ABSTRACT

In response to the epidemic of non-communicable diseases (NCDs) in the Caribbean, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, “Uniting to Stop the Epidemic of Chronic Non-communicable Diseases” and declared the second Saturday in September to be “Caribbean Wellness Day” (CWD). CWD is a call-to-action for engaging the population of the Member States in confronting NCDs and their risk factors.

This report reviews the genesis, implementation, and institutionalization of CWD in CARICOM and beyond. The study used quantitative and qualitative methods, including 29 surveys, 7 in-depth interviews, and analysis of media content. Data was provided by NCD focal points at the Ministry of Health in 15 CARICOM countries, as well as by 7 non-governmental and 4 private organizations.

Branding materials were well received and locally adapted; much of CWD media content originated from organization websites and were not community-based. Events typically focused on physical activity and health screenings and were attended by up to 3 000 participants. Though most were held in city centers, some CWD activities have involved rural and indigenous populations.

CWD has become a catalyst for multisectoral engagement and health promotion activities. Inspired by CWD, PAHO initiated “Wellness Week in the Americas,” which includes CWD and promotes its tenets across the Region of the Americas. As CWD further develops, consideration should be given to reliable, adequate, and sustainable financing; to measuring and evaluating its impact on NCDs; and to widening its reach to include those outside of city centers.

Keywords
Chronic disease, prevention & control; health promotion; international cooperation; Caribbean Region

RESUMEN

En respuesta a la epidemia de las enfermedades no transmisibles en el Caribe, los jefes de Gobierno de la Comunidad del Caribe (CARICOM) emitieron en el 2007 la Declaración de Puerto España, “Unidos para detener la epidemia de las enfermedades crónicas no transmisibles”, y propusieron instaurar el segundo sábado de septiembre como el “Día del Bienestar en el Caribe”. Este día es un llamado a la acción para fomentar la participación la población de los Estados Miembros contra las enfermedades no transmisibles y sus factores de riesgo.

Este informe examina la génesis, la puesta en marcha y la institucionalización del Día del Bienestar en el Caribe en CARICOM y otros lugares. En el estudio se emplearon métodos cuantitativos y cualitativos, entre ellos 29 encuestas, 7 entrevistas exhaustivas y el análisis del contenido de medios de difusión. Los datos fueron proporcionados por puntos focales para las enfermedades no transmisibles del Ministerio de Salud de 15 países de CARICOM, así como por siete organizaciones no gubernamentales y cuatro organizaciones privadas.

Los materiales de imagen institucional fueron bien recibidos y se adaptaron localmente; gran parte del contenido sobre el Día del Bienestar en los medios de difusión provenía de los sitios web de organizaciones y no de las comunidades. Los eventos se centraron generalmente en la actividad física y los exámenes médicos de tamizaje, y asistieron hasta 3 000 personas. Aunque la mayoría se celebraron en el centro de las ciudades, algunas actividades se han realizado con poblaciones rurales e indígenas.

El Día del Bienestar en el Caribe se ha convertido en un catalizador para la participación multisectorial y las actividades de promoción de la salud. Inspirada en él, la OPS instituyó la “Semana del Bienestar en las Américas”, que incluye a su vez el Día del Bienestar en el Caribe y difunde sus principios en toda la Región de las Américas. Conforme el Día del Bienestar en el Caribe evolucione aún más, debe pensarse en obtener un financiamiento confiable, adecuado y sostenible; en medir y evaluar sus repercusiones en materia de enfermedades no transmisibles; y en ampliar su alcance para abarcar a quienes viven lejos del centro de las ciudades.

Palabras clave
Enfermedad crónica, prevención & control; promoción de la salud; cooperación internacional; Región del Caribe

RESUMO

Em resposta à epidemia de doenças não transmissíveis (DNTs) no Caribe, os chefes de governo da Comunidade do Caribe (CARICOM) emitiram a Declaração de Porto de Espanha de 2007, “Unidos para deter a epidemia de doenças crônicas não transmissíveis”, e declararam o segundo sábado de setembro o “Dia do Bem-estar no Caribe”. Trata-se de uma chamada à ação aos Estados Membros para engajar a população a enfrentar as DNTs e os fatores de risco associados.

Este informe faz uma análise da origem, implantação e institucionalização do Dia do Bem-Estar no Caribe no CARICOM e outras regiões. Neste estudo foram empregados métodos quantitativos e qualitativos, com 29 inquéritos, 7 entrevistas aprofundadas e uma análise de conteúdo de mídias. Os dados foram fornecidos pelos centros de coordenação de DNTs nos ministérios da Saúde de 15 países da CARICOM, assim como por sete organizações não governamentais e quatro entidades privadas.

Os materiais de branding foram bem aceitos e adaptados ao contexto local. Grande parte de conteúdo de mídia do Dia do Bem-Estar no Caribe foi proveniente de sites de entidades e não foram originados nas comunidades. Os eventos normalmente envolveram atividade física e exames de prevenção de saúde, com o comparecimento de até 3.000 participantes. Apesar de a maioria dos eventos ter sido realizada em centros urbanos, ocorreram algumas atividades para populações rurais e indígenas.

O Dia do Bem-Estar no Caribe é um incentivador para a participação multissetorial e para atividades de promoção da saúde. Inspirada nesta iniciativa, a Organização Pan-Americana da Saúde (OPAS) instituiu a “Semana do Bem-Estar nas Américas”, englobando e promovendo os princípios do Dia do Bem-Estar no Caribe em toda a Região das Américas. Com a expansão deste acontecimento, é preciso considerar como custeá-lo de maneira adequada, segura e sustentável, mensurar e avaliar a repercussão que ele tem e ampliar o seu alcance para chegar às populações fora dos centros urbanos.

Palavras-chave
Doença crônica, prevenção & controle; promoção da saúde; cooperação internacional; Região do Caribe

In response to the epidemic of non-communicable diseases (NCDs) in the Caribbean, the Caribbean Community (CARICOM) Heads of Government issued the 2007 Port-of-Spain Declaration (the POS Declaration), “Uniting to Stop the Epidemic of Chronic Non-communicable Diseases” (¹1. Samuels TA, Hospedales CJ. From Port-of-Spain Summit to United Nations High Level Meeting CARICOM and the Global Non-communicable Disease Agenda. West Indian Med J. 2011;60(4):387. – ⁵5. Caribbean Community. Declaration of Port-of-Spain: uniting to stop the epidemic of chronic non-communicable diseases. Georgetown, Guyana: Caribbean Community Secretariat; 2007. Available from: https://caricom.org/media-center/communications/statements-from-caricom-meetings/declaration-of-port-of-spain-uniting-to-stop-the-epidemic-of-chronic-ncds Accessed 23 May 2018.
https://caricom.org/media-center/communi... ). To commemorate this landmark summit, the Heads declared the second Saturday in September as “Caribbean Wellness Day” (CWD). The CWD mandate is a public call- to-action that seeks to inspire CARICOM Member States to engage in an ‘all-of-society’ response to NCDs and their risk factors. Understanding how this initiative has mobilized societies across the Caribbean provides valuable lessons for other region-wide initiatives.

CARICOM and the Pan American Health Organization (PAHO) were responsible for developing and advancing CWD to capture the imagination of citizens in facilitating healthy lifestyle changes. It was envisioned that multisectoral contributions to CWD would enhance collaboration for NCD prevention and control. This study sought to understand the genesis, implementation, and institutionalization of CWD celebrations in CARICOM and beyond.

MATERIALS AND METHODS

Quantitative and qualitative methods included 26 surveys, media content abstraction, and 7 in-depth semi-structured interviews, conducted consecutively to allow information garnered from one methodology to inform the lines of investigation at the next phases. Phase 1 was an analysis of CWD initiatives in 19 of the 20 participating CARICOM Member States that sought to obtain a holistic understanding of successful practices and lessons learned.

A SurveyMonkey^® (SurveyMonkey Inc., San Mateo, California, United States) online questionnaire was used from April – September 2015 (available upon request from the corresponding author). It was completed by NCD focal points from the governments of 15 of the 20 CARICOM Member States and representatives from 7 civil society organizations and 4 private organizations in 17 of the 20 CARICOM Member States (Table 1). Twenty (74%) of the 26 persons completing the survey had been involved with CWD from its inception in 2008.

Seven key informants were interviewed from regional institutions, including CARICOM, PAHO, Caribbean Public Health Agency (CARPHA), the Healthy Caribbean Coalition (HCC), and the University of the West Indies, in May – July 2015.

Phase 2 was an inventory and analysis of CWD content found on the Internet from 2006 (baseline year) – 2014. The search garnered content through Google Search™ (Google Inc., Mountain View, California, United States), online newspapers, and social media from each respective Member States. Google searches quantified CWD presence on the Internet and in publications, while the search of newspapers and social media outlets ascertained media coverage of CWD celebrations.

Dedoose^® online software (Dedoose, Manhattan Beach, California, United States) was used to manage and analyze the qualitative data. An inductive approach was employed to develop individual codes as the team examined patterns, ambiguities, and outliers among the transcripts. Similarities and differences in participants’ perceptions were explored.

Content analysis was conducted to ascertain how the media delivered CWD health messages. Specifically, analysis focused on how people received the information in terms of the amount of space related to health issues and whether the space was formatted as articles, editorials, letters, advertisements, visual references, or graphics (⁶6. Roberts JM, Crossley N. Introduction. The Sociological Review. 2004;52:1–27. doi:10.1111/j.1467-954X.2004.00471
https://doi.org/10.1111/j.1467-954X.2004... – ⁸8. Ramanadhan S, Mendez S, Rao M, Viswanath K. Social media use by community-based organizations conducting health promotion: a content analysis. BMC Public Health. 2013;13(1):1.). E-publications of popular daily newspapers, social media in the form of Facebook^® (Facebook Inc., Menlo Park, California, United States), Twitter^® (Twitter Inc., San Francisco, California, United States) and organizational websites were reviewed for the same period (2006 – 2014). In countries with multiple daily newspapers, the study sample included the two dailies with the highest readership. Headlines and complete articles were examined for the manifest content. Status updates, links, photos, videos, and events on Facebook were also examined. The media coding process was both inductive and deductive; codes were identified from the key informant interviews and from the initial examination of a sample of newspaper articles, with a few codes added iteratively. Analysis was conducted by two researchers, with a third researcher resolving any issues with coding variability. Content analysis was then applied to determine frequency of topic areas.

The Chair of the Institutional Review Board of the University of the West Indies (Bridgetown, Barbados) advised that since no personal information was to be collected and participants were providing only data related to their professional knowledge and expertise, its approval was not necessary. However, each participant gave consent and provided all relevant information (available by request from the corresponding author).

RESULTS

Establishing Caribbean Wellness Day

Regional support.

Following the 2007 NCD summit, PAHO, CARICOM, the Ministries of Health, and civil society collectively determined CWD events, branding, and messaging. PAHO also supported CWD through the production of a logo, posters, videos, and a web presence (⁹9. Pan American Health Organization. Caribbean Wellness Week / Caribbean Wellness Day. Available from: www.paho.org/hq/index.php?option=com_content&view=category&layout=blog&id=1434&Itemid=42095&lang=en Accessed 23 May 2018
www.paho.org/hq/index.php?option=com_con... ), as well as promotional materials to be used by countries for the inaugural event.

The CWD slogan, logo, posters, stickers, and fact sheets were mostly used by government officials. Civil society and the private sector reported more varied use, with the CWD logo being the most used of the official media available. Their utilization also showed a higher degree of adaptation than that of the governments’ (Figure 1).

National implementation.

NCD focal points in Ministries of Health formed the CWD nexus, collaborating with PAHO and leveraging local support. In spite of its name, civil society and private sectors seemed to hold a nationalistic view of CWD, with only three respondents acknowledging its regional character. However, NCD focal points in government were all aware of CWD regional origins, likely due to the collective planning in which they had participated.

Regional experts concurred, noting that beyond the initiation of CWD celebrations, there was little sharing of experiences or collaboration among Member States. One key informant explained that CWD organization and execution was heavily dependent on NCD focal points who primarily leveraged support at the national level.

Furthermore, countries were encouraged to customize CWD, and some extended their events beyond a single day and beyond a single theme. For instance, it was reported by a regional stakeholder that activities “weren't restricted to just diet and exercise, but it proliferated in general promoting [of] various [NCD] themes in which the country itself had a specific interest.”

Some countries, such as Trinidad and Tobago and Guyana, hosted events throughout the month of September, and many countries celebrated a week of activities. CWD also had a compound slogan where “Love That Body” was intended to be the first phrase, and countries each added a second phrase such as, “Love That Body, Portions Count” and “Love That Body, Move That Body” to bring various themes into focus.

Inspired by CWD, in 2011 PAHO initiated “Wellness Week in the Americas,” promoting the tenets of CWD during a week across the other countries in the Region of the Americas. Participating locations included New York City and Washington, D.C., in preparation for the 2011 United Nations Special Assembly on NCDs; Aruba, Cuba, and Puerto Rico also had their own celebrations.

National collaborators.

Both NCD focal points and respondents from non-governmental organizations (NGOs) reported that there are specific Ministry of Health-led CWD committees. The committees tend to begin planning 3 months in advance for September's CWD events; with 5 out of the 7 committees meeting after CWD to evaluate that year's activities and plan future wellness actions. Six countries produced formal, written CWD plans, and three of these included monitoring and evaluation elements.

The makeup of CWD committees has changed over time with non-governmental participation peaking in 2010 and 2011 (the year of the United Nations High Level Meeting on NCDs), followed by significant contraction in all sectors in 2012. Non-governmental funding increased from 0% in 2008 to 14% percent in 2014, though Ministries of Health remain the main funders and drivers of CWD.

Since 2009, the scope of CWD activities run by non-governmental sectors has also increased to include planning and development, bringing critical human resources and greater NCD response (Figure 2). However, there were notable differences between CWD-related activities run by civil society and those run by the private sector. While both groups were heavily involved with activities described as health promotion, the private sector lent expertise in planning and logistics, while civil societies focused on health screenings and organized its volunteers to smoothly run events.

CWD has been a catalyst for multisectoral engagement for NCD response, by strengthening and expanding existing links. Government respondents further corroborated this position stating that due to CWD, civil society and the private sector became more integrated in the national NCD response, initiating their own CWD activities and increasingly being incorporated into national NCD committees/commissions. One government respondent stated:

CWD activities

Since inception, there have not been any notable changes in CWD activities other than the annual theme, decided upon annually at the regional level. Since CWD is not a funded mandate, its activities have varied among countries according to their resources. Typically, activities have included health promotion activities, such as health fairs, health screening, exhibitions, weight loss competitions, and/or healthy cooking demonstrations; and physical activity, such as sponsored 5K walks, football matches, general maintenance of sports fields, or mass public exercise sessions. Public attendance at CWD events has ranged from about 200 participants to more than 3 000 in some of the larger countries.

Typically, CWD promotion starts 1 month in advance, using multiple methods. The most common methods used have been radio talk shows and public service announcements via radio and television, followed by Facebook and Twitter. Posters and fact sheets with recommended actions for each sector were considered very helpful and informative, but some stakeholders felt the promotion needed to be more dynamic. Media reports, supported by information from interviews and survey results, indicated that CWD was concentrated in and around city centers, where 50% of activities took place. Schools hosted 22% of CWD activities; work places, 15%; faith-based organizations, 7%; and rural districts, 5%. Event-centered activities focused on physical activity, and sometimes included free entertainment and health checks.

Although CWD events have been concentrated in and around city centers, there was consensus on the need to extend CWD into underserved communities that have received little outreach. As one regional stakeholder explained, “…maybe we are targeting the same people every year. The settings approach is very important…[but] we have to support the countries in …targeting different, special areas.”

Some progress has been made, including CWD outreach and activities among the indigenous populations in Belize, Guyana, and Suriname.

Online media profile of CWD

In all, 249 individual items or “hits” were retrieved from Google using the search term “Caribbean Wellness Day” for the years 2006 (baseline year) – 2014. No hits were obtained for 2006, indicating that the POS Declaration served as the catalyst for this regional wellness initiative (Figure 3). Results further showed a 10-fold increase in CWD website content from 2007 – 2014.

CWD content (44% of items) was predominantly extracted from websites created and run by PAHO, CARICOM, CARPHA, and HCC. The information available on these websites was, in some cases, shared among these regional organizations, and subsequently used or replicated by other external websites. Some of the same content was repeatedly shared on the same platforms. Often, the original information was about upcoming CWD activities, flyers on upcoming events, the CWD logo and slogan, and reports on how CWD was celebrated.

Most of the relative internet content was sourced from upstream groups; community-based organizations infrequently produced this content (Table 2). Facebook accounted for only 1% of all CWD content on the Internet and was produced by 7 of the 19 countries, with most of the posts made after 2011. In addition, 169 online newspaper articles were reviewed. The most frequently occurring main subject area was CWD commemoration activities (72 articles; 42.6%) and discussions of CWD day itself and the POS Declaration (49; 30%). Other main subjects were NCD risk factors and multisectoral partnerships developed to support CWD. With respect to content highlighted in the body of the articles, the majority of the CWD content was related to physical activity, NCD risk factors, and intersectoral partnerships (Table 1). There was limited discussion on CWD as a catalyst for behavioral change or for multisectoral action.

Media reports corroborated the evidence from interviews and surveys, indicating that CWD activities were mostly concentrated in and around city centers: 50% of activities identified online occurred in urban settings. Furthermore, media confirmed that CWD was most often an event focused on physical activity, sometimes offering free entertainment and health checks.

Monitoring and evaluation

Government respondents were heavily involved in monitoring and evaluating CWD. This typically consisted of narratives of the day's activities, along with photographs, forwarded to regional organizations. This monitoring was described as “observatory,” “mainly descriptive,” and “celebratory” of CWD events, contributors, and participants. These reports were collated and presented to the annual CARICOM Ministers of Health caucus. Although this kind of documentation was done well, respondents argued that, “it has some limitations…[a] country might say it was quite successful…however, there is no such validation of the information as correct.” In 2010, a formal evaluation was published (⁴4. Alleyne G, Samuels TA. The West Indian Medical Journal and the Non-communicable Diseases (NCDs): the next 60 years. West Indian Med J. 2011;60(4):379.), but no other formal evaluations have been carried out since due to lack of resources.

Respondents had a shared view that more “in-depth” and “standardized” monitoring and evaluation need to be conducted to enhance the NCD response. While limited resources were acknowledged as a significant barrier, it was also understood that documenting the number of people reached and the health behaviors changed could, according to a regional stakeholder, “demonstrate value for money in terms of investment for resource mobilization.”

Barriers and facilitators

The main challenge reported was a lack of funding for CWD, understandable since the POS Declaration is an unfunded mandate and the Caribbean region faces significant economic constraints. Only the Government of Suriname has a specific budgetary line-item for CWD; all other countries make special provisions for it. Lack of funds for marketing, for example, contributed to an inability to target disengaged communities.

Another challenge was the disconnect between the regionally-determined theme and national CWD plans. Either way, as one regional stakeholder stated, “we have to accept; it is still [a] very health, vertical-oriented approach.” Yet, it can be said that because the mandate is unfunded, it requires ingenuity to host the celebration and gives rise to greater intersectoral collaboration.

Overall, CWD is considered to be successful in spite of its limited resources and partnerships between and within countries. Regional interest and “excitement” exist—Member States have been willing to participate in planning meetings and to share their experiences. More specifically, respondents state that, “what worked well was mass public activity; we're good at that in the Caribbean, partying!” and that, “in the region we like celebrations… so a lot of work focuses on the day.”

Settings with very limited financial and human resources were able to adapt by being “very creative” in their methodology: instead of holding an event, they capitalized on an existing one, such as a cricket match or school event. As such, strong CWD branding, coupled with strong political will, has been hailed as key to keeping CWD on the forefront of NCD activities. Respondents reported that CWD success hinged on consistent championing; that it must be “significantly tied to the dynamism of the health promotions officer or NCD focal point” who can keep CWD “alive” and “growing.” Yet, one respondent warned that: “the CMO and even Minister [of Health] have to take more strong leadership… go into the field to speak to the nation… to the community…and share his experience and convince people.”

DISCUSSION

CWD was the only new mandate in the 2007 POS Summit Declaration and was intended to be its “public face.” This study found that CWD has been successfully implemented in all CARICOM countries except Haiti; and that it has inspired similar observances globally.

What remains to be investigated is the impact that CWD has made on NCD awareness and its associated health behaviors among the public, and what social and political changes have been attained. Appropriate monitoring and evaluation must be enhanced to provide data to assess CWD progress in broader terms. While activities associated with health awareness days typically focus on individual-level interventions, Purtle and Roman (¹⁰10. Purtle J, Roman LA. Health awareness days: sufficient evidence to support the craze? Am J Public Health. 2015;105(6):1061–5.) suggest these are opportunities to advocate for policies that create environments conducive to behavioral change.

Social media as a health promotion and evaluation tool has become more formalized in recent years. One method proposed for this type of study is to analyze time trends. A quasi-experimental design is used to compare the occurrence of news reports and social media presence related to the subject of the awareness day, with the assumed counterfactual estimates without the celebration, in order to determine whether the celebration was associated with a peak in social media presence (¹¹11. Ayers JW, Westmaas JL, Leas EC, Benton A, Chen Y, Dredze M, et al. Leveraging big data to improve health awareness campaigns: a novel evaluation of the great American smokeout. JMIR Public Health Surveill. 2016;2(1):e16.). Analysis of social media can indicate that the public is seeking further information on the subject, which may be an indicator of awareness and attention. Comments from the public on such postings may indicate opinions and interests. However, users of social media are not a representative sample of the general population, so it is not appropriate to generalize from these postings. Because the science of utilizing social media to reflect public opinion is still in its infancy, any data it generates should be triangulated to validate conclusions arrived at through analysis of just the social media postings and responses (¹²12. Bright J, Great Britain Department for Work and Pensions. The use of social media for research and analysis: a feasibility study. Leeds: Corporate Document Services; 2014.).

Thus, information found on Facebook pages could be cautiously considered as a proxy of grassroots buy-in of CWD. However, in this study, the results are likely an underestimation of CWD's true presence in social media. Regarding Facebook, researchers only had access to publicly-available information associated with the search phrase, “Caribbean Wellness Day.” It is possible that CWD-related content was posted to social media without any reference to the term, “Caribbean Wellness Day.” Therefore, given the personalized nature of social media content, and especially considering the inherent nationalistic variation of the celebrations, much content may have been missed. For example, many Member States have progressed to celebrating “Wellness Week.” Perhaps, as CWD becomes ingrained in society with more community-based initiatives, its social media footprint will become more defused.

The gains made by CWD may decline if care is not taken to address issues of “message fatigue” and cultural and socioeconomic barriers to participation (¹⁰10. Purtle J, Roman LA. Health awareness days: sufficient evidence to support the craze? Am J Public Health. 2015;105(6):1061–5.). Regional collaboration was limited to the provision of CWD themes by the regional health sector, with individual countries being encouraged to customize the regional slogan for their communities.

Given the variation in resource capacity throughout the region, respondents believed that structured regional collaboration would assist in meeting CWD goals. The establishment of a regional oversight group to provide technical assistance, such as toolkits, may help CWD flourish for advancing policy and mobilizing sectors. However, despite the wide use of toolkits as a mode of knowledge transfer, their effectiveness has not been assessed and their sources are rarely documented (¹³13. Barac R, Stein S, Bruce B, Barwick M. Scoping review of toolkits as a knowledge translation strategy in health. BMC Med Inform Decis Mak. 2014;14:121.). These are weaknesses that the existing CWD toolkit, and its proposed enhancement, need to address.

Because regional organizations lead in online dissemination of CWD, they should actively participate in the proposed regional oversight group. In this way, the embassies and organizations, such as the Organization of Eastern Caribbean States, the Food and Agricultural Organization, the United Nations Children's Fund, the United Nations Development Programmed, and the United Nations Educational, Scientific, and Cultural Organization, can be better mobilized to enhance their support of CWD.

Conclusions

Since its inception, CWD has been observed annually by most CARICOM Member States. While its observance is indicative of the initiative's success, it has also encouraged greater multisectoral links in the response to NCDs. Regional organizations have played a seminal role in creating an environment that fosters networking and collaboration in hosting the celebrations throughout the region. NCD focal points have also been key, following their own informal “roadmap” or toolkit to guide their activities. Despite the growth and success of CWD, there is no explicit, formal framework to assist countries in establishing CWD goals or for monitoring and evaluating its impact. Recently, there has been less CWD collaboration among Member States. Hence, there is a growing consensus among some regional partners that having regional-level oversight might assist CWD in better fulfilling its potential as a strategic component of an overall NCD communication plan.

Throughout its 10-year lifespan, the scope of CWD celebrations has remained the same, with evidence that its wellness message is being recycled through the same audience. Widening the scope of CWD celebrations to reach a broader audience, at both the national and regional levels, should be considered. Moreover, a comprehensive evaluation protocol is needed to assess the impact that CWD is making on reducing NCD risk factors among the populations of the CARICOM countries.

Acknowledgements.

We thank survey respondents and interviewees, the CWD focal points, and multisectoral partners for their continued dedication to CWD.

REFERENCES

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History