Historical and epidemiological transitions in urban Caribbean foodscapes: understanding the past to enhance future healthy eating

Current public health strategies fail to effectively promote adequate nutrition in populations, because they focus on individuals' behaviours and choices without addressing larger influences such as food cultures and food systems. Instead, healthy environments need to be created that enable easy access to healthy and nutritious food. Cities in an increasingly urbanising world are ideal places for such transformation.

The Caribbean region has identified chronic non-communicable diseases such as diabetes and heart disease as a major threat to population health, social and economic development, and has made a concerted commitment to address this problem through a comprehensive, multi-sectoral response that includes urban planning. To inform their efforts and accelerate action, we propose a cross-disciplinary project to understand historical and epidemiological transformations in two neighbouring but contrasting cities, Kingston (Jamaica) and Port-au-Prince (Haiti), to be able to identify the ways cities in low and middle income countries impact on their populations' food practices, opportunities and in turn health. We aim to develop an in-depth understanding of underlying mechanisms that have led to both 'unhealthy' spaces (e.g. fast food dense neighbourhoods) or 'healthy' spaces (e.g. urban gardens). By investigating how these social, political and economic determinants of nutrition have developed and shaped into contemporary foodscapes, the goal of our project is to inform the prevention of chronic diseases by enhancing healthy eating strategies. The project will map health data onto the historical data to produce an interactive map of the evolution of foodscapes, which will be used to engage with both policymakers and the public as a tool to aid the creation of healthy environments that enable easy access to healthy and nutritious food.

Under the guidance of leading historians and global health researchers, early career researchers at the University of the West Indies will conduct feasibility research merging methods from historical and health research. A historical work package will use online newspaper archives, and innovatively combine with interviews with local experts to examine changes in urban population growth and urban inequality and its impact on food production and consumption, the availability of food outlets, and dining habits from the Second World War to present. A health work package will examine major epidemiological trends in nutrition for the same time frame and assess its impact on NCDs through an analysis of existing public health survey and routine data, and combine this analysis with focus group data on contemporary food practices and choices. This feasibility fieldwork will be carried out in Kingston, Jamaica, and Port-au-Prince, Haiti, in preparation for the development of a larger follow-up grant proposal expanding to the wider region and similar settings. This feasibility work will be prepared during a Project Co-Development Workshop in Jamaica to which we will invite regional stakeholders from academia, government and civil society (e.g. health NGOs) to agree on common research goals that tie into current practice and policy projects (e.g. regeneration plans for parts of Kingston); and it will be consolidated in a final Project Co-Analysis Workshop to analyse the data and develop a sustainable collaborative research strategy and future projects.

Melding humanities and epidemiological methods and expertise, we propose a highly innovative project with a research question novel for both fields, and based around a unique collaboration. It will build the methodological capacity needed to understand the mechanisms that have produced 'unhealthy' and reduced 'healthy' foodscapes in urban areas in low and middle income countries, which is essential for urban planners working to create healthy urban food environments.

Relevance: Chronic non-communicable diseases (NCDs) are responsible for the vast majority of deaths in all but the poorest countries in the world, an urgent concern beyond the public health field for governments, society at large, and regional and international organisations. The UN high-level declaration on the prevention of NCDs has committed governments to taking concerted action in particular for low and middle income countries (LMICs). This has been spearheaded by the Caribbean Community (CARICOM) as their Port of Spain NCD Declaration in 2007 brought together CARICOM Heads of Government to lead to a call to action, and their commitment was renewed in 2016. A central policy focus concerns healthy nutrition. CARICOM's regional food and nutrition security policy and action plan that includes the commitment to improve the nutritional status, especially of the poor and vulnerable, to address the NCD crisis.

Who will benefit: As we found in previous MRC funded research with these stakeholders [MR/N005384/1; MR/P025250/1], multi-sectoral collaborations require more concrete guidance as to how best to address recognised challenges such as the proliferation of processed and fast foods. Direct beneficiaries of this project will be policymakers in both public health and urban planning, as well as civil society organisations such as health NGOs represented by our partner the Healthy Caribbean Coalition as key institutions involved in both community outreach work and lobbying national and regional government. This includes governments in the selected countries but also regional policymakers in the Caribbean. The project will most markedly benefit our LMIC partner institution, the Caribbean Institute for Health Research (CAIHR) at the University of the West Indies (UWI) Mona, Jamaica, whose mandate is to deliver research that addresses regional and global health priorities, working closely with regional stakeholders such as the Caribbean Public Health Agency (CARPHA), CARICOM, and the Pan American Health Organization (PAHO). Furthermore, policymakers of governments in regions that are similarly vulnerable can benefit from the findings of this project; through our existing connections through current (NIHR, MRC, AHRC and ESRC) GCRF funding with Africa and South Pacific and Western Pacific, which all also focus on social determinants of NCDs, we aim to bring in new partners from other regions when we develop a full research programme as the output of this project.

How will they benefit: To accelerate policy action to fulfil the CARICOM targets agreed in the Port of Spain NCD Declaration, the project's short term aim is to establish a sustainable partnership between the academic partners - connecting humanities and medical faculties in the UK and at UWI through this project and UWI with State University of Haiti - and government and non-government stakeholders, with the aim to inform the complex challenge of creating healthy food environments in the Caribbean with new strategies. While a historical framing of contemporary foodscapes is recognised to be important (e.g. to explain changes in food culture and proliferation of fast foods), we will be able to identify specific needs to support our project stakeholders to address knowledge and data gaps in LMIC settings. A key product of the project will be a digital map of the evolution of urban foodscapes to inform current regeneration plans and outreach activities (see Pathways to Impact). In the medium to longer term, we will establish a comprehensive programme of research that includes understanding of underlying mechanism that drive public health challenges and limitations in effective NCD prevention more widely to include physical inactivity, smoking and excessive alcohol consumption in the region and beyond. Part of our dissemination will provide our stakeholders with clear guidance how our insights can be applied to these larger challenges.