SEE ALSO baby friendly; climate change; food poverty; health; Maternal, Newborn and Child Health; lifestyle; non-communicable disease; overweight and obesity; social movements
Malnutrition refers to insufficient, excessive or imbalanced consumption of nutrients. Malnutrition increases the risk of infection and infectious diseases, and even moderate malnutrition weakens the immune system (Lawrence and Worsley, 2007).
Addressing malnutrition is a focus of public health in promoting good health and prolonging life through nutrition and the primary prevention of nutrition-related illness in the population (Lawrence and Worsley, 2007). Malnutrition is an especially important health concern in women, children and the elderly. Pregnancy and breastfeeding mean that women have additional nutrient requirements. Children can be at risk from malnutrition even before birth as their nutrition levels are directly tied to the nutrition of their mothers. The elderly are also at risk of malnutrition because of changes in appetite and energy levels and can have chewing and swallowing problems. Public health nutrition interventions include the promotion of breastfeeding, improved water supply, food fortification with vitamins and minerals, healthy eating behaviours for school children and healthy lifestyles including eating a balanced diet. Public health nutrition can be more effective when combined with other interventions, for example, for the treatment of the major childhood illnesses that emphasize prevention through immunization and improved sanitation. Interventions which have been shown to be most effective involve education, peer group leaders and environmental changes such as offering healthy food options (Swinburn, Eggar and Raza, 1999).
In developed countries the diseases of malnutrition are associated with nutritional imbalances or excessive consumption. For example, over-nutrition is an excessive supply of nutrients relative to the amounts required for normal growth and development. The term can refer to obesity brought on by the overconsumption of foods high in caloric content, as well as the oversupply of a specific nutrient due to the excessive intake of dietary supplements or nutritional imbalances. In practice, these can be caused by certain types of diets used to control weight gain (WHO, 2013). Many low-income and middle-income countries now exhibit a double burden of malnutrition, continued stunting of growth and deficiencies of essential nutrients along with the emerging issue of overweight and obesity.
Maternal and child under-nutrition consists of stunting, wasting and deficiencies of essential vitamins and minerals. The need is to focus on the crucial period from conception to a child’s second birthday, the first 1000 days in which good nutrition and healthy growth have lasting benefits throughout life. The main challenges for maternal and child under-nutrition are to enhance and expand the quality and coverage of nutrition-specific interventions such as adequate food and nutrient intake, feeding, parenting practices, micronutrient supplementation, the promotion of breastfeeding and the treatment of severe acute malnutrition. Nutrition-sensitive interventions are also important and include a safe and hygienic environment, food security, social safety nets, early child development and women’s empowerment. However, another crucial level of action refers to the environments and processes that underpin and shape political and policy processes (Shekar, Ruel-Bergeron and Herforth, 2013).
Protein and energy malnutrition (PEM) (also called protein-energy under-nutrition) refers to a form of malnutrition where there is inadequate protein intake in the diet. Protein-energy malnutrition affects children the most because they have less protein intake and this can result in stunting, wasting and deficiencies of essential vitamins, minerals and micronutrients causing an increased susceptibility to infection. Whilst protein malnutrition is detrimental at any point in life, prenatally it can have lifelong effects. Prenatal protein nutrition is vital to the development of the foetus, especially for the brain, to avoid the susceptibility to diseases and obesity in adulthood. Two common forms of PEM in children are marasmus and kwashiorkor. The different forms depend on the balance of non-protein and protein sources of energy. Marasmus (also called the dry form of PEM) is more common than kwashiorkor and causes weight loss and depletion of fat and muscle. In developing countries, marasmus is the most common form of PEM in children. Kwashiorkor (also called the wet form of PEM) is associated with premature abandonment of breastfeeding and may also result from an acute illness, such as gastroenteritis, in a child that already has PEM. A diet that is more deficient in protein than energy may be more likely to cause kwashiorkor than marasmus, for example, in regions where the staple foods are low in protein and high in carbohydrates such as yams, cassavas and sweet potatoes. In both marasmus and kwashiorkor, bacterial infections such as pneumonia and gastroenteritis can contribute to anorexia and worsen muscle wasting. Starvation is an acute, severe form of PEM as it is a complete lack of nutrients and usually occurs when food is unavailable such as during famine. The most important preventive strategy is to reduce poverty and improve nutritional education alongside public health measures such as improved water and sanitation (Morley, 2013).
The main challenges to address malnutrition are to expand the quality and coverage of nutrition interventions to those who need them and in regard to influencing the political processes that underpin nutrition policy (Gillespie et al., 2013). Civil society also has an important role – for example, Scaling-Up Nutrition is a social movement founded on the principle that all people have a right to food and good nutrition and that malnutrition has multiple causes. The movement implements both nutrition interventions and nutrition-sensitive approaches. Nutrition interventions include support for exclusive breastfeeding up to six months of age and continued breastfeeding, together with appropriate and nutritious food, up to two years of age, fortification of foods, micronutrient supplementation and treatment of severe malnutrition. Nutrition-sensitive interventions include supporting small farms as a source of income for women and families, improving access to reduce infection and disease, improving access to services and empowering women to be community leaders (Scaling-Up Nutrition, 2014).
KEY TEXTS
•Edelstein, S. (2010) Nutrition in Public Health. 3rd edn (Boston: Jones & Bartlett Learning)
•Knudsen, J. (2007) Malnutrition: Risk Factors, Health Effects and Prevention (New York: Nova Science Publications Inc)
•Lawrence, M. and Worsley, T. (2007) Public Health Nutrition: From Principles to Practice (London: Open University Press)
Maternal, Newborn and Child Health
SEE ALSO baby friendly; child protection; communicable disease; health information systems; hygiene; malnutrition; youth
Maternal, Newborn and Child Health (MNCH) collectively refers to the health of women during pregnancy, childbirth and the postpartum period, newborn infants under 28 days of age, children under 5 years and up to 10 years of age. MNCH can be used to describe programmes that are inclusive of interventions to improve and protect the health of mothers, their newborn and other children including the making pregnancy safer initiative (WHO, 2010c).
Maternal health refers to the health of women during pregnancy, childbirth and the period shortly after childbirth. It is estimated that about 800 women die from pregnancy or childbirth-related complications every day: for example, 287 000 women died during childbirth and pregnancy in 2013. Almost all of these deaths occurred in low-income countries and could have been prevented (WHO, 2014d). Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to, or aggravated, by the pregnancy or its management, but not from accidental or incidental causes (WHO, 2012b). Between 2003 and 2009, for example, most maternal deaths were due to direct obstetric causes. Haemorrhage, hypertensive disorders and sepsis were responsible for more than half of maternal deaths worldwide and a quarter was attributable to indirect causes, although regional estimates vary significantly (Say et al., 2014). The maternal mortality ratio is a ratio of the number of maternal deaths during a given time period per 100,000 live births during the same time period. Worldwide, the maternal mortality ratio fell by 34% between 1990 and 2008 with the largest decline seen in eastern Asia and northern Africa (63% and 59%, respectively) (Wilmoth et al., 2010). The maternal mortality rate is the number of maternal deaths in a population divided by the number of women of reproductive age, usually expressed per 1000 women (WHO, 2014d).
Newborn (also called neonatal) health refers to that of an infant under 28 days of age when it is at the highest risk of death and when it is crucial that appropriate feeding and care are provided to improve the chances of survival (WHO, 2012a). Every year almost three million infants die in the first 28 days of life and 2.6 million are stillborn. Newborn deaths account for 40% of all deaths among children under five years of age and the majority of these (75%) occur during the first week of life. Between 25% and 45% of these deaths occur within the first 24 hours of life (WHO, 2012a). Three major causes account for more than 80% of neonatal mortality, namely, complications of prematurity, intra-partum-related neonatal deaths (including birth asphyxia) and neonatal infections. Most newborn deaths could be prevented if access were to be provided to needed care during labour, childbirth and in the first week of life. It is also important that these interventions are delivered by the same health care provider (or team) and in the same place. To improve newborn health, the World Health Organization also recommends the implementation of community mobilization through facilitated participatory learning groups and action cycles with women’s groups, particularly in rural settings with low access to health services (WHO, 2014e).
The Every Newborn: an action plan to end preventable deaths is an international initiative that sets out to end preventable newborn deaths and stillbirths by 2035. The action plan aims for fewer than ten newborn deaths per 1000 live births and less than ten stillbirths per 1000 total births. This will require an intensification of political attention and leadership, greater individual and community empowerment, investment for an effective outcome on mortality as well as harmonization of funding and successful implementation at scale. Particular attention will have to be given to increasing health worker numbers and skills to deliver quality childbirth care for the newborn, mothers and children (Mason et al., 2014).
Child health is generally interpreted as being up to ten years of age, with adolescent health starting above this age. Child mortality refers to the death of a child before the age of five years and mostly occurs in low-income countries resulting from preventable conditions with malnutrition often being an underlying cause in about a third of all cases (Black et al., 2008). Prevention and treatment strategies that have proven effective for reducing child mortality include vaccinations, oral rehydration therapy, antibiotics, treatment of malaria and breastfeeding. A more integrated approach to managing illnesses that can provide even greater outcomes by addressing the overall health of the child is Integrated Management of Childhood Illness (IMCI). IMCI includes both preventive and curative elements to reduce death, illness and disability among children under five years of age (WHO, 2005). In public health programmes IMCI lists five major causes of death among children in low-income countries: pneumonia, diarrhoea, malaria, measles and under-nutrition. Targeting specific disease is matched with three other important components: improving health worker performance, health systems support and family and community practices (Tulloch, 1999). IMCI programmes, once strongly implemented, with high training coverage of facility-based workers and health systems strengthening, in a setting where services utilization is high, can contribute to reaching poor families (Victora et al., 2006).
The impact in relation to MNCH in regard to the Millennium Development Goals was tracked by progress towards the achievement of goal 4 (to reduce child mortality) and goal 5 (to improve maternal health). The annual decline of maternal mortality, for example, was less than half of the rate required to meet the target in 2015 (Wilmoth et al., 2010). The post-2015 development agenda addressing MNCH will have to help women to access skilled care during pregnancy, childbirth and after birth by strengthening all levels of the health system. However, broader factors, sometimes beyond the control of agencies, will also have an important role in addressing MNCH including poverty, financial barriers, distance to health care, political commitment and cultural beliefs and practices.
KEY TEXTS
•UNICEF (2009) State of the World’s Children: Maternal and Newborn Health (New York: UNICEF)
•WHO (2010c) ‘Working with Individuals, Families and Communities to Improve Maternal and Newborn Health’. WHO/MPS/09.04 (Geneva: World Health Organization)
•World Health Organization (2005) Model IMCI Handbook: Integrated Management of Childhood Illness (Geneva: UNICEF/World Health Organization)
SEE ALSO gender mainstreaming; health networks; lifestyle; mental health; sexual health; tobacco control; violence; women’s health; workplace health
Men’s health is concerned with identifying, preventing and treating conditions that are most common or specific to men (Sabo and Gordon, 1995).
Men die, on average, before women. The reasons for this are not completely understood but men may have some genetic predisposition for lower life expectancy and have different lifestyle patterns that increase risk factors: for example, men tend to drink and smoke more than women. The leading causes of death for men, for example, in the United States with variation for age and ethnicity, are diseases of the heart, stroke, respiratory diseases, liver disease, unintentional injuries and suicide (CDC, 2014). The state of men’s health in Europe shows marked differences in health outcomes between men indicating that as a population group they are varied and have needs related to their biology, culture and socio-economic context. Working-age men have significantly higher mortality rates than working-age women and tend to underuse health services. For example, levels of suicide are much higher in men compared to women but their diagnosis of depression remains low indicating the poor utilization of services (Malcher, 2011).
Men’s health interventions focus on prevention, education, screening test and stress reduction. Public health campaigns have focused on raising awareness of issues on suicide, prostate and testicular cancer, erectile dysfunction; alcohol misuse, obesity, smoking, heart disease, stress and sexual health. One men’s health project in a Canadian city, for example, focused on male immigrants from Latin America who experienced the stresses of finding housing and work in a foreign culture, with a different language, often under the uncertainty of whether they would be able to stay permanently. These men also smoked and this was the focus of a health department that initially used education campaigns, designed in culturally sensitive ways and marketed through channels such as church and refugee assistance groups. But community workers also knew that, until their lives and living conditions improved, smoking would never be much of an issue for these men. Spanish-speaking health workers, still working to develop smoking awareness interventions, also asked the men about their greatest health worries. Consensus developed that their teenage children had nowhere to go and to combat drugs and petty crime they wanted to create a drop-in centre for Hispanic youth. The project then started to address stress and the quality of men’s participation in the youth centre as role models and leaders (Labonte, 1998).
Public health campaigns have also built public/private initiatives, for example, the Premier Football League in the United Kingdom made a pledge as part of the Responsibility Deal initiative in the United Kingdom to promote healthier lifestyles. The purpose was to increase levels of physical activity amongst adult male football fans, aged 18–35 years and living in areas of high deprivation with the aim of reducing coronary heart disease, diabetes and cancer. Sessions were held at community venues and delivered by a health trainer seconded to the football club to encourage physical activity. The initiative resulted in positive health outcomes across a range of indicators with over 40% of men improving their level of physical activity, 30% making improvements to their diet and 30% reducing their alcohol consumption (Responsibility Deal initiative, 2014).
Public health strategies have encouraged the involvement of men, for example, to improve sexual and reproductive health, the prevention and care of sexually transmitted infections, family planning, safe motherhood and in the promotion of women’s and family health. Men have also been engaged to help change sexist, risky and violent behaviour towards women in the communities in which they live. One study, for example, found that almost a third of 58 programmes evaluated in Africa were successful in encouraging men to end violence against women, to care for their pregnant wives and their children (Keeton, 2007). In South Africa, the ‘Stepping Stones’ approach used gender behaviour transformation workshops over an eight-week period and a three-hour safer sex course for both men and women, divided into separate groups, to encourage participants to communicate about sexual and reproductive health and to develop relationship skills. A randomized controlled trial found that the programme brought about behavioural changes that reduced sexually transmitted infections in male participants. The study also found that more than half of male participants reported less severe violence towards their intimate partners and less casual and transactional sex, more condom use and less alcohol abuse (Keeton, 2007).
Internationally there are a number of men’s health networks and forums that aim to reduce premature mortality, foster health care, education and services, to increase physical and mental health and to reduce violence and addiction. Men’s health networks support educational and screening campaigns, undertake data collection, provide counselling, referral and therapy services. Men’s health networks work actively with health care providers and agencies to support better government programmes and to advocate for adequate funding of research and education on men’s health needs.
The focus of men’s health has been on physical assessment and lifestyle advice with the tendency to utilize stereotypical aspects of masculinity and of male behaviour as a way to draw men into public health programmes (Courtenay, 2011). Associating health issues to one gender fails to recognize the key role that gender relations play in the generation of specific social and health practices for both men and women. Gender equality initiatives can have a positive impact on the way men’s needs are taken into account both within government health strategies and at the public health practitioner level (Malcher, 2011).
KEY TEXTS
•Courtenay, W. (2011) Dying to Be Men: Psychosocial, Environmental and Bio-Behavioural Directions in Promoting the Health of Men and Boys (London: Routledge)
•Robertson, S. (2007) Understanding Men’s Health: Masculinity, Identify and Wellbeing (London: Open University Press)
•Sabo, D. and Gordon, D. (1995) Men’s Health and Illness: Gender, Power and the Body (London: Sage)
SEE ALSO disability; health; non-communicable disease; peer education; social movements
Mental health is a state of wellbeing in which people are able to realize their potential and can cope with the everyday stresses of life, can work productively and are able to make a valued contribution to society (WHO, 2001).
Multiple social, psychological and biological factors determine the level of mental health of a person. Poor mental health is associated with rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, risks of violence and physical ill health. There are also specific personality factors that make people vulnerable to mental disorders as well as genetic factors and imbalances in chemicals in the brain (WHO, 2001). The determinants of mental health are driven by factors such as income, housing and employment and by psychosocial factors such as relationships and life satisfaction. A key consideration is the balance between addressing individual-level determinants targeting inequities in mental health among the vulnerable and those broader social determinants which help to explain population-level patterns of mental health (Barry and Friedl, 2008).
Poor mental health and poverty can interact in a negative cycle, one that increases the likelihood that those living with mental disorders will drift into or remain in poverty. Two principal causal pathways for this pattern are social causation and social drift. In social causation, conditions of poverty increase the risk of mental disorder through heightened stress, social exclusion, decreased social capital and increased risks from violence. Conversely, in social drift, people with mental disorders are at increased risk of drifting into, or remaining in, poverty through increased health expenditure, reduced productivity, stigma and loss of employment. The link between income and ill health, for example, is stronger for mental health than for general health. The social causation pathway might apply more readily to common mental disorders such as depression, whereas social drift might be more applicable to disorders such as schizophrenia and intellectual disabilities (Lund et al., 2011).
Mental health promotion involves actions to create conditions that support and maintain healthy lifestyles including mental health. Mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health (WHO, 2001). They do this by using strategies that foster supportive environments and individual resilience, while showing respect for culture, equity, social justice, interconnections and personal dignity (Joubert, Taylor and Williams, 1996). Mental health promotion has a wide range of health, social and economic benefits including improved physical health, increased emotional resilience, greater social inclusion, higher employment and less poverty. National mental health policies should not therefore be solely concerned with mental disorders, but should also address the broader issues which promote mental health (WHO, 2001).
A wide range of mental health promotion programmes and policies across the lifespan and across settings at the individual and community levels are effective. Mental health programmes that target early childhood, for example, engage in interventions such as home visits for pregnant women, pre-school psychosocial activities and combined nutritional and psychosocial help for disadvantaged populations. The ‘Prenatal and Infancy Home Visiting’ programme, in the United States impacted successfully on a range of behaviours including child abuse, conduct disorders and substance abuse. Parent-training programmes such as ‘The Incredible Years’ and ‘Triple P Positive Parenting’ in Australia have improved parent–child interaction. Other programmes directly or indirectly address the mental health of communities, such as ‘Communities that Care’ by using multiple interventions to prevent violence and aggression (Sturgeon, 2007). Programmes that target unemployment and depression include the JOBS Programme, which has been tested and replicated in large-scale randomized trials in several countries. With regard to older people, controlled trials have demonstrated that exercise improves general mental well-being, and there is some evidence that befriending and early screening have had positive mental health outcomes (Sturgeon, 2007).
Mental health pressure groups have unified themselves with a history of resistance for people living with mental disorder to gain more respect, dignity and autonomy (Allsop, Jones and Baggott, 2004). The collective action among mental health service users in Nottingham in England developed into a national advisory network and grew out of the meetings held by patients on hospital wards. Although involved in the personal development of its members, the main aim of the group was to have an influence on shaping mental health policy and services (Barnes, 2002). Mad Pride is a mass movement and international network of mental health services, users and their allies who identify themselves as being psychiatric survivors, consumers and ex-patients. The movement started in response to local community prejudices towards people with a psychiatric history living in boarding homes in Toronto, Canada and has been followed in England, Australia, South Africa and the United States. Mad Pride has been successful in providing an opportunity to empower psychiatric survivors and raise public consciousness about human rights through various actions such as art, street theatre, music, poetry and protests (Mad Pride, 2013).
The responsibility for promoting mental health extends across all disciplines and government departments and involves the integration of mental health promotion within public health initiatives, primary care and across sectors such as education and employment. Policies, for example, that focus solely on curing or preventing mental illness will not necessarily deliver on improved mental health at a population level (Barry and Friedl, 2008). It is important to recognize that cross-cultural assumptions about the experience of mental health can be problematic in delivering large-scale public health programmes. A climate that respects and protects basic civil, political, socio-economic and cultural rights is fundamental. Without the security and freedom provided by these rights, it is very difficult to maintain a proper level of mental health.
KEY TEXTS
•Barry, M. and Jenkins, R. (2007) Implementing Mental Health Promotion (Oxford: Churchill Livingstone Elsevier)
•Cattan, M. and Tilford, S. (2006) Mental Health Promotion: A Lifespan Approach (London: Open University Press)
•Sharma, M., Atri, A. and Branscum, P. (2011) Foundations of Mental Health Promotion (Boston: Jones & Bartlett Learning)