Faith-based leaders’ perceptions on the implementation of programs to promote healthy lifestyles in churches in Barbados- a mixed-methods analysis (preprint)

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.

Adaptation of a Community-based Type-2 Diabetes Mellitus Remission Intervention During COVID-19: Empowering Persons Living With Diabetes to Take Control (preprint)

Background: The Barbados Diabetes Remission Study-2 reported that a community-based low-calorie diet (LCD) for weight loss and diabetes remission was both an acceptable implementation strategy and a clinically effective intervention. This study aimed to examine the adaptability of the face-to-face BDRS-2 protocol into an online modality.Methods: The Iterative Decision‐making for Evaluation of Adaptations framework questions the necessity of the adaptation and the preservation of core elements of the intervention during the adaptation process – these elements were identified as the 12-week intervention duration, weekly monitoring of participants for change in weight and fasting blood glucose and daily 840kcal allowance. The adaptation outcomes were documented using the framework for reporting adaptations and modifications to evidence-based interventions. Implementation effectiveness was determined by fidelity to core intervention elements. Intervention effectiveness was determined from the analysis of clinical data.Results: We decided that an adaptation was needed as the COVID-19 measures to control transmission prohibited in-person interactions, and that key elements of the intervention could be preserved during the adaptation process. Adaptations were made to the following: (1) The context in which the data was collected: participants self-measured at home instead of being measured by community health advocates (CHA) at a community site. (2) The context in which the data was entered: participants first posted their measurements to a mobile application site which was accessible by the CHAs. As with the original protocol, CHAs then entered the measurements into an online database. (3) The formulation of the LCD: participants substituted the liquid formulation for a solid meal plan of equivalent caloric content. There was increased fidelity to the attendance schedule with the online format (1 incomplete entry out of 45 entries), as compared to the face-to-face modality (1 absence out of 20 visits). Regarding the solid meal plan, 1 participant logged difficultly averaging non-exact potion sizes. Weight change ranged from -14.3kgs to 0.4kgs over the 12-week period and all group members achieved induction of diabetes remission. Conclusion: Larger studies are needed to confirm that this adapted online protocol is both acceptable and clinically effective while maintaining fidelity to key elements of the original protocol.Trial Registration: NCT03536377  registered 24th May 2018 at https://clinicaltrials.gov/ct2/show/NCT03536377

COVID-19 containment in the Caribbean: the experience of Small Island Developing States (preprint)

Background. Small island developing states (SIDS) have limited absolute resources for responding to national disasters, including health emergencies. Since the first confirmed case of COVID-19 in the Caribbean on 1st March 2020, non-pharmaceutical interventions (NPIs) have been widely used to control the resulting COVID-19 outbreak. We document the variety of government measures introduced across the Caribbean and explore their impact on aspects of outbreak control. Methods. Drawing on publically available information, we present confirmed cases and confirmed deaths to describe the extent of the Caribbean outbreak. We document the range of outbreak containment measures implemented by national Governments, focussing on measures to control movement and gatherings. We explore the temporal association of containment measures with the start of the outbreak in each country, and with aggregated information on human movement, using smartphone positioning data. We include a set of comparator countries to provide an international context. Results. As of 25th May, the Caribbean reported 18,755 confirmed cases and 631 deaths. There have been broad similarities but also variation in the number, the type, the intensity, and particularly the timing of the NPIs introduced across the Caribbean. On average, Caribbean governments began controlling movement into countries 27 days before their first confirmed case and 23 days before comparator countries. Controls on movement within country were introduced 9 days after the first case and 36 days before comparators. Controls on gatherings were implemented 1 day before the first confirmed case and 30 days before comparators. Confirmed case growth rates and numbers of deaths have remained low across much the Caribbean. Stringent Caribbean curfews and stay-at-home orders coincided with large reductions in community mobility, regularly above 60%, and higher than most international comparator countries. Conclusion. Stringent controls to limit movement, and specifically the early timing of those controls has had an important impact on containing the spread of COVID-19 across much of the Caribbean. Very early controls to limit movement into countries may well be particularly effective for small island developing states. With much of the region economically reliant on international tourism, and with steps to open borders now being considered, it is critical that the region draws on a solid evidence-base to balance the competing demands of economics and public health.