Developing theory and methods for evaluating the impact of community food initiatives on NCD risk, social and economic wellbeing and the environment.

Lead Research Organisation: University of Cambridge
Department Name: MRC Epidemiology Unit

Abstract

Chronic non-communicable diseases such as diabetes, cardiovascular disease and cancer are responsible for the vast majority of deaths in all but the poorest low and middle income countries (LMICs). They are particularly rising in LMICs and are higher in many LMICs than in high income countries. A key driver of this health burden is poor quality nutrition, including diets high in energy dense and highly processed foods and low in fruit, vegetables and fibre. There are several factors that may contribute to poor diets, including poor conditions for growing, storing and transporting fruit and vegetables, and a reliance on relatively expensive food imports. In small island developing states (SIDS) the relationship between a reliance on food imports, poor nutrition and a high burden of chronic diseases is particularly apparent.

Community-based agricultural food production initiatives are one possible approach to improving food and nutritional security and to reducing the risk of chronic diseases. They can also help to improve 'food sovereignty' by increasing the ability of populations to influence their own food systems in ways that are sustainable and promote health. Such initiatives may take several forms, but are owned, organised and managed locally, and produce either fresh or minimally processed food for local consumption. While the potential contribution of such initiatives is recognised, there is very little evidence available on what their impacts actually are in terms of health, social well-being, economics or the environment. There is an urgent need for improved evidence on their impacts, and this proposal is concerned with developing and testing methods to contribute towards filling this evidence gap.

The proposal is designed to help establish a transdisciplinary research programme with the conceptual and methodological skills necessary to undertake robust evaluations of community-based food production initiatives in LMICs. The evaluation of the initiatives will include their contribution to promoting health and social wellbeing, their economic and environmental impacts, and their sustainability. The development work proposed here will be undertaken in two contrasting middle income SIDS, St Vincent and the Grenadines and Fiji. Both are actively engaged in promoting local food production for local consumption, and their well-defined geographical boundaries and relatively small size provide ideal settings to undertake development work. However, the overall goal is to develop a framework and methods that are readily adaptable and applicable to other LMIC settings in which nutritional insecurity is a major contributor to the risk of chronic diseases, including many settings in sub-Saharan African, where levels obesity and diabetes are already high and increasing.

In this project we will update and expand existing evidence reviews on community-based food initiatives in LMICs. In the two chosen settings, we will develop and test research methods to investigate the current nutritional adequacy of local diets and the contribution of community-based food production, and find out who is involved in and supports local food production. We also aim to develop methods to estimate the environmental impacts such as on local water use and carbon emissions. Finally, we aim to determine the major challenges and successes in establishing and sustaining selected initiatives, and how barriers to success might be overcome. The findings will enable us to develop an evaluation framework and refine methods to design a programme of work to robustly evaluate and compare community-based food production initiatives in Africa, the Caribbean and Pacific from the perspective of their impacts on chronic disease risk, social and economic well-being and the environment.

Technical Summary

Rates of obesity, diabetes, cardiovascular disease, and many cancers, are higher in many low and middle income countries (LMICs) than in high income countries. Poor quality diet, characterised by the consumption of energy dense and highly processed foods, low intake of fruit, vegetables and fibre is a major determinant of this increasing burden. There is an urgent need for improved evidence on the impact of agricultural interventions in LMICs on nutrition, health and other aspects of well-being. The proposal is designed to help establish a transdisciplinary research programme with the conceptual and methodological skills necessary to undertake robust evaluations in LMICs of community-based food production initiatives.

In this project we will update and expand existing systematic reviews of published and grey literature on community-based food initiatives in LMICs. In the chosen settings, St Vincent and the Grenadines and Fiji, with established community-based food production initiatives (CFPI), we will develop and test mixed methods to investigate the current nutritional adequacy of local diets and the contribution of community-based food production, and map key stakeholders and potential economic and social benefits of local food production. We also aim to develop feasible methods to estimate the environmental impacts such as on local water use. Focusing on selected CFPIs in each setting as evaluation targets, we aim to determine the major challenges and successes in establishing and sustaining such initiatives, and how barriers to success might be overcome. We will collate findings to derive an evaluation framework and refine methods to design a programme of work to robustly evaluate and compare community-based food production initiatives in the Caribbean and Pacific, and in comparable LMIC settings in Africa, including South Africa, from the perspective of their impacts on NCD risk, social and economic well-being and the environment.

Planned Impact

Relevance: Chronic non-communicable diseases (NCDs) are responsible for the vast majority of deaths, and age-standardised prevalence rates of obesity and diabetes and mortality rates from cardiovascular disease and many cancers are higher in many low and middle income countries (LMICs) than in high income countries. The burden of NCDs is 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 chronic non-communicable diseases (NCDs), for example, has committed governments around the world to taking concerted action, recognising the direct impact of NCDs on the economic and social development in particular for LMICs and calling for a multi-sectoral response. Food security and sovereignty are central upstream determinants of NCDs and community-based food production a poignant example of such multi-sectoral effort required.

Who will benefit: While a multi-sectoral ('whole of government' and 'whole of society') response has been identified as playing a vital part in comprehensive approach to prevent and control NCDs, multi-sectoral collaborations require evidence and guidance to develop, implement, evaluate and sustainably support their initiatives. Direct beneficiaries of this project will be civil society organisation as organisers of community-based food production initiatives. Further direct beneficiaries will be governmental and non-governmental organisation as initiators and supporters of such initiatives. This includes governments in the selected countries but also regional policy-makers as both in the Caribbean and the Pacific setting intergovernmental regional collaborations are established to pool resources and expertise. Furthermore, policy-makers of governments in regions that are similarly vulnerable can benefit from the findings of this project. For example, our South African partners have a strong interest in this research programme and see relevance for policy-making in their setting. Finally, research partners will directly benefit from this project. There is an increasing interest in natural experimental studies to evaluate policy responses and 'real life' initiatives that tackle upstream determinants of health. As a relatively novel research field, this project will contribute to further develop methods for such evaluations, with strong guidance within the MRC Epidemiology Unit who contributed to the MRC guidance on evaluating natural experiments.

How will they benefit: As a development project, the short term benefit will be to identify specific needs to support the development and maintenance of community-based food production initiatives, particularly for relevant key organisation in the two identified regions. The impact plan outlines how these will be engaged.
In more medium term, with the successful establishment of a comprehensive programme of research, we can cumulate robust evidence for their complex impact, including potential unintended consequences for the settings such as the potential negative environmental impact in terms of water pollution or carbon emission. With robust evidence beneficiaries across sectors will be able to make a case for further support of such initiatives and identify concrete factors that might need addressing to reduce negative impacts. The researchers directly involved in the project, at the University of Cambridge, the University of the West Indies, the University of the South Pacific and the University of Witwatersrand will be involved in highly innovative methods development work; this will include local colleagues and postdoctoral researchers. Researchers beyond the direct collaboration will benefit will be access to tools, conceptual framework and related guidance made publically available (see academic beneficiaries).

Publications

10 25 50
 
Description Small Island Developing States (SIDS) have some of the highest burdens of obesity and diabetes globally, alongside a high reliance on food imports of low nutritional quality. SIDS governments have committed to increasing local food production to improve nutrition, but evidence on how different food sources contribute to diet quality is lacking.

We aimed to develop a toolkit that captures information on dietary quality, how, and how frequently food is sourced and why those sources are used. The dietary assessment tool needed to include contextually relevant foods and food sources and enable standardised evaluations for investigating associations between food source and diet quality in SIDS. We designed a mixed-method toolkit, including a qualitative research design to understand local food systems as well as food preferences and practices.

To develop the tool kit, we conducted evidence reviews of existing approaches, and then co-designed methods as a multidisciplinary international team including regional investigators and stakeholders. To obtain individual-level 24h dietary recall data to derive a dietary diversity score, we adapted a Food and Nutrition Technical Assistance (FANTA) tool. This was complemented by a 'dietary screener' developed from the diet component of World Health Organization's STEPS survey to assess consumption of specified foods and beverages associated with non-communicable diseases, plus standard anthropometric measurements and blood pressure. We tailored an existing questionnaire, developed originally for Southern Africa, to assess how often foods were obtained from a range of sources, including a variety of informal and formal vendors, own production, borrowing and exchanging. The qualitative component included stakeholder interviews across the food supply chain and community focus groups in informal and formal settlements.

Designing this context-relevant and comprehensive tool to assess foods and food sources was challenging, especially to adequately link food sources to dietary quality. Undertaking the 24h dietary recall and food group classification plus facilitating qualitative interviews and focus groups requires intensive training for data collectors. We are using lessons learned from feasibility studies in Fiji and St Vincent and the Grenadines to refine this toolkit, and will use it, and make it available, to help evaluate the contribution of local food production initiatives to healthy nutrition.
Exploitation Route As noted elsewhere in the submission for this grant, the methodologies developed from this funding were used in collaboration with the Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA), helping to evaluate projects with food producers in the Pacific, and the funding's outcomes have provided the basis for a new award (ICoFaN). ICoFaN is working with NGO partners to co-create, implement and evaluate interventions in St Vincent and Fiji, and is also extending this work to Haiti (in partnership with the State University of Haiti) - the poorest country in the Americas, with a high triple burden of malnutrition.

We are still writing up and submitting the main findings, and we hope that these outputs will provide a basis for further work by others - both from using our methodologies, and in addressing new research questions arising from our findings.
Sectors Agriculture, Food and Drink,Communities and Social Services/Policy,Environment

 
Description As described in the section on 'engagement' we have worked with Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA) to help evaluate some of their work in the Pacific, and with them undertaken dissemination activities (workshop, webinar, policy brief) aimed at farmers, nutritionists and public health practitioners, and government policy makers respectively. The study outputs have also contributed to two successful grant applications, both of which concern working closely with local stakeholders in the Caribbean and Pacific in the implementation and evaluation of interventions. Finally, worth saying that our findings are still being prepared for academic dissemination, with one paper currently under review, two more to be submitted in the next two months, and two after that planned before the end of the year. We will have more to report on impact next year.
First Year Of Impact 2019
Sector Agriculture, Food and Drink,Communities and Social Services/Policy
Impact Types Policy & public services

 
Description IDRC: Food, Environment and Health
Amount £201,000,000 (JMD)
Organisation International Development Research Centre 
Sector Public
Country Canada
Start 04/2018 
End 03/2022
 
Description Intervention Co-creation to Improve Community-based Food Production and Household Nutrition in Small Island Developing States (ICoFaN)
Amount £990,000 (GBP)
Funding ID BB/T008857/1 
Organisation Biotechnology and Biological Sciences Research Council (BBSRC) 
Sector Public
Country United Kingdom
Start 02/2020 
End 02/2023
 
Description Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA) 
Organisation Technical Centre for Agricultural and Rural Cooperation ACP-EU
Country Netherlands 
Sector Public 
PI Contribution We worked with CTA to adapt the data collections tools (quantitative and qualitative) developed by us, and to plan and implement data collection to contribute to the evaluation of two CTA projects in the Pacific. The team in the UK (Cambridge and Exeter) were largely responsible for modifying the data collection tools, and along with the team in the Caribbean they designed the REDCap tablet based data collection system. The team in the Pacific planned and implemented the data collection. The UK team analysed the quantitative data, and assisted the Pacific team in the analysis of the qualitative data. Pacific and UK teams prepared presentations for a workshop in the Pacific, organised by CTA.
Collaborator Contribution The CTA provided funding to carry out the evaluation of two of their projects, all of which went to the University of the South Pacific. They worked closely with the research team, which provided valuable learning on CTA's activities to support increased local food production in the Pacific. The CTA organised and hosted the two webinars (described under 'engagement') which provided the research team with access to interested policy makers and practitioners in the Pacific.
Impact Presentations to members of the 8 projects that are part of Innov4AGPacific; two webinars on improving nutrition in the Pacific through local food production; policy brief based on this work. The collaboration is multidisciplinary: CTA largely provides technical support on agriculture, colleagues at University of the South Pacific are environmental scientists and predominantly qualitative researchers; most colleagues in the UK have backgrounds in public health, epidemiology and nutrition.
Start Year 2019
 
Description Community Food and Health Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This multidisciplinary workshop, held in Cambridge in September 2017, brought together researchers from the Caribbean (University of the West Indies, Ministry of Health in St Vincent and the Grenadines, Caribbean Farmers Network) and Pacific (University of the South Pacific and Secretariat of the Pacific Community).
Year(s) Of Engagement Activity 2017
 
Description Food Systems in Latin America and the Caribbean 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This workshop was designed to review research currently underway in Latin America and the Caribbean related to food systems and health and to set priorities for future research, and research collaborations.
Year(s) Of Engagement Activity 2017
 
Description Presentation on current activities and future plans for Global Public Health Research 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The presentation was designed to communicate our current research agenda for Global Public Health to the whole of the MRC Epidemiology Unit.
Year(s) Of Engagement Activity 2017
 
Description Public Lecture 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Public lecture given at the University of the South Pacific, Fiji, by Co-Investigator Cornelia Guell (University of Exeter) and Research Associate Catherine Brown (University of the West Indies) to an interdisciplinary academic, policy (e.g. National Food and Nutrition Centre, Fiji), and lay audience. We provided an overview of the project aims, introduced the Caribbean partner field site St Vincent and the Grenadines to the Fijian audience, and presented preliminary findings of the systematic scoping review.
Year(s) Of Engagement Activity 2018
URL https://pace.usp.ac.fj/event/dr-cornelia-guell-ms-catherine-brown-understanding-community-food-produ...
 
Description Webinar organised by Technical Centre for Agricultural and Rural Cooperation ACP-EU (CTA) on addressing the burden of malnutrition in Pacific Island States 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This activity was the culmination of a collaboration with the Technical Centre for Agricultural and Rural Cooperation (CTA). The research team, through Nigel Unwin, had been approached by CTA to assist with the evaluation of their Innov4AGPacific projects. The lead project officer at CTA, Judith Francis, had learnt about the Community Food and Health Project (CFaH) through her links with the University of the South Pacific and our collaborators there (led by Dr Morgan Wairiu). We worked with Judith to adapt the CFaH data collection tools to help evaluate two of CTA's 8 Pacific projects, aiming to improve local food production and nutrition. The two webinars were delivered in February 2020, and included presentations on the burden of malnutrition and related diseases in the Pacific, the aim and methods developed by CFaH, findings from the two CTA projects that were evaluated using CFaH's tools (this work was carried out in July through September 2019), and policy implications and responses. The webinars were held in real time, and are now available on YouTube and through the CTA website.
Year(s) Of Engagement Activity 2020
URL https://www.youtube.com/watch?v=yOU9I2-Nn8k