ABSTRACT

In the English-speaking Caribbean, an estimated 46% of men and 61% of women are currently overweight or obese, and 8% of children younger than 5 years are also overweight. To combat this worsening epidemic, driven by unhealthy dietary patterns, the Heads of Government of the Caribbean Community (CARICOM) issued the 2007 Port-of-Spain Declaration, which included mandates on the provision of healthy school meals, promotion of healthy dietary patterns, and reintroduction of physical education in schools. These mandates are aligned with evidence-based approaches used in childhood obesity prevention programs. School-based interventions, including curriculum revisions, are part of a multipronged approach to improve nutrition in children and are designed to complement and reinforce other interventions in schools. However, formal evaluation of the Port-of-Spain Declaration showed that most CARICOM member countries had difficulty implementing the mandates related to schools and diet. The Improving Household Nutrition Security and Public Health in the CARICOM project, in collaboration with regional institutions, the CARICOM Secretariat, and the Caribbean Examinations Council, sought to enhance nutrition education through revision of region-wide primary and secondary school curricula to increase the focus on prevention of noncommunicable diseases. This paper describes the process of revising the Caribbean Examinations Council’s Human and Social Biology syllabus for secondary schools and the CARICOM Health and Family Life Education Regional Curriculum Framework for primary schools, which was achieved through multisectoral collaboration. We used the Framework for Reporting Adaptations and Modifications-Enhanced model to describe the process through which the modifications were made.

Keywords
Schools; curriculum; health education; noncommunicable diseases; Caribbean

RESUMEN

Se calcula que, en el Caribe de habla inglesa, el 46% de los hombres y el 61% de las mujeres tienen sobrepeso o son obesos, así como el 8% de los menores de 5 años. Para combatir esta epidemia creciente, debida a los hábitos de alimentación poco saludables, los Jefes de Gobierno de la Comunidad del Caribe (CARICOM) emitieron en el 2007 la Declaración de Puerto España, que incluía mandatos relativos al suministro de comidas escolares saludables, la promoción de hábitos de alimentación saludables y la reintroducción de la educación física en las escuelas. Estos mandatos están en consonancia con los enfoques basados en la evidencia que se aplican en los programas de prevención de la obesidad infantil. Las intervenciones en los centros escolares, entre ellas la revisión de los planes de estudios, forman parte de una estrategia multidimensional dirigida a mejorar la nutrición infantil, y tienen la finalidad de complementar y reforzar otras intervenciones en las escuelas. Sin embargo, los resultados de la evaluación formal de la Declaración de Puerto España mostraron que la mayoría de los países miembros de la CARICOM tuvieron dificultades para poner en práctica los mandatos relativos a las escuelas y la alimentación. El proyecto “Mejorar la seguridad nutricional de los hogares y la salud pública en la Comunidad del Caribe”, en colaboración con instituciones regionales, la Secretaría de la CARICOM y el Caribbean Examinations Council, se propuso mejorar la educación nutricional por medio de la revisión de los planes de estudio de las escuelas primarias y secundarias de toda la región, para prestar mayor atención a la prevención de las enfermedades no transmisibles. En este artículo se describe el proceso de revisión del temario del Caribbean Examinations Council en materia de Biología Humana y Social para las escuelas secundarias, así como del marco curricular regional de educación para la salud y la vida familiar de la CARICOM para las escuelas primarias, que se llevó a cabo mediante una colaboración multisectorial. Para describir el proceso por el cual se realizaron las modificaciones, los autores usaron el modelo ampliado del marco para informar las adaptaciones y modificaciones (FRAME, por su sigla en inglés).

Palabras clave
Instituciones académicas; curriculum; educación en salud; enfermedades no transmisibles; Región del Caribe

RESUMO

No Caribe anglófono, estima-se que atualmente 46% dos homens e 61% das mulheres estejam com sobrepeso ou obesidade e que 8% das crianças menores de 5 anos também estejam com sobrepeso. Para combater essa epidemia que se agrava, impulsionada por padrões alimentares pouco saudáveis, os chefes de governo da Comunidade do Caribe (CARICOM) emitiram a Declaração de Port-of-Spain de 2007, que incluía mandatos sobre o fornecimento de refeições saudáveis nas escolas, a promoção de padrões alimentares saudáveis e a reintrodução da educação física nas escolas. Esses mandatos são consistentes com abordagens baseadas em evidências usadas em programas de prevenção da obesidade infantil. Intervenções realizadas nas escolas, incluindo revisões curriculares, fazem parte de uma abordagem multifacetada para melhorar a nutrição das crianças, com o objetivo de complementar e reforçar outras intervenções nas escolas. Entretanto, a avaliação formal da Declaração de Port-of-Spain mostrou que a maioria dos países membros da CARICOM teve dificuldade em implementar os mandatos relacionados às escolas e à dieta. O projeto Melhorando a Segurança Nutricional das Famílias e a Saúde Pública na CARICOM, em colaboração com instituições regionais, a Secretaria da CARICOM e o Conselho de Exames do Caribe, buscou aprimorar a educação nutricional por meio da revisão dos currículos do ensino fundamental e médio em toda a região para aumentar o foco na prevenção de doenças não transmissíveis. Este artigo descreve o processo de revisão do programa de Biologia Humana e Social do Conselho de Exames do Caribe (para escolas do ensino médio) e da Estrutura Curricular Regional de Educação em Saúde e Vida Familiar da CARICOM (para escolas do ensino fundamental), que foi alcançado por meio de colaboração multissetorial. Usamos o modelo avançado da Estrutura para Informar Adaptações e Modificações (FRAME) para descrever o processo utilizado para fazer as modificações.

Palavras-chave
Instituições acadêmicas; currículo; educação em saúde; doenças não transmissíveis; Região do Caribe

Obesity is a major risk factor for noncommunicable diseases (NCDs), and its burden is increasing in the Caribbean, with particular concern for the rising rates in children (¹1. Pan American Health Organization. Core indicators 2019: health trends in the Americas. Washington, DC: PAHO; 2019. Available from: https://iris.paho.org/handle/10665.2/51542 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/515... , ²2. Pan American Health Organization. Noncommunicable diseases in the Region of the Americas: facts and figures. Washington, DC: PAHO; 2019. Available from: https://iris.paho.org/handle/10665.2/51483 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/514... ). Dietary patterns are the main driver for the obesity epidemic (³3. Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. Obes Rev. 2018 Aug;19(8): 1028–64. doi: 10.1111/obr.12694
https://doi.org/10.1111/obr.12694... ). The small island developing states of the Caribbean region import on average 60% of the foods they consume, mostly ultraprocessed and unhealthy foods, with some countries importing more than 80% of their consumption (⁴4. Food and Agriculture Organization of the United Nations, Subregional Office, Barbados. State of food insecurity in the CARICOM Caribbean – meeting the 2015 hunger targets: taking stock of uneven progress. Rome: FAO; 2015. Available from: https://www.fao.org/3/i5131e/i5131e.pdf [cited 2022 Dec 6].
https://www.fao.org/3/i5131e/i5131e.pdf... ).

Systematic reviews have shown the effectiveness of school-based interventions such as health education in changing nutrition behavior and physical activity levels (⁵5. Nally S, Carlin A, Blackburn NE, Baird JS, Salmon J, Murphy MH, et al. The Effectiveness of school-based interventions on obesity-related behaviours in primary school children: a systematic review and meta-analysis of randomised controlled trials. Children. 2021;8:489. doi: 10.3390/children8060489
https://doi.org/10.3390/children8060489... –⁷7. Verstraeten R, Roberfroid D, Lachat C, Leroy JL, Holdsworth M, Maes L, et al. Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review. Am J Clin Nutr. 2012;96(2):415–38. doi: 10.3945/ajcn.112.035378
https://doi.org/10.3945/ajcn.112.035378... ). Empirical evidence supports the use of schools as effective settings for childhood obesity prevention programs because they are ideal for the implementation of nutrition and physical activity education, and the provision of healthy meals (⁶6. Kelishadi R, Azizi-Soleiman F. Controlling childhood obesity: a systematic review on strategies and challenges. J. Res Med Sci. 2014;19:993–1008.). Many school-based interventions target diet-only, physical activity-only, or both (⁷7. Verstraeten R, Roberfroid D, Lachat C, Leroy JL, Holdsworth M, Maes L, et al. Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review. Am J Clin Nutr. 2012;96(2):415–38. doi: 10.3945/ajcn.112.035378
https://doi.org/10.3945/ajcn.112.035378... , ⁸8. Mukamana O, Johri M. What is known about school-based interventions for health promotion and their impact in developing countries? A scoping review of the literature. Health Educ Res. 2016;31(5):587–602. doi: 10.1093/her/cyw040
https://doi.org/10.1093/her/cyw040... ), but these are not integrated into the school curricula. The evidence suggests that the content of school curricula and pedagogical approaches are important adjuncts to these programs. Therefore, nutrition education programs integrated into school curricula are recommended (⁹9. World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Making every school a health-promoting school: global standards and indicators for health-promoting schools and systems. Geneva: WHO and UNESCO; 2021. Available from: https://www.who.int/publications/i/item/97892400250592 [cited 2022 Dec 9].
https://www.who.int/publications/i/item/... , ¹⁰10. Pulimeno M, Piscitelli P, Colazzo S, Colao A, Miani A. School as ideal setting to promote health and wellbeing among young people. Health Promot Perspect. 2020;10(4): 316–24. doi: 10.34172/hpp.2020.50
https://doi.org/10.34172/hpp.2020.50... ).

The Caribbean Community (CARICOM) comprises 20 countries. Fifteen are full members (Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat (a British overseas territory in the Leeward Islands), Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago) and five are associate members (overseas territories of the United Kingdom of Great Britain and Northern Ireland: Anguilla, Bermuda, British Virgin Islands, Cayman Islands, and Turks and Caicos Islands). CARICOM countries have had varied success in implementation of the mandates of the 2007 Port-of-Spain Declaration on NCDs related to schools (¹¹11. The evaluation of the 2007 CARICOM Heads of Government POS NCD Summit Declaration: The Investigators Detailed Report October 2017 [internet]. Available from: https://food4changecaribbean.org/wp-content/uploads/2018/01/POSDEVAL_The-Investigators-report_FINAL.pdf [cited 2021 Nov 9].
https://food4changecaribbean.org/wp-cont... ). As a result, the Improving Household Nutrition Security and Public Health in the CARICOM project (short name: Food and Nutrition (FaN)) research group made the decision to dedicate one stream of its interventions to schools. One of these interventions included collaboration with the Caribbean Examinations Council (CXC^®) to adapt the syllabuses of certain subjects taught at the secondary level, namely: CSEC^® Human and Social Biology (¹²12. Caribbean Examinations Council. Caribbean Secondary Education Certificate CSEC® Human and Social Biology Syllabus. Kingston: CXC; 2010. Available from: https://www.cxc.org/SiteAssets/syllabusses/CSEC/CSEC%20Human%20and%20Social%20Biology.pdf [cited 2021 Nov 9].
https://www.cxc.org/SiteAssets/syllabuss... ) and CCSLC^® Integrated Science (¹³13. Caribbean Examinations Council. Caribbean Certificate of Secondary Level Competence CCSLC® Integrated Science Syllabus. Kingston: CXC; 2012. Available from: https://www.cxc.org/SiteAssets/CCSLC/SYLLABUSES/CCSLCIntegratedScienceSyllabusJune%202012.pdf [cited 2021 Nov 9].
https://www.cxc.org/SiteAssets/CCSLC/SYL... ) (CSEC^®: Caribbean Secondary Education Certificate; CCSLC^®: Caribbean Certificate of Secondary Level Competence). To address the primary level, the FaN research group partnered with the CARICOM Secretariat to review and revise the Health and Family Life Education (HFLE) Regional Curriculum Framework (¹⁴14. Caribbean Community Secretariat, United Nations Children’s Fund. Health and Family Life Education Regional Curriculum Framework ages 5 years to 12 years. Bridgetown: UNICEF Office for Barbados and the Eastern Caribbean; 2010. Available from: https://data.miraquetemiro.org/sites/default/files/documentos/Health%20and%20Family%20Life%20Education%20Regional%20Curriculum%20Framework.%20%20Ages%205-12%202010_3.pdf [cited 2021 Nov 9].
https://data.miraquetemiro.org/sites/def... ), which is an existing intervention to equip young people with life skills to cope with the challenges of everyday life (¹⁵15. Caribbean Community Secretariat, United Nations Children’s Fund. A strategy for strengthening health and family life education in CARICOM Member States. Bridgetown: UNICEF Office for Barbados and the Eastern Caribbean; Available from: https://data.miraquetemiro.org/sites/default/files/documentos/A%20Strategy%20for%20Strenghtening%20HFLE.%202010.pdf [cited 2022 Nov 10].
https://data.miraquetemiro.org/sites/def... ).

This paper describes the process of revising the CSEC^® Human and Social Biology syllabus and the HFLE Regional Curriculum Framework (for ages 5–12 years), through a multisectoral collaboration, to improve the coverage of topics related to the prevention of NCDs to bring about positive behavior change in dietary patterns and physical activity among schoolchildren.

AUTHORITIES FOR CURRICULUM DESIGN IN THE CARIBBEAN

The CXC^® was established in 1972 by CARICOM to replace the United Kingdom-based examinations. The CXC^® provides high-quality syllabuses, valid and reliable examinations, and certificates of international repute. It also supports educational institutions by developing syllabuses and examinations, and administering examinations. The CXC^® comprises 16 participating countries (Anguilla, Antigua and Barbuda, Barbados, Belize, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and Tobago, and Turks and Caicos Islands): 12 are full Member States of CARICOM and four are Associate Member States (¹⁶16. Caribbean Community Secretariat. Institutions: Caribbean Examinations Council (CXC) [internet]. Available from: https://caricom.org/institutions/caribbean-examinations-council-cxc/ [cited 2022 Dec 15].
https://caricom.org/institutions/caribbe... , ¹⁷17. Caribbean Examinations Council. Organisation summary [internet]. Available from: https://www.cxc.org/about/background/ [cited 2022 Dec 15].
https://www.cxc.org/about/background/... ).

The CARICOM Secretariat’s department of Human Resource Development is the competent authority for the regional HFLE curriculum. In 2003, at CARICOM’s Council on Human and Social Development, representatives of CARICOM Member States agreed to the development of an HFLE Regional Curriculum Framework to guide CARICOM countries in developing national curricula that placed life skills at the core of school-based health education programs. The initial framework was completed in 2004 (¹⁴14. Caribbean Community Secretariat, United Nations Children’s Fund. Health and Family Life Education Regional Curriculum Framework ages 5 years to 12 years. Bridgetown: UNICEF Office for Barbados and the Eastern Caribbean; 2010. Available from: https://data.miraquetemiro.org/sites/default/files/documentos/Health%20and%20Family%20Life%20Education%20Regional%20Curriculum%20Framework.%20%20Ages%205-12%202010_3.pdf [cited 2021 Nov 9].
https://data.miraquetemiro.org/sites/def... ).

REVISION PROCESS

The Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) (¹⁸18. Stirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14:58. doi: 10.1186/s13012-019-0898-y
https://doi.org/10.1186/s13012-019-0898-... ), a model for describing adaptations in implementation science, was used to guide the description of the curriculum revision process. Using this framework, we examined: 1) when in the implementation phase of the curricula the revision occurred, whether the revision was planned, and the goal of the revision; 2) the reasons for the curricula revision; 3) who participated in the decision to make modifications; 4) what was modified, and for whom; 5) the nature of the content modification; and 6) whether the changes to the curricula were fidelity-consistent, that is the core elements or functions of what was being modified were preserved during the revision process.

Timing, planning, and goals of the revisions

The revisions were made during 2018 to 2022 in the maintenance/sustainment phase of the curricula as the CSEC^® Human and Social Biology syllabus and the HFLE Regional Curriculum Framework were already implemented. The revisions were planned and purposeful with the overall goal of enhancing education on NCD risks, with emphasis on nutrition and physical activity, in the Caribbean region. An additional goal specific to the HFLE curriculum for primary schools was to support implementation of the curriculum framework through the creation of digital educational resources to support its delivery.

Sociopolitical, organizational, and recipient reasons for the modifications

The modifications to the CSEC^® Human and Social Biology syllabus and the HFLE Regional Curriculum Framework occurred in the context of a region in which five of the 14 CARICOM Member States were classified as high-income countries and seven as upper middle-income countries, according to the World Bank (¹⁹19. World Bank. World development indicators – The world by income and region [internet]. Available from: https://datatopics.worldbank.org/world-development-indicators/the-world-by-income-and-region.html [cited 2022 Dec 15].
https://datatopics.worldbank.org/world-d... ). These countries are experiencing the worst epidemic of premature mortality from NCDs in the region of the Americas, as well as rapid increases in obesity in children and adolescents. About 8% of children younger than 5 years and 10.8% of adolescents are overweight or obese (¹1. Pan American Health Organization. Core indicators 2019: health trends in the Americas. Washington, DC: PAHO; 2019. Available from: https://iris.paho.org/handle/10665.2/51542 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/515... , ²2. Pan American Health Organization. Noncommunicable diseases in the Region of the Americas: facts and figures. Washington, DC: PAHO; 2019. Available from: https://iris.paho.org/handle/10665.2/51483 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/514... , ²⁰20. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington, DC: PAHO; 2014. Available from: https://iris.paho.org/handle/10665.2/49138 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/491... ). In Barbados, the prevalence of overweight and obesity in children aged 9–10 years was 30%, and 12% of the obese children had high systolic blood pressure as a result (²¹21. Gaskin PS, Hall RV, Chami P, St John MA, Gaskin D, Molaodi OR, et al. Associations of blood pressure with body composition among Afro-Caribbean children in Barbados. PLoS One. 2015;10(3):e0121107. doi: 10.1371/journal.pone.0121107
https://doi.org/10.1371/journal.pone.012... ). Consumption of ultraprocessed foods high in sugar, salt, and fats, low intake of vegetables, fruits and fiber, and a decline in physical activity have have been main drivers of this epidemic of obesity and NCDs (³3. Popkin BM, Reardon T. Obesity and the food system transformation in Latin America. Obes Rev. 2018 Aug;19(8): 1028–64. doi: 10.1111/obr.12694
https://doi.org/10.1111/obr.12694... , ²⁰20. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington, DC: PAHO; 2014. Available from: https://iris.paho.org/handle/10665.2/49138 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/491... ).

Regional and international mandates and policies in response to the burden of NCDs and NCD-risk factors also prompted the revision of the CSEC^® Human and Social Biology syllabus and the HFLE Regional Curriculum Framework. CARICOM Heads of Government met and issued the 2007 Port-of-Spain Declaration on NCDs, mandating “the re-introduction of physical education in our schools…[and] programs aimed at providing healthy school meals and promoting healthy eating” (²²22. Caribbean Community Secretariat. Declaration of Port-of-Spain: Uniting to stop the epidemic of chronic NCDs. Georgetown: CARICON; 2007. Available from: https://caricom.org/declaration-of-port-of-spain-uniting-to-stop-the-epidemic-of-chronic-ncds/ [cited 2021 Nov 9].
https://caricom.org/declaration-of-port-... ). A formal evaluation of the implementation of the mandates of the Port-of-Spain Declaration on NCDs showed that most CARICOM countries had most difficulty implementing the mandates related to communications, schools, and diet (¹¹11. The evaluation of the 2007 CARICOM Heads of Government POS NCD Summit Declaration: The Investigators Detailed Report October 2017 [internet]. Available from: https://food4changecaribbean.org/wp-content/uploads/2018/01/POSDEVAL_The-Investigators-report_FINAL.pdf [cited 2021 Nov 9].
https://food4changecaribbean.org/wp-cont... ). One of the key recommendations arising from this evaluation was the need to promote healthy living in different settings, such as schools, workplaces, and faith-based institutions (¹¹11. The evaluation of the 2007 CARICOM Heads of Government POS NCD Summit Declaration: The Investigators Detailed Report October 2017 [internet]. Available from: https://food4changecaribbean.org/wp-content/uploads/2018/01/POSDEVAL_The-Investigators-report_FINAL.pdf [cited 2021 Nov 9].
https://food4changecaribbean.org/wp-cont... ). Additionally, countries in the Americas committed to the Pan American Health Organization’s 5-year Plan of Action for the Prevention of Obesity in Children and Adolescents which called for improving school nutrition and physical activity environments (²⁰20. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington, DC: PAHO; 2014. Available from: https://iris.paho.org/handle/10665.2/49138 [cited 2022 Dec 9].
https://iris.paho.org/handle/10665.2/491... ). Furthermore, the World Health Organization (WHO) has a health promoting schools initiative that has a school curriculum standard that promotes the development, review, and implementation of evidence-informed school curricula to increase health literacy and positively influence attitudes and behaviors (⁹9. World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Making every school a health-promoting school: global standards and indicators for health-promoting schools and systems. Geneva: WHO and UNESCO; 2021. Available from: https://www.who.int/publications/i/item/97892400250592 [cited 2022 Dec 9].
https://www.who.int/publications/i/item/... , ²³23. World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Making every school a health-promoting school: implementation guidance. Geneva: WHO, UNESCO; 2021. Available from: https://apps.who.int/iris/handle/10665/341908 [cited 2022 Dec 9].
https://apps.who.int/iris/handle/10665/3... ). Curriculum revisions, therefore, need to be one part of a multipronged approach to improve nutrition in children and to be designed to complement and reinforce other interventions in schools.

Collaboration with the CARICOM Secretariat and CXC^® was crucial as these institutions provide platforms for regional cooperation and endeavor to provide countries with updated regional models to adapt and adopt. Revisions at this level would, therefore, have more reach than if implemented at the national level.

The revision was also deemed necessary to equip its recipients – children and, by extension, their parents – with the information and skills to understand their food environment and the nutrition required for healthy growth and development.

Decision to revise

The revision of the CSEC^® Human and Social Biology syllabus was decided by CXC^®, as part of their routine syllabus maintenance (Figure 1) and the CARICOM Chief Education Officers supported the initiative to revise the HFLE Regional Curriculum Framework (ages 5–12 years) when presented to them by FaN representatives. The FaN project team provided logistical and financial support to accelerate the revisions by CXC^® and the CARICOM Secretariat, and thereby played an important role in the decision to make these modifications.

A coalition of stakeholders deliberated on how to modify the curricula. The coalition included: academic researchers from the FaN project; schoolteachers; dieticians; and curriculum development and measurement officers. For the CSEC^® Human and Social Biology syllabus, one revision committee and subject panel was set up, while for HFLE, three revision groups were established, one group for each of the following categories: early childhood (3–4 years); lower primary (5–8 years); and upper primary (9–12 years). Each group met on four consecutive days, except for the revision committee for the CSEC^® Human and Social Biology syllabus which had a 3-day meeting. Given the need for a coherent learning structure for children from early childhood through to primary and secondary school, two members of CXC^® (curriculum development officer and measurement officer) were involved in the HFLE curriculum revision and development process (Figure 2). We also partnered with financial and civil society organizations – the Caribbean Development Bank and the United Nations Children’s Fund (UNICEF) – which were integral members of the steering committee for the HFLE curriculum revision.

All decisions on how to modify the curricula were made with consideration of the overall goal of the revisions, which was to enhance education on NCD risks.

Content modifications

Content modifications are defined as those made to the intervention procedures, materials, or delivery. The level of content modification considers for whom and for what reasons the modification is made (²⁴24. Stirman SW, Miller CJ, Toder K, Calloway A. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement Sci. 2013;8:65. doi: 10.1186/1748-5908-8-65
https://doi.org/10.1186/1748-5908-8-65... ). The content modifications in this revision process took place at the organizational level and mostly involved tweaking/refining (Table 1 and Table 2), as the changes made did not alter the approach used (¹⁸18. Stirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14:58. doi: 10.1186/s13012-019-0898-y
https://doi.org/10.1186/s13012-019-0898-... ). The changes mainly updated the language and age and cultural appropriateness of the syllabus, and introduced specific content related to NCD risks. For example, these changes included: 1) using higher order learning objectives and including affective and psychomotor domains (²⁵25. Bloom’s taxonomy [internet]. Available from: https://bloomstaxonomy.net/ [cited 2022 Nov 10].
https://bloomstaxonomy.net/... ); 2) adding to the explanatory notes of the CXC^® Human and Social Biology syllabus; and 3) updating the sample lesson plans and ensuring continuity between the age groups in the HFLE Regional Curriculum Framework to ensure the appropriateness of the material so that NCD risk components (nutrition and physical activity) were clearly included with recommendations on how to explore the content in the class setting.

The revision of the HFLE Regional Curriculum Framework also involved adding elements (¹⁸18. Stirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14:58. doi: 10.1186/s13012-019-0898-y
https://doi.org/10.1186/s13012-019-0898-... ) with a new section for children ages 3–4 years being developed and incorporated.

Modification of implementation strategies

Digital resources, including story scripts, audio recordings of stories, videos, and worksheets, were created, in collaboration with nongovernmental and nonprofit organizations, to support HFLE instructors in implementing the curriculum. These materials, which draw on the themes in the curriculum, are readily available to the public on the FaN and CARICOM websites and can be used independently of the curriculum.

Fidelity of the modifications

The modifications made were fidelity-consistent, that is they did not change the goals, structure, or core components of the CXC^® syllabus or the HFLE Regional Curriculum Framework. They were well aligned with the aims of the CSEC^® Human and Social Biology syllabus which include, “to develop competencies that will enable students to adopt healthy lifestyles” and “to provide a foundation for further study or specialized training in fields … which require an understanding of the structure and functioning of the human body and the application of biological principles to the maintenance of health and healthy living” (¹²12. Caribbean Examinations Council. Caribbean Secondary Education Certificate CSEC® Human and Social Biology Syllabus. Kingston: CXC; 2010. Available from: https://www.cxc.org/SiteAssets/syllabusses/CSEC/CSEC%20Human%20and%20Social%20Biology.pdf [cited 2021 Nov 9].
https://www.cxc.org/SiteAssets/syllabuss... ). The modifications were also consistent with the theme of the HFLE Regional Curriculum Framework: appropriate eating and fitness. Three of the objectives under this HFLE theme relate to making healthy dietary choices and reducing NCD risks (¹⁴14. Caribbean Community Secretariat, United Nations Children’s Fund. Health and Family Life Education Regional Curriculum Framework ages 5 years to 12 years. Bridgetown: UNICEF Office for Barbados and the Eastern Caribbean; 2010. Available from: https://data.miraquetemiro.org/sites/default/files/documentos/Health%20and%20Family%20Life%20Education%20Regional%20Curriculum%20Framework.%20%20Ages%205-12%202010_3.pdf [cited 2021 Nov 9].
https://data.miraquetemiro.org/sites/def... ). Additionally, the involvement of high-level stakeholders from each relevant authority in the revision process served to ensure fidelity of the modifications.

OUTPUTS OF THE REVISION

The modifications to the CSEC^® Human and Social Biology syllabus were approved by CXC^®’s Sub-Committee of the School Examinations Committee and the revised syllabus (²⁶26. CXC store. Human and social biology [internet]. Available from: https://cxc-store.com/syllabuses-subject-reports/csec/science-and-maths/human-and-social-biology [cited 2023 Apr 27].
https://cxc-store.com/syllabuses-subject... ) was put into effect for examinations from May/June 2022; 17 293 children in CARICOM registered for this examination in 2022 (²⁷27. Caribbean Examinations Council. Registration data for CSEC® Human and Social Biology May to June 2022. Kingston : CXC Western Zone Office; 2022.).

The three HFLE curriculum working group meetings resulted in two main outputs: 1) a new HFLE Regional Curriculum Framework for the early childhood level (ages 3–4 years) and 2) a revised HFLE Regional Curriculum Framework for the primary level (ages 5–12 years). These outputs were presented as a merged document (²⁸28. Caribbean Community Secretariat. Health and Family Life Education (HFLE) [internet]. Available from: caricom.org/hfle/ [cited 2023 Apr 27].
caricom.org/hfle/... ) to CARICOM Ministers of Education at the 38th meeting of CARICOM’s Council for Human and Social Development – Education in October 2019, where they were endorsed for implementation in the region. The digital resources (²⁸28. Caribbean Community Secretariat. Health and Family Life Education (HFLE) [internet]. Available from: caricom.org/hfle/ [cited 2023 Apr 27].
caricom.org/hfle/... ) created to support HFLE instructors in implementing the curriculum were approved at the 44th meeting of the Council for Human and Social Development – Education in October 2022.

DISCUSSION

We used FRAME to successfully document the nature, process, and outcomes of modifications to standard curricula used throughout the Caribbean to address NCD risk factors in children through education on healthy eating, the drivers of unhealthy eating, and physical activity. Despite growing interest in the field of implementation science, few articles have described the process of planned modifications of interventions (²⁹29. von Thiele Schwarz U, Förberg U, Sundell K, Hasson H. Colliding ideals – an interview study of how intervention researchers address adherence and adaptations in replication studies. BMC Med Res Methodol. 2018;18(1):36. doi: 10.1186/s12874-018-0496-8
https://doi.org/10.1186/s12874-018-0496-... , ³⁰30. Sundell K, Beelmann A, Hasson H, von Thiele Schwarz U. Novel programs, international adoptions, or contextual adaptations? Meta-analytical results from German and Swedish intervention research. J Clin Child Adolesc Psychol. 2016;45(6):784–96. doi: 10.1080/15374416.2015.1020540
https://doi.org/10.1080/15374416.2015.10... ). Our use of FRAME to assess this modification provides structure and enhances the body of work on implementation of interventions.

Before this revision process, several countries in the Caribbean had done national ad hoc revisions to the HFLE Regional Curriculum Framework, but these needed strengthened coordination and resourcing. Through multisectoral collaboration between education and health organizations including from academia, regional political organizations, and civil society, we succeeded in accelerating and enhancing this revision process. Multisectoral collaboration often provides greater benefits than the work of individual sectors (³¹31. Kuruvilla S, Hinton R, Boerma T, Bunney R, Casamitjana N, Cortez R, et al. Business not as usual: how multisectoral collaboration can promote transformative change for health and sustainable development BMJ. 2018;363 doi: 10.1136/bmj.k4771
https://doi.org/10.1136/bmj.k4771... –³³33. Bay J, Morton S, Vickers M. Realizing the Potential of adolescence to prevent transgenerational conditioning of noncommunicable disease risk: multi-sectoral design frameworks. Healthcare. 2016;4(3):39. doi: 10.3390/healthcare4030039
https://doi.org/10.3390/healthcare403003... ). Such collaboration enhances the product, improves stakeholder perception of the value of the product, and ensures the content is age and culturally appropriate (³¹31. Kuruvilla S, Hinton R, Boerma T, Bunney R, Casamitjana N, Cortez R, et al. Business not as usual: how multisectoral collaboration can promote transformative change for health and sustainable development BMJ. 2018;363 doi: 10.1136/bmj.k4771
https://doi.org/10.1136/bmj.k4771... , ³³33. Bay J, Morton S, Vickers M. Realizing the Potential of adolescence to prevent transgenerational conditioning of noncommunicable disease risk: multi-sectoral design frameworks. Healthcare. 2016;4(3):39. doi: 10.3390/healthcare4030039
https://doi.org/10.3390/healthcare403003... ). Furthermore, multisectoral collaboration increases stakeholder buy-in and ensures that relevant stakeholders are aware of and operate according to policies, strategies, or frameworks that are in place (³²32. de Leeuw. Engagement of sectors other than health in integrated health governance, policy, and action. Annu Rev. 2017;38:329–49 doi: 10.1146/annurev-publhealth-031816-044309
https://doi.org/10.1146/annurev-publheal... , ³⁴34. Sobers NP, Bishop L, Ng SW, Soares-Wynter S, Greaves NS, Murphy MM. Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis. Implement Sci Commun. 2021;2:79. doi: 10.1186/s43058-021-00184-z
https://doi.org/10.1186/s43058-021-00184... ). The evidence indicates that interventions for school-aged children should go beyond the school and extend to a whole-of-society approach (³²32. de Leeuw. Engagement of sectors other than health in integrated health governance, policy, and action. Annu Rev. 2017;38:329–49 doi: 10.1146/annurev-publhealth-031816-044309
https://doi.org/10.1146/annurev-publheal... , ³⁴34. Sobers NP, Bishop L, Ng SW, Soares-Wynter S, Greaves NS, Murphy MM. Understanding the need for a whole-of-society approach in school nutrition policy implementation: a qualitative analysis. Implement Sci Commun. 2021;2:79. doi: 10.1186/s43058-021-00184-z
https://doi.org/10.1186/s43058-021-00184... ).

In our curricula revision process, contributors to the process in the health sector relied on education contributors as experts in curricula development, design, and assessment, while contributors in the education sector relied on health contributors as content experts to inform the needed changes. Importantly, individuals in these sectors who participated in the revision process operated at different levels; for example, the education sector was represented by teachers in direct contact with students up to staff within Education and Human Resource Development at the CARICOM Secretariat. We relied on nongovernmental and nonprofit organizations – the Ashe Company (an edutainment and theatre arts company) and Slow Food Barbados, respectively – to produce the HFLE digital education resources. These resources were, in part, informed by school-aged children who were prize winners in the Food4Change story-writing competition that was based on the HFLE themes and hosted by the FaN project in 2021. Other partners not directly involved in modifying the curricula helped in the overall planning and oversight, including civil society partners, UNICEF, and the Caribbean Development Bank. This collaboration enabled endorsement of our revisions at a policy level, thereby ensuring an impact on a greater cross-section of children and parents. Many other interventions which incorporate nutrition programs into curricula do so at a community or school level with limited reach.

The success of our multisectoral collaboration was driven by many factors including: 1) “drive change” – agitation for intersectoral collaboration; 2) “design” – use of existing infrastructure, recognition of expertise, and resource acquisition; 3) “realize” – importance of stakeholder feedback and building relationships in adaptation processes; and 4) “relate” – building and investing in relationships (³¹31. Kuruvilla S, Hinton R, Boerma T, Bunney R, Casamitjana N, Cortez R, et al. Business not as usual: how multisectoral collaboration can promote transformative change for health and sustainable development BMJ. 2018;363 doi: 10.1136/bmj.k4771
https://doi.org/10.1136/bmj.k4771... ). In our process, the “drive change” was through members of the research team who were the main campaigners for multisectoral collaboration for this revision process and met with several stakeholders in education, children’s advocacy, and health before planning the revisions. We demonstrated elements of successful “design” by: recognizing the existing processes and supporting the relevant authorities (CXC^® and the CARICOM Secretariat) to carry out their mandates; and acknowledging and using the expertise of the nongovernmental and nonprofit organizations to create the digital aids for the HFLE Regional Curriculum Framework. Additionally, success of multisectoral collaboration requires sustained funding (³¹31. Kuruvilla S, Hinton R, Boerma T, Bunney R, Casamitjana N, Cortez R, et al. Business not as usual: how multisectoral collaboration can promote transformative change for health and sustainable development BMJ. 2018;363 doi: 10.1136/bmj.k4771
https://doi.org/10.1136/bmj.k4771... ) which we were able to secure through project funding from the International Development Research Centre, Canada to fast track the much-needed revisions. We demonstrated the “realize” component of the model by our inclusion of a range of stakeholders who provided regular feedback on the process and content of the curriculum revisions. As regards the “relate” component, we facilitated increased interagency collaboration and relationship-building between the two authorities by including CXC^® personnel in the HFLE curriculum revision process for the primary level to facilitate alignment with the secondary education curriculum reform. In addition, as institutional and national mechanisms for implementing curriculum changes are not included within the CARICOM Secretariat structure, we mirrored the established processes of CXC^® for the revision of the HFLE Regional Curriculum Framework and provided technical input to the CARICOM Secretariat.

The outputs of this process contribute directly to one recommendation of the WHO Commission on Ending Childhood Obesity (ECHO), namely “require inclusion of nutrition and health education within the core curriculum in schools” (³⁵35. World Health Organization. Report of the Commission on Ending Childhood Obesity. Geneva: WHO; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/204176/?sequence=1 [cited 2022 Dec 10].
https://apps.who.int/iris/bitstream/hand... ). While knowledge alone is not sufficient to drive behavior change (⁶6. Kelishadi R, Azizi-Soleiman F. Controlling childhood obesity: a systematic review on strategies and challenges. J. Res Med Sci. 2014;19:993–1008., ⁷7. Verstraeten R, Roberfroid D, Lachat C, Leroy JL, Holdsworth M, Maes L, et al. Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review. Am J Clin Nutr. 2012;96(2):415–38. doi: 10.3945/ajcn.112.035378
https://doi.org/10.3945/ajcn.112.035378... ), it is a necessary first step. A process will be needed to support the ongoing training of teachers and monitoring of the adoption of the revised curricula in all schools in the region. Regional and national coordination will also be needed to support HFLE teacher training and content resource development to strengthen and accelerate the effective teaching of the HFLE Regional Curriculum Framework and acquisition of its learning outcomes in CARICOM Member States.

Conclusion

Recommendations to influence upstream determinants of NCDs consistently call for multisectoral collaborations that are not easily achieved (³³33. Bay J, Morton S, Vickers M. Realizing the Potential of adolescence to prevent transgenerational conditioning of noncommunicable disease risk: multi-sectoral design frameworks. Healthcare. 2016;4(3):39. doi: 10.3390/healthcare4030039
https://doi.org/10.3390/healthcare403003... , ³⁵35. World Health Organization. Report of the Commission on Ending Childhood Obesity. Geneva: WHO; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/204176/?sequence=1 [cited 2022 Dec 10].
https://apps.who.int/iris/bitstream/hand... ). Competing priorities and the propensity for sectors to work vertically often act as barriers. We overcame these potential challenges and allowed the systems within one organization to inform and enhance systems in another and successfully modified several educational interventions. Thus, in a coherent and structured intervention to support the relevant authorities in this regard, a number of curriculum revisions were achieved, from early childhood to the end of secondary school, as part of a multipronged approach to increase dietary diversity in the Caribbean. These revisions must be appropriately implemented and evaluated at the country level to determine the knowledge and behavior outcomes.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.

Acknowledgements.

We thank the following people for their contribution as members of the HFLE Revision Steering Committee: Martin Baptiste, Ninian Blair, Rudolph Cummings, Cher Macnack-Lamsberg, and Paul Murphy. We also thank all the teachers, reviewers, and consultants who participated in the CXC^® and HFLE curriculum revision process: Andrea Baptiste, Hermione Baptiste, Alicea Bigby-Smart, Paulette Blackwood, Michele Blake, Dionne Browne, Kerian Calixte, Denise Carter-Taylor, Mary Chase, Catherine Clifford, Sophia Edwards-Gabriel, Donna Giles, Kimberly Glasgow Charles, Vanessa Grahams, Mavis Guiste, Charisse Gumbs, Tanya Harding, Rachel Harris, Pamela Hunte, Claudia Jack, Morella Joseph, Coleen King Cameron, Keisha Laurie, Ian Marshall, Patricia McPherson, Camille Mitchell, Celeste Murray, Charlotte Noble, Hedda Phillips-Boyce, Pauline Samuda, Joselyn Theophile-Richardson, Paula Trotter, Patricia Warner, Patricia Welch, Renee Weston-Joseph, Cyrilene Willoughby, and Davelyn Wilson.

REFERENCES

Publication Dates

History