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Purpose: This study explored medical educators' understanding of the term transgender and their attitudes and perspectives regarding (1) health system responsiveness to transgender needs and (2) transgender curriculum in medical education. Methods: The study employed purposive sampling of medical educators responsible for design and delivery of curriculum. Fifteen of 18 eligible educators participated in Zoom focus groups (FG1 n=7, FG2 n=8). FGs averaged 93 min and were recorded, transcribed verbatim, and analyzed using a qualitative interpretivist methodology with deductive and inductive coding assisted by NVivo 12 Pro software. Results: Educators were knowledgeable about the term transgender and the physical and psychosocial needs of transgender people. Participants viewed transgender care as a significant emerging health area. However, infrequent personal or clinical contact, coupled with constraints in human and other resources, resulted in the perception that transgender content as a stand-alone component of curriculum is difficult to justify. Participants articulated a need for broad-based diversity content, including disabilities, primarily at the undergraduate level. Educators saw transgender health as relevant for undergraduate-level psychiatry and postgraduate medical specializations. Analysis and discussion framed participant perspectives in the context of stigma, discrimination, and medicolegal and health systems that impede access to health care for transgender people. Conclusion: Participants demonstrated knowledge of transgender and transgender health care needs. Areas for improvements in health care responsiveness were identified, particularly related to structural stigma and discrimination. Although participants expressed interest in including transgender health in the curriculum, this would require pragmatic optimization of teaching resources.

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Introduction: Learning style (LS) frameworks have been implemented by educators to promote participatory learning in order to strengthen learner engagement and to enhance learning outcomes. Self-efficacy has been shown to have an association with learning style and is a predictor of clinical performance and other qualities in medical students. This study examined the perspectives of second and final year medical students in a Caribbean-based medical school, relative to their learning approaches, teaching exposures and preparation for assessments. Methods: An interpretivist qualitative approach was used to analyze data from two focus groups, conducted as part of a sequential mixed-methods study (November 2018-February 2019) with medical students in the second and final year of study. Discussions were audio-recorded, transcribed verbatim, and inductively coded with in-depth thematic analysis assisted by NVivo software. Results: Six Year 2 (Female: Male = 5:1) and seven Year 5 (Female: Male = 5:2) participants, ranging between 18 and 34 years and with a range of LS were recruited into the study. Analysis and data reduction produced three organizing themes: "Dynamics of information delivery and acquisition", "Pivoting", and "LS identification, awareness and mutability", and the global construct "Individual and environmental factors modulate the influence of LS preference in triggering self-efficacy". In managing information received in class, students used textbooks, YouTube videos, and collaborative learning to augment perceived gaps in lectures and their personal notes. Learning style self-awareness is useful for facilitating self-efficacy throughout medical school, especially at points of transition within the programme of study. Conclusion: LS theory and testing appear to be useful for student and teacher awareness. In practice, honing students' adaptability to varying learning settings may be more relevant in helping students achieve self-efficacy.

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Purpose: Diabetes mellitus (diabetes) is a major health concern in Barbados. In 2013, the reported prevalence (18.7%) was double global levels, with diabetes accounting for 10.4% of total deaths in 2016. Barbados has a rapidly aging population and older adults living with diabetes are more at risk of developing complications. Poorly managed diabetes represents a high burden for individuals and society due to direct healthcare costs for treatment, and to indirect costs due to loss of productivity from disability and premature mortality. Good diabetes self-management promotes glycemic control. Self-management is enhanced by social support and challenged by external shocks. This study explored the role of social support in diabetes self-management among older people in Barbados during the COVID-19 pandemic. Methods: Qualitative secondary thematic analysis of semi-structured individual telephone interviews with adults aged 65-84 years living with diabetes in Barbados during a partial COVID-19 lockdown period. Sampling was purposive, aided by gatekeepers who provide services to elderly people. Verbatim interview transcripts coded using an inductive method were subjected to thematic analysis by three qualitative researchers using NVIVO software. Results: Four organising themes: "Balance", "Social Capital", "Resilience", and "Adaptations to COVID-19", informed the global theme "Adaptive Diabetes Self-Management Response", which captures resilience mechanisms of older adults who balanced facilitators including self-reliance and religious faith, and barriers such as perceived ageist discrimination in workplace policies designed to reduce COVID-19 exposure. Accordingly, elderly Barbadians living with diabetes were resilient, selectively incorporating available social support mechanisms to maintain self-management and overall well-being during the COVID-19 pandemic. Conclusion: The emergent evidence for resilience among older persons in this setting is important for informing health system interventions to improve quality of life for PLWD. The views of the elderly should be explicitly considered in policies designed to enhance the self-management of chronic health conditions.

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Mental health professionals (MHPs) have roles supporting mitigation, preparation, and recovery in the global climate crisis. This commentary describes initiatives in the Caribbean to address climate-related threats to individuals and communities focussing on the role of MHPs in supporting community-based projects, regional public health disaster responses, and climate research.

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Purpose: The COVID-19 pandemic has caused significant disruption to medical education and clinical training and resulted in stressors that impede student learning. This study aimed to assess student satisfaction and self-efficacy in a novel online clinical clerkship curriculum delivered during the COVID-19 pandemic. Methods: Fourth- and fifth-year medical students completed an online survey in January 2021 covering the following areas: student satisfaction, self-efficacy, and perceived effectiveness of online versus face-to-face learning. Results: Just over half of students (51%) were satisfied with online clerkship delivery. However, fewer than half of students (46%) believed online learning effectively increased their knowledge, compared to 56% of students who believed face-to-face learning was effective. The perception of the effectiveness of online learning and face-to-face teaching for clinical skills was 18% and 89%, respectively (p < 0.0001). Few students perceived online teaching to be effective for developing social competencies (27%) compared to face-to-face instruction (67%) (p < 0.001). In addition, mean self-efficacy scores were higher for persons who perceived online teaching to be effective for increasing knowledge, improving clinical skills, and developing social competencies. Overall, students' perception of online learning was strongly associated with online self-efficacy. Conclusion: Student satisfaction and perceived self-efficacy in online learning were higher than reported acceptance of online clerkship curriculum.

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BACKGROUND: The Barbados Diabetes Remission Study-2 reported that a low-calorie diet for weight loss and diabetes remission implemented within the community and supported by trained community health advocates was both an acceptable implementation strategy and a clinically effective intervention. This study aimed to examine the adaptability of the face-to-face protocol into an online modality. METHODS: The Iterative Decision-making for Evaluation of Adaptations (IDEA) framework guides researchers in examining the necessity of the adaptation and the preservation of core intervention elements during the adaptation process. Adaptation outcomes were documented using the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS). Implementation outcome was determined by fidelity to core elements. Intervention effectiveness was determined from the analysis of clinical data. RESULTS: We decided that an adaptation was needed as COVID-19 control measures prohibited in-person interactions. The core elements-i.e. 12-week intervention duration, daily 840-kcal allowance, and weekly monitoring of weight and blood glucose-could be preserved during the adaptation process. Adaptations were made to the following: (1) the context in which data were collected-participants self-measured at home instead of following the original implementation strategy which involved being measured by community health advocates (CHA) at a community site; (2) the context in which data were entered-participants posted their measurements to a mobile application site which was accessible by CHAs. As with the original protocol, CHAs then entered the measurements into an online database; (3) the formulation of the low-calorie diet-participants substituted the liquid formulation for a solid meal plan of equivalent caloric content. There was non-inferiority in fidelity to attendance with the online format (97.5% visit rate), as compared to the face-to-face modality (95% visit rate). One participant deviated from the calorie allowances citing difficulty in estimating non-exact portion sizes and financial difficulty in procuring meals. Weight change ranged from - 14.3 to 0.4 kg over the 12-week period, and all group members achieved induction of diabetes remission as determined by a FBG of < 7mmol/l and an A1C of < 6.5%. CONCLUSION: The results suggest that this adapted online protocol-which includes changes to both the implementation strategy and the evidence-based practice-is clinically effective whilst maintaining fidelity to key elements. Utilization of the IDEA and FRAME-IS adaptation frameworks add scientific rigour to the research. TRIAL REGISTRATION: ClinicalTrials.gov NCT03536377 . Registered on 24 May 2018.

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OBJECTIVES: The aims of this feasibility study were to (1) examine the implementation of a community-based health advocate (CHA) training programme to develop the clinical skills needed to support a diabetes remission protocol based on a low-calorie diet (LCD) and (2) investigate if participant weight loss can be achieved and diabetes remission induced under these conditions. METHODS: This tripartite study followed a type 2 implementation-effectiveness design. Three faith-based organisations (FBOs) were purposively selected as study sites. Implementation outcomes were guided by the Consolidated Framework for Implementation Research. During the pre-implementation phase, site 'readiness' to facilitate the intervention was determined from a site visit and an interview with the FBOs' leadership. During the implementation phase, congregants could volunteer for the 10-week CHA training which included practical exercises in weight, glucose and blood pressure (BP) measurement, and a summative practical assessment. Acceptability and implementation effectiveness were assessed via survey. During the intervention phase, other congregants and community members with T2DM or pre-diabetes and overweight were invited to participate in the 12-week LCD. Anti-diabetic medication was discontinued on day 1 of the intervention. Clinical effectiveness was determined from the change in weight, fasting blood glucose (FBG) and BP which were monitored weekly at the FBO by the CHA. HbA1C was performed at weeks 1 and 12. RESULTS: The FBOs were found to be ready as determined by their adequate resources and engagement in health-related matters. Twenty-nine CHAs completed the training; all attained a passing grade at ≥1 clinical station, indicating implementation effectiveness. CHA feedback indicated that the programme structure was acceptable and provided sufficient access to intervention-related material. Thirty-one persons participated in the LCD (11 T2DM:20 pre-diabetes). Mean (95%CI) weight loss was 6.0 kg (3.7 to 8.2), 7.9 kg in males vs 5.7 kg in females; A1C (%) decreased from 6.6 to 6.1, with a greater reduction in those with T2DM when compared to pre-diabetes. FBG decreased from 6.4 to 6.0mmol/L. T2DM remission rates were 60% and 90% by A1C<6.5% and FBG<7mmol/L respectively. Pre-diabetes remission was 18% and 40% by A1C<5.7% and FBG<5.6 respectively. CONCLUSION: Implementation of a community-based diabetes remission protocol is both feasible and clinically effective. Its sustainability is to be determined. Adaptability to other disorders or other settings should be investigated. TRIAL REGISTRATION: NCT03536377 registered on 24 May 2018.

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BACKGROUND: Only three of twenty Caribbean Community (CARCICOM) countries have mandatory school nutrition policies despite one third of the region's children being overweight or obese. In Barbados, there are nutrition guidelines which lack the legal mandate of a formal policy. We aim to assess the comprehensiveness of current national nutrition guidelines and to understand the factors operating in the inner and outer school setting that may influence the implementation of a mandatory school nutrition policy from the perspectives of school administrators. METHODS: A documentary analysis of existing nutritional guidelines was conducted along with qualitative semi-structured interviews in primary (elementary) and secondary (high) schools in Barbados. We purposively sampled six primary and four secondary school administrators (principals, deputy principals or senior teachers) to explore their knowledge and views on the National School Nutrition Guidelines. The deterministic implementation paradigm, Consolidated Framework for Implementation (CFIR), was used to explore the complexities within the inner and outer settings of schools. Documentary analysis used a theory-based framework informed by the Wellness School Assessment Tool-school policy analysis questionnaire. Interview transcripts were team coded using thematic analysis with constant comparison facilitated by NVIVO software version12. RESULTS: School administrators were unaware of the existing National School Nutrition Guidelines which documentary analysis found to be restrictive and weak for implementation. Administrators envisioned a government-led (outer setting), whole of society approach as the most effective strategy for the development and implementation of a proposed mandatory school nutrition policy. School administrators identified lack of financial and human resources as barriers to nutrition policy implementation. Formal and informal food vendors are institutionalized in schools and are influential determinants of the school food environment. Schools have individually reached into the outer setting to work with civil society organizations and private individuals to provide financial support and nutrition expertise to their institutions. Mass media campaigns in the outer setting may influence child and parental food choices. CONCLUSION: School administrators describe that government-led, CSO supported policy development using a whole-of-society approach has implications for improving nutrition policy implementation. Our findings demonstrate the use of a deterministic implementation framework in the pre-implementation phase of school nutrition policy development.

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Individuals in low-income and middle-income countries (LMICs) account for approximately two-thirds of cancer deaths worldwide, and the vast majority of these deaths occur without access to essential palliative care (PC). Although resource-stratified guidelines are being developed that take into account the actual resources available within a given country, and several components of PC are available within health care systems, PC will never improve without a trained workforce. The design and implementation of PC provider training programs is the lynchpin for ensuring that all seriously ill patients have access to quality PC services. Building on the Breast Health Global Initiative's resource-stratified recommendations for provider education in PC, the authors report on efforts by the Jamaica Cancer Care and Research Institute in the Caribbean and the Universidad Católica in successfully developing and implementing PC training programs in the Caribbean and Latin America, respectively. Key aspects of this approach include: 1) fostering strategic academic partnerships to bring additional expertise and support to the effort; 2) careful adaptation of the curriculum to the local context and culture; 3) early identification of feasible metrics to facilitate program evaluation and future outcomes research; and 4) designing PC training programs to meet local health system needs.

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[ABSTRACT]. Like many nations in the Americas, the countries of the Caribbean are facing increasing morbidity and mortality associated with noncommunicable diseases (NCDs). In 2007, based on advocacy by Sir George Alleyne and others, the Caribbean Community (CARICOM) convened the first in the world Heads of Government NCDs Summit. This summit issued the Port of Spain Declaration that served not only as a rallying point to accelerate the regional NCDs response, but also as a catalyst for the first United Nations high-level meeting on NCDs in September 2011. In 2014, seven years after the CARICOM NCDs Summit, a formal evaluation of the Port of Spain Declaration (POSDEVAL) was conducted to investigate its impact and learn lessons to support and further accelerate its implementation. One mechanism was to review successes and challenges in the NCDs response and effectively communicate findings to stakeholders and the public. The results of the evaluation and the implementation of the Port of Spain Declaration are presented by other papers in this supplement. The present paper describes the communication and social information process used for sharing POSDEVAL findings across multiple layers of social influence in the Caribbean, primarily in 2016 – 2017. The main steps of the communication process are shared as a possible strategy for disseminating NCDs research information and accelerating control and policy adoption in other Small Island Developing States and middle-income countries.

[RESUMEN]. De modo similar al de otras naciones en la Región de las Américas, los países del Caribe se enfrentan a una morbilidad y mortalidad en aumento asociadas a las enfermedades no transmisibles (ENT). En el 2007, gracias al apoyo de sir George Alleyne, entre otros, la Comunidad del Caribe (CARICOM) celebró la primera cumbre de jefes de Gobierno sobre las ENT. Fruto de esta cumbre fue la Declaración de Puerto España, que supuso un punto de confluencia para acelerar la respuesta regional a las ENT, además de un catalizador para la primera reunión de alto nivel de la Asamblea General de las Naciones Unidas sobre las ENT, que tuvo lugar en septiembre del 2011. En el 2014, siete años después de la cumbre de CARICOM sobre las ENT, se llevó a cabo una evaluación formal de la Declaración de Puerto España para investigar su repercusión y extraer las lecciones que respalden y aceleren en mayor medida su ejecución. Uno de los mecanismos consistió en evaluar los logros y retos en la respuesta a las ENT y comunicar eficazmente los resultados a los interesados directos y el público general. En otros artículos de este suplemento se presentan los resultados de la evaluación y la ejecución de la Declaración de Puerto España. En el presente artículo se describe el proceso de comunicación e información social empleado para divulgar los resultados de la evaluación entre los distintos ámbitos de influencia social en el Caribe, especialmente entre los años 2016 y 2017. A modo de posible estrategia, se describen las principales medidas del plan de comunicación para divulgar la información relacionada con la investigación sobre las ENT y acelerar las medidas de control y la formulación de políticas en los pequeños estados insulares en desarrollo y los países de ingresos medianos.

[RESUMO]. À semelhança de várias nações nas Américas, os países do Caribe enfrentam um aumento da morbidade e mortalidade associadas às doenças não transmissíveis (DNTs). Em 2007, fundamentada na defesa da causa feita por Sir George Alleyne e outros, a Comunidade do Caribe (CARICOM) convocou a primeira Cúpula de Chefes de Governo sobre DNTs. Esta reunião culminou com a Declaração de Porto de Espanha que serviu não só como um ponto de encontro para acelerar a resposta regional às DNTs, mas também como um estímulo à primeira Reunião de Alto Nível das Nações Unidas sobre DNTs, em setembro de 2011. Em 2014, sete anos após a Cúpula sobre DNTs da CARICOM, foi realizada uma avaliação formal da Declaração de Porto de Espanha (POSDEVAL) para avaliar o impacto produzido e os ensinamentos tirados a fim de subsidiar e acelerar sua execução. Uma das estratégias usadas foi examinar os êxitos e desafios na resposta às DNTs e comunicar de modo efetivo os resultados aos interessados diretos e ao público. Os resultados da avaliação e execução da Declaração de Porto de Espanha são apresentados em outros artigos neste suplemento. O presente artigo descreve o processo de comunicação e informação social usado para divulgar os resultados da POSDEVAL entre as diversas esferas de influência social no Caribe, sobretudo no período de 2016–2017. Os principais passos da estratégia de comunicação são partilhados como uma possível estratégia para disseminar dados de pesquisas sobre DNTs e acelerar o controle e a adoção de políticas em outros Pequenos Estados Insulares em Desenvolvimento e países de média renda.

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Like many nations in the Americas, the countries of the Caribbean are facing increasing morbidity and mortality associated with noncommunicable diseases (NCDs). In 2007, based on advocacy by Sir George Alleyne and others, the Caribbean Community (CARICOM) convened the first in the world Heads of Government NCDs Summit. This summit issued the Port of Spain Declaration that served not only as a rallying point to accelerate the regional NCDs response, but also as a catalyst for the first United Nations high-level meeting on NCDs in September 2011. In 2014, seven years after the CARICOM NCDs Summit, a formal evaluation of the Port of Spain Declaration (POSDEVAL) was conducted to investigate its impact and learn lessons to support and further accelerate its implementation. One mechanism was to review successes and challenges in the NCDs response and effectively communicate findings to stakeholders and the public. The results of the evaluation and the implementation of the Port of Spain Declaration are presented by other papers in this supplement. The present paper describes the communication and social information process used for sharing POSDEVAL findings across multiple layers of social influence in the Caribbean, primarily in 2016 - 2017. The main steps of the communication process are shared as a possible strategy for disseminating NCDs research information and accelerating control and policy adoption in other Small Island Developing States and middle-income countries.

De modo similar al de otras naciones en la Región de las Américas, los países del Caribe se enfrentan a una morbilidad y mortalidad en aumento asociadas a las enfermedades no transmisibles (ENT). En el 2007, gracias al apoyo de sir George Alleyne, entre otros, la Comunidad del Caribe (CARICOM) celebró la primera cumbre de jefes de Gobierno sobre las ENT. Fruto de esta cumbre fue la Declaración de Puerto España, que supuso un punto de confluencia para acelerar la respuesta regional a las ENT, además de un catalizador para la primera reunión de alto nivel de la Asamblea General de las Naciones Unidas sobre las ENT, que tuvo lugar en septiembre del 2011.En el 2014, siete años después de la cumbre de CARICOM sobre las ENT, se llevó a cabo una evaluación formal de la Declaración de Puerto España para investigar su repercusión y extraer las lecciones que respalden y aceleren en mayor medida su ejecución. Uno de los mecanismos consistió en evaluar los logros y retos en la respuesta a las ENT y comunicar eficazmente los resultados a los interesados directos y el público general.En otros artículos de este suplemento se presentan los resultados de la evaluación y la ejecución de la Declaración de Puerto España. En el presente artículo se describe el proceso de comunicación e información social empleado para divulgar los resultados de la evaluación entre los distintos ámbitos de influencia social en el Caribe, especialmente entre los años 2016 y 2017. A modo de posible estrategia, se describen las principales medidas del plan de comunicación para divulgar la información relacionada con la investigación sobre las ENT y acelerar las medidas de control y la formulación de políticas en los pequeños estados insulares en desarrollo y los países de ingresos medianos.

À semelhança de várias nações nas Américas, os países do Caribe enfrentam um aumento da morbidade e mortalidade associadas às doenças não transmissíveis (DNTs). Em 2007, fundamentada na defesa da causa feita por Sir George Alleyne e outros, a Comunidade do Caribe (CARICOM) convocou a primeira Cúpula de Chefes de Governo sobre DNTs. Esta reunião culminou com a Declaração de Porto de Espanha que serviu não só como um ponto de encontro para acelerar a resposta regional às DNTs, mas também como um estímulo à primeira Reunião de Alto Nível das Nações Unidas sobre DNTs, em setembro de 2011.Em 2014, sete anos após a Cúpula sobre DNTs da CARICOM, foi realizada uma avaliação formal da Declaração de Porto de Espanha (POSDEVAL) para avaliar o impacto produzido e os ensinamentos tirados a fim de subsidiar e acelerar sua execução. Uma das estratégias usadas foi examinar os êxitos e desafios na resposta às DNTs e comunicar de modo efetivo os resultados aos interessados diretos e ao público. Os resultados da avaliação e execução da Declaração de Porto de Espanha são apresentados em outros artigos neste suplemento. O presente artigo descreve o processo de comunicação e informação social usado para divulgar os resultados da POSDEVAL entre as diversas esferas de influência social no Caribe, sobretudo no período de 2016­2017. Os principais passos da estratégia de comunicação são partilhados como uma possível estratégia para disseminar dados de pesquisas sobre DNTs e acelerar o controle e a adoção de políticas em outros Pequenos Estados Insulares em Desenvolvimento e países de média renda.