI Reviewer. Data were narratively synthesized, and results displayed as tables, figures and an interactive evidence gap map.ResultsWe found 147 eligible studies describing interventions to promote the consumption of locally produced food. Only two studies reported the impact of intervention on local versus non-local food procurement and we identified a lack of a standard framework for assessing the impact of changing food source practice. Most studies reported dietary outcomes, mainly fruit and vegetable intake, and less used metrics for dietary diversity, particularly in the Global North. A small proportion (5%) reported ecosystem related outcomes. All home growing interventions were conducted in the Global South and most school-based growing interventions were conducted in the Global North. Agroecological principles were applied to Global North and Global South interventions, but a greater proportion of the Global South studies applied agroecological practices (GS 30%; GN 4%).DiscussionThis map of experimental research on local food interventions identifies key differences in intervention types and agroecological principles and practices applied in Global South and Global North countries, potential learnings between settings, and gaps in the evidence. We call for greater coherence in the development, evaluation and reporting of local food interventions to enable synthesis on their effectiveness and to strengthen evidence on local food approaches aiming to improve human nutrition and planetary health.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42023428104, identifier [CRD42023428104].

IntroductionHaiti is the poorest country in the Americas and has the highest levels of gender inequality. It has high burdens of malnutrition and food insecurity. Our aim in this study was to investigate differences between female and male heads of farms in their farm's size and income and in their nutritional status.MethodsWe conducted a mixed-method study with a quantitative survey with 28 female and 80 male farmers and qualitative semi-structured interviews with seven women and 11 men, in nine rural communities, Plateau de Rochelois, Nippes, Haïti.ResultsWe found that significant inequalities existed between female and male heads of farms in this region of Haiti. Farm income was associated with farm size, with female farmers having on average smaller farms, and markedly lower farm incomes compared to male farmers, even after adjusting for the fact that their farms were smaller. Male farmers also had more access to seeds, financing and transportation to market. In addition, female farmers had markedly higher levels of overweight and obesity. In both male and female heads of farms around 1 in 20 were underweight.DiscussionThese findings complement those from other settings, showing that female farmers in low- and middle- income countries typically face severe challenges in accessing resources such as land, credit, and inputs, which can limit their productivity and income-generating potential. Gender sensitive interventions to promote farmer health, well-being and productivity are required.

BackgroundCaribbean populations face complex health issues related to diet and food security as they undergo a rapid nutrition transition, resulting in some of the world's highest number of premature deaths from noncommunicable diseases (NCDs). Despite policy efforts to promote local and regional food consumption, reliance on food imports remains high with many Caribbean countries importing more than 80% of their food from larger economies. Previous regional research revealed the importance of food sharing practices in the Caribbean, with implications for the consumption of local foods, food security, and community resilience against climate change. However, there is limited understanding of these practices and how they have evolved.MethodsUsing a transition lens, we explored the generational, life course, and sociocultural factors influencing food sharing practices in the Caribbean. We conducted semistructured online interviews with 10 intergenerational dyads involved in food sharing recruited from the virtual campus of the University of West Indies. Our study sample included 20 participants, ranging from 18 to 83 years old, from five English-speaking Caribbean countries (6 different islands).ResultsFood sharing practices had a central role within the social fabric of all participants, contributing to their mental health and well-being. They represented a fundamental aspect of participants' culture and traditions, driving a sense of belonging and connection among Caribbean communities. However, contemporary food sharing practices indicated a move towards more convenience-oriented and processed foods, with reduced time spent cooking and a decline in the use of food sources such as backyard gardens, fishing, and marketplaces, with a preference for supermarkets. These trends, particularly observed among younger generations, aligned with the ongoing nutrition transition in the Caribbean and were influenced by various sociopolitical and environmental factors such as climate events, economic fluctuations, urbanisation, and changing family structures.ConclusionsThe evolving landscape of food sharing practices in the Caribbean has linkages with various domains of nutrition, health, society, culture, environment and globalisation. While a transition towards less healthy diets will increase the risk of many NCDs, the intrinsic cultural, social, and emotional benefits of food sharing could also positively impact health outcomes in the Caribbean region.

IntroductionEvidence 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.MethodsTen 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.ResultsNegative 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.DiscussionMeasures 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.

Small Island Developing States (SIDS) include 37 UN member countries sharing economic, environmental, and social vulnerabilities and intractable health challenges. In over 80% of SIDS, more than one in six adults die prematurely from a non-communicable disease (NCD), with poor diet being a major factor. Complex upstream food system determinants include marginalised local food production and reliance on low nutritional quality food imports. These drivers need to be seen against colonial and post-colonial political-economic legacies as well as the environmental and climate crises that challenge local production systems. A range of policy commitments (eg, the 2023 Bridgetown Declaration on NCDs and Mental Health) highlight these complex interdependencies and call for cross-sectoral food system policies to improve food security, food sovereignty, and nutrition, including integrating measures for climate change adaptation and mitigation. Although addressing these intersecting challenges will also depend on global efforts, the unique approach of SIDS can inform other settings.

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.

IntroductionSmall Island Developing States have disproportionately high food insecurity rates, related to complex challenges and vulnerabilities. The COVID-19 pandemic highlighted that within these settings, crises often overlap. We aimed to assess the impact of the concurrent COVID-19 pandemic and volcanic eruption on food production and security in St. Vincent and the Grenadines (SVG).MethodsAn interpretive mixed-methods study was conducted among a convenience sample of consenting adults ≥18 years from 100 households in SVG through a cross-sectional survey and participant interviews (10 households) between September 2021 and March 2022. Food insecurity prevalence over the past year was assessed using the Food Insecurity Experience Scale (FIES; Rasch modeling) and impacts to livelihoods from the pandemic and volcanic eruption was assessed using an adapted Caribbean COVID-19 Food Security and Livelihoods Impact Survey (Caribbean COVID-19 FS&L Survey). Data were analyzed using logistic regression.ResultsDuring the pandemic, 59% of the participants reported decreased income, 63% had no access to markets, 81% had no access to food aid; 34% of the participants had a change in food sources, and 81% reported that food production was negatively impacted by the volcanic eruptions, of which 68% reported decreased food production. The interviews highlighted that access to markets were restricted by fear of leaving home and contracting the COVID-19 virus, and participants who received food aid stated that the number of items were not sufficient for larger families. Almost half of the participants were severely food insecure [48% (95% C.I. 31.2,57.8)]; almost two thirds were moderately to severely food insecure [64% (95% C.I. 50.0, 74.2)]; mean FIES score 5.31 (95% C.I. 5.0,5.6). After adjusting for gender, age, education, and household size, moderate to severe food insecurity was associated with no access to food aid during the pandemic and post-eruptions (odds ratio 3.7; 95% confidence interval 1.5, 9.1; p = 0.004).ConclusionFood insecurity rates were high during the COVID-19 pandemic, exacerbated by volcanic eruptions and insufficient access to food aid. Our results suggest the need for the development of strategies and interventions aimed at increasing the resilience of food systems to mitigate the effects of future disasters.

IntroductionSmall island developing states (SIDS) are a diverse group of coastal and tropical island countries primarily located in the Caribbean and Pacific. SIDS share unique social, economic, and environmental vulnerabilities, high dependency on food imports, and susceptibility to inadequate, unhealthy diets, with high burdens of two or more types of malnutrition. Our objective was to examine trends in food availability, imports, local production, and risks of non-communicable diseases (NCDs) in three SIDS: Haiti, Saint Vincent and the Grenadines (SVG) and Fiji. MethodsData on food availability, imports, exports, and production was extracted from the Food and Agriculture Organization Database (FAOSTAT), and on overweight, obesity and diabetes prevalence from the NCD Risk Factor Collaboration database (NCD-RisC) from 1980 to 2018. Data were collated, graphed, and used to calculate import dependency ratios (IDRs) using Excel and R software. ResultsBetween 1980 and 2018, the availability of calories per capita per day has risen in Fiji and SVG by over 500, to around 3000. In Haiti, the increase is around 200, to a level of 2,200 in 2018, and in all three settings, > 10% of calories in 2018 came from sugar. In Fiji and Haiti, the availability of fruit and vegetables is < 400 g per person per day (the minimum intake recommended by WHO). Between 1980 and 2010, both Fiji and SVG experienced high IDRs: around 80% (Fiji) and 65% (SVG). In Haiti, IDR has more than doubled since 1980, to around 30%. The prevalence of obesity (BMI > 30 Kg/m(2)) has increased since 1980 (by 126% to 800%) and is substantially higher in women. In the most recent data for Fiji, an estimated 35% of women are obese (24% men); in SVG, 30% women (15% men); and in Haiti, 26% women (15% men). ConclusionThe increase in per capita availability of calories, which has taken place since 1980, is concurrent with an increase in IDR, a loss of local food, and increases in obesity prevalence. These findings highlight the importance of further research to understand the drivers of food supply transformations, and to influence improving nutrition, through production, availability, and consumption of nutritious local foods.

Background Small Island Developing States have high levels of food insecurity and nutrition-related disease. One determinant is a dietary shift from consumption of local foods high in nutritional quality to nutrient poor imported food. A community intervention was designed to support the recovery of backyard gardens in St. Vincent and the Grenadines post volcanic-eruption and the impact of the intervention on food security in relation to dietary diversity (DD) and BMI was evaluated. Methods A mixed-method prospective study was conducted with adults from 100 households within rural areas. The survey was administered at baseline, six and 12 months (September 2021-September 2022); included the Food Insecurity Experience Scale (FIES); adapted Minimum Dietary Diversity (MDD) for Women of Reproductive Age; and measured BMI. Food insecurity status was assigned using Rasch analysis in R. Stata 17 was used for descriptive and inferential analyses. Semi-structured monthly interviews over six months with a representative from 10 purposely chosen households aimed to gain contextual insights on the intervention and experiences of food security through thematic analysis. Results A total of 177 adults participated. Food insecurity increased incrementally over 12 months e.g. moderate to severe from 35% to 57% and severe from 16% to 39%. FIES score increased overtime from 2.57 to 4.31 (md= -1.74 (-2.79, -0.44). Mean DD score (consuming ≥5 of 10 food groups) decreased overtime from 3.33 (95% C.I. 2.93,3.73) to 2.47 (95% C.I. 1.84, 3.11), md=0.86 (-0.14, 1.46). However , there was an increase in daily fruit and vegetable consumption from 1.87 to 2.36, (md=-0.49 (-0.88,-0.11). Mean BMI decreased from 28 to 25.7 over 12 months, (md=2.3 (1.02, 4.79). BMI ≥25 decreased from 64% to 48%. Adjusting for age, sex, education; household size, there was a significant cross-sectional association between the FIES score and BMI, (p=0.034, 95% C.I. 0.00,0.03) at baseline. Significant longitudinal associations were observed between the FIES score and DD (p=0.015), and the FIES score and BMI (p=0.016) when adjusted for time. The qualitative data point to complex concurrent impacts of the volcanic-eruption and the COVID-19 pandemic, including food insecurity through job losses, displacement of usual food sources and limited access to market and food-aid. Conclusion Our quantitative results suggest that the backyard garden intervention was not associated with a decrease in food insecurity or increase in DD, but qualitative insights highlighted complex concurrent challenges to food access experienced by households. This study highlights the need for the development of food security strategies post crises.

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.

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.

Rapid weight loss using a very low-calorie diet (VLCD) for 2 to 3 months followed by weight maintenance has been shown to lead to the restoration of normal glucose and insulin metabolism in people recently diagnosed with type 2 diabetes. We explored the barriers and facilitators of adhering to a VLCD for remission in an Afro-Caribbean population. Twenty-five participants completed an eight-week VLCD followed by a six-month structured weight maintenance phase. Semi-structured interviews and focus groups were thematically analysed. Cravings for ‘usual foods’ consumed by friends and family, stigma of diabetes and resulting lack of disclosure and the participants’ busy schedules were noted as predominant challenges throughout the study. In turn, social support and the participants’ internal drive were considered as key facilitators for success. VLCD is a feasible approach for type 2 diabetes remission. Self-motivation and supportive environments are however crucial in meeting and maintaining the weight loss goals.

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.