Policy Paper
Towards a Healthier Society Malta Medical Students’ Association Policy Paper Date of adoption: 31st January 2016 Date of expiry: 31st January 2019 University of Malta
Towards a Healthier Society Malta Medical Students’ Association Policy Paper
Contents Introduction ................................................................................................................ ii Healthy Eating ............................................................................................................ 1 Healthy diet and weight .......................................................................................... 1 Overweight and obesity .......................................................................................... 2 Underweight and eating disorders .......................................................................... 2 Main text ................................................................................................................. 3 Mental Health ............................................................................................................. 6 Main Text ................................................................................................................ 7 Sexual Health ........................................................................................................... 10 Local Statistics ...................................................................................................... 11 Main Text .............................................................................................................. 11 Social Inclusion ........................................................................................................ 13 Local Statistics ...................................................................................................... 13 Main Text .............................................................................................................. 14 Summary .................................................................................................................. 17
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References ............................................................................................................... 18
Introduction
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During the autumn of 2015, a number of workshops organised by the Malta Medical Students’ Association (MMSA) were held at the University of Malta, in preparation for the General Assembly of the International Federation of Medical Students Associations’ (IFMSA) to be held in Malta in March 2016. The workshops were entitled ‘Towards a Healthier Society’; and addressed healthy eating, mental and sexual health, and social inclusion in youths, who are the basis of tomorrow’s societies. This policy paper is intended to complement the workshops and to outline the position of the MMSA on these subjects.
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The definition of health quoted most often is the one formulated in 1946 by the World Health Organisation (WHO), defining health as “a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity� (Awofeso, n.d.).
Healthy Eating Healthy diet and weight A healthy diet and physical activity are cornerstones of a healthy lifestyle in terms of well-being as well as the absence of disease. While a healthy diet is known to guard against the effects of malnutrition, and protect against non-communicable diseases (such as heart disease, stroke, diabetes and cancer), an unhealthy diet and lack of physical activity have been identified as leading global risks to health (World Health Organisation, n.d.). Current recommendations for a healthy diet include:
Increased consumption of vegetables and fruit, whole grains, legumes and nuts
Balancing energy intake and expenditure
Free sugars should be limited to less than 10% of the total energy intake. A reduction to less than 5% of the total energy intake is linked to additional health benefits
Total fat should not exceed 30% of the total energy intake. Unsaturated rather than saturated fats should be consumed, and industrial trans fats should be eliminated.
No more than 5g of salt should be consumed daily, as this helps prevent hypertension and reduces the risk of heart disease and stroke in the adult population
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The Body Mass Index (BMI), defined as weight (in kilograms) divided by the square of height (in meters) (kg/m2), is the measure most commonly used to gauge whether an individual is at a healthy weight (World Health Organisation, n.d.). The normal
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(World Health Organisation, n.d.)
range for adults over 20 years of age of both sexes is quoted at 18.5 to 24.9, while growth charts and calculator applications are used to determine the normal range for children and teenagers as their bodies undergo a number of changes as they grow (World Health Organisation, n.d.).
Overweight and obesity Overweight (BMI >25) and obesity (BMI >30) are defined as “abnormal or excessive accumulation of fat that presents a risk to health� (World Health Organisation, n.d.). Worldwide, childhood obesity is increasing at an alarming rate, particularly in Western societies, and Maltese children lead the trend (Grech, 2007). In particular, over the past decades the Maltese diet has changed from one high in complex carbohydrates and low in fats, especially animal fats, to one that is high in total fats and low in complex carbohydrates (Bellizzi, 1993). Childhood obesity is associated with a large number of malignant and non-malignant conditions, in addition to accounting for an alarming proportion of healthcare budgets (Grech, 2007). Adolescents have significant knowledge about healthy eating, but find it difficult to follow recommendations and frequently consume food perceived as unhealthy; citing lack of time, limited availability of healthy options in schools and general lack of concern in following recommendations as barriers to healthy eating (Croll, et al., 2001).
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Underweight is defined as a BMI of less than 18.5 (World Health Organisation, n.d.), while eating disorders, a subgroup of behavioural syndromes associated with physiological disturbances (World Health Organisation, 1992), are characterised by a dread of fatness and excessive preoccupation with body weight and image (World Health Organisation, 1992). Eating disorders include anorexia nervosa, in which the individual induces and sustains deliberate weight loss, bulimia nervosa which is characterised by repeated episodes of overeating followed by vomiting or use of purgatives, and others which meet separate criteria for diagnosis (World Health
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Underweight and eating disorders
Organisation, 1992). Furthermore, it is estimated that up to 80% of patients also suffer from anxiety or depression (Anon., 2014). Eating disorders, which according to the National Statistics Office are estimated to affect 0.9% of the population (Dalli, 2014), typically affect adolescent girls and young women, but may also affect adolescent boys and older women up to the menopause (World Health Organisation, 1992). Individuals who have troubled personal or family relationships, low self-esteem, a family history of eating disorders, or perfectionist or obsessive tendencies, are at a higher risk of developing an eating disorder (Dalli, 2014), however Western cultural attitudes and beliefs have been identified as contributing factors (Miller & Pumariega, 2001).
Main text In view of the above, the Malta Medical Students’ Association (MMSA) feels that it should outline its position on the issue of healthy eating in the Maltese Islands as it applies to youths. 1. We call on the government to: a. Collect and make available data on the situation at both extremes of unhealthy eating and weight among Maltese youths; to update local statistics, and in view of the fact that eating disorders by nature are likely to be underreported. b. Review, assess and apply policies related to healthy eating in the local population.
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2. We believe that a national, far-reaching, coherent and holistic healthy lifestyle programme that addresses the problem of unhealthy eating, in particular that of obesity, at all levels, is a priority. This would involve:
a. Effective education of the community, focusing on the positive aspects of living a healthy life rather the negative outcomes of unhealthy eating and lack of physical exercise b. Collaboration between government departments (including education, transport and public health), the health industry and medical profession, and the food industry, through: i. Increased incentives towards the growth, sale and use of fresh fruit and vegetables ii. Decreased incentives towards the production and sale of processed foods containing saturated fats and free sugars iii. Ensuring the availability and affordability of a wide range of healthy choices, especially in educational institutions, public buildings and hospitals; and controlling the availability of unhealthy options in educational institutions as well as in their vicinity iv. Promoting and providing for the safe use of alternate transport such as walking or cycling which in itself encourages physical activity v. Promoting healthy dietary practices from an early age through encouraging breastfeeding and protecting young working mothers vi. Making nutritional and dietary advice and counselling available and accessible at the primary health care level, and addressing unhealthy weight in terms of prevention as well as cure
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c. Use of media:
i. More media space should be dedicated to educating the public in addition to visual campaigns used to raise awareness. ii. The role of media, including the internet and social media, in the perpetuation of unhealthy perceptions about body image, should be carefully considered. Images which have been altered to reflect unrealistic ideals or body proportions should be labelled, and their use should be discouraged in favour of role models promoting a healthy lifestyle. 3. We believe that education is essential to a healthy lifestyle. a. Education in schools should not only cover nutrition and culinary skills, but should also allow for and encourage physical activity and exercise, by giving due importance to physical education sessions and by means of sports programmes and extra-curricular activities b. Education should also target parents and families who often set a poor example
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c. The level of social tolerance to living an unhealthy lifestyle should also be addressed
Mental Health According to the World Health Organisation, mental health may be described as a state of well-being in which the individual realises his or her abilities, and is able to work productively and fruitfully, to cope with the normal stresses of life, and to make a contribution to the community (World Health Organisation, 2014). Conversely, the term ‘mental disorders’ encompasses a wide range of problems characterised by abnormal emotions, thoughts, behaviour and relationships (World Health Organisation, 2014). The associations of mental health problems are numerous: increased rates of physical ill health and a poorer quality of life, a lower likelihood of employment, and higher rates of premature death, in addition to social prejudice and stigma which may lead to isolation and exclusion (McCollam, et al., 2008). Adolescence, particularly between 11 and 15 years of age, is a challenging period in view of the physical and emotional changes of growth, changing social relationships, and increased academic expectations and pressures (Currie, et al., 2012). During this period adolescents also begin to take decisions which may affect their health and health-related behaviour (including mental health) independently, and behaviours established during these years may extend into adulthood (Currie, et al., 2012).
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Although the incidence of mental disorders (including depression and suicidal behaviour, substance abuse, eating disorders and psychotic disorders) increases from childhood through adolescence into adulthood, they are frequently underrecognised and undertreated (Directorate-General Health and Consumer Protection, 2000). It is estimated that 15 to 20% of adolescents from Member States of the European Union (EU) suffer from mental disorders (Directorate-General Health and Consumer Protection, 2000). 14% of all suicides (one of the three leading causes of death among young people) occur between the ages of 15 and 24 (Directorate-
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Risk factors for mental health problems in children and youths include low socioeconomic status, poor familial and social support (including poor parental mental health during early childhood), bullying, poor body image and self-esteem (especially among girls) and school pressure (McCollam, et al., 2008).
General Health and Consumer Protection, 2000), and at least one child under the age of 14 dies by suicide every 48 hours in the EU (McCollam, et al., 2008).
Main Text In view of the above, the Malta Medical Students’ Association (MMSA) feels that it should outline its position on the issue of mental health in the Maltese Islands as it applies to youths. 1. We call on the government to quantify and qualify the mental health situation among Maltese youths by collecting data to accurately assess the current local situation in view of the fact that there are few available statistics, and that mental health problems are likely to be underreported. Local statistics should then be compared to those from other countries with similar cultural backgrounds, to identify programmes or solutions which may be adapted and implemented locally, and to aid in the formulation of targeted and effective mental health interventions. 2. We believe a comprehensive mental health programme should be formulated and implemented. a. Mental health promotion as part of the education curriculum in Maltese schools should be addressed, as this would provide equal skills and opportunities to students of all socioeconomic backgrounds. i. Current curricula and teaching practices should be reviewed, and extended to include youths at higher secondary levels as well as those in secondary levels
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1. Lessons should aim to build youths’ coping skills during adolescence
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ii. Teaching methods and content of lessons should be regularly updated
2. Teaching sessions should be delivered by persons with adequate knowledge and skills, and there should be periodic opportunities for educational or medical professionals to refresh and hone their skills iii. Initiatives should also target children and youths at risk of low educational achievement, mental health problems, and offending behaviour. b. We believe that mental health should be tackled holistically. i. Mental health education programmes should use a ‘whole school’ approach, promoting mental health in students and staff, preventing bullying and working with parents and families. ii. Parenting support and psychosocial interventions should be available to families, especially those at risk. iii. Mental health should be part of workplace health and safety policies, in the form of: 1. Programmes to address workplace relationships, role expectations and stress management 2. Initiatives to reduce the strain of unemployment and assist re-entry to work 3. Programmes to maintain individuals who develop mental health problems in employment
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3. We believe that mental health campaigns targeting youths, in the form of written information or advertising in public spaces, are a valuable contribution
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iv. Health screening programmes should also include mental health.
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to awareness among youths and help break the taboo surrounding mental health.
Sexual Health According to the World Health Organisation, sexual health requires not only the possibility of having pleasurable and safe sexual experiences, but also a positive and respectful approach to sexuality and relationships (World Health Organisation, n.d.). In addition, sexuality (comprising sex, gender identities and roles, sexual orientation as well as reproduction, intimacy and pleasure), which is influenced by a multitude of social and biological factors, is considered to be a central aspect of being human (World Health Organisation, n.d.). Thus in 2010 the National Sexual Health Policy for the Maltese Islands recognised the effect of sexuality education starting in childhood on positive sexuality (The Ministry for Health, the Elderly and Community Care, 2010). Five distinct elements are required for effective sexuality education: the subject must be taught comprehensively (covering both the biological and psychological viewpoints) and should cover a wide variety of subjects without taboo, in schools by specially trained teachers (Beaumont & Maguire, 2013). Furthermore, the contribution of parents should be sought as they have a right to be involved in their children’s education, and attendance of such lessons should be compulsory (Beaumont & Maguire, 2013). However in 2010 the available evidence showed that sexuality education in Malta was poor and uneven across schools, as a result of timetable restrictions, lack of the required teaching skills by educational professionals, and lack of coordination between teachers, parents and even between schools in terms of targets and standards for sexuality education (The Ministry for Health, the Elderly and Community Care, 2010).
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The more severe consequences of poor sexual health range from sexually transmitted infections (including genital herpes, syphilis, gonorrhoea, chlamydia and HIV/AIDS) and unplanned pregnancies to loss of educational, social and economic opportunities, the psychological effect of abuse or coercion, chronic diseases and cancer, and even premature death (The Ministry for Health, the Elderly and Community Care, 2010).
Local Statistics A local study published in 2012 showed that 41% of youths aged between 16 and 18 had already engaged in at least one sexual activity (Anon., 2015). 32% admitted to unprotected sexual activity, and 6% acknowledged having been under the influence of drugs or alcohol at the time (Anon., 2015). In 2013 the incidence rate in Malta for syphilis, gonorrhoea and chlamydia lay at 9.3%, 14.5% and 33.8% respectively, in all cases showing a significant increase when compared with values from 2009, and much higher rates when compared to other European countries such as Spain and Greece (World Health Organisation, 2013). Between 2000 and 2009, 936 babies were born to Maltese teenage mothers, amounting to 2.5% of all deliveries during that time period (The Ministry for Health, the Elderly and Community Care, 2010).
Main Text In view of the above, the Malta Medical Students’ Association (MMSA) feels that it should outline its position on the issue of sexual health in the Maltese Islands as it applies to youths. 1. We call on the government to quantify and qualify the sexual health situation among Maltese youths by: a. Beginning data collection to accurately assess the current local situation in view of the fact that the available statistics are out of date. b. Comparing local statistics to those from other countries with similar cultural backgrounds, and identifying programmes or solutions which may be adapted and implemented locally.
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a. Current curricula and teaching practices should be reviewed, and standardised across the educational system
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2. We believe sexuality education in the Maltese schools, in particular of students at secondary and higher secondary levels, should be addressed.
b. Teaching methods and content of lessons should be updated i. Lesson plans should be regularly updated to reflect topical issues such as consent, gender equality and identity, and cyberbullying ii. Teaching sessions should be delivered by persons with adequate knowledge and skills, and there should be periodic opportunities for educational or medical professionals to refresh and hone their skills 3. We believe that sexuality education should be tackled holistically, with the involvement of parents, guardians, care-givers and families in the education of their children. a. Parents should be aware of school curricula as regards sexuality education b. Families should be encouraged to discuss sexual health more openly
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4. We believe that sexual health campaigns targeting youths, in the form of written information or advertising in public spaces, are a valuable contribution to awareness among youths and help break the taboo surrounding sexual health.
Social Inclusion Active social inclusion is defined as the enabling of all citizens, especially those with the most disadvantages, to participate fully in society (European Commission, 2015), and as the process by which society battles poverty and exclusion from societal, economic and political processes, in order to create a “society for all� (Atkinson & Marlier, 2010). An inclusive society provides equal opportunities to all its citizens, regardless of differences of gender, race, generation, geography, class or origin; thus giving all citizens a voice and responsibilities when the society is confronted with new challenges, while promoting peaceful democracy and quelling armed rebellion (Atkinson & Marlier, 2010). Health in a society is affected by its socioeconomic context, including labour markets, welfare systems and public policies; and economic recessions are known to have a considerable impact on the health and well-being in a society, especially on that of vulnerable groups (Frasquilho, et al., 2015). Equally, health status has been shown to improve by ascending the social and income hierarchy, and the healthiest societies are those in which there is equitable wealth distribution in addition to reasonable prosperity (Podnieks, 2008).
Local Statistics Children and youths, irregular migrants, persons with disability, persons with mental health problems, and persons who are dependent on alcohol or drugs or both are considered to be vulnerable groups in the Maltese Islands (Social Policy Ministry, 2008-2010). In addition, the following subgroups of children and youths are deemed to be at greater risk of social exclusion and poverty: Children and youths living in
o unemployed or single parent households
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o institutions or care
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Children and youths who witness or are victims of abuse or domestic violence
Children and youths with o A disability o Emotional or mental problems, or dependency issues o Literacy difficulties
Teenage parents
Youths who are unemployed or inactive
(Social Policy Ministry, 2008-2010) In 2012, the at-risk-of-poverty rate stood at 31% for Maltese children, compared with the rate of 28% for children from the Member States of the European Union, and the rate of 23.1% for the general Maltese population (Ministry for the Family and Social Solidarity, 2014). The literacy rate in Malta rose to 92.8% in 2005, and the rate of early school-leavers dropped from 48.2% in 2003 to 37.6% in 2007, while the youth employment rate stood at 46.1% in 2007 (Social Policy Ministry, 2008-2010). Early-school leaving has been associated with unemployment and low status occupations, as well as criminal behaviour and substance abuse later in life (Vallejo & Dooly, 2008).
1. We call on the government to:
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In view of the above, the Malta Medical Students’ Association (MMSA) feels that it should outline its position on the issue of social inclusion in the Maltese Islands as it applies to youths.
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Main Text
a. Further quantify and qualify the local situation through collecting and analysing data b. Review, assess and apply policies related to social inclusion in the local population. 2. We believe education is a key determinant of health, through the development of skills, increasing opportunities for job security and income, and improving the ability to access and understand information. a. Current curricula and teaching practices should be reviewed, standardised across the Maltese educational system, and shaped to address illiteracy, absenteeism and learning difficulties. b. Factors related to the non-completion of secondary education should be identified to better combat early school-leaving. 3. We believe that social inclusion may be achieved through a holistic, multilevel approach. a. Families should continue to be assisted and supported through: i. Incentivising childcare and providing employment opportunities, especially for young mothers ii. Increasing the availability of adequate affordable housing
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iv. Measures to increase the social inclusion of children and youths with a disability
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iii. Extending services for youths with mental health issues, problems with dependency, or difficult behaviour; while ensuring that the services provided are dedicated, targeted and ageappropriate, and that the welfare of children and youths making use of such services is prioritised
b. The social aspects of migration, equality, diversity and integration should be addressed in view of the increasing numbers of migrants from a multitude of cultural backgrounds arriving in the Maltese Islands over the last few years.
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4. We believe that awareness campaigns on the rights of children and youths (particularly on the rights of the subgroups most at risk of exclusion), in the form of written information or advertising in public spaces, together with health promotion programmes targeting youths, are an effective addition to a community-based approach to social inclusion.
Summary Health is commonly defined as “a complete state of physical, mental and social wellbeing and not merely the absence of disease or infirmity” (Awofeso, n.d.). International research has collectively shown that health is affected by numerous factors, and that strategies to promote a healthy lifestyle and improve health in a population must therefore be far-reaching and holistic.
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There is little quantitative data on incidence and prevalence rates related to youths in Malta, especially as related to healthy eating, mental health and sexual health. In light of this, the Malta Medical Students’ Association wishes to call upon the government to begin collecting data to quantify the situation, and to review and implement local policies. Furthermore, we believe that education is essential to health, and that awareness and educational campaigns are a valuable tool in promoting health and social inclusion among youths, who form the basis of tomorrow’s society.
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Dalli, K., 2014. ‘Shocking number self-refer to eating disorder, obesity clinic’. [Online] Available at: http://www.timesofmalta.com/articles/view/20140719/local/-Shockingnumber-self-refer-to-eating-disorder-obesity-clinic-.528279 [Accessed 30 January 2016].
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