Adaptation and Pilot of the Nutrition Environment Measurement Tool for Stores (NEMS-S) in Central and Western Cuba

Abstract

Purpose: Cuba has experienced rapidly increasing obesity rates over the last fifteen years. Among other factors, consumer nutrition environments – defined by the availability, price, and quality of healthy foods – predict individuals’ food choice and population-level obesity prevalence. However, data describing Cuba’s nutrition environment remain scarce. Furthermore, existing assessment instruments, such as Glanz, et al.’s Nutrition Environment Measures Survey for Stores (NEMS-S), have not been validated in the Cuban context. Consequently, our project aimed to modify NEMS-S for use in Cuba and pilot the adapted instrument in geographically distinct Cuban communities. Methods: We first modified NEMS-S to incorporate typical healthy and unhealthy Cuban foods; key informant interviews strongly influenced this process. Next, we utilized housing quality and population density data to identify two 1 km squared survey tracts, one each in the cities of Havana and Cienfuegos. Rather than pilot the adapted NEMS-S in peri-urban and rural Cuba, we deviated from our initial project plan; controlled for urban location, population density, and socioeconomic status; and varied by region to account for regional dietary variation. We piloted the adapted NEMS-S in a total of 40 food retail outlets (21 in Havana, 19 in Cienfuegos) classified into five distinct categories, collecting data on indicator food availability, price, and quality. Results: Our data analysis included descriptive statistics for both composite and non-composite food availability, price, and quality for the 10 indicator food categories, five types of food retail outlets, and two regions. We also utilized geomapping techniques to map distribution and type of food outlets within the two survey tracts to assess the viability of mapping community nutrition environments in limited resource settings. Lastly, we leveraged qualitative analysis techniques to assess how effectively the adapted NEMS-S captures: A) availability, price, and quality of healthy and unhealthy Cuban foods; and B) the uniqueness of Cuba’s socialist food system and food pricing structure. Conclusions: Our survey did not demonstrate variation in composite nutrition environment quality scores between Central and Western Cuban cities; however, our analysis revealed substantial variation in nutrition environment quality scores and healthy food availability by type of food outlet. Project findings will impart improved understanding of factors influencing obesity prevalence in Cuba; suggest public health policy implications, both for Cuba and other countries; provide baseline data describing the Cuban nutrition environment before trade liberalization with the United States; and offer insight into how to best modify nutrition environment assessments for developing country settings.