National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2017 - 2021

15 TRINIDAD AND TOBAGO’S RESPONSE TO THE NCD EPIDEMIC

15 Policies, Programmes, and Strategies ii LIST OF ACRONYMS to Respond to the NCD Challenge

16 Tobacco Use

16 Reduction in Harmful Use of Alcohol

1 FOREWORD 16 Unhealthy Diet and Physical Inactivity

16 Childhood Obesity

17 Progress Made

17 Strengthening of Clinical Care Capacity

2 INTRODUCTION

17 The Chronic Disease Assistance

2 Methodology Programme (CDAP)

2 Limitations 17 Evidence-based National Guidelines/

2 Regional and International Protocols/Standards Declarations on NCDs utilised 17 Surveillance and Research in the NSP NCD 17 Population based Surveys

17 Research

3 THE HEALTH SYSTEM

3 The Regional Health Authorities

4 Role of County Medical Officers 18 STRATEGIC FRAMEWORK of Healthin Prevention & Control 18 Purpose of NCDs 18 Context

18 Vision

18 Goal

5 SITUATIONAL ANALYSIS 18 Principles/Approaches

5 Demography

6 NCD Risk Factors

6 Common Modifiable Risk Factors 20 PRIORITY AREAS AND TARGETS

7 Tobacco Use

7 Alcohol Use

8 Physical Activity 22 KEY PLANNED ACTIONS

8 Fruit and Vegetable Consumption/ Unhealthy Diets

8 Intermediate/Biological Risk Factors 32 APPROACH TO IMPLEMENTATION AND MONITORING

8 Overweight and Obesity

8 Childhood Obesity

9 Hypertension

9 Cholesterol 33 BUDGETARY CONSIDERATIONS

9 Elevated Blood Glucose

9 Raised Risk of NCDs

11 MORTALITY AND MORBIDITY DUE TO NCDS

11 Heart Disease

12 Cancer

12 Diabetes

14 SOCIAL DETERMINANTS OF HEALTH AND ECONOMIC BURDEN OF NCDS

14 Poverty

14 Gender and NCDs

14 Economic Burden of NCDs National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 Table of Contents continued

34 APPENDICES

34 APPENDIX1: SWOT Analysis

35 APPENDIX 2: Stakeholder Analysis

36 APPENDIX 3: Cross-Sectoral Government Engagementto Reduce Risk Factors

37 APPENDIX 4: Roles for Key Government Ministries

41 APPENDIX 5: Life Course Factors

42 APPENDIX 6: WHO Best Buys

43 APPENDIX 7: WHO Global Monitoring Targets

45 APPENDIX 8: Declaration of Port-of-Spain

47 REFERENCES National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 TABLE OF FIGURES Figure 1: Declarations and international and regional frameworks used in the development of the National Strategic Plan for the Prevention and Control of NCDs. Figure 2: Map of the Regional Health Authorities in Trinidad and Tobago. Figure 3: Population pyramids for Trinidad and Tobago for 2000 and 2011. Figure 4: Changes in life expectancy in the Caribbean. Figure 5: Risk factors of NCDs. Figure 6: Prevalence of students who ever smoked cigarettes from GYTS 2000, 2007, and 2011. Figure 7: Obesity/Overweight status of children in Trinidad and Tobago in 1999 and 2009. Figure 8: Distribution of BMI in secondary school children. Figure 9: Four leading causes of mortality in Trinidad and Tobago. Figure 10: Prevalence of diabetes in Trinidad and Tobago compared to the regional and global prevalences. Figure 11: Cost of cancer, hypertension, and diabetes (TT$ Millions). Figure 12: Mechanisms to operationalise the Health in All Policies approach. TABLE OF TABLES Table 1: Health services delivery. Table 2: Common modifiable behavioural risk factors of NCDs. Table 3: Distribution of NCD risk factors among persons ages 15-64 years by sex from the 2011 STEPS Risk Factor Survey. Table 4: NCD mortality in Trinidad and Tobago. Table 5: Priority areas, specific objectives, and targets. Table 6: Trinidad and Tobago National Strategic Plan for the Prevention and Control of Non Communicable Diseases. Table 7: Stakeholders internal and external to the Government for the response to NCDs. Table 8: Cross-sectoral government engagement to reduce risk factors. Table 9: Possible roles of government ministries in NCD prevention and control. Table 10: Life course factors. Table 11: WHO Best Buys. i National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 LIST OF ACRONYMS AA Alcoholics Anonymous AHPC&PH Advisor, Health Promotion, Communications, and Public Health ASA Annual Service Agreement BMI Body Mass Index CARDI Caribbean Agricultural Research & Development Institute CAREC Caribbean Epidemiology Centre CARIAD Caribbean Institute on Alcoholism and Other Drug Problems CARICOM Caribbean Community CARPHA Caribbean Public Health Agency CBO(s) Community-based Organisation(s) CCDE Certified Caribbean Diabetes Educators CCH Caribbean Cooperation in Health CCM Chronic Care Model CDAP Chronic Disease Assistance Programme CFNI Caribbean Food and Nutrition Institute (now incorporated into CARPHA) CHRC Caribbean Health Research Council CMO Chief Medical Officer CMO(s)H County Medical Officer(s) of Health Corp Comm Corporate Communications Unit, Ministry of Health COSTAATT College of Science, Technology and Applied Arts of Trinidad and Tobago CPC Caribbean Program Coordination CNO Chief Nursing Officer CSO Central Statistical Office CVD Cardiovascular Diseases CWD Caribbean Wellness Day DATT Diabetes Association of Trinidad and Tobago DERPi Helen Bhagwansingh Diabetes Education Research and Prevention Institute DG WHO Director General, World Health Organization DHV District Health Visitor ENDS/ ENNDS Electronic Nicotine Delivery Systems/Electronic Non-Nicotine Delivery Systems EPI Expanded Programme for Immunisation ERHA Eastern Regional Health Authority FAO Food and Agriculture Organization FBO(s) Faith-based Organisation(s) FCTC Framework Convention for Tobacco Control GAP WHO Global Action Plan for the Prevention and Control of NCDs GDP Gross Domestic Product GDM Gestational Diabetes GMPC General Manager, Primary Health Care GORTT Government of the Republic of Trinidad and Tobago GSHS Global School Health Survey GYTS Global Youth Tobacco Survey HED Health Education Division, Ministry of Health HiAP Health in All Policies HiPTT Health in Pregnancy in Trinidad and Tobago HP Health Promotion HPRP Directorate of Health Policy, Research and Planning, Ministry of Health HPTSS Health Programmes and Technical Support Services HPV Human Papilloma Virus HR Human Resources, Ministry of Health HSHRPDU Health Sector Human Resource and Planning Development Unit, Ministry of Health IADB Inter-American Development Bank IEC Information, Education and Communication IHD Ischemic Heart Disease JHMI Johns Hopkins Medical Institutions LAC Latin America and the Caribbean MET(s) Metabolic equivalent(s) MOA Ministry of Agriculture, Land and Fisheries MOE Ministry of Education MOFA Ministry of Foreign Affairs MOH Ministry of Health MOHSP MOH Strategic Plan MOLA Ministry of Legal Affairs National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 ii MONS Ministry of National Security MOPD Ministry of Planning and Development MOSYA Ministry of Sport and Youth Affairs MOTI Ministry of Trade and Industry N&MD Nutrition and Metabolism Division, Ministry of Health NAC North America and the Caribbean NADAPP National Alcohol and Drug Abuse Prevention Programme NCD(s) Non Communicable disease(s) NCDNC NCD National Commission NCDTAC NCD Technical Advisory Committee NCDU NCD Unit NCM National Coordinating Mechanism NCRHA North-Central Regional Health Authority NDC National Drug Council NGO Non-Governmental Organisation NIHERST National Institute of Higher Education, Research, Science and Technology NPTA National Parent Teacher Association of Trinidad and Tobago NSDSL National Schools Dietary Services Limited NSP NCD National Strategic Plan for the Prevention and Control of NCDs NWRHA North-West Regional Health Authority OAS Organization of American States OVI Objectively Verifiable Indicators P&C Prevention and Control PA Physical Activity PAFNCD Partners Action Forum on the Prevention and Control of NCDs PAFWC PAF Working Committee PAHO Pan American Health Organization PHC Primary Health Care PMCD Public Management Consulting Division POA Plan of Action PTA Parent Teacher Association QOC Quality of Care Project RHA Regional Health Authority ROI Return on Investment SCOPE Sharing Community Ophthalmology Path SDH Social Determinants of Health SHP School Health Programme SOP(s) Standard Operating Procedure(s) STEPS WHO STEPwise approach to Surveillance STPOA Short Term Plan of Action SWRHA South West Regional Health Authority TCU Tobacco Control Unit, Ministry of Health THA Tobago House of Assembly TOR Terms of Reference TRHA Tobago Regional Health Authority TSTT Telecommunications Services of Trinidad and Tobago Limited TTANDi Trinidad and Tobago Association of Nutritionists and Dieticians TTBA Trinidad and Tobago Breastfeeding Association TTCS Trinidad and Tobago Cancer Society TTMA Trinidad and Tobago Medical Association TTO Trinidad and Tobago UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children's Fund USC University of the Southern Caribbean UTT University of Trinidad and Tobago UWI University of the West Indies, St Augustine WHA World Health Assembly WHO World Health Organization WOG Whole of Government WOS Whole of Society iii National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 FOREWORD The health of a nation is a fundamental determinant of the quality of life of its citizens and directly influences expenditure, productivity, and the achievement of sustainable developmental goals. Health is therefore an instrument of development. Unfortunately, significant increases in the domestic occurrence of Non Communicable Diseases (NCDs) namely, heart disease, diabetes, cancer and cerebrovascular disease, threaten to erode decades of public sector investment. In recent years, NCDs have become the leading cause of morbidity and mortality in Trinidad and Tobago. Without action, the increasing prevalence of NCDs will continue to unduly burden our health system, consume already scarce resources and severely undermine our socioeconomic advancement. The good news is that collectively, we have the ability to dramatically reduce the occurrence of NCDs through the implementation of proven cost-effective strategies. While the Government is best poised to implement the broad-based policy and legislative actions necessary, it is clear that a collaborative approach is required. Individuals, stakeholder groups, the wider society and the Government must work collectively and decisively to reduce the threat of NCDs and improve the health of our people. It is in this context that I present the National Strategic The Honourable Terrence Deyalsingh Plan for the Prevention and Control of Non Communicable Minster of Health Diseases. This holistic action-based plan takes into account the entire NCD health care management spectrum. The plan seeks to harness the collective efforts of both the public and private sector in order to synergise and integrate NCD prevention and control at all stages in the life course and engage stakeholders via the whole of society and whole of government approaches. Additionally, it takes into consideration the range of health interventions necessary to combat the prevalence of NCDs including; policy and environmental changes, healthy lifestyle promotion, early detection and treatment of metabolic risk factors, advocacy and community outreach, surveillance, and research. Fundamentally, the success of this initiative will be determined by our ability to change deeply entrenched habits and accept personal responsibility for our health status. With your support, I am confident that this National Plan for the Prevention and Control of Non Communicable Diseases will become a living blueprint for a more proactive response to our national health needs and be the catalyst for the creation of a society of happier, healthier, fitter people…living longer and more productive lives. The Honourable Terrence Deyalsingh Minister of Health​

1 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 INTRODUCTION The National Strategic Plan for the Prevention and Data and evidence to guide the development of the Control of Non Communicable Diseases (NSP NCD) plan were gathered from several sources in the Ministry outlines the strategic direction for the response to Non of Health (MOH), the Central Statistical Office (CSO), Communicable Diseases (NCDs) in Trinidad and Tobago academia, and research studies on NCDs and their risk (TTO), and the strategic outcomes that partners from factors. In 2012, the results of the 2011 Trinidad and government, private sector, and civil society will be Tobago STEPS NCD Risk Factor Survey (STEPS) were engaged to collaborate towards their achievement over released. This data established baseline on key risk the period 2017-2021. This plan is in alignment with factors, and was utilised in the development of the NSP the national development strategy of the Government NCD. The consultative process used in the development of the Republic of Trinidad and Tobago (GORTT), of the plan also maximised availability of outcomes of which acknowledges that multiple factors and social other similar or relevant dialogues, which had taken determinants combine together to affect the health of place in the recent past. individuals and communities including inter alia, where LIMITATIONS people live, work, play, the environment, genetics, income, education, and relationship with friends Comprehensive data on the NCD situation in Trinidad and family�. It utilises key approaches to population and Tobago was difficult to obtain. Several data sources health and development including primary health care, used were dated and the data obtained varied according universal health coverage, standards of care, integrated to the source. This was compounded by the absence management, the Health in All Policies (HiAP), and of a national NCD surveillance system and lack of multisectoral approaches which involve the whole of collation and analysis of data from the Regional Health government (WOG) and whole of society (WOS). Authorities (RHAs). Several proxies were utilised such as using hospital admissions to represent morbidity In order to address the varied determinants of health, data. A comprehensive surveillance system will be many of which are outside of the health sector, the plan important to the implementation and monitoring of embraces the following core principles: the NSP NCD. More peer reviewed, policy-related 1. Prevention-focus research is needed, as well as collation and analysis 2. Equity of data covering five (5) to ten (10) year periods to 3. Inclusiveness generate trends. 4. People centred REGIONAL AND INTERNATIONAL 5. Evidence-based & results-driven DECLARATIONS ON NCDS UTILISED METHODOLOGY IN THE NSP NCD The development of the strategic plan included The NSP NCD is guided by several international and engagement with partners throughout the process. regional frameworks and declarations, which inform the Through stakeholder consultations, ideas and strategic approach adopted in the plan to address our perspectives of internal and external stakeholders were national NCD situation and local determinants of health. garnered to facilitate their contribution to and buy-in for These include: the proposed approaches to implementation of the plan. 2003 • Framework Convention on Tobacco Control (FCTC) 2004 • WHO Global Strategy on diet, physical activity and health • UN High Level Meeting on NCDs and • CARICOM Heads of Government • WHO Set of Recommendations on

2007 Summit on the NCD and Declaration 2010 Marketing of Foods and Non-Alcoholic 2011 UN Declaration on NCDs • Strategic Plan of Action for the Prevention and of Port of Spain Beverages to Children Control of NCDs for countries of CARICOM • PAHO Plan of Action for Prevention and Control of NCDs 2014 • WHO NCD Global Monitoring Framework 2013 in the Americas 2013-2020 • WHO Global Plan for the Prevention and Control of NCDs 2013-2020 • Helsinki Health Promotion Conference - Health in All Policies Figure 1: Declarations and International and Regional Frameworks used in the Development of the National Strategic Plan for the Prevention and Control of NCDs. � Ministry of Planning and Development, Government of the Republic of Trinidad and Tobago. 2016. National Development Strategy 2016-2030 (Vision 2030). Retrieved from http://www.social.gov.tt/wp-content/uploads/2017/01/V2030-as-at-August-29th-2016.pdf National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 2 THE HEALTH SYSTEM The MOH is the national authority charged with Public health and population based programmes, oversight of the entire health system in TTO. which focus on wellness and preventive care, are The MOH plays a central role in the protection of the made available through the MOH, the vertical services population’s health and in ensuring that all organisations and national programmes and civil society. Personal and institutions that produce health goods and services health care services at the primary, secondary, and conform to standards of quality, care, and safety �. tertiary levels are available through the Regional Health The health system in TTO comprises several entities, Authorities (RHAs), civil society, and the private sector. which must work as a cohesive and committed whole. THE REGIONAL HEALTH AUTHORITIES These entities include public, private, and civil society agencies working together to produce the public good Responsibility for the provision of clinical health care called ‘population health’. Through collaboration among services in TTO was contracted out from the MOH these entities, public and personal health care services to the RHAs with the passing of the Regional Health are provided to citizens, with a reach to all communities. Authorities Act No. 5 in 1994. RHAs are autonomous Table 1: Health Services Delivery � Type of Health Service Sector Institution Public Population Personal Health based Health Care Programmes Programmes Services Ministry of Health Ministry of Health Vertical Services Public Sector Regional Health Authorities Other Ministries, State Agencies Private for profit Private Civil Society Sector Community Public Self-Managed People Care TRHA bodies that own and operate health facilities in their respective Regions�. There are five RHAs in TTO, which deliver public health care services to the population of TTO on behalf of the MOH through a network of one hundred and five (105) health centres located in communities close to the population, and NWRHA eight hospitals. NCRHA The MOH is responsible for corporate governance and NWRHA - North West Regional leadership of the health sector, policy setting, quality ERHA Health Authority assurance and regulations, monitoring and evaluation, NCRHA - North Central Regional Health Authority and public health services for the population �. The ERHA - Eastern Regional RHAs provide a basket of primary, secondary, and Health Authority tertiary health services to the population based on SWRHA SWRHA - South West Regional Health Authority national health priorities established by the MOH TRHA - Tobago Regional and on continuing assessment of health needs of the Health Authority communities served. Figure 2: Map of Regional Health Authorities in Trinidad and Tobago � � Ministry of Health, Trinidad and Tobago. n.d. “Ministry of Health - Overview.” Ministry of Health, Trinidad and Tobago. (http://www.health.gov.tt/sitepages/default.aspx?id=38). � Ministry of Health, Trinidad and Tobago. 2016. The Ministry of Health - Trinidad and Tobago. Retrieved from Ministry of Health, Trinidad and Tobago: http://www.health.gov.tt

3 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 They follow the policy direction of the MOH, provide • Coordinating the development of strategies to services in accordance with the standards of support the delivery of the Ministry’s NSP NCD; care, SOPs, and guidelines from the Ministry. The • Health situation analysis, health risk assessment, Ministry allocates financial resources to the RHAs and disease surveillance; through Annual Service Agreements (ASAs) for the implementation of these services. • Primary health care and health promotion These agreements also serve as a mechanism for principles; monitoring and evaluation. • Social participation and intersectoral collaboration ROLE OF COUNTY MEDICAL OFFICERS OF at the community level; and HEALTH IN PREVENTION & CONTROL OF NCDS • Ensuring the timely implementation of the essential public health functions at the A key role of the MOH is ensuring that the essential county level including: public health functions are delivered to promote and protect the health of the population. The o Public health surveillance, research and reporting; County Medical Officers of Health (CMOsH), senior o Monitoring and evaluation of the implementation public health administrators within the MOH, have of MOH policies, programmes, services and health a critical function of coordinating and monitoring situation assessment; the implementation of these essential public health functions. The Ministry retains other national o Health promotion; programmes that are critical to the discharge of o Facilitating social participation in the response to NCD these functions that are dedicated to the promotion prevention and control; and and protection of the health of the population, thus contributing to social and economic development of o Quality assurance and standards of care to track the country. progress in personal and population based services. The role of the CMOH in the implementation of the NSP NCD will involve strengthening and renewing the primary care approach for NCD Prevention and Control through: • Providing leadership for the development and delivery of the primary health response to NCDs at the community level; � Ministry of Health, Trinidad and Tobago. 2011. “Strategic Plan: Fiscal Years 2012-2016.”. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 4 SITUATIONAL ANALYSIS Trinidad and Tobago has experienced an epidemiological observed in more than seven other Caribbean countries transition over the last 40 years. NCDs are now the for the same period. Research is needed to determine major health problems, replacing the communicable the reasons for this. Of note also is the earlier onset of diseases of the 1960s. Several factors have contributed NCDs in the population. to this, including an ageing population, urbanisation, and Today onset of NCDs is being observed more frequently significant changes in the lifestyle of the population. in the under 45 years age group�. DEMOGRAPHY The country’s population is approximately 1.35 million, 2005 to 1965 to co with an estimated 8.6% of the population living in urban Mar ti 2010 1970 r to Ri ue areas. Males account for 50.2% of the population, while niq u 1 1 P 80.1 70.7 e Gu ad e b a Cu e lop 79.4 2 68.5 2

80 MALE FEMALE .I. ub a S.V

75-79 U. 78.9 3 68.2 3 Ar ao 70-74 ba r ac Cu Cu

65-69 Pu 78.3 4 68.2 4 a er 60-64 aic to Ri m 55-59 co 5 5 Ja 77.9 67.5 50-54 .I. Cu r S.V U. 45-49 ac a en Age Group Fr 6 76.1 66.7 6 o 40-44 as ch tig a An Gu m ud 35-39 ha rb ian Ba ua 30-34 & a 75.9 7 65.2 7 Ba & ua Ba 25-29 o tig ag rb 20-24 ud An To b 75 8 65 8 a d& ida

15-19 Ar in 10-14 ub Tr 9 9 a 74.7 64.8 e iqu

5-9 Ba tin rb 0-4 ad ar a 10 10 M ian os 74.5 64.7 u hG 6 4 2 0 2 4 6 Ba ha c Percentage m Fr en as 74.3 11 64.4 11 Figure 3: Population pyramids for Trinidad and Tobago for 2000 and 2011� St . e *2000 – orange and blue; 2011 – grey outline c liz Be Lu ia 74 12 64.3 12 s do Be r ba lize 72.7 13 64.2 13 Ba t females account for 49.8%�. The population pyramids in Do m Ja i nc en .V m Figure 3 reveal the continuing demographic transition of St ini aic ca a 72.2 14 64 14 e lop ep the ageing population. Between 2000 and 2011, while nR a de Gu t lic there was growth in the youngest age group (0-4 years), na a e go 72.2 15 63.6 15 ad en a m ad ub there was significantly more growth in the age group ba ya en inc ina Gr en 72 16 63 16 45-80+ years. To Gu . St e Gr ur am V rin Su d& 17 17 The crude birth and death rates are 12.83 births and S 71.9 62.4 c ia 8.23 per 1 000 population respectively. The fertility rate Lu da . 69.6 18 61.6 18 St ini is 1.71 children per woman and the infant mortality rate n a lic ya ub is 12.0 per 1 000 live births�. Life expectancy at birth is Tr 19 19 Gu ep 69.3 59.1 nR ca 73.9 years for females and 66.5 years for males�. m ini 65.2 20 56.9 20 Do The 2016 Evaluation of the Port-of-Spain Declaration iti revealed that while overall life expectancy in TTO Ha Ha iti 60.7 21 46.3 21 increased from 64.8 to 69.3 between 1970 and 2010, this increase was far less than the 10-15 year increases Figure 4: Changes in life expectancy in the Caribbean� � Central Statistical Office, Trinidad and Tobago. 2016. “Population Mid Year Estimates.” Central Statistical Office. (http://cso.gov.tt/data/?productID=31- Population-Mid-Year-Estimates). � Central Statistical Office. 2012. “Trinidad and Tobago 2011 Population and Housing Census: Demographic Report.” Ministry of Planning and Sustainable Development, Port-of-Spain. (https://guardian.co.tt/sites/default/files/story/2011_DemographicReport.pdf).

5 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 NCD RISK FACTORS Personal factors such as age, ethnicity, and genetic factors are not amenable to change. However, NCDs The NCD problem is growing rapidly because of the share common risk factors that are modifiable. Critical high and increasing prevalence of NCD risk factors in actions for prevention and control of NCDs must be the population. There are several types of factors that directed at the modifiable risk factors which include: increase the risk for the development of NCDs. UNDERLYING COMMON SOCIOECONOMIC MODIFIABLE NCDs CULTURAL, POLITICAL RISK FACTORS NON-MODIFIABLE • HEART DISEASE AND ENVIRONMENTAL RISK FACTORS • DIABETES DETERMINANTS • UNHEALTHY DIET • PHYSICAL INACTIVITY • CANCER • GLOBALISATION • AGE • STROKE • TOBACCO USE • URBANISATION • GENETICS • CHRONIC • HARMFUL USE OF • POPULATION ALCOHOL RESPIRATORY AGEING DISEASES Figure 5: Risk factors of NCDs. Table 2: Common modifiable behavioural risk factors of NCDs. NCDs COMMON MODIFIABLE RISK FACTORS Harmful Use Tobacco Unhealthy Diet Physical Inactivity of Alcohol Heart Disease Yes Yes Yes Yes Diabetes Yes Yes Yes Yes Cancer Yes Yes Yes Yes Stroke Yes Yes Yes Yes � Pan American Health Organization. 2015. “Health Situation in the Americas: Basic Indicators 2015.”. (http://www.paho.org/hq/index.php?option=com_ docman&task=doc_download&gid=31791&Itemid=270&lang=en). � PAHO/WHO and CARICOM. (2016). Evaluation of the 2007 CARICOM Heads of Government Port-of-Spain NCD Summit Declaration. Retrieved from http://www.onecaribbeanhealth.org/wp-content/uploads/2016/10/ACCELERATING-ACTION-ON-NCDS-POSDEVAL-Report.pdf � Ministry of Health, Trinidad and Tobago. 2012. “Trinidad and Tobago Chronic Non-Communicable Disease Risk Factor Survey [Pan American STEPS].”. (http://www.health.gov.tt/news/newsitem.aspx?id=394). National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 6 • Modifiable behavioural risk factors: tobacco use, TOBACCO USE alcohol abuse, unhealthy diets, and physical inactivity; About one fifth of the population smoke and the prevalence is much higher among men than among • Modifiable biological risk factors: obesity, high blood women. The average age of initiation to smoking is pressure, high cholesterol, and raised blood glucose. around 17 years in both sexes, and manufactured cigarettes are the preferred form of tobacco use. The When left unchanged, modifiable behavioural risk average number of cigarettes smoked per day was 11.5 factors progress and intermediate biological risk factors cigarettes. In 2004, tobacco was attributable to 7% of (high blood pressure etc.) develop. Without the relevant all NCD deaths – 9% of deaths due to ischemic heart management and control, these intermediate biological disease, 61% of deaths due to lung cancer �� . risk factors will progress to chronic diseases such as heart disease, diabetes, cancers, and stroke. Regarding smoking and youth, while Figure 6 shows that the prevalence of smoking cigarettes among NCD risk factors are also influenced by other factors students has decreased steadily over the period 2000 in the society where people, live, learn, work, love and – 2011, there is no room for complacency. The 2011 play. These are referred to as social determinants GYTS showed that 30% of students in Forms 1 to 4 had of health (SDH), and include, but are not limited to, smoked a cigarette at least once in their lives and 18% socioeconomic, cultural, environmental and political were current smokers. The use of tobacco products factors, over which individuals have limited control, and other than cigarettes had increased from 4.8% in 2000 for which action is required by governments, private to 12% in 2011�� �� ��. sector, and civil society. ALCOHOL USE Data from several national surveys including the 2011 STEPS NCD Risk Factor Survey, the Global School Health Forty percent of respondents to the STEPS survey were Survey (GSHS - 2007 and 2011), the Global Youth current drinkers (defined as having consumed a drink Tobacco Survey (GYTS - 2000, 2007, and 2011), and the within the 30 days prior to survey implementation),

2011 Evaluation of School Meals Options revealed that and drinking was found to begin at an early age. The the prevalence of NCD risk factors in the population 2011 GSHS showed that in TTO among the 13-15 was high. year olds, 36.4% of students had an alcoholic drink in the month preceding the survey, with 86.5% of these 50 45 Prevalence (%) 40 35 30 -- Boys Girls

0 Overall 25 20 2000 2007 2011 GYTS Survey Year Figure 6: Prevalence of students who ever smoked cigarettes from GYTS 2000, 2007, and 2011 �� �� �� �� World Health Organization. (n.d.). WHO | What is Moderate-intensity and Vigorous-intensity Physical Activity? Retrieved from World Health Organization: http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/

7 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 children admitting to having a first alcoholic drink before INTERMEDIATE/BIOLOGICAL RISK FACTORS the age of 14 years ��. Both the 2011 GSHS and the Modifiable behavioural risk factors lead to intermediate

2011 STEPS surveys also indicate that young people risk factors (biological risk factors) which require medical engage in binge drinking (defined as engaging in heavy management. These include being overweight or obese, episodic drinking – five and four drinks for men and or having high cholesterol, high blood pressure, or high women respectively, on any one day in the last 30 days). blood sugar. Further, nearly 60% of alcohol users in TTO either rarely eat food while drinking or do not do so at all �. This is OVERWEIGHT AND OBESITY noteworthy, because research shows that alcohol is absorbed at an accelerated rate on an empty stomach. As in the rest of the Caribbean, the prevalence rate of obesity in TTO has been increasing rapidly. Just over PHYSICAL ACTIVITY fifty-five per cent (55.7%) of the population ages 15-64 years were overweight or obese. Among females, 34% Men spend more time on physical activity (PA) overall. were overweight and 32% obese. Among men, 40% were For the age group 15-64 years, men spend more than overweight and 19% are clinically obese. There was a 100 minutes per day whereas women spent only 14.3 marked increase in obesity over the age of 24 years � minutes. Twice as many males than females engage in high-level activity (>3000 MET-minutes per week), CHILDHOOD OBESITY but more females engage in low or moderate physical activity. Physical activity tends to be seasonal between This is of particular concern due to its impact on the both genders. This pattern of PA might explain the development of risk factors and NCDs later in life. Over gender difference observed in relation to body mass the past two decades, TTO has seen the emergence of index (BMI) levels - a higher percentage of men are NCDs such as Type 2 diabetes among its youth. The overweight when compared to women, and a higher results of the Survey of BMIs conducted by the Caribbean percentage of women than men are obese �. Food and Nutrition Institute (CFNI) for the MOH in 2010, revealed that overweight and obesity in schoolchildren FRUIT AND VEGETABLE CONSUMPTION/ aged 5-18 years, increased from 11% in 1999, to 23% in UNHEALTHY DIETS 2009 representing an increase of 109 %. Over the same 10-year period, obesity in children increased some 400% The results of the STEPS survey confirmed that the from 2.4% to 12.5% ��. diet of the population of TTO is deficient in fruits and vegetables. Ninety percent (90%) of the population This five (5)-fold increase in obesity in children over a have less than five servings of fruit and vegetables 10-year period means that TTO has significant childhood daily. With respect to the diet of children, the 2007 obesity problem that must be arrested immediately, GSHS revealed that overall, 51.6% of students usually given that it can contribute to higher levels of adolescent drank sugar sweetened carbonated soft drinks two or and adult obesity. Research has shown that 24% of three times per day ��. The 2011 GSHS found that the school-aged children (5-18 years) are overweight or number had increased to 74.6% of students drinking obese and as high as 35% in St George East ��. sugar sweetened carbonated beverages within the Figure 8 details this. past 30 days ��. This, accompanied by the finding from the Evaluation of School Meals options that Ultimately, this high level of overweight and obesity, among the frequently consumed foods, there was an beginning from childhood and continuing in adulthood, overabundance of staples (carbohydrate rich foods) further contributes to the overall increased risk of and a scarcity of fresh fruits or vegetables offered to NCDs in the population. This leads to increased limb children in school settings, indicates that unhealthy amputations, heart attacks, kidney disease, and eating practices continue to be a source of concern blindness, which are increasing health care costs, while amongst our children ��. at the same time reducing the productive capacity of those affected. �� United Nations Country Team. 2006. “Common Country Assessment: Republic of Trinidad and Tobago.”. (https://www.scribd.com/document/156420644/ Common-Country-Assessment-Revised-March-31-Final). �� Alleyne, Leo E. 2000. “Trinidad and Tobago (Ages 13-15) Global Youth Tobacco Survey (GYTS) FACT SHEET.”. (http://nccd.cdc.gov/gtssdata/Ancillary/ DownloadAttachment.aspx?ID=501). �� Alleyne, Leo. 2007. “Trinidad & Tobago (Ages 13-15) Global Youth Tobacco Survey (GYTS) FACT SHEET.”. (http://nccd.cdc.gov/gtssdata/Ancillary/ DownloadAttachment.aspx?ID=502). �� Procope-Beckles, Marilyn. 2011. “Trinidad and Tobago 2011 Country Report Global Youth Tobacco Survey (GYTS).”. (http://nccd.cdc.gov/gtssdata/Ancillary/ DownloadAttachment.aspx?ID=1173). National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 8 Table 3: Distribution of NCD Risk Factors among persons ages 15-64 years by Sex from the 2011 STEPS Risk Factor Survey � . Prevalence by sex % Risk Factors Overall Prevalence % Male Female Tobacco Use 33.5 9.4 21.1 Alcohol consumption 50.6 30.9 40.0 Less than 5 servings of 91.5 92.8 89.3 Fruit and Vegetables Low levels of physical activity (defined as <600 MET - minutes 33.0 57.0 45.4 per week) Figure 6: Prevalence of students who ever smoked cigarettes from GYTS 2000, 2007, and 2011�� �� �� Overweight/Obesity 52.3 59.0 55.7 *Low levels of physical activity defined as <600 MET**-minutes per week. ** Metabolic Equivalents (METs) are commonly used to express the intensity of physical activities. MET is the ratio of a person's working metabolic rate relative to their resting metabolic rate. One MET is defined as the energy cost of sitting quietly and is equivalent to a caloric consumption of 1kcal/kg/hour¹⁰. HYPERTENSION CHOLESTEROL More than 1 in 5 adults, about one billion people, The prevalence of elevated total cholesterol (≥ 6.2 worldwide have raised blood pressure. Complications mmol/L) or being currently on medication for raised from hypertension account for 9.4 million deaths cholesterol was 23.5% overall, 28.3% in males and 18.9% worldwide every year. Hypertension is the most in females �. important preventable cause of heart disease and ELEVATED BLOOD GLUCOSE stroke worldwide. Hypertension causes around half of all deaths from stroke and heart disease, and The prevalence of elevated fasting blood glucose (≥ 6.1 contributes to premature mortality. The higher the mmol/L) or being currently on medication for elevated blood pressure, the higher the risk of damage to the blood glucose was 20.5% overall, 19.8% in males and heart and blood vessels in major organs such as the 21.2% in females �. brain and kidneys. RAISED RISK OF NCDS In TTO, 26.3% of persons surveyed had elevated blood pressure or were currently on anti-hypertensive With respect to the five critical NCD risk factors - medication (29.8% of males and 23.1% of females) �. smoking, overweight/obesity, high blood pressure or on A retrospective database study of data collected from medication, consuming less than 5 servings of fruits and 14 793 persons by the Ministry of the People and Social vegetables, low levels of physical activity – only 1% of the Development over the period August 2006 to January population had no (0) risk factors. Just over half of the 2008 revealed a self-reported hypertension prevalence population ages 25 to 64 years (51%), had three or more of 30.4% �. This high prevalence of hypertension of the risk factors and are at increased risk of developing increases the risk of mortality from heart disease and NCDs �. diabetes, the two top causes of death in the country. �� Ministry of Health, Trinidad and Tobago. 2011. “Global School-based Student Health Survey Trinidad and Tobago 2011 Fact Sheet.”. (http://www.paho.org/trt/ index.php?option=com_docman&task=doc_download&gid=31&Itemid=). �� Procope-Beckles, Marilyn. 2007. “GSHS 2007 Report Trinidad and Tobago.”. (http://www.paho.org/trt/index.php?option=com_docman&task=doc_ download&gid=28&Itemid=).

9 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 Percentage 0% 5% 10 15 20 25 30 35 40 % % % % % % % 25% St. George East 20% Caroni 15% Percentage St. George West 10% St. Patrick St. Andrew 5% St. David 1999 2009 Victoria 0% ■ Overweight ■ Obese Figure 7: Obesity/Overweight status of children in Figure 8: Distribution of BMI in secondary school children ��. Trinidad and Tobago in 1999 and 2009 �� �� Caribbean Food and Nutrition Institute. 2009. “2009 Annual Report.”. (http://iris.paho.org/xmlui/bitstream/handle/123456789/2786/AnnualReport09%20CFNI. pdf?sequence=1). �� Ministry of Health, Trinidad and Tobago. 2014. “Interim Nutrition Standard for Food Offered for Sale in Schools in Trinidad and Tobago.”. �� Government of Republic of Trinidad and Tobago. 2008. Trinidad and Tobago Multiple Indicator Cluster Survey 3: Final Report 2008. Retrieved from https:// mics-surveys-prod.s3.amazonaws.com/MICS3/Latin%20America%20and%20Caribbean/Trinidad%20and%20Tobago/2006/Final/Trinidad%20and%20Tobago%20 2006%20MICS_English.pdf �� Ministry of Health, Trinidad and Tobago. 2015. “Hospital Utilisation Reports.”. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 10 MORTALITY AND MORBIDITY DUE TO NCDS NCDs are significant causes of morbidity and mortality diets and physical inactivity. The details are shown globally. The WHO has projected that they account for below in Table 4 and Figure 9 below �� . over 70% of all deaths, with 80% occurring in developing HEART DISEASE countries. Notably, TTO has one of the highest rates globally for NCDs. They account for over 60% of deaths Heart disease is the leading cause of death in TTO, annually. Of the NCDs, heart disease is the number and is also the leading cause of premature death in one cause of death, accounting for a quarter (25%) of all both men and women. Analysis of age standardised deaths annually, followed by diabetes (now the second premature mortality due to cardiovascular disease leading cause of death) accounting for 14%, cancer (13 (CVD) in TTO revealed that between 2000 and 2008, %), and cerebrovascular disease (10 %). Regarding sex the age adjusted mortality rates from CVD declined for and NCDs, annual mortality figures stand at 52% of both men and women, more so in women than in men. deaths in males and 41% of deaths in females. Of these Further research will need to be conducted regarding deaths, 70% were adjudged to be premature (occurring what contributed to this reduction. One suggestion is before age 70), and 4 out of 10 can be prevented as they that the introduction of the Chronic Disease Assistance all share the same modifiable behavioural risk factors Programme (CDAP), which ensures free access to including tobacco use, harmful use of alcohol, unhealthy essential medications for managing the major NCDs, Table 4: NCD Mortality Rate in Trinidad and Tobago��

2015 Cause-specific Number of NCD % of Deaths in 2015 death rates deaths in 2015 (per 100,000 population) Heart Disease 2673 25% 198.0 Diabetes 1497 14% 110.9 Cancer 1390 13% 103.0 Cerebrovascular Disease 1069 10% 79.2 NCDs Overall 6629 62% 491.2 0% 5% 10% 15% 20% 25% 30% Heart Disease Diabetes Cancer Stroke Figure 9: Four leading causes of mortality in Trinidad and Tobago�� �� Pan American Health Organization. 2013. “Trinidad and Tobago Cancer Profile.”. (http://www.paho.org/hq/index.php?option=com_docman&task=doc_ download&gid=23013&Itemid=270&lang=en). �� Social Investigations Division, Ministry of the People and Social Development. 2014. “Research Note: Cancer Volume 1, Issue 5.”. (http://www.mpsd.gov.tt/ sites/g/files/g728121/f/201404/Research%20Note%20-%20Cancer1.pdf).

11 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 40 35 World Source: IDF Diabetes Atlas, 7th Edition 2015

30 Trinidad and Tobago NAC 25 Prevalence (%) 20 15 10 5 0 20 25 30 35 40 45 50 55 60 65 70 75 -2 4 -2 9 -34 -3 9 -4 4 -49 -5 4 -5 9 -64 -6 9 -7 4 -79 Age (years) Figure 10: Prevalence of Diabetes in T&T, compared to the prevalence regionally and globally��. played a role in the reduction as the period of time since the vaccine’s introduction in 2013. In 2015, only reviewed coincides with the period of time over which 45.6% of the target population received the first dose CDAP was available. of the HPV vaccine, and of those, only 48.8% completed the series (22.3% of the overall target population) ��. CANCER This indicates that there will be little reduction in Trinidad and Tobago has one of the highest cancer cervical cancer rates in the future, if vaccination rates mortality rates in the Caribbean ��. Between 2001 and pap smear screenings are not increased. and 2008, the annual number of deaths from cancer DIABETES increased progressively from 1,201 to 1,417. In 2008, mortality was shown to be higher for men than TTO ranks among the countries with the most prevalent women. In the case of the men, prostate cancer was and fastest-growing cases of diabetes ��. In adults ages the most prevalent (34%), followed by lung cancer (13%), 20 to 79 years, there are approximately 140 300 cases colorectal cancer (12%), pancreatic cancer (6%), and of diabetes. The prevalence of diabetes is 14.5%, with stomach and non-Hodgkin lymphoma cancers (both 4%). about 88 – 90% of patients having Type 2 diabetes. Breast cancer was identified as the leading cause of There are approximately 39,400 undiagnosed cases of cancer death among women (23%), followed by cervical diabetes ��. Approximately 1 594 deaths are attributable and colorectal cancers (each 11%), ovarian cancer (7%), to diabetes, and 50% of deaths occur before age 65 . and lung and pancreatic cancers (each 5%) ��. TTO has a very high rate of diabetic complications ��. Cervical cancer is preventable through HPV vaccination. Foot infections are the most common complication However, HPV vaccination rates in TTO have been low of diabetes requiring hospital admission, accounting �� Pan American Health Organization. 2013. “Trinidad and Tobago Cancer Profile.”. (http://www.paho.org/hq/index.php?option=com_docman&task=doc_ download&gid=23013&Itemid=270&lang=en). �� Social Investigations Division, Ministry of the People and Social Development. 2014. “Research Note: Cancer Volume 1, Issue 5.”. (http://www.mpsd.gov.tt/ sites/g/files/g728121/f/201404/Research%20Note%20-%20Cancer1.pdf). �� Expanded Programme on Immunisation, Ministry of Health, Trinidad and Tobago. 2015. “Immunisation Report.”. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 12 for 14% of all hospital admissions in TTO ��. There are The Health in Pregnancy in Trinidad and Tobago (HiPTT) over 500 amputations per year. Diabetic retinopathy team, led by researchers from the Helen Bhagwansingh is the leading causes of adult blindness in TTO, with Diabetes Education Research and Prevention Institute approximately 10% of diabetics having sight-threatening (DERPi) and the University of the West Indies, lesions ��. St Augustine (UWI), estimate that of the 20 000 pregnancies in T&T each year, 1 in 5 are complicated Gestational diabetes (GDM) is also of interest because, by diabetes – 1 000 cases of diabetes, and 3 000 in addition to being detrimental to mothers and babies estimated cases developed during pregnancy �� . as it increases the frequency of perinatal morbidity and mortality, there is an established relationship linking maternal obesity and diabetes with an increased predisposition to the development of childhood diabetes. This therefore results in a vicious cycle in which obesity and diabetes result in more diabetes. GDM also indicates a significant risk of future maternal diabetes and CVD ��. �� Johns Hopkins Medicine. 2012. “New and Comprehensive Study of Diabetes Care in Trinidad and Tobago Released.” Johns Hopkins Medicine. (http://www. hopkinsmedicine.org/news/media/releases/new_and_comprehensive_study_of_diabetes_care_in_trinidad_and_tobago_released). �� International Diabetes Federation. 2015. “Trinidad and Tobago | International Diabetes Federation.” International Diabetes Federation. (http://www.idf.org/ membership/nac/trinidad-and-tobago). �� Trinidad and Tobago Health Sciences Initiative. 2014. “Diabetes Outreach Programme Collaboration Final Report for Completion: January 31, 2014.”. �� Islam, Shariful, Patrick Harnarayan, Shamir O. Cawich, Steve Budhooram, Vinoo Bheem, Vijai Mahabir, Shiva Ramsewak, Imran Aziz, and Vijay Naraynsingh. 2013. “Epidemiology of Diabetic Foot Infections in an Eastern Caribbean Population: a Prospective Study.” The Permanente Journal 17(2):37-40. �� Pan American Health Organization. 2016. Hyperglycemia and Pregnancy in the Americas. Final report of the Pan American Conference on Diabetes and Pregnancy (Lima Peru: 8-10 September 2015). Washington, DC: PAHO. Retrieved from http://iris.paho.org/xmlui/bitstream/ handle/123456789/28208/9789275118832_eng.pdf?sequence=5&isAllowed=y �� Teelucksingh, S., Ramsewak, S., Sirjusingh, A., Chamely, S., Mallalieu, K., Chow, H., & Lutchmansingh, F. 2016. Health in Pregnancy in Trinidad and Tobago.

13 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 SOCIAL DETERMINANTS OF HEALTH AND ECONOMIC BURDEN OF NCDs POVERTY about TT$8.7 billion annually. This represents a cost of approximately 5% of the current GDP. . Poverty is one of the drivers of NCDs, and developing NCDs can lead to catastrophic health expenses leading Figure 11 below details the cost of healthcare services families to impoverishment. The poor often find it and productivity losses related to cancer, hypertension, challenging to purchase healthy food options and and diabetes in TTO. Diabetes had the highest total cost the aggressive marketing and accessibility of cheap of about TT$3.5 billion, followed by hypertension at obesogenic foods facilitates their continued high TT$3.3 billion. The total cost of cancer was TT$2 billion, consumption and the trend of increasing obesity. On which was largely due to many fewer cancer patients the other hand, the economic burden due to NCDs is compared with the number of diabetic and hypertensive very high. patients ��. GENDER AND NCDS The proportion of indirect cost versus health care services differ across the NCDs as indicated in the IADB Gender should be considered when planning to address Assessment. Indirect cost was 58% of the hypertension NCDs in T&T. During the Men’s Health Caravan project, cost and 65% of the diabetes cost. The highest the MOH learned that men are less likely than women proportion of 90% was estimated for cancer ��. to seek health care, follow a health regime, and prefer to receive health promotion information from other Prevention through lifestyle modification and men. On the other hand, women generally access public medication management can substantially reduce health services, prepare the food, have high levels of the complications, mortality, and productivity losses NCDs themselves, and are responsible for taking care related to diabetes and hypertension. Investment of all persons in the family with NCDs. This challenge in prevention interventions are urgently needed to is not insignificant, as approximately 41.6% of the decrease the incidence and reduce the substantial labour force comprises women ��. More qualitative and economic burden ��. quantitative research is needed to distil the contribution of the socio-cultural factors on the lifestyles of the Diabetes and hypertension are due to highly modifiable citizens of TTO and the implications for the growing behavioural factors and prevention interventions can epidemic of NCDs. reap huge benefits. A 50% reduction, which can be achieved through sustained prevention interventions, ECONOMIC BURDEN OF NCDS can result in savings of almost TT$2.0 billion in just labour productivity. Cancers also have substantial The recent study, Rapid Assessment of the Economic productivity losses because of the higher proportion of Dimensions of Non-communicable Diseases in Trinidad deaths at younger ages. Interventions for prevention and Tobago, conducted by RTI Interational for the and early identification of cancers can have substantial Inter-American Development Bank (IADB) Trinidad benefits to the economy; a 20% reduction in cancer and Tobago, estimated that the economic burden mortality can reduce productivity losses by about from diabetes, hypertension, and cancer to TTO is TT$360 million ��. $190 Cancer $1,814 ■ Healthcare Services Hypertension $1,310 $1,863 ■ Productivity Loss Diabetes $1,216 $2,315 $ $1,000 $2,000 $3,000 $4,000 Millions Figure 11: Cost of cancer, hypertension, and diabetes (TT$ Millions)�� �� Central Statistical Office. 2016. CSO | Statistics. Retrieved from Central Statistical Office, Ministry of Planning and Development: http://cso.gov.tt/statistics/ �� RTI International. 2016. Rapid Assessment of the Economic Dimensions of Non-communicable Diseases in Trinidad and Tobago. �� Poon-King, Celia M. 2015. “Framework for Creating a Tobacco and Related Products Surveillance System and Estimation of the Quantity, Volume, and Turnover of Licit and Illicit Tobacco Products in Trinidad and Tobago.”. �� Ministry of Health, Trinidad and Tobago. 2011. “World Diabetes Day.” Ministry of Health, Trinidad and Tobago. (http://www.health.gov.tt/news/newsitem. aspx?id=298). National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 14 TRINIDAD AND TOBAGO’S RESPONSE TO THE NCD EPIDEMIC In TTO, the MOH and its divisions use a variety of The MOH has utilised all of the above strategies to approaches to operationalise the multisectoral create opportunities for public, private, and civil society collaboration approach. These include: participation in the response to NCDs, and to catalyse • Cabinet committees development of healthy public policies in all sectors of • Intersectoral committees, working groups, government. Some mechanisms utilised include: and joint actions Health in all Intersectoral/ Policies approach Whole Government Action Multisectoral action involving public, private sectors, Policies that improve social and between government agencies economic conditions impacting NGOs and Civil Society in the public sector well-being focused on vulnerable/ underserved populations Figure 12: Mechanisms to operationalise the Health in All Policies approach. 1. Cabinet Appointed Committees using a ‘Whole of public education programs to communities throughout Government’ approach, which involves joint action TTO. by public sector, private sector, NGOs, and civil POLICIES, PROGRAMMES, AND STRATEGIES TO society groups to establish Committees of Cabinet RESPOND TO THE NCD CHALLENGE. with mandates in relation to NCD prevention, management, and control. These include: The MOH has developed a suite of population based • Technical Advisory Committee on Chronic Diseases health policies in collaboration with its partners, • Partners Forum Committee for Action on Chronic guided by key international and regional resolutions, Diseases (the Partners’ Forum) frameworks, and strategic approaches from the • Committee on the Social Determinants of Health UN, WHO, PAHO, and CARICOM. The GORTT has participated in the development of several regional and 2. Ministry of Heath Committees with representation international treaties and resolution in relation to NCD from different public sector ministries and agencies: prevention and control. Progress made by TTO since • The Quality Council the Declaration of Port-of-Spain and the 2011 UN High • Tobacco Control Committee Level Meeting on the Prevention and Control of Non • Smoking Cessation Sub-Committee Communicable Diseases include: 3. Collaboration with NGOs and Civil Society groups: Tobacco Use �� At the programmatic level, the MOH has been collaborating with a wide range of civil society i. The Tobacco Control Act, developed using FCTC partners in their outreach programmes to raise framework, was passed in 2009 and enacted in awareness and provide increased access to 2010 resulting in, among other things, the banning screening for NCDs risk factors. Several NGOs work of smoking in public spaces and the prohibition of the in partnership with the MOH and the RHAs to promotion and sale of tobacco products to children. support the implementation of health promotion campaigns, e.g. Fight the Fat and Check Yuhself... ii. Development of a smoking cessation programme Know Your Number campaigns, the National at the primary care level. Training of a cadre of Wellness Fest and Caribbean Wellness Campaign. one hundred primary care professionals in smoking cessation techniques and twenty-five (25) primary Engagement of Civil Societies: The MOH provides care managers in designing tobacco dependence funding to several NGOs to assist in NCD prevention treatment programmes integrated into health activities at the primary health level in communities. centre programmes. Further many other NGOs and private sector organisations collaborate with the MOH, its Vertical iii. Establishment of two (2) smoking cessation Services, RHAs and the THA in bring prevention and clinics integrated into primary care health services �� Caribbean Public Health Agency. 2014. “CWD.” Caribbean Public Health Agency. (http://carpha.org/Media-Centre/Caribbean-Wellness-Day). �� Johns Hopkins Medicine. 2012. “New and Comprehensive Study of Diabetes Care in Trinidad and Tobago Released.” Johns Hopkins Medicine. (http://www. hopkinsmedicine.org/news/media/releases/new_and_comprehensive_study_of_diabetes_care_in_trinidad_and_tobago_released).

15 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 in two (2) health centres – the Chaguanas • Survey of BMI repeated in 2017. Health Centre, and the Arima Health Centre. - Primary School Nutrition Quiz to build health literacy iv. The Tobacco Control Regulations intended to about NCD risk factors and healthy lifestyles developed deal specifically with the packaging and labelling and implemented from 2008 to present. of tobacco products was developed and passed ii. The “Check Yuhself ...Know Your Numbers” Campaign, in 2013. Implementation is expected to be developed by MOH over the period 2011 to 2014, enforced in 2017. was implemented in all RHAs and in settings outside v. Establishment of a dedicated Tobacco Control Unit the health centres (in workplaces, schools, farmers’ in 2014 to enforce and monitor the markets, FBOs, and other community settings). implementation of the Tobacco Control Act and the This created increased access for persons to receive Tobacco Control Regulations. health screening for key biological risk factors of NCDs - blood pressure, blood sugar, BMI, cholesterol Reduction in Harmful Use of Alcohol level. The campaign also increased awareness i. National Policy on Alcohol developed. about the actions to be taken to get to recommended target values. Over the period 2011 to 2014, over ii. The National Alcohol and Drug Abuse Prevention 25,000 persons were screened for NCD Risk Factors in Program (NADAPP), in collaboration with CARIAD, programmes conducted by RHAs, the Health Education OAS, and the National Drug Council (NDC), trained Division, and NGO partners. persons from the health sector, other public sector agencies, and NGOs in alcohol and drug use iii. Fight the Fat Campaign, 2012-2014. prevention and treatment. - Three cohorts of persons (approximately 75) iii. Development and enactment of legislation for including public sector workers, NGO partners, and the use of the breathalyser. Enforcement of laws persons from FBOs were trained as Lay Health to prevent drunk driving, for example, increased Promoters, and NCD Peer Educators. use of breathalyser. iv. Caribbean Wellness Day (CWD) Unhealthy Diet and Physical Inactivity �� - Caribbean Wellness Day is commemorated annually and used to catalyse joint actions by multiple sectors i. Campaigns targeting healthy eating and active living for NCD prevention and control. Celebrations have developed and implemented in varied settings from been expanding annually throughout the country 2008 to present. since it started in 2008, and now each RHA develops - Move Into SHAPE T&T campaign implemented and implements coordinated programmes of activity post Declaration of POS from 2008 to 2010, and to highlight critical actions for NCD prevention and NCD health education campaign promoting: control in alignment with the CARICOM framework ��. • Screening for NCD risk factors Childhood Obesity • Healthy weight i. Childhood Obesity Camps, themed ‘Healthy Me’ • Avoiding use of tobacco and alcohol implemented to empower children assessed as • Physical activity overweight or obese to build healthy lifestyles skills and • Eating healthy. work toward achieving health targets for improved - National School Health Policy drafted. well-being. The camps concentrate on three (3) main thematic areas: Healthy Me, Active Me, - Workplace Health Promotion Policy for Loving Me. The camps have been implemented in Public Sector Agencies drafted. community settings, in collaboration with a coalition of Workplace Healthy Lifestyle initiative developed  partners from RHAs, NGOs, other sectors, and academia and piloted in the MOH and implemented in annually from 2012 - 2015. public sector workplaces with focus on Staff Health Assessment and health education. ii. The Draft Childhood Obesity Prevention Policy has been developed. - Research on childhood obesity in TTO iii. Nutrition Standards for Food Sold to Children • Survey of BMI and Evaluation of School Meals in Schools developed. Options conducted in primary and secondary schools in 2009. iv. School Health Education programme, “Healthy Me” �� Johns Hopkins Medicine. n.d. “Trinidad and Tobago Health Sciences Initiative: Johns Hopkins Medicine International.” Johns Hopkins Medicine. Retrieved April 25, 2016 (http://www.hopkinsmedicine.org/international/international_affiliations/latin_america_caribbean/trinidad_tobago_health_sciences_initiative.html). �� Barnoya, J., & Yan, Y. 2013. Trinidad and Tobago and cardiovascular disease mortality. Possible causes and implications. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 16 for reduction of risk factors of NCDs was developed i. The MOH also has SOPs and treatment and care and introduced at primary school level. protocols for NCDs in secondary care. v. Healthy Lifestyle Clinic for Management of ii. The Maternal and Child Health Manual was revised, Children with NCDs established in 2012, at the published, and distributed to stakeholders in 2015. Wendy Fitzwilliam Children Hospital to treat and iii. Diabetic and cardiology outreach programmes support children assessed as obese in the schools initiated. Through collaboration among many and/or referred for management of diabetes or other ministries, academic institutions in TTO, the Johns NCDs. A multidisciplinary team comprised of Hopkins Medicine International (JHMI), and local paediatric endocrinologists, paediatricians, organisations the following was achieved �� �� �� : nutritionists, and nurses serve the clinic. a. Cardiology outreach programme. Clinicians Progress Made completed 24 months of comprehensive i. Over 2,000 primary school students have participated cardiology education and training in cardiac in the School Health Caravan. BMI was assessed to catheterisation, electrophysiology, monitor risk profile of children. echocardiography, and preventive medicine. ii. Companion Healthy Lifestyle Reader developed to b. Diabetes outreach programme. Programme provide information about healthy eating and physical development and evaluation can now be guided activity and chronic diseases. by the data collected from 16,920 patients. Three white papers developed based on evidence iii. Over 250 teachers of participating schools were collected on the state of care of diabetics, barriers screened for NCD risk factors. to self-care of diabetics, and the prevalence of iv. Over the period 2010 to 2016, over 350 primary obesity in primary school children. schools participated in the National Primary School c. The diabetic retinopathy screening pilot Nutrition Quiz. This quiz serves to evaluate learning programme was undertaken in SWRHA. after exposure to the school health education caravan and use of the companion Healthy Lifestyle Reader d. 2112 individual patient diabetes education for Primary Schools. sessions were conducted. v. Annually, at least six (6) Childhood Obesity/Healthy e. The Certified Caribbean Diabetes Educators Lifestyle Camps are conducted. (CCDE) course was adapted for T&T. vi. Specialist paediatric clinics introduced in 2014 at two SURVEILLANCE AND RESEARCH health centres in the NWRHA to focus on the health Population based Surveys and development of children. These clinics include childhood obesity prevention services implemented i. The PAHO/WHO STEPS Non Communicable by a multidisciplinary team of health professionals. Diseases Prevalence and Risk Factor Survey (STEPS), which was undertaken in 2011 �: STRENGTHENING OF CLINICAL CARE CAPACITY a. established baseline data on NCD risk factors for chronic diseases in the population that would allow The Chronic Disease Assistance Programme (CDAP) tracking trends over time, and monitoring i. The GORTT expanded the CDAP, which provides achievement of targets, and citizens afflicted with NCDs with approximately 51 b. determined prevalence rates for diabetes, prescription drugs, free of charge, at all public health hypertension, and elevated cholesterol. facilities and most private pharmacies nationwide.  Since 2008, it now includes the provision of free blood ii. Evaluation of School Meals Options and Survey glucose testing strips to diabetics ��. of BMIs completed. Evidence-based National Guidelines/Protocols/ iii. GSHS and GYTS conducted. Standards Research Guidelines for the management of diabetes, hypertension, and depression in primary care have i. A national research agenda for NCDs has been been approved. These guidelines were disseminated developed and implementation is being scaled up. to the RHAs, and health care workers in the RHAs were ii. MOH and PAHO conducted a review of CVD trained. data over the period 2004-2010. Results showed that CVD mortality declined by 18.8 over the last 10 years ��.

17 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 STRATEGIC FRAMEWORK A. PURPOSE Goal To provide strategic direction to an effective, By 2025, reduce the burden of preventable mortality coordinated national response to the priority NCDs, (before the age of 70) due to heart diseases, diabetes, namely heart disease, diabetes, cancer, and stroke, cancer, and stroke by 25% and associated risk factors. It facilitates utilisation AND of the “whole of government” and “whole of society” approaches to achieve the goal. The Strategic Plan In five years, reduce the prevalence of: provides the outcomes to which the efforts of all stakeholders must be focused. i. High blood pressure by 20%; ii. High cholesterol by 20%; CONTEXT iii. High blood sugar by 20%; iv. Adult overweight/obesity by 10%; The NSP NCD is aligned with numerous frameworks v. Adolescent overweight/obesity and other strategic plans at many levels. At the (ages 13 – 15 years) by 12%; national level, prevention, and control of NCDs have vi. Child overweight/obesity by 15%; been identified as a priority on the Health and National Development Agenda of the Republic of Trinidad Principles/Approaches and Tobago ��. • Multisectoral Action - the solutions for addressing NCDs formed one of the priorities in Caribbean the epidemic lie outside the health sector. Cooperation in Health (CCH) III and in the new CCH IV It is imperative that all sectors be engaged in a broad (2016-2020). Emphasis was placed on translating based response with full participation of the relevant the commitments of the GORTT to the NCD agenda at government sectors, civil society, private sector, different levels, particularly an ensuring its alignment and the media. Partnerships, strategic alliances, and with the Port-of-Spain Declaration (2007) ��. networks among and within sectors must sustain This Declaration influenced the development of the UN the response. Political Statement on NCDs in 2011. • Health Promotion - empowering individuals The other strategic frameworks that informed this and communities to take advantage of an enabling Strategic Plan were: environment to control, improve, and maintain physical, mental, social, and spiritual well-being. • PAHO Regional Strategy - Integrated Approach the Prevention and Control (P&C) of Chronic Diseases • Primary Health Care and Prevention- including Diet, Physical Activity & Health, 2007 with due consideration to the spectrum of services for prevention, treatment, care, rehabilitation, and • Political Declaration of the High Level Meeting of the support, utilising evidence based standards of care. UN General Assembly on the Prevention and Control Services must be reoriented to be patient-centred, of NCDs, 2011 (Resolution A/RES/66/2) with seamless coordination among levels of care • CARICOM Strategic Plan of Action (POA) for the P&C and incorporation of health promotion and disease of NCDs, 2011-2015 prevention along the life course (Appendix 5). • WHO Global Plan of Action for the P&C of NCDs, • Evidence-based – policies, programmes, strategies 2013-2020 or interventions based on the latest scientific evidence and/or best practice, proven cost • PAHO Regional POA on NCDs, 2013-2019 effectiveness, affordability, and public health • Outcome Document of the High-level Meeting of the practices, taking cultural considerations and national UN General Assembly on the Comprehensive Review experience into account e.g. WHO Best Buys and Assessment of the Progress Achieved in the (see Appendix 6). Prevention and Control of NCDs, 2014 • Equity and Universal Health Coverage – (Resolution A/RES/68/300) all people should have access, without discrimination, C. GOALS AND STRATEGIC PRIORITIES to nationally determined sets of the needed promotive, preventive, curative, and rehabilitative Vision basic health services and essential, affordable, Happier, healthier, fitter people…living longer and more quality medicines without it causing financial productive lives. �� Ministry of Planning and Development, Government of the Republic of Trinidad and Tobago. 2006. -Vision 2020 Operational Plan 2007-2010. Retrieved from http://www.transforme.gov.tt/sites/default/files/sites/default/files/library/documents/Vision%202020%20Operational%20Plan%202007-2010.pdf �� CARICOM. 2007. “DECLARATION OF PORT-OF-SPAIN: UNITING TO STOP THE EPIDEMIC OF CHRONIC NCDs.” (http://caricom.org/media-center/ communications/statements-from-caricom-meetings/declaration-of-port-of-spain-uniting-to-stop-the-epidemic-of-chronic-ncds). National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 18 hardships and/or impoverishment. This is based status, as enshrined in the Universal Declaration of on the human rights approach which recognises that Human Rights. the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other

19 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 PRIORITY AREAS AND TARGETS There are four priority areas in this National Strategic Plan for Prevention and Control of NCDs: TABLE 5: PRIORITY AREAS, SPECIFIC OBJECTIVES, AND TARGETS. PRIORITY AREAS TARGETS Priority Area #1: • Reduce proportion of adults (aged 18+ years) and adolescents Risk Factor Reduction and engaging in insufficient physical activity by 20%; Health Promotion • A 5% relative reduction in mean population intake of salt/sodium; 1. Specific Objectives • Increase the prevalence of adult (aged 18+ years) population 1.1. Reduce use of tobacco, consuming ≥ five total servings (400 grams) of fruit and ENDS/ENNDS and vegetables per day by 20% by 2018; related products • Reduce the harmful use of alcohol among persons 15+years by 1.2. Reduce the harmful 10% and among youth aged 13-15 years by 10%; and use of alcohol • Reduce the prevalence of current tobacco use in persons aged 15+ 1.3. Increase availability, years by 10% and among adolescents 13-15 years by 10%. accessibility and consumption of healthy foods 1.4. Increase levels of physical activity Priority Area #2: • Implement the comprehensive chronic care model/NCD treatment Comprehensive and protocol for at least 70% of all primary health care facilities; Integrated Care and • Implement self-management education based on guidelines for Management for NCDs the treatment and care for 80% of persons with NCDs; 2. Specific Objective • Admissions to hospitals for heart attacks and strokes reduced by 30%; 2.1. Provide quality, people-centred, • Rate of diabetes-related lower-limb amputations evidence-based care for the decreased by 20%; integrated management of • Maintain universal access (CDAP) for availability of essential NCDs and their risk factors, medicines for the treatment and care of NCDs in the public and using a PHC approach (Health private sectors; Promotion, Prevention, • At least 70% of eligible people receiving drug therapy and Primary Care Management, counselling (including glycaemic control) to prevent heart attacks and Treatment). and strokes; • Increase by 50% the proportion of persons who are aware of their disease status with regards to hypertension, diabetes dyslipidaemia and cervical cancer; and • Increase by 50% the proportion of persons with hypertension, diabetes, and dyslipidaemia for whom the condition is controlled in keeping with recommended targets. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 20 PRIORITY AREAS TARGETS Priority Area #3: • Foster and develop the research capacity, agenda and database Surveillance, Monitoring and for NCDs with government sectors, academia, civil society, private Evaluation, and Research sector, and the NGOs within the first two years e.g. the DERPi research project to conduct maternal diabetes screening and early 3. Specific Objective detection and management; 3.1. Strengthen national • Scale up the screening for cervical cancer to a national capacity for programme; surveillance of NCDs, their risk factors, • Develop and implement National Chronic Disease Surveillance determinants and System and Unit within the first two years; consequences, as well • Improve the quantity and quality of NCD data by at least 90% as for monitoring of based on international criteria; health interventions • Institutionalise the analysis of international, regional, and local and national trends and targets in prevalence of the NCDs and their risk factors programme and the degree of implementation of national NCD programmes; implementation; and and promote research for prevention and control • Develop and implement a monitoring and evaluation plan for all of NCDs. the components and programmes under NCDs and the continuous tracking of the core targets, strategic priorities, and outcomes for NCDs. Priority Area #4: • Develop and institute all of the appropriate governance Governance, Policy, arrangement to effectively manage, operationalise, and monitor and Advocacy all the components, programmes and strategic priorities and outcomes under NCDs; 4. Specific Objective • Foster strategic partnerships with wider government sectors, 4.1. To ensure effective academia, civil society, private sector, and the NGOs for the design leadership, and and implementation of NCD programmes; governance for multisectoral • Incorporate and institutionalise the concept of “Health in coordination, all Policies” to the wider government and society with an partnerships, and appropriate portfolio of policies for an effective NCD prevention healthy public policies and national response; for implementation of • Adequate sustainable and predictable funding to support the NCD the strategic plan. programmes secured; • Ensure all of the components are adequately staffed and supported with the required resources; and • Reduce/eliminate the use of soft drinks in schools by implementing the National Nutrition Standards for Foods Offered to Children.

21 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 KEY PLANNED ACTIONS TABLE 5: Trinidad and Tobago National Strategic Plan for the Prevention and Control of Noncommunicable Diseases PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS 1 1.1 1.1.1 Policy Brief MOH –TCU, HPRP NADAPP Risk Factor Reduce the Develop policy for developed. Min of Legal Affairs, Reduction and prevalence of current Electronic Nicotine Draft policy produced Min of Education, Health Promotion tobacco use in Delivery Systems/ and submitted for NPTA persons aged 15+ Electronic approval. years to 13% and Non-Nicotine among adolescents Delivery Systems 13-15 years by 10% (ENDS/ENNDS) in 3 years. 1.1.2 Draft amendments to Legislation reviewed MOH – Legal MOH Legal Dept., tobacco control and amendments Department, TCU, Min of Legal Affairs, legislation to include identified. ENDS/ENNDS. Legal Brief prepared and submitted to CPC for review 1.1.3 Strengthen and Cadre of 60 health MOH –TCU, HED PAHO, MOH/CMOH expand smoking professionals and RHAs, NGOs, cessation programme NGOs trained in in primary care delivering cessation settings. services. 20 primary care RHAs, THA PAHO, NGOs – supervisors trained MOH –CMOsH Cancer Society, Chest to design tobacco and Heart Assoc, treatment programs Heart Foundation, for its integration DATT into PHC. One (1) additional smoking cessation clinic established at the primary care level. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 22 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS 1.1.4 Develop and TORs for consultancy HCU, NCDU, HED, NADAPP, IADB implement services to develop evidence-based social marketing / tobacco use behaviour change prevention public interventions education and promoting smoke- awareness program free living in youths for youth and adults developed. 1.2 1.2.1 TORs for MOH, NADAPP, UWI Reduce the harmful Develop Policy on establishment of HPRP, HED use of alcohol among prevention of harmful multisectoral Alcohol persons 15+years by use of alcohol by Policy committee 3% and among youth children and youth developed and aged 13-15 years by approved. 5%. HED, PAHO, UWI, AA, Multisectoral Alcohol MOH, NADAPP, HPRP Policy committee established. Policy brief for MOH, NADAPP, prevention of harmful HPRP, HED use of alcohol developed. 1.2.2 TORs for consultant MOH, NADAPP, Draft an alcohol to develop alcohol HPRP, HED marketing and marketing and education strategy education. targeting prevention Initiative developed. of alcohol use and abuse by children and youth.

23 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS 1.3 1.3.1 Increase availability, Development of Finalize Childhood MOH-HPRP, HED, CARPHA, NSDSL, accessibility, and policies on marketing Obesity Prevention N&MD PAHO, MOE, MOA, consumption of of high fat, high Policy. NPTA healthy foods and sugar, high salt foods, promote physical and sugar sweetened National Nutrition MOH-HED, HPRP, RHAs, CARPHA, activity. non-alcoholic Standard for Food N&MD, CMOsH NSDSL, PAHO beverages in keeping Offered in Schools with WHO guidelines, revised and approved. and policies on RHAs, MOE, MOA, access to health Guidelines for use of NPTA, UWI, USC, nutrition for children National Nutrition TTANDi along the life course. Standard developed. National School MOH-HED, HPRP, PAHO, CARPHA, Health Policy revised N&MD, SHP, HACU, UNICEF and submitted for CMOsH approval. Young Child Feeding MOH- CMO, CARPHA, PAHO, Policy finalised and AHPC&PH HPRP, TTANDi, Paediatrician submitted for N&MD, CMOsH RHAs Assoc approval. Consultation on Young Child Feeding Policy conducted. Review of MOH- CMO, CARPHA, PAHO, implementation of AHPC&PH N&MD, TTANDi, Paediatrician new WHO Growth HED, CMOsH RHAs Assoc Monitoring Standards in the RHAs. Assessment of equipment and records/ forms for implementation of WHO Growth Monitoring Standards conducted. 1.3.2 Establish baseline for Salt Study proposal MOH- AHPC&PH, PAHO, CARPHA population sodium revised and CMO, HPRP, HED and Trans fat intake. submitted for CMOsH approval. TORs for Consultant /Researcher to conduct Salt Study developed and approved. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 24 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS Consultant retained. Trans fat study reviewed and MOH- CMO, PAHO, CARPHA submitted for AHPC&PH, HPRP, approval. HED CMOsH TORs for consultant to conduct Trans Fat Study developed and approved. Consultant /Researcher to conduct Trans Fat Study retained. PAHO Trans-fat Fee Americas Strategy adopted. Policy Brief on marketing of high fat, MOH- CMO, PAHO, CARPHA, high salt, high sugar AHPC&PH, HPRP, TTANDi, Corp Comm, foods to children HED, N&MD, CMOsH MOE developed. Consultation on Policy on marketing MOH- AHPC&PH of high fat, high salt, CMO, HPRP, HED high sugar foods. CMOsH 1.3.3 Workplace Health Implement Promotion policy MOH - HED, HPRP, PAHO, CARPHA, Workplace Health revised HR, CMOs RHAs Promotion policy promoting physical Action plan for activity and access to MOH- HED HPRP, HR PAHO, CARPHA implementing healthy foods in CMOsH Workplace Health public sector Promotion Ministries programme developed. Survey of existing Workplace Healthy Lifestyle programmes in government ministries. Workplace Healthy Lifestyle programmes MOH - HED, HPRP, in government CMOsH ministries. Workplace Health MOH - HED, HPRP, Promotional Tool Kit CMOsH developed

25 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS Manual for Training of MOH - HED, N&MD, Workplace Lay Health CMOsH, RHAs Promoters developed Consultant for MOH- HED, N&MD, developing CMOsH, RHAs Workplace Toolkit and Training Manual retained 1.3.4 Develop health Healthy Lifestyle MOH- HED, N&MD PAHO, RHAs, MOE, education and social School Health CMOsH, Corp Comm N&MD, DATT, marketing campaigns Education program TTANDi, NSDSL, promoting healthy reviewed and NAMDEVCO, eating and active updated NADAPP, living in collaboration with public, private, Healthy Lifestyle MOH- HED, N&MD MOE, PAHO, Corp and civil society School Health CMOsH, RHAs, Corp Comm, RHAs, NGOs, stakeholders. Education Comm and CBOs programme (for Primary Schools) re. NCDs and their risk factors, implemented in 10 schools in each County. Public Education MOH - HED, N&MD, /Behaviour Change CMOsH campaign promoting fruit and vegetable use developed. TORs for consultancy MOH- HED, N&MD PAHO, RHAs, MOE, services to develop CMOsH, RHAs, Corp MOA, NGOs and Public Education Comm CBOs /Behaviour Change developed and Consultant retained. Current Health CARPHA, PAHO, Education/IEC RHAs, MOE material promoting healthy eating and active living revised and reproduced. Seminar conducted MOE, NPTA, TTUTA, for parentVs, NGOs teachers, NGOs, and civil society groups to build advocacy for healthy foods conducted. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 26 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS Parent education CARPHA, PAHO, material in support of TTMA Infant and Young Child Feeding Policy and implementation of new WHO Growth Monitoring Standards developed. 2. 2.1 2.1.1 Integrated care and Standardised SOPs Audit adherence to Audit conducted and MOH- CMO, PAHO, TTMA, UWI management of and treatment CHRC guidelines for report prepared. AHPC&PH, HPRP, NCDs and their risk protocols developed diagnosis, treatment, THA, CMOsH factors risk factor. for the major NCDs and support of diabetes and hypertension. Round table/ MOH - CMO, Symposium on use of AHPC&PH, HPRP, standardised CMOsH, RHAs, THA treatment protocols conducted for primary care professionals. 2.1.2 Adoption of Chronic Review of Chronic MOH - AHPC&PH, PAHO, TTMA, UWI Care Model (CCM) and Care Model (CCM) CMO, HPRP, HED, for use in managing conducted. CCM CMOsH, RHAs, THA persons with NCDs customised for use in Trinidad and Tobago. Trinidad and Tobago. Twenty five (25) MOH - AHPC&PH, primary care HED, CMOsH, RHAs, professionals trained THA, HCU as trainers in use of CMM for the management of NCDs conducted At least one (1) MOH - CMO, HPRP, workshop on the HED, CMOsH implementation of CCM in PHC implemented in each county. Evaluate implementation of “Point of care” testing in health centres.

27 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS Treatment and management protocols for the major NCDs reviewed and recommendations made for the harmonisation of practice across the 2.1.3 RHAs. Community and NCD Risk Factor MOH - CMO, CMOsH, RHAs, THA, CARPHA, settings based NCD Screening Plan for HED, HPRP, HR PAHO, NCD Alliance risk factor screening use in community and other related programme designed. settings reviewed NGOs and CBOs and updated. Healthy Lifestyle MOH - CMOsH, HED, CARPHA, PAHO, Passport reviewed NCDU, HPRP TTMA and amended for use as a self-management tool. NCD Risk Factor MOH - CMOsH, HED, CARPHA, PAHO, Screening NCDU, RHAs, THA TTMA, NGOs related Programme in to NCDs, CBOs community settings established and implemented in each RHA to screen at least 5 000 persons annually. NCD Risk Factor MOH - CMO, CMOsH, PAHO, CARPHA Screening detailing HED, HPRP, HR distribution of risk factors (behavioural and biological) and referrals for follow up care submitted to MOH annually. TORs for design of MOH - HED, HPRP, PAHO, RHAs, THA, social marketing AHPC&PH, CMO CARPHA, PAHO, campaign promoting DATT, Cheast and annual pap smear, Heart Association, breast NSDSL, TTANDi, NCD self-examination, and Alliance and other accessing annual related NGOs and NCD risk factor CBOs screening. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 28 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS 2.1.4 Strengthen early Implementation of MOH - CMO, EPI, PAHO, TTCS, RHAs, detection and the HPV vaccine NCDU, HED, CMOsH THA treatment of major strategy reviewed. cancers: cervical, breast, prostate, Review existing MOH - CMO, NCDU, colon, lung cancer. cancer screening Executive Advisor to programme for the Minister of cervical, breast, and Health, Health prostate screening in Systems Advisor, primary care settings. CMOsH, RHAs Standardise cancer screening protocols developed for cervical, breast, and prostate cancers. Review of National Cancer Plan. Identify components for implementation in 2018-2019. Extract key actions from National Cancer Plan and develop two (2) year implementation plan for prevention, early detection and treatment of major cancers by the end of 2017. Host National Symposium of Cancer by end 2017 to share with key stakeholders. 3. 3.1 3.1.1 Surveillance, Improve quality of Surveillance system NCD Core data set MOH - AHPC&PH, RHAs, THA, CARPHA, Monitoring and NCD data and for NCDs, their and data capture CMO, HPRP, NCDU, PAHO, CSO, UWI, Evaluation and establish real time determinants and forms designed and NSU private sector Research NCD surveillance data risk factors designed. piloted in two (2) pilot capture and reporting sites in at least two from public health (2) RHAs. sector. Community health services reporting matrix redesigned to capture NCD health system indicator data.

29 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS Patient self check MOH - HPRP, NCDU, assessment for NSU nursing notes designed and piloted in two (2) RHAs. 3.1.2 Track local trends in Strengthen Cancer MOH - CMO, CARPHA, PAHO, the prevalence of the Registry and update AHPC&PH, HPRP, RHAs, THA NCDs and their risk analysis of cancer NCDU, NSU factors, and analyse data to present day. the efficacy of implementation of Develop plan for MOH - HED, CSO, IADB, PAHO, national NCD establishment of AHPC&PH UWI, RHAs, THA programmes. other NCD registries. Develop plan for MOH - CMO, CARPHA, CSO, UWI, implementing STEPS AHPC&PH, HPRP THA survey. BMI Survey in MOH - CMO, CARPHA, CSO, MOE, Schools conducted. AHPC&PH, HPRP, THA CMOsH, N&MD GSHS and GYTS PAHO, CDC, CSO, repeated. MOE, THA Review health centre RHAs, THA, CARPHA, growth monitoring PAHO data on <5 children to establish obesity levels in the 0-5 years population group. 4. 4.1 4.1.1 Effective leadership Dedicated budget for NCD governance Transitional NCD MOH - AHPC&PH, NSU, RHAs,THA, and governance for NCDs developed. strategy Working Committee NCD Plan Oversight IADB, PAHO, implementation of implemented. identified and TORs Committee, CMO, CARPHA, public Strategic Plan, issued. NCDU, HSHRPDU, sector, NGOs, civil multisectoral action HR, CMOsH society, private sector and HiAP as it applies to NCD prevention and control. NSP NCD approved. NSP NCD published and widely disseminated National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 30 PRIORITY TARGETS YEAR 1 OUTPUT LEAD AGENCY OTHER SECTORS/ AREAS ACTIONS INDICATORS OR INSTITUTION STAKEHOLDERS National NCD MOH - AHPC&PH, Symposium NCD Plan Oversight convened to bring Committee, CMO, together researchers NCDU and implementers in all sectors towards the achievement of the objectives of the NSP NCD. High-level MOH - AHPC&PH, multisectoral NCD Plan Oversight National NCD Committee, CMO, Intersectoral NCDU Mechanism established to coordinate public, private, and civil society response in relation to the NSP NCD. High-level intragovernmental NCD mechanism (reporting to Cabinet) designed. 4.1.2 Human Resources TORs for consultant MOH - AHPC&PH, IADB, PAHO, Plan for to develop HR plan NCD Plan Oversight CARPHA, RHAs, THA, implementing NCD for supporting Committee, CMO, CMOsH, PMCD Strategic Plan implementation of NCDU, HSHRPDU, HR developed. the NSP NCD developed. NCD Unit in the MOH established and positions filled. Consultant retained. Nursing curriculum MOH - AHPC&PH, PAHO, Nursing reviewed and CMO, NCDU, CNO, Council, RHAs, strengthened in HSHRPDU, HR CMOsH, UWI, USC, support of the NCD TTMA programme needs at the primary and secondary levels. Clinical updates conducted for primary care professionals and allied health professionals in NCD prevention and care.

31 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 APPROACH TO IMPLEMENTATION AND MONITORING AND EVALUATION Implementation will be guided by the same principles o Services must be reoriented to be patient-centred, and approaches selected for the development of the with seamless coordination among components Strategic Plan. and levels of care and incorporating health promotion and disease prevention. • Multisectoral Action - It is imperative that all sectors be engaged in a broad-based response with o For individuals, at each contact with the health full participation of the relevant government sectors, system, their total needs for NCD prevention and civil society, private sector, and the media. control must be addressed. Partnerships, strategic alliances, and networks • Evidence-based – collaboration between policy among and within sectors must sustain the response. makers, researchers, and implementers will be critical o Achievement of the WOG and the WOS approaches to setting the research agenda and as importantly to will be accomplished through a governance translating the findings taking cultural considerations structure that includes the establishment of a and national experience into account. cabinet level mechanism for inclusion of NCDs • Universal Health Coverage – in applying the on the policy agenda of all ministries and the principle of equity, rather than equality, emphasis HiAP approach. Supporting this high-level will be placed on increasing the depth of knowledge mechanism, there would need to be a mechanism and understanding, among health and related for the engagement of all sectors simultaneously professionals, of the inequitable distribution - the WOG/WOS approach - through the of social determinants that exist at the establishment of a Cabinet appointed council, community level. Age, gender, and ethnicity commission, or an analogous body on NCDs, as dimensions will be incorporated into the design and recommended in the Declaration of Port-of-Spain. execution of policies and interventions. The Minister of Health will initiate or leverage meetings of Ministers and/or Permanent THE STRATEGIC PLAN WILL BE Secretaries to monitor the WOG approach. IMPLEMENTED IN PHASES: o It is critical that stakeholders, including the • Phase I will last one year – there will be a focus public, be kept informed. A communication on strengthening the capacity of the MOH to support strategy will be developed in Phase 1, and the national multisectoral response. A dedicated NCD its implementation monitored throughout Unit will be established with a multisectoral team and the five years. reporting to the Permanent Secretary. Among the first actions for the Unit will be the development o For meaningful participation of stakeholders of an Action Plan for year 1 and the Monitoring and and partners, capacity-building opportunities will Evaluation Framework. During this phase, be integrated throughout the first 2 years. opportunity will be taken to finalise and seek • Health Promotion – individuals and communities approval for draft policies and to discuss with all will be empowered to contribute to and to take sectors their role in the response to NCDs. This advantage of an enabling environment for their phase will also see the completion of the mobilisation health through their involvement in decision for the implementation of the IADB loan. making. The MOH and other government sectors will • Phase II will last 3 years and will see the provide technical guidance with evidence and intensification of the implementation of the plan with promote culturally sensitive solutions rather than be the execution of Annual Action Plans and the prescriptive. The private sector will be urged to take reporting to the citizenry through the Partners the lead in promoting and advancing the health of the Forum plans. workforce. • In Phase III, Year 5 the achievements under the • Prevention-focused Integrated Care – while this Plan will be evaluated and recommendations made. will be centred on the primary care centres there Subsequently, another five-year plan with be will be due consideration to ensuring that package of developed for the period 2020 – 2025. services agreed to for treatment, care, rehabilitation, and support are provided. Integration will be sought The implementation of this plan will build on and at two levels: optimise on-going efforts of numerous stakeholders in National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 32 the public and private sectors. Experiences and lessons sector must be accompanied by budgetary inputs from learned from CARICOM neighbours and countries in the numerous sources. wider regional and global community will be sought With respect to the public sector, the GORTT taking Robust monitoring and evaluation will be critical to the into account its national economic and fiscal situation, results-based approach to management and continuous will endeavour to address its global commitment to “… planning and programming of the national response to increase and prioritise budgetary allocations…” for the the NCD epidemic. Monitoring will allow the whole of prevention and control of NCDs. In particular, efforts society to be confident in its celebration of achievement will be made to adequately resource the national of the targets and evaluation will determine if the coordinating mechanism (NCM) and the NCD Unit interventions selected have been effective and at in the MOH. In this regard, the GORTT will explore affordable costs. creative mechanisms to dedicate the revenues derived from tobacco, alcohol, and other such products for the This Plan does not include the full monitoring and prevention and control of NCDs and for the operations evaluation framework. Table 5 summarises the targets of the “Commissions”, as stated in the Port-of-Spain that will form the basis of the global monitoring and Declaration. TTO’s contribution to this. Development of the detailed framework to facilitate monitoring of the progress The budget for the national strategic programme will be towards the specific objectives will be given priority in developed for each annual action plan and submitted the first year. This will be comprehensive and aligned for approval within the national budgeting process. It to address reporting monitoring commitments made will be important for the NCD Unit to be able to report at the global, regional LAC, and CARICOM levels. The on the totality of the budget and expenditure on NCDs aim will be to have and promote with donors the use of especially within the public sector. “ONE Monitoring Framework”, a lesson for efficient use The availability of the IADB Loan will present a unique of limited resources, learned from the HIV sector. This opportunity to accelerate the implementation of the needs to be complemented by the building of capacity strategic framework. However, all loans are finite and for monitoring and evaluation among partners in the have to be repaid. Thus, from the beginning, attention government and non-government sectors. will be paid to the efficiency of the implementation BUDGETARY CONSIDERATIONS of the loan program of work. In addition, the national coordinating body will collaborate with the NCD Unit to While the government has responsibility for the develop a resource mobilisation strategy to ensure the leadership and coordination of the national response, sustainability of the critical interventions after the the multisectoral nature of the response requires that loan period. the full engagement of many government ministries and agencies as well as from the civil society and private

33 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 APPENDICES

APPENDIX 1: SWOT ANALYSIS Strengths Weakness • Political will and commitment evident. • Incoherence among sectoral policies; missed opportunities for NCD friendly policies. • NCDs are identified as a priority in the • Several policies to modify NCD Risk Factors are in national development agenda of the Republic of different draft stages. Trinidad and Tobago. • There is inadequate ongoing monitoring and evaluation • The MOH has a Strategic Plan for the Fiscal Years of the national response, including at RHA level. 2012-2016, (MOHSP) which is closely aligned and coherent with the direction given for health • Gaps in governance - No national coordinating mechanism. • Well trained cadres of CMOsH • There is no dedicated NCD Unit in the Ministry of Health. • Adequate network of health centres in terms of numbers; Tobago has highest ratio to population. • No standing process for joint planning and monitoring of programmes with the MOH and RHAs. • Active participation by NGOs, private sector, and academia. • In the absence of a national policy based on the Chronic Care model adopted by CARICOM, each RHA has • Health Education Unit with experience in addressing developed different initiatives to address the NCD wide range of public health challenges prevention, treatment, and care. • Some baseline data available from the 2011 • Overlap in the functions of the RHAs and the CMOsH STEPS survey. with respect to surveillance of population health. • Critical lack of nursing personnel, especially in community health services where knowledge of the Opportunities multiple cultures and ability to communicate in English are important. • Need to introduce new disciplines to provide • Better use could be made of the development and comprehensive national response of health promotion, monitoring of the Annual Services Agreement for the disease prevention, treatment, support, and acceleration of the evidenced-based actions required to rehabilitation. achieve national NCD objectives, indicators, and targets. Information Systems and Information Technology • CMOsH well trained in public and community health. • National Surveillance Unit mandate does not include • Range of training institutions available. routine surveillance of NCDs. With better coordination and joint planning human • Inadequate health information systems and technology resource needs as defined in NCD work force plan support to seamless chronic care across levels and to could be met. facilitate monitoring of response. • Limited funding available should redirect focus on to Financing primary care. • Resource allocation favours secondary and tertiary care. • Revitalisation of multisectoral coordination governance of response to HIV. • There is no dedicated budget for NCDs, in particular for PPP is one of key strategies for achievement of promotion, prevention, and research. political priorities. • Agriculture is a new priority. • Local government reform should strengthen Threats community approaches. • Mounting pressure to open additional hospitals and hospital beds. • Current economic climate requires reduction in public expenditure. • Downturn in the economy leads families to purchase cheaper obesogenic foods. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 34

APPENDIX 2: STAKEHOLDER ANALYSIS the sectors and actors. Participation of all sectors and actors is needed at the planning as well as Reducing the risk factors of NCDs calls for the implementation stages in order to mobilise the engagement of nearly all sectors within, and outside intellectual capital, expertise, and human and of, the government. It also calls for recognition that financial resources for creative interventions. the selection of healthy lifestyles is influenced by Table 7 below provides a glimpse into the number many factors outside of the control of individuals. of partners that could be involved in the response to The UN Political Declaration on the Prevention and NCDs in T&T. Control of NCDs, recognised that “…the rising prevalence, morbidity, and mortality of non-communicable diseases • Whole of Government (WOG) approach recognises worldwide can be largely prevented and controlled through that health is both an input for and benefit of collective and multisectoral action by all Member States development and that it depends to a large degree and other relevant stakeholders at the local, national, on the economic, physical, and social environment regional, and global levels,…” and included among the determinants – factors outside the remit of the public relevant stakeholders, individuals, and communities in health sector. This calls for joint planning to build into addition to that range of stakeholders identified below. all sector plans the policies, programs and This concept is incorporated into the two strategic interventions that would facilitate making healthy approaches to which the GORTT has committed: choices the easy choice . • Whole of Society (WOS) approach – built on the The WOS and WOG approaches are not new to T&T concept that health is everybody’s business. In or to the health sector. Since the mid-nineties, it has the case of NCDs, the necessary changes to achieve been a strategic approach to the expanded response to a reduction in the prevalence of the risk factors the HIV epidemic. Since 2011, it has been the approach require significant changes in the environment where adopted for the modernisation of the T&T civil service, in we live, work, and play, and socio-cultural shifts that which WOG is defined as ��: will not occur without the engagement of all NGOs – Health/NCD • Chest & Heart Association of T&T • Diabetes Association of T&T, • T&T Cancer Society Ministry of Health • Coalition for Tobacco Control Nearly all technical and • Family Planning Association of T&T non-technical units. • T&T Heart Foundation • Caribbean Sport Development Agency Regional Health Authorities Non-Government Non-Health NGOs – women’s organisations, CDAP youth and sports organisations; service clubs Government Non-Health Ministries/ Private Sector: Government Agencies • Insurance companies, Ministry of Food Production • Food & Beverage manufacturers & importers, Ministry of Trade, Industry, • Employers’ Confederation Investment and Communications • Chamber of Industries and Commerce Ministry of Education • Health and Wellness Businesses Ministry of Sport • Private Hospitals and Labs Ministry of Finance Ministry of Community Development Trade Unions Ministry of Legal Affairs Professional Associations e.g. TTANDi Media Medical Practitioners Academia - UWI: HEU, Medical Faculty; UTT, CARDI CARICOM Secretariat & CARPHA UN: PAHO, WHO, FCTC, UNDP, FAO, UNFPA Table 6: Stakeholders internal and external to the Government for the Response to NCDs. 35 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 “Public service agencies working across portfolio With regard to an effective response to NCDs, the most boundaries to achieve a shared goal and an common approach to engagement of stakeholders integrated government response to particular issues. is within the context of the risk factors and disease Approaches can be formal and informal. specific treatment and control elements. Tables 7 and 8 They can focus on policy development, program demonstrate that nearly all government sectors need to management, and service delivery.” participate in the efforts to reduce the prevalence of the modifiable risk factors of the NCDs.

APPENDIX 3: CROSS-SECTORAL GOVERNMENT ENGAGEMENT TO REDUCE RISK FACTORS NCD RISK FACTORS SECTOR Harmful use Tobacco Physical inactivity Unhealthy diet of alcohol Agriculture, Lands & Fisheries  X   Public Administration & Communication     Community Development, Culture & the Arts     Education     Housing & Urban Development     Labour & Small Enterprise Development     Energy X    Environment     Finance     Trade & Industry     Foreign & CARICOM Affairs     Health     Planning & Development   X  Legal Affairs  X   �� Ministry of Public Administration 2011 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 36 NCD RISK FACTORS SECTOR Harmful use Tobacco Physical inactivity Unhealthy diet of alcohol National Security  X   Tourism     Sports & Youth Affairs     Social Development & Family Services     Works & Transport     Rural Development & Local Government     Public Utilities    

APPENDIX 4: ROLES FOR KEY GOVERNMENT MINISTRIES MINISTRY POSSIBLE ROLES IN NCD PREVENTION AND CONTROL Health  Brief members of the Cabinet, and of Parliament on the status of the NCD epidemic and the need for multisectoral action.  Convene all ministries to plan and implement WOG plan of action including developing healthier workforce.  On-going surveillance of incidence and prevalence of NCDs and risk factors; monitoring trends and making projections.  Provide treatment, care and management of persons with NCDs.  Develop and implement food, nutrition, and physical activity policies.  House Secretariat for coordinating mechanisms. 37 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 MINISTRY POSSIBLE ROLES IN NCD PREVENTION AND CONTROL Agriculture, Lands & Fisheries  Review and revise existing policies on food security.  Develop measures to make fruit and vegetables more available and accessible.  Provide incentives to farmers to grow wide variety of fruits and vegetables. Community Development,  Introduce valuing health as integral to development. Culture and the Arts  Include as component of best village competition.  Competitions for creative use of local agriculture produce in healthy recipes prepared by adults & children and in the local retail food sector Education  Ensure the implementation, and monitoring and evaluation of health education curricula in primary and secondary schools.  Review policies on participation in physical activity for all students.  Review existing school meals programme; develop policies regarding the quality of food available in and around the school environment (in collaboration with National School Dietary Services).  Train teachers and other staff in health education to promote healthy lifestyles among children.  Establish mechanisms for the involvement of PTAs in healthy lifestyle programme.  Ensure healthy food available on school compounds and campuses.  Engage students in innovative health promotion programmes Finance  Review fiscal measures in relation to the manufacturing and importation of unhealthy foods.  Increase taxes on tobacco, in accordance with FCTC, and on alcohol and sugary drinks.  Reduce duties on exercise equipment National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 38 MINISTRY POSSIBLE ROLES IN NCD PREVENTION AND CONTROL Foreign Affairs  Coordinate position on global health issues across diplomatic fora.  Collaborate with MOH on interventions and promote participation of nationals in international health events. Labour & Small Enterprise  Develop policies on health promotion in workplaces and Development for workers and families.  Liaise with the trade unions on matters relating to health in the workplace.  Strengthen occupational health and safety programmes for worker’s health. Legal Affairs  Update or draft new legislation in support of NCD sensitive policies. Planning and Development  Establish policies for the development of recreational and green spaces in communities Public Administration  Ensure each Ministry develops health promotion programs and facilitate participation by civil servants. Sport & Youth Affairs  Ensure the Involvement of Youth Commissioners in community education programmes.  Integrate health promotion into all child development opportunities.  Develop programmes to encourage participation in sporting activities throughout the life course.  Improve safety and security in community sporting facilities. Tourism  Promote health and wellness tourism. 39 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 MINISTRY POSSIBLE ROLES IN NCD PREVENTION AND CONTROL Trade & Industry  Review trade agreements to identify instances where unhealthy choices are being facilitated.  Provide incentives for manufacturing of healthy products using indigenous foods.  Develop policies for food and nutrition labelling.  Develop policies on health promotion in workplaces and for workers and families.  Liaise with the trade unions on matters relating to health in the workplace.  Strengthen occupational health and safety programmes for worker’s health. Social Development & Family  Train home-helpers in relevant aspects of the management of Services chronic non-communicable diseases.  Maintain opportunities for physical activity and social integration among the elderly.  Establish policies for healthy foods and snacks in day nurseries and pre-schools. Works & Transport  Improve facilities for walking, through the provision of sidewalks where possible.  Ensure that road safety is considered in environmental and otherassessments for new projects and the analysis of transport policy.  Review road safety targets and establish national road safety plans.  Provide cycling lanes in appropriate areas. National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 40

APPENDIX 5: LIFE COURSE FACTORS �� Table 9: Life Course Factors STAGES OF LIFE FACTORS CONTRIBUTING TO NCDS Foetal stage Slow foetal growth, poor maternal nutritional status, and low socio- economic position at birth Infancy and childhood Lack of breast–feeding, inadequate growth rate, inadequate diet, lack of physical activity, low socioeconomic position, and poor education of the mother Adolescence Inadequate diet such as low intake of fruits and vegetables and high–energy intake, physical inactivity, and tobacco and alcohol use Adult Behavioural risk factors such as high saturated–fat intake, elevated salt consumption, reduced fruit and vegetable intake, tobacco and alcohol use, lack of physical activity, and related biological risk factors �� Pan American Health Organization. 2007. “Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control and Chronic Diseases.”. 41 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021

APPENDIX 6: WHO BEST BUYS �� Table 10: WHO Best Buys RISK FACTOR / DISEASE INTERVENTIONS Tobacco use • Tax increases • Smoke-free indoor workplaces & public places • Health information and warnings • Bans on tobacco advertising, promotion and sponsorship Harmful alcohol use • Tax increases • Restricted access to retailed alcohol • Bans on alcohol advertising Unhealthy diet and • Reduced salt intake in food physical inactivity • Eliminate trans fat • Public awareness through mass media on diet and physical activity & targeted behaviour change programs Cardiovascular disease (CVD) • Counselling and multi-drug therapy for people with a and diabetes high risk of developing heart attacks and strokes (including those with established CVD) • Treatment of heart attacks with aspirin Cardiovascular disease (CVD) • Hepatitis B immunisation to prevent liver cancer (already scaled up) and diabetes • HPV Vaccine • Screening and treatment of pre-cancerous lesions to prevent cervical cancer �� World Economic Forum and World Health Organization. 2011. “From Burden to "Best Buys": Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries.” Geneva. (http://www.who.int/nmh/publications/best_buys_summary.pdf). National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 42

APPENDIX 7: WHO GLOBAL MONITORING TARGETS �� Framework Target Indicator Element OUTCOMES Premature mortality 1. A 25% relative reduction in the 1. Unconditional probability of dying between ages of 30 and 70 from overall mortality from cardiovascular from cardiovascular diseases, cancer, diabetes or chronic noncommunicable diseases, cancer, diabetes, or respiratory diseases disease chronic respiratory diseases Additional indicator 2. Cancer incidence, by type of cancer, per 100 000 population BEHAVIOURAL RISK FACTORS Harmful use of 2. At least 10% relative reduction 3. Total (recorded and unrecorded) alcohol per capita (aged alcohol in the harmful use of alcohol, as 15+ years old) consumption within a calendar year in litres appropriate, within the national of pure alcohol, as appropriate, within the national context context 4. Age-standardized prevalence of heavy episodic drinking among adolescents and adults, as appropriate, within the national context 5. Alcohol-related morbidity and mortality among adolescents and adults, as appropriate, within the national context Physical inactivity 3. A 10% relative reduction in 6. Prevalence of insufficiently physically active adolescents, prevalence of insufficient defined as less than 60 minutes of moderate to vigorous physical activity intensity activity daily 7. Age-standardized prevalence of insufficiently physically active persons aged 18+ years (defined as less than 150 minutes of moderate-intensity activity per week, or equivalent) Salt/sodium intake 4. A 30% relative reduction in mean 8. Age-standardized mean population intake of salt (sodium population intake of salt/sodium chloride) per day in grams in persons aged 18+ years Tobacco use 9. Prevalence of current tobacco use among adolescents ~ 5. A 30% relative reduction in prevalence of current tobacco 10. Age-standardized prevalence of current tobacco use usereduction in prevalence of among persons aged 18+ years current tobacco use BIOLOGICAL RISK FACTORS Raised blood pressure Diabetes and obesity m 6. A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances 7. Halt the rise in diabetes & obesity 11. Age-standardized prevalence of raised blood pressure among persons aged 18+ years (defined as systolic blood pressure 140 mmHg and/or diastolic blood pressure 90 mmHg) and mean systolic blood pressure 12. Age-standardized prevalence of raised blood glucose/diabetes among persons aged 18+ years (defined as fasting plasma glucose concentration ≥7.0 mmol/l (126 mg/dl) or on medication for raised blood glucose) 13. Prevalence of overweight and obesity in adolescents (defined according to the WHO growth reference for school agedchildren and adolescents, overweight – one standard deviation body mass index for age and sex, and obese – two standard deviations body mass index for age and sex) 43 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 Framework Target Indicator Element BIOLOGICAL RISK FACTORS Diabetes and obesity 7. Halt the rise in diabetes & obesity 14. Age-standardized prevalence of overweight and obesity in persons aged 18+ years (defined as body mass index 25kg/m² for overweight and body mass index 30 kg/m² for obesity)) 13 Additional indicators 15. Age-standardized mean proportion of total energy intake from saturated fatty acid in persons aged 18+ years 16. Age-standardized prevalence of persons (aged 18+ years) consuming less than five total servings (400 grams) of fruit and vegetables per day 17. Age-standardized prevalence of raised total cholesterol among persons aged 18+ years (defined as total cholesterol 5.0 mmol/l or 190 mg/dl); and mean total cholesterol concentration NATIONAL SYSTEMS RESPONSE Drug therapy to 8. At least 50% of eligible people 18. Proportion of eligible persons (defined as aged 40 years prevent heart attacks receive drug therapy and and older with a 10-year cardiovascular risk 30%, including and strokes counselling (including glycaemic those with existing cardiovascular disease) receiving drug control) to prevent heart attacks therapy and counselling (including glycaemic control) to prevent and strokes heart attacks and strokes NATIONAL SYSTEMS RESPONSE Essential 9. An 80% availability of the 19. Availability and affordability of quality, safe and efficacious noncommunicable affordable basic technologies and essential noncommunicable disease medicines, including disease medicines essential medicines, including generics, and basic technologies in both public and private and basic technologies generics required to treat major facilities to treat major noncommunicable diseases in both noncommunicable public and private facilities m m diseases Additional indicators 20. Access to palliative care assessed by morphine-equivalent 21. Adoption of national policies that limit saturated fatty acids and virtually eliminate partially hydrogenated vegetable oils in the food supply, as appropriate, within the national context and national programmes 22. Availability, as appropriate, if cost-effective and affordable, of vaccines against human papillomavirus, according to national programmes and policies 23. Policies to reduce the impact on children of marketing of foods and non-alcoholic beverages high in saturated fats, trans fatty acids, free sugars, or salt 24. Vaccination coverage against hepatitis B virus monitored by number of third doses of Hep-B vaccine (HepB3) administered to infants 25. Proportion of women between the ages of 30–49 screened for cervical cancer at least once, or more often, and for lower or higher age groups according to national programmes or policies �� World Health Organization. (n.d.). Non Communicable Diseases Global Monitoring Framework: Indicator Definitions and Specifications. Retrieved from http:// www.who.int/nmh/ncd-tools/indicators/GMF_Indicator_Definitions_Version_NOV2014.pdf National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 44

APPENDIX 8: DECLARATION OF PORT-OF-SPAIN �� UNITING TO STOP THE EPIDEMIC OF CHRONIC NON- National Commissions on NCDs or analogous bodies COMMUNICABLE DISEASES to plan and coordinate the comprehensive prevention and control of chronic NCDs; We, the Heads of Government of the Caribbean Community (CARICOM), meeting at the Crowne Plaza 3 Our commitment to pursue immediately a legislative Hotel, Port-of-Spain, Trinidad and Tobago on 15 agenda for passage of the legal provisions related September 2007 on the occasion of a special Regional to the International Framework Convention on Summit on Chronic Non-Communicable Diseases Tobacco Control; urge its immediate ratification in all (NCDs); States which have not already done so and support the immediate enactment of legislation to limit Conscious of the collective actions which have in the or eliminate smoking in public places, ban the sale, past fuelled regional integration, the goal of which is to advertising and promotion of tobacco products to enhance the well-being of the citizens of our countries; children, insist on effective warning labels and Recalling the Nassau Declaration (2001), that “the introduce such fiscal measures as will reduce health of the Region is the wealth of Region”, which accessibility of tobacco; underscored the importance of health to development; 4 That public revenue derived from tobacco, alcohol Inspired by the successes of our joint and several efforts or other such products should be employed, inter that resulted in the Caribbean being the first Region in alia for preventing chronic NCDs, promoting health the world to eradicate poliomyelitis and measles; and supporting the work of the Commissions; Affirming the main recommendations of the Caribbean 5 That our Ministries of Health, in collaboration Commission on Health and Development which included with other sectors, will establish by mid strategies to prevent and control heart disease, stroke, 2008 comprehensive plans for the screening and diabetes, hypertension, obesity and cancer in the Region management of chronic diseases and risk factors so by addressing their causal risk factors of unhealthy that by 2012, 80% of people with NCDs would diets, physical inactivity, tobacco use and alcohol abuse receive quality care and have access to preventive and strengthening our health services; education based on regional guidelines; Impelled by a determination to reduce the suffering and 6 That we will mandate the re-introduction of physical burdens caused by NCDs on the citizens of our Region education in our schools where necessary, provide which is the one worst affected in the Americas; incentives and resources to effect this policy and ensure that our education sectors promote Fully convinced that the burdens of NCDs can be programmes aimed at providing healthy school reduced by comprehensive and integrated preventive meals and promoting healthy eating; and control strategies at the individual, family, community, national and regional levels and through 7 Our endorsement of the efforts of the Caribbean collaborative programmes, partnerships and policies Food and Nutrition Institute (CFNI), Caribbean supported by governments, private sectors, NGOs and Agricultural Research and Development Institute our other social, regional and international partners; (CARDI) and the regional inter-governmental agencies to enhance food security and our strong Declare - support for the elimination of trans-fats from the 1 Our full support for the initiatives and mechanisms diet of our citizens, using the CFNI as a focal point aimed at strengthening regional health institutions, for providing guidance and public education to provide critical leadership required for designed toward this end; implementing our agreed strategies for the 8 Our support for the efforts of the Caribbean reduction of the burden of Chronic, Regional Negotiating Machinery (CRNM) to pursue Non-Communicable Diseases as a central priority of fair trade policies in all international trade the Caribbean Cooperation in Health Initiative negotiations thereby promoting greater use of Phase III (CCH III), being coordinated by the indigenous agricultural products and foods by CARICOM Secretariat, with able support from the our populations and reducing the negative effects of Pan American Health Organization/World Health globalisation on our food supply; Organization (PAHO/WHO) and other relevant partners; 9 Our support for mandating the labelling of foods or such measures as are necessary to indicate their 2 That we strongly encourage the establishment of nutritional content through the establishment of the appropriate regional capability; 45 National Strategic Plan for the Prevention and Control of Non Communicable Diseases Trinidad and Tobago 2017 -2021 10 That we will promote policies and actions aimed at as the joint Secretariat for the Caribbean increasing physical activity in the entire population, Cooperation in Health (CCH) Initiative to be the entity e.g. at work sites, through sport, especially mass responsible for revision of the regional plan for the activities, as vehicles for improving the health of the prevention and control of NCDs, and the monitoring population and conflict resolution and in this context and evaluation of this Declaration. we commit to increasing adequate public facilities 15 We hereby declare the second Saturday such as parks and other recreational spaces to in September “Caribbean Wellness Day,” in encourage physical activity by the widest cross commemoration of this landmark Summit. section of our citizens; 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