Exploring the development and prevention of the childhood obesity epidemic in Barbados using the socio-ecological framework: a qualitative study

Abstract

Introduction

Barbados is currently experiencing an epidemic of childhood obesity, representing an urgent public health concern. The government has implemented policies encouraging healthier lifestyles. Concurrently, civil society organisations have undertaken numerous bottom-up initiatives and advocacy. Despite these efforts, there is little knowledge about how different community partners and sectors experience and perceive these initiatives or how local contextual factors affect their success. Understanding these perspectives is crucial to inform culturally appropriate and sustainable initiatives.

Methods

Semi-structured interviews were conducted in May 2023 with participants (n=27) who were deemed critical in childhood obesity prevention through purposive and snowball sampling. Recruitment was facilitated by community partners, the Healthy Caribbean Coalition and the Heart and Stroke Foundation of Barbados. Interviews were then transcribed and analysed using an inductive thematic analysis framework along with the socio-ecological model to examine how different actors perceived the contributors, challenges and solutions for childhood obesity.

Results

Participants highlighted several interconnected factors that contribute to childhood obesity in Barbados, such as the country’s dependence on imported foods, cultural norms and preferences and the long-lasting effects of colonialism. Lack of coordination across sectors as well as a lack of resources were major obstacles to the implementation of successful interventions. Participants described numerous strategies to address childhood obesity, including the School Nutrition Policy, Sugar-Sweetened Beverage Tax, advocacy efforts and targeted community-led programmes, all of which could be striated across the socio-ecological model.

Conclusion

Findings from this study show that tackling childhood obesity necessitates culturally responsive and context-specific approaches based on the perceptions and experiences of community members and sector officials. Developing and maintaining successful initiatives requires cross-sectoral collaboration and civil society engagement and buy-in. Long-term and equitable reductions in childhood obesity can be achieved by strengthening the execution of current programmes and policies while continuing to document and understand local experiences and contexts.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Prior studies on the epidemic of childhood obesity in Barbados have identified some of the common, global determinants of and contributors to childhood obesity. They have also called for the implementation of mandatory school nutrition policies and physical activity guidelines as potential solutions to the nation’s rising childhood obesity rates.

WHAT THIS STUDY ADDS

• This study highlights the precise parameters and purpose of these recommendations since they were put into place: how they interact to affect the current state of Barbados children’s eating habits and levels of physical activity, how different audiences feel about these recommendations, the cultural factors that contribute to childhood obesity in Barbados, and an examination of culturally sensitive solutions to this problem.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Other countries can implement our culturally relevant results that highlight strategies and barriers to policy and practice implementation to mitigate their respective growing rates of childhood obesity.

Introduction

According to the WHO, childhood obesity is ‘one of the most serious global public health challenges of the 21st century’, reaching epidemic levels across high-, low- and middle-income countries.1 2 In the present study, childhood obesity is defined according to the biomedical model, wherein obesity in children is defined as two SD above the worldwide growth reference median set by the WHO. Children who are overweight or obese are at higher risk of developing other non-communicable diseases (NCDs), lower quality of life and higher mortality.3 4 Obesity is well understood as a multifactorial disease, influenced by their socioeconomic environment, in addition to their biological predispositions with at least 14 thematic UN SDG targets playing a role in the obesity epidemic worldwide.3–5

NCDs in the Barbadian context

Caribbean nations have some of the highest rates of obesity worldwide,6 7 with 34.8% of individuals in Barbados between the ages of 5 and 19 living with overweight or obesity in 2010 (before intervention implementation).8 Barbados and other Caribbean Community (CARICOM) members convened the world’s first summit on NCDs in Port of Spain, Trinidad and Tobago, and developed the ‘Port of Spain Declaration: Uniting to Stop the Epidemic of Chronic NCDs’ in 2007 (table 1).9 Each Caribbean nation’s government, civil society, and commercial sectors pledged to work towards preventing and controlling NCDs, with particular recommendations to address the rising prevalence of childhood obesity. Barbados was one of the CARICOM members with the strongest commitment to the Port of Spain Declaration, according to Samuels and Unwin’s 2014 assessment of adherence to these recommendations.10 To encourage healthy eating, Barbados implemented a 10% tax on sugar-sweetened beverages (SSBs) in 2015 (table 1), a WHO-endorsed recommended practice.11–13 Although the Barbadian government also published guidelines for healthy eating and physical activity in schools, the absence of a legal framework and lack of buy-in from educators and school staff resulted in low adoption and awareness in school settings.14 A shift towards community action has been spurred by the growing recognition of childhood obesity and associated elevated NCD risk as a major concern throughout Barbados.11 In order to remove SSBs and other unhealthy foods from the school environment, civil society organisations and individuals from the healthcare, education and religious sectors have proposed community-level initiatives and pushed for a comprehensive set of regulations (table 1). Significant government action resulted from this civil society activism, including the establishment of the National School Nutrition Policy in 2023 and a 10% tax increase on SSBs in 202215 (table 1).

Table 1.

Timeline overview of childhood obesity prevention initiatives in Barbados

Year implemented	Initiative	Organisations involved	Description
2007	Port of Spain Declaration	CARICOM	Commitment to working towards preventing and controlling NCDs with specific recommendations to address the increasing incidence of childhood obesity.
2011	U-Report	United Nations Children’s Fund and Ministry of Youth Sports and Community Empowerment	Collects the opinions of youth from social media. The data (mostly opinions on health and climate change) inform policymaking decisions related to health and well-being by including youth voices (ie, youth aged 13 to 29).
2015	Sugar-sweetened beverage (SSB) tax (10%)	Government of Barbados	Aimed to decrease the purchase of sugar-sweetened beverages among consumers.
2018	Childhood Obesity Programme	Heart and Stroke Foundation Barbados (HSFB)	Created to address the high rates of childhood obesity in Barbados through media campaigns, policy advocacy, and health education.
2019	Childhood Obesity Prevention Coalition	Civil Society	A cross-sectoral coalition aimed at advocating for the National School Nutrition Policy, founded by HSFB.
2019	Model School Programme	HSFB, Healthy Caribbean Coalition (HCC), Barbados Muslim Association	Eliminated unhealthy food options in cafeterias while also improving physical education and health programming in six select schools across the country.
2022	Sugar-sweetened beverage tax (20%)	Government of Barbados	Aimed to increase the previous SSB Tax to further deter individuals from consuming sugar-sweetened beverages.
2023	Mass media campaigning	Childhood Obesity Prevention Coalition	Aimed to increase the uptake of health education and promotion among the general public to increase awareness and prevent childhood obesity.
2023	National School Nutrition Policy	Government of Barbados	Banned SSBs and unhealthy foods within and around schools.

CARICOM, Barbados and other Caribbean Community; NCDs, non-communicable diseases.

Geopolitical context of Barbados

Historically, Barbados was colonised by the British Empire in 1627, and enslaved labour through the transatlantic slave trade, forming the predominant monocultural sugar plantation by 1680.16 Foods and cooking styles introduced during the time of colonisation and enslavement continue to persist in local culture, influencing cultural food choice and preferences for sweetened foods. Postcolonially, land size remains a limiting factor for the production of diverse crops, leading to the agricultural industry contributing to 1.7% of the nation’s GDP in 2022.17 This geopolitical context is mirrored across other Small Island Developing States, where dependence on imported ultra-processed foods is linked to high rates of NCDs, including childhood obesity.7 Similar to patterns observed worldwide, dietary preferences and food availability, compounded by an increasingly sedentary lifestyle of children and youth, increase the overall risk for developing NCDs that worsen across the life course.2

Socio-Ecological model in the context of childhood obesity

The Socio-Ecological Model (SEM), developed by McLeroy and colleagues18, provides a useful framework for examining various levels of influence associated with childhood obesity and serves as the foundation for analysis in this paper.18 Accordingly, interactions at the individual, interpersonal, institutional, environmental and policy levels each contribute to health outcomes. Within the context of childhood obesity, individual-level factors include dietary practices, physical activity and genetic predispositions of the child, while interpersonal-level factors include family dynamics, parental behaviours and a child’s social network.18 19 At the institutional level, schools have a crucial influence, providing opportunities for physical exercise and support of nutrition policies.18 19 Broader environmental elements include access to safe recreational areas and nutritious foods. Policy-level influences include government actions that directly or indirectly impact childhood obesity rates.18 19

Research purpose

Thus, this research uses an exploratory qualitative study approach to examine the childhood obesity landscape within Barbados to understand how these different actors work together towards the goal of lowering the rates of childhood obesity through the lens of the SEM.

Materials and methods

Study design and sampling

This study received research ethics approval from the University of Toronto (00044139) and the University of the West Indies, Cave Hill (CREC-CH.00182/04/2023), Barbados. Funding was provided by the Reach Alliance, a research organisation in partnership with the Munk School of Global Affairs & Public Policy, University of Toronto, as well as the Mastercard Centre for Inclusive Growth.

Semi-structured qualitative interviews took place with community partners and members of government to learn about their perspectives on rising childhood obesity rates in Barbados, including associated social determinants, barriers and possible solutions. To recruit participants who were best informed on the research topic, purposeful sampling was employed, whereby organisations involved with childhood obesity interventions were consulted to identify potential participants. Following this, snowball sampling was used by asking participants whether they had any recommendations for other community partners whose voices and opinions are involved in addressing the epidemic of childhood obesity. While snowball sampling may have introduced selection bias, the majority of recruitment was primarily done via purposive sampling. Additionally, when snowball sampling was used, the research team ensured to intentionally recruit individuals with differing roles or viewpoints to ensure a diverse and representative sample group.

Sixty-four potential participants were invited according to the following inclusion criteria: a) at least 18 years old; and b) hold relevant knowledge of childhood obesity due to lived experiences and/or professional participation in childhood obesity care, education or interventions. 23 participants were interviewed in-person over the course of 10 days in Barbados, and four participants were interviewed virtually. The participants self-identified themselves into the following categories: registered health professionals and/or ministry of health (n=3); non-health ministries of government, education, agriculture or finance (n=10); community organisations (health NGOs, religious organisations) (n=8); youth health advocates (n=3); recent secondary model school alumni (n=2) and public health academics (n=1). The recruitment of participants continued until theme saturation was achieved. Saturation was defined as the point at which further interviews yielded no new topics or insights. Based on evidence that 92% thematic saturation is reached within the first 12 interviews in a homogenous population, the initial saturation point was having at least 12 representatives from government and 12 representatives from civil society.20 In the field, saturation was reached at 27 participants (13 government members and 14 civil society members).

Data collection and storage

Semi-structured interviews followed a protocol with guiding questions and probes that lasted between 30 and 60 min. Participants were asked about the contributors to Barbados’ childhood obesity epidemic, initiatives they were aware of, the public awareness of childhood obesity and associated initiatives, and obstacles to participants’ success in preventing and reducing childhood obesity.

With the participants’ consent, interviews were recorded (with audio and/or video). One team member conducted the interview; at least one other member took handwritten notes during the interview. The study team then transcribed each recording into an encrypted server before erasing the recordings. All personally identifiable information was replaced by a subject number, and any personal information was eliminated. Interview recordings were kept for 48 hours on a server that complied with Canada’s Freedom of Information and Protection of Privacy Act (FIPPA) and was password-protected and encrypted.

Data analysis

After all interviews were completed, an inductive thematic analysis of transcripts was conducted to assist in creating a codebook with Nvivo 12. The process involved assessing the most prevalent and relevant topics across all interviews, defining and naming the themes, and refining which participant statements were the most relevant to each theme. Each transcript was coded independently by the research team, after which they reconvened to compare codes and interpretations to achieve consensus. In cases of disagreements in coding, team members discussed the differences and moved towards consensus by the following two pathways: (1) defining the differences and how each code was perceived to reduce ambiguity, (2) if consensus was not reached, subcategories were added to the code for better clarity. Finally, emerging themes were stratified under the SEM to analyse the results.

Patient and public involvement

There was no patient or public involvement with regard to the design, conduct, reporting, or dissemination plans of this research.

Researchers’ Positionality

The research team, having a diverse background, shared an insider lens with some participants on different aspects of their identities, including race, religion, gender, age, parenthood or educational background. These identities may have helped participants feel more open to sharing their insights. The research team also acknowledged the potential power imbalance of being members of an academic institution in the Global North. To mitigate this, the study design, consent procedures and data collection were developed in consideration with cultural norms and community relevancy. A key component of the research process was partnering with community organisations, notably the Heart and Stroke Foundation of Barbados and the Healthy Caribbean Coalition. These partners assisted with participant recruiting, in-field logistical support and offered guidance on culturally relevant engagement strategies. This engagement promoted more responsive, equitable and participatory research methods.

Results

Interview responses were summarised in four major categories: (1) contributing factors that influence high rates of childhood obesity, (2) key interventions that target childhood obesity, (3) barriers to the success of interventions and (4) suggested strategies for future interventions

Factors that influence the high rates of childhood obesity

When participants were asked what they believed was the cause of high rates of childhood obesity in Barbados, there were varied responses that could be stratified across the SEM. Participant responses suggest that the development of the childhood obesity epidemic is perceived to be influenced by factors at the environmental level rather than the individual level (figure 1). Four major environmental factors appeared to be responsible for the high rates of childhood obesity in Barbados:

Figure 1.

Socio-ecological landscape of participant responses regarding contributing factors to the childhood obesity epidemic in Barbados (arrows define direction of influence). BMI, body mass index; NCDs, non-communicable diseases.

(1) The influence of the food and beverage industry: Five participants from civil society, government and finance described the food and beverage industry as influencing available food choices for children and integrating itself into the cultural environment through effective marketing and promotion. The availability of ultra-processed foods was believed to have increased in the contemporary environment, taking up more space in mini-marts, school vendors and grocery stores. The food and beverage industry also sponsors school events and provides school supplies with the purchase of food items, which were described as counteracting and contradicting any nutritional education for children.

One Barbadian fast-food chain was described as integrating itself as a part of the local culture through effective marketing that fosters a sense of national pride, holding significance for milestone celebrations such as birthdays. [Participant 2, Finance Sector]: “It was a big thing, to have your birthday party at [local fast-food chain]. That’s the only fast-food restaurant that does parties. So even now as an adult, I feel sad that I didn't have a party (laughter). It really is a rite of passage.”

By establishing themselves as culturally significant symbols for Barbadians, the food industry contributes to the childhood obesity crisis by normalising the consumption of ultraprocessed foods by children and families alike.

(2) Cultural preferences for unhealthy foods and higher BMI: The majority of participants thought that the high rates of childhood obesity were influenced by cultural norms and values in Barbados. 12 participants identified traditional Barbadian food as staples containing high sugar, fats and salt. These participants also described a strong cultural interest in ‘sweets’, and that local foods are ‘extra-sweet’ compared with equivalent foods they would find abroad.

In addition to dietary preferences, five participants felt that there is a misunderstanding of the clinical definition of obesity compared with what is culturally perceived as obese. Participants described how it is common to find the perception that ‘chubby’ babies and children signal good health. One female participant described her personal experience growing up, in which girls with higher BMIs were considered more attractive. [Participant 7, Civil Society]: “When I was in school, I remember there was always this concept that girls who were bigger were more sought after. That was always a thing. I remember that, sort of cultural ‘thing’ around ‘body’ and your body shape. It was never like, ‘I wanna be skinny,’ it’s always ‘I wanna be big’.”

As such, it is evident that cultural perceptions, practices and understandings may strongly influence food and lifestyle choices.

(3) High cost of living in Barbados: Two perspectives arose from participants regarding the cost of living and its effects on lifestyle choices among 11 participants. Seven participants (four civil society, three government) described the high cost of living as an influencing contributor to the food landscape and food choice. The high cost of living is a result of being an island reliant on imported goods and foods, predominantly from the United States. Families living in lower socio-economic conditions choose cheaper food options that tend to be high in sugars, salts and fats. A secondary perspective emerged among four participants from civil society organisations, that while Barbados is indeed an expensive place to live, public perception is that affordable healthy foods are not available on the island, and that this misconception has perpetuated a reliance on unhealthy food choices. [Participant 3, Civil Society]: “Now there’s a perception in Barbados that healthier foods are more expensive. It’s a perception because the reality is that you can get healthier foods. Not necessarily what you think is healthier foods, but you can get healthier options. Local vegetables, local fruits, local produce. It (affordable healthy food) is accessible. You just have to make the time for it.”

Based on their responses, it is evident that while the role of the cost of living is a highly influential environmental factor, there is a lack of nutritional literacy that supports understanding about access to healthy foods.

(4) Sedentary lifestyle caused by the digital and built environments: Four participants (civil society and government) described that the shift towards a more sedentary lifestyle for children may be influenced by (1) the rise of the digital environment, (2) low access to safe play areas and walkable neighbourhoods in Barbados. An emphasis on competitive sport rather than daily physical activity may present barriers across civil society and investment in the built environment for all people, abilities and interests in Barbados. Improving opportunities to achieve this in the built environment is central to addressing obesity-mediated diseases.

(5) Legacy of colonialism and transatlantic slavery: While most participants discussed the contemporary environment, five participants (four civil society, one government) took time to note how Barbados’ history of extractive colonialism under British rule has influenced both contemporary culture and cross-generational disposition. They emphasised that the ramifications of slavery has resulted in enduring socioeconomic disparities, compounded by the high cost of living, which disadvantages many families from accessing healthy food options. In addition to this, the historical reliance on low-cost, high-energy-dense foods during slavery has shaped modern dietary patterns, and the intergenerational transmission of metabolic traits can further increase the risk of childhood obesity. Thus, the legacy of colonialism impacts all levels of the SEM (figure 1).

Overall, these contributing factors have a robust ecology that uniquely interacts with each socio-ecological level across the life course and in an intergenerational manner. In addition, the policy level was not framed to have any contributing factors by participants, although it was clear that the policy level had a role to play in each level of responses stratified across the SEM (figure 1).

Current initiatives/interventions

Participants were asked to describe the childhood obesity prevention initiatives or interventions that they were currently involved in, as of 2023. Their responses were then stratified across the socio-ecological model (table 2).

Table 2.

Current initiatives and interventions from the Childhood Obesity Prevention Coalition and Government stratified by socio-ecological level based on participant responses (2023)

Targeted level	Civil society			Government policy
Individual (Child)	Cool School Nutrition Tours	Yute Gym	Gamified Nutrition and Fitness Challenges	None Mentioned
Interpersonal	Identity-specific health education (religious, gender, employment)			Sugar-Sweetened Beverage Tax
Institutional	Model School Programme			School Nutrition Policy
Environmental	Mass Media Campaigning			Basket of Goods
Policy	Government Policy Advocacy			U-Report

Individual (Child)

Interpersonal

Institutional

Environmental

Policy

Individual Level: Initiatives that directly target children included both prevention initiatives (in-school nutritional workshops and gamified fitness and nutrition challenges on social media to raise awareness) and targeted treatment interventions (Yute Gym, focused on creating a judgement-free environment to support children currently managing obesity).

Interpersonal level: Some initiatives focused on health education that targeted groups interacting directly with children, including parents and youth leaders. One participant highlighted the work being done by the Muslim Ladies Association of Barbados, where they modify nutrition and lifestyle education through the lens of religion and gender. Using the SSB tax, the government aims to deter families from purchasing SSBs through policy. This tax, and the subsequent increase to 20% in 2022, was heavily advocated for by the Childhood Obesity Prevention Coalition and is a demonstration of successful government advocacy by civil society.

Institutional Level: The Model School Programme served as a guide for the development and implementation of the National School Nutrition Policy. [Participant 14, Civil Society]: “Six model schools provide a significant template as a pilot to show how a ban or restriction of unhealthy food into the school environment (could work). We've been working with them since 2019. The experience of those model schools became significant as a ‘lessons learnt’ document that we were able to share with the Ministry of Health and Wellness and the Ministry of Education when they were developing the (National School Nutrition) policy”. Five participants from the civil society highlighted the importance of the school environment as a prime setting to implement effective initiatives.

Environmental Level: Mass media campaigning (both physical and digital) aims to influence the broader context in which people make choices by shaping social norms and community expectations (predominantly targeted at sugar-sweetened beverages). Similarly, the National Basket of Goods (table 1) aims to assist families in overcoming financial barriers by reducing the cost of essential ingredients, thereby improving the accessibility of nutritious food options.

Policy Level: The Childhood Obesity Prevention Coalition advocates to the government for a variety of policies, including some that have already been implemented (National School Nutrition Policy and increased SSB taxation) and others that are still being considered (such as the front-of-package warning labels). Moreover, the incorporation of youths’ perspectives and experiences into the policymaking process through platforms like U-Report ensures that policies are sensitive to the needs of the populations they are meant to benefit.

Based on these responses, civil society actors conducted more childhood obesity interventions and prevention initiatives, and targeted all levels of the SEM, with intervention implementation by the Barbadian government through the establishment of new policies (table 2). In a complementary manner, government and civil society organisations target different levels of the SEM; while policy does not directly target the level of child behaviour (individual-level), civil society is able to reach this level through preventative and reactive initiatives. This suggests that the unique strengths, weaknesses and levels of influence that both sectors hold are compensated by each other.

Barriers to improving current interventions/initiatives

When asked about what barriers to success exist in improving current initiatives, three main threats were identified:

Low Resources: Five participants in civil society described that a lack of financial resources is the largest threat to any initiative they run, constraining the ability to plan, implement, and sustain interventions, thereby decreasing the efficacy and reach of present and planned interventions. Alongside having low financial resources, participants from both civil society and government described how low human resources were also a strong barrier. For example, one participant in government, in particular, described that because they are the only person with their level of expertise, they must prioritise more pressing or unexpected responsibilities delaying childhood obesity initiatives, despite their passion. [Participant 10, Government]: “Our country was one of the most highly indebted countries just 4 years ago. I work with my counterparts at the (government ministry). They're keen on school nutrition policy, but then we are short on staff. I've been trying to revise the new policy document since last year, but I've been pulled sideways into other things. I just haven't had any time to sit down and write. I pretty much will have to take my vacation to sit down and do the work”.

Low compliance: Participants from both government and civil society described that a lack of public support towards new policies was a crucial barrier for successful intervention. For example, school vendors, teachers, and parents were described as negatively receiving the newly implemented School Nutrition Policy as it impacted their livelihoods. Snack vendors feared losing income, teachers had concerns that enforcing the policy would take away from their main role as educators, and parents wanted autonomy to choose the food they wanted to send their children to school with. Participants speculated that this was due to having poor policy sensitisation for these important groups and also not involving or consulting them in the policy development process. Low compliance was also thought to be caused by cultural preferences and norms, particularly when recommended health behaviours clash with traditional and cultural food preferences. Consequently, interventions may be less likely to be accepted or adopted as a result of these cultural influences.

Political will: Three participants in the civil society and one in the government noted that an important variable in the success of initiatives is the willingness of the government in power to support childhood obesity prevention initiatives. [Participant 6, Civil Society]: “Every single thing is dependent on political will,” especially when “we can have the best campaigns in the world, but if you don’t have the right people pushing the campaigns it will not work.”

This highlights that the policy level is considered the most effective way to address the epidemic by these participants. While civil society organisations advocate for prevention, oftentimes the government is slower to react until the burden is evident, as described by Participant 8, Department of Commerce: “(most governments) become reactive, especially when there are high cases of NCDs”.

From these responses, it is evident that childhood obesity is shaped by a combination of structural, economic and cultural barriers across various levels of the SEM, compounding in settings that are unsuitable for effective interventions.

Strategies for improved intervention success and for new initiatives

Participants were asked what they would like to see next to improve childhood obesity reduction and prevention initiatives without considering the limitation of funding availability.

Improving individual (child) education and behaviour: Participants in the health sector were interested in developing gamified nutrition and exercise programmes, such as by incorporating rewards and challenges. Gamified interventions were believed to boost children’s motivation and maintain their interest, which in turn improves their understanding of nutrition, ultimately helping them develop long-term knowledge that promotes healthier eating habits.

Improving interpersonal education: There was agreement among ten participants in government, civil society and finance sectors that health education is fundamentally necessary to reduce childhood obesity rates in the long term. They believed that an improvement in health education, such as through workshops or small group activities in community settings, can result in families practicing healthy behaviours together, reinforcing knowledge, exemplifying positive habits and promoting consistent adoption of healthier lifestyles.

Improving institutions: Participants suggested having healthier options for food vendors to sell, thereby increasing children’s access to healthy food options in school settings. Enhanced collaboration between organisations can facilitate programme coordination and resource sharing to optimise individual efforts.

Improving environment: At the environmental level, participants in the Department of Commerce and Ministry of Agriculture describe working towards increasing the availability of reasonably priced, nutritious foods, through improvements to the National Basket of Goods (table 1). This strategy could facilitate healthier familial lifestyles by lowering the cost of essential ingredients, helping to establish supportive environments that promote accessible and healthier eating habits (figure 1).

Improving policy: Participants in civil society, finance and agriculture all agreed that there should be improvements in policies for food labelling to enhance individual autonomy by providing individuals with clear, easily accessible information on nutritional content and empowering them to make informed decisions.

While participants had diverse suggestions that covered all areas of the SEM to improve childhood obesity prevention initiatives, what remains to be determined is how collective responsibility and action can help strategise meaningful and widespread uptake of behavioural change.

Discussion

Conclusion

Our findings suggest that multisectoral health initiatives provide a robust response to the dynamic development of the childhood obesity epidemic in Barbados as they target multiple levels across the SEM multi-level ecological approaches can strategically disperse the ‘load’ of public health interventions across multiple organisations. The study’s main findings are listed below, along with pertinent literature that supports and contextualises each finding.

1. School-based prevention initiatives that focus on increasing physical activity and increasing nutritional education have proven to be effective methods to prevent childhood obesity, with successful interventions documented in Italy and in Spain.21–24 Since such initiatives are relatively new in Barbados, putting them into practice and assessing them could encourage healthier behaviours among children and establish schools as places that foster long-term wellness. Furthermore, as indicated by the participants’ responses, engaging the school sector in upcoming policy development processes can promote buy-in and ownership, thereby increasing the possibility of successful implementation and adherence to these policies in the school environment. This aligns with our analysis of the influencing factors to childhood obesity –the institutional level has direct interaction with the individual level, and it is the level that can be directly regulated and influenced by the policy level. Thus, the improvement of institutional level initiatives will be crucial for sustainable impact in the fight against childhood obesity.

2. At the interpersonal and individual levels, conversations among families about health, nutrition and fitness can lead to a greater awareness, leading to changing habits. Specifically, previous research has shown that educating children as young as 3 years old about healthy eating habits can help to prevent future obesity.21 Therefore, Barbados’ health education initiatives should target families and parents to start children on a healthier path as early as possible.

3. The food industry has impeded childhood obesity prevention efforts through marketing techniques, such as branding and persuasive advertising, that specifically target children. This encourages a preference for nutrient-poor foods and shapes unhealthy eating behaviours from a young age that are difficult to reverse later in life.25 Therefore, this industry should be engaged in the development of healthier food options and echoing messaging for health promotion, which can be enforced through government regulations. This challenge is reflected in other Latin American nations, including Mexico, Chile and Colombia, and that competing interests in policy implementation must be addressed by improving systems of transparency and accountability to reduce the impact of the food industry on public health policy.26

4. Further advocacy, alignment and incentivisation from government involvement seem necessary, as political will was highlighted as a major barrier to progress. Research suggests that policy can effectively address obesity and that unhealthy foods marketed to children must be regulated in addition to other forms of prevention. This has been demonstrated in Australia, where children who had access to restricted advertising for unhealthy foods had lower energy intake and greater BMI reductions than children who did not.27 Moreover, the SSB taxes and school nutrition policies implemented by the Barbadian government are examples of effective policymaking and alignment with public health messaging to combat its childhood obesity epidemic.11

5. Participant responses also identified the unique aspects of the Barbadian experience and culture that must be acknowledged to ensure success, such as the intergenerational impacts of slavery and cultural norms and preferences for higher BMI in children. As outlined in figure 1, colonialism strongly influences every level of the socio-ecological model and is often a missing contextual piece in improving tailored public health interventions. This is supported by research that identifies that childhood obesity prevention interventions with cultural adaptations are more easily acceptable by their local contexts.24 28 Colonialism and the history of enslavement, in relation to current health crises in the Caribbean, provide critical context for persistent structural inequities, cultural dietary patterns and health disparities that shape modern-day risk factors and will help guide more effective and culturally sensitive interventions.29 30

Strengths and weaknesses of the study

A key strength of this study is the wide range of participants with unique viewpoints, experiences and subject matter expertise, lending to a well-rounded understanding of the nature of challenges, historical perspectives, implementation of childhood obesity prevention strategies and existing and proposed strategies in Barbados. In addition, using all SEM levels as a framework to examine the determinants of childhood obesity within the scope of our study contributes to the use of the SEM in childhood obesity research.31 One limitation involved the absence of direct contact with children, teachers or parents, as restricted by University of Toronto ethics. Thus, to understand children’s behaviours and opinions, the research team relied on participants’ perceptions. As such, there was a risk for proxy bias influencing their comments about groups and variables not captured with the participant cohort (children and the school environment). Although the research team acknowledges the importance of this group, to lessen proxy bias, the research team concentrated on a system-level perspective on the interventions’ implementation. Therefore, interpretations of the efficacy, barriers and strategies for school-based interventions are limited to the perspectives of government and civil society actors.

This study illuminates the health landscape of Barbados in relation to childhood obesity and offers several opportunities to support the development of further multidisciplinary initiatives across sectors and across the life course. The successes, gaps and opportunities highlighted herein can be used as a framework for other communities dealing with childhood obesity, using Barbados as an exemplar case study on strategies that can be adapted within their local contexts.

Future studies should evaluate the National School Nutrition Policy rollout in Barbados’education system, to determine if there are quantifiable improvements to childhood obesity rates. This can be done through a pre-post evaluation to assess the overall effectiveness and help guide refinements for the policy, as demonstrated by Chile’s example of SSBs purchased per capita before and after the implementation of its SSB taxation policies.32 Moreover, collecting views from children, families and educators can support involvement of affected groups and identification of the needs within the educational environment as partners in the longitudinal and life-course process of reducing childhood obesity rates.

Data availability statement

Data are available upon reasonable request. Data are available upon reasonable request. According to approved Research Ethics Board submission and protocol, data can only be shared until 3 July 2028 before data has to be destroyed.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by two Ethics Committees for this research: Name: The University of the West Indies Cave Hill, Barbados, West Indies Campus Research Reference Number: CREC-CH.00182/04/2023 Name: Office of Research Ethics, University of Toronto reference number: 00044139. Participants gave informed consent to participate in the study before taking part.