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The Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act was enacted on the 15th January 2016 with the purpose of establishing and ensuring an inter-ministerial lifelong approach favouring physical education and healthy balanced diets for a healthy lifestyle and reducing the level of noncommunicable diseases throughout all age groups. The act stipulates that there shall be established an Advisory Council on Healthy Lifestyles, to provide advice on any matter related to healthy lifestyles particularly to:
- advise the Minister on matters relating to health,physical activity and nutrition;
- advise the Minister on policies, action plans and regulations intended to reduce the occurrence of noncommunicable diseases among the general public;
- upon the request of any other Minister advise such Minister on such matters as may be required in order to achieve the objectives of the Act;
- encourage an inter-ministerial approach to issues related to physical activity and a healthy lifestyle; and
- encourage a lifelong approach, from intrauterine life till old age, to physical activity and a healthy lifestyle.
The Strategy for the Prevention and Control of Non-communicable Disease in Malta was developed in 2010 with the overall goal of developing a multifactorial approach to NCD prevention through tackling common risk factors targeting both at a population level, and also high-risk groups. The strategy aims to:
- Reduce the burden of NCD by targeting the following major chronic diseases: cardiovascular disease, chronic obstructive pulmonary disease, mental ill-health and cancer;
- Reduce the burden of oral diseases;
- Improve the individual risk profile by focusing on: four lifestyle-related factors: diet, physical activity, tobacco and alcohol; and four biological risk factors: obesity, hypertension, hyperlipidaemia and carbohydrate abnormalities
‘A Healthy Weight for Life: A National Strategy for Malta’ seeks to address the many challenges we are experiencing to maintain a healthy weight across the population. It aims to halt the rising overweight and obesity rates and eventually to decrease the number of people suffering from this condition, subsequently reducing morbidity and mortality from related conditions and healthcare and productivity costs and aiming towards an improved quality of life. This covers the time-frame 2012-2020.
In order to promote healthy eating, the following priority areas for action were identified:
- To improve the availability and uptake of a healthy diet by the Maltese population through healthy public policies across Government.
- To work with stakeholders on consumer education about healthy eating and moderation as underlying principles of healthy eating.
- To promote exclusive breast feeding for the first six months of life and to continue breastfeeding in the first years of life.
- To support pregnant women and new mothers to adopt healthy eating habits for themselves and their families through education and community initiatives.
- To support schools and families so that meals and snacks, including drinks, prepared for school aged children are nutritious and appetising, without being energy-dense and/or containing excess amounts of fats, trans-fatty acids, salt and sugar.
- To regulate audiovisual advertising, such as advertising of unhealthy foods especially that directed at children.
- To support schools to implement all the recommendations of the Healthy Eating Lifestyle Plan (HELP) document and to strengthen the Personal and Social Development (PSD) and Home Economics curricula as related to nutrition and healthy choices.
- To set up a National Task Force led by the Ministry responsible for Health to develop action plans on the introduction of agreed mechanisms to reduce salt and sugar, limit saturated fat and eliminate transfat content in local food products.
- To set up a Healthy Food Scheme using colour coding so that healthy food is easily identifiable
- In order to promote physical activity, the following priority areas for action were identified:
- To increase physical activity through healthy public policies, so that the living environment is one that promotes healthy choices.
- To implement the recommendation of three hours of physical activity weekly for all schoolchildren.
- To encourage children and parents to use a screen time log, reduce the number of hours of watching television, use of computer/video games to a maximum of two hours per day for children, and to encourage sit down meals as family time as opposed to TV dinners, whenever possible.
- To support Local Councils to increase the opportunities available for physical activity, including the use of legislation and enforcement to improve safety on the roads, availability of open spaces and increase walkability in built-up areas.
- Committment has been made to the following initiatives:
- To increase and improve weight management and physical activity classes for adults.
- To set up community initiatives such as cookery clubs and community gardens, focusing especially on lower socio-economic groups and older persons.
- To increase and improve parentcraft and breastfeeding classes.
- To provide training and guidelines to health professionals in primary care in order to improve the delivery of holistic advice and management on all issues related to nutrition, physical activity and weight management and ensure that it contains the same key messages.
- To work with stakeholders to develop a national curriculum and certification for facilitators of weight management programmes.
- To set up multi-disciplinary clinics for the management of excess weight in adults and children.The National ‘Food and Nutrition Policy and Action Plan for Malta’ covers the period 2015-2020, and addresses the main public health challenge facing the Maltese Nation in the area of nutrition and food security that are associated with diet-related noncommunicable diseases and conditions including obesity whilst promoting better health and wellbeing for the Maltese population. Its vision is to improve dietary habits to maximise health and well-being, the goals of which are:
- To assist the Maltese population towards adopting a healthy dietary pattern across the lifecourse;
- To encourage all government entities to place health in the consideration of all policies related to the production, marketing, sale, provision and choice of food;
- To be responsive to the links with the social determinants of health and health inequalities and focus on the most vulnerable groups;
- To implement dietary intake and nutritional status surveillance and monitoring of the population with a special focus on children;
- To accelerate action in the field of obesity prevention and control by means of the implementation of the actions proposed in the Healthy Weight for Life Strategy, with a focus on children, comprehensive preventive and treatment approaches and intersectoral action under the leadership of the Ministry for Energy and Health.
- To promote healthy nutrition as the basis for healthy behaviours for the population of Malta;
- To increase the vegetable and fruit intake in the population;
- To reduce salt intake;
- To reduce the consumption of foods high in saturated fats, trans-fats and sugars;
- To address inequalities in food accessibility;
- To halt and reverse the obesity trend in children, adults and older persons
Actions that specifically address young persons include:
- To promote plain water consumption in schools
- To reduce the availability and intake of foods high in fat, sugar, and salt in schools
The National Sexual Health Strategy was developed in 2011 following the launch of the National Sexual Health Policy. The principles guiding this strategy are underpinned by human rights and social justice principles. The core principles stemming from this approach are:
- Respect and care towards human life from its conception
- Individual rights and responsibilities in the context of the broader society
- Adequate, accessible and accurate information and education which is equally accessible to all members of the population, enabling informed choices
- Freedom from exploitation and abuse
- Freedom to express one’s sexuality
- Psychological and physical expression of one’s sexuality in the context of a sound family unit is valued as an essential cornerstone of a society while respecting diverse family structures and lifestyle choices
The objectives of this strategy include:
- Determining and providing educational, social and support services that match the prevalent needs by an appropriately resourced, competent and skilled workforce working within a supportive environment
- Determining and providing adequate, accessible and equitable health services that match the prevalent needs by an appropriately resourced, competent and skilled workforce working within a supportive environment
- Identification of the role and contribution of the media as a tool to inform and educate all the members of the population on all aspects of sexual health, including the provision of an appropriate channel that can be used to help individuals to develop the skills needed to make informed choices
- Establishing pathways and implementing initiatives to conduct research, monitoring and surveillance to secure accurate data specifically pertaining to the Maltese islands. This will also involve the collation of information to be able to map the social, cultural and religious dimensions of sexuality, within our specific national context.
- Enhancing the capacity to project and plan to address the challenges of the future and developing further co-operation with other countries and partnerships with stakeholders
The National Breast Feeding Policy and Action Plan 2015-2020 seeks to increase both the initiation of breastfeeding rates at hospital discharge and its exclusive continuation for the first six months. With many mothers falling into the youth age group of 15-30 years, this is most relevant for youths. This policy updates the previous policy in line with current scientific evidence on the short and long term benefits of breast feeding to the mother and child, to achieve higher exclusive breastfeeding rates for the first six months and thereafter for breastfeeding to continue with appropriate complementary foods.
This policy outlines actions for promoting the initiation and maintenance of exclusive breastfeeding. The evidence-based policy initiative include all population groups, different settings such as community, workplace, hospital or health centre, and promotes supportive environments and training for health professionals and other groups. The Policy recommends that all health, social and allied workers and institutions caring for mothers, infants and young children should aim at promoting breastfeeding. All hospitals, maternity units and primary health care facilities should adopt and implement effective strategies for the promotion, protection and support of breastfeeding as outlined in the Baby Friendly Hospital Initiative, which is a joint WHO/UNICEF initiative. All health, social and allied workers caring for mothers, infants and young children should get the education, training and skills development required to implement this policy. Strategies should be developed for the promotion and support of breastfeeding in the community, by involving fathers and family, the wider community and employers. The policy also outlines the indicators to be used for monitoring and areas of research required.
The National Cancer Plan aims to reduce incidence, prolong survival and ensure the best quality of life possible for cancer patients by ensuring the prevention of preventable cancers and the provision of high quality and equitable cancer services to all cancer patients in Malta.
Children and adolescents are a priority in the Mental Health Strategy: Building Resilience: Transforming Services that was pubished in 2019.
A series of initiatives to promote mental health in schools are planned. There is also a focus on increasing the time spent on physical activity since this can reduce mental illness.
Young people spend much time in the digital setting. Recognition of the risks associated with mental illness is growing. On the other hand there are opportunitites that can be exploted to provide positive mental health mesaging and online support to young persons using digital technoloiges.
A national centre for child and adolescent mental health will be developed as part of the implementaiton of this strategy.
Other Ministry of Health plans and strategies only target Youth in a limited way:
The purpose of the National Cancer Plan is to reduce incidence, prolong survival and ensure the best quality of life possible for cancer patients by ensuring the prevention of preventable cancers and the provision of high quality and equitable cancer services to all cancer patients in Malta.
A Whole School Approach to A Healthy Lifestyle: Healthy Eating and Physical Activity Policy aims to promote healthy eating and physical activity in the whole school community. The Policy takes a two-pronged approach – the promotion of healthy eating, and the promotion of physical activity – and gives high priority to these two themes through holistic education; it strengthens the necessary framework and supports an enabling school environment to help the whole school community to adopt healthier patterns of living by encouraging physical activity; it promotes healthy foods and limits the availability of products high in salt, sugar and fats; it empowers children to achieve the required physical and health literacy, to adopt a healthy lifestyle from an early age and to make informed choices about their lifestyles throughout the life course; it makes provision for a flexible curriculum which highlights health, nutrition, food safety and hygiene and food preparation, and promotes physical activity; and it ensure that clear and consistent messages about food, drink and physical activity are delivered across the school day.
Other than the Whole School Approach to a healthy lifestyle policy, there are no top-level policies, strategies or programmes specifically targeting young people. All others encourage healthy lifestyles and healthy nutrition on a population basis. However, a number of projects and initiatives do focus on children and young people.
Prevention throughout the life course remains the best answer to health and wellbeing. The Health Promotion and Disease Prevention Directorate continues its work in supporting and empowering individuals to adopt a healthy lifestyle, encouraging people to make healthier choices to help reduce their risk of illness. This is done through a variety of services and programmes in the community, in health centres, schools, local councils, hospitals and at work places. These include various outreaches, health initiatives in the work place and presentations particularly focusing on youth.
Relevant government departments have implemented various European Union initiatives. The Toybox project was developed for the prevention of obesity in early childhood, and campaigns aimed towards the prevention of obesity in early childhood, and later cancer, the use of tobacco and drinking and driving. The Toybox intervention is a multi-component, kindergarten-based, family-involved intervention, focusing on the promotion of water consumption, healthy snacking, physical activity and the reduction/ breaking up of sedentary time in preschool children and their families.
The School fruit scheme is now being implemented in all primary schools, providing all school children with a seasonal fruit on a weekly basis, currently twice a week. While this exposes children to fruit, it also attempts to bring across the right messages of the benefits involved.
Health factor is a teacher’s tool kit developed as part of a healthy lifestyle project with kindergarten classes. This was designed to assist Kindergarten teachers with teaching their pupils the importance of healthy eating and physical activity, encouraging them to learn to make healthy life choices and better their chances of becoming active healthy adults.
Over a decade ago the Food and beverage standards for school tuckshops were introduced. Adapted from the report of the Task Force for Appropriate School Nutrition Environments, and revised by the Home Economics Seminar Centre staff, these stipulate lists of permissible foods and drinks, and prohibited foods and drinks, as well as nutrient based guidelines for food and drink providers. While the implementation of the standards is mandatory only in state-run schools, this can, and should be scaled up for full implementation also by church and private schools.
In 2018, the Procurement of Food for Schools Regulations were passed as subsidiary legislation, regulating for food sold or provided by schools. The Criteria for Food Procurement was drawn up by the Advisory Council for the Procurement of food for Schools Regulations during school hours in accordance with Chapter 550 of the Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act. The criteria are updated from time to time and current update took place in October 2018.
A successful initiative following on from introduction of the Criteria for Food Procurement was a collaborative effort between the Superintendence of Public Health, the Health Promotion and Disease Prevention Directorate and Malta Dairy Products Ltd, the leading dairy producer in Malta. Discussions led to the reformulation of yogurt products resulting in Benna’s innovative Yummy Kids Yogurt range, as the only yogurt range on the local market that is made of fruit and vegetables. These yogurts are intended exclusively for a younger cohort. The sugar content in these yogurts is very low (less than 10g per 100g), making them the only yogurts available in the market which children can take to school.
Two sets of Dietary Guidelines have been developed: The Dietary Guidelines for Maltese Infants and Young Children, and The Dietary Guidelines for Maltese Children. The former is a guide for the parents of children aged 6 months to 3 years, suggesting weaning guidelines that aim to offer the best information on how to gradually introduce babies to a wide range of new foods, tastes and textures, so that, by the age of one year, babies can enjoy a balanced and healthy diet. The Principles of the ‘Healthy Plate’ allow for the practicing of good eating habits up to the age of 3 years. The Dietary Guidelines for children aims to support parents, grandparents and guardians to provide a healthy lifestyle for children aged 3 to 12 years.
The conditions and settings in which people live, as well as their life styles, influence their health and quality of life which in turn affects productivity as health equity is central to any developmental effort. Poverty, unequal distribution of wealth, lack of education, rapid urbanization, aging, and social, economic, and environmental determinants are contributing factors. The Social Determinants of Health Unit was set up with the aim of supporting, guiding and strengthening the intersectoral capacity across government and society in order to develop, implement, monitor and evaluate initiatives to promote and address health equity through addressing the Social Determinants of health. The EU funded project ‘Establishing a national platform to address Social Determinants of Health’ has so far included a large research study among the general population, collecting data on various social determinants of health in Malta among those over the age of 16. Results of this study will feed in to a nationwide campaign to increase awareness of the social determinants of health which will target different age groups and focus on the lower socio-economic classes. One of the components of the campaign includes the development of healthy recipes that can be prepared on a budget, using seasonal produce. Another aspect of this EU project relates to a smaller research module done in collaboration with the Ministry for Education, from which an Assessment tool for use by teachers in the classroom was developed. This tool can be used to identify those children who may be at risk of ill health due to their social background and status. This will enable such children to be observed, and referred to a guidance counsellor or other services as may be necessary
Malta took part in the Joint Action on Nutrition and Physical Activity (JANPA) project. The overall aim of the project is to contribute halting the rise of overweight and obesity in children and adolescents by 2020. In accordance with the policy actions that addresses overweight and obesity at European level and as a contribution to the EU Action plan on childhood obesity 2014-2020. JANPA focused on aspects such as: the economic burden of obesity in national health systems, the multilevel and multi-sectorial and life-course approach for preventing health problems that originate from childhood obesity, sedentary lifestyle and unhealthy nutrition and related health problems, taking into account social inequality.
Malta is also part of another Joint action initiative called Chrodis Plus, a three-year initiative (2017-2020) led by the Institute of Health Carlos III and is being funded by the European Commission and the participating parties. The initiatives on chronic diseases should build on four cornerstones:
- health promotion and primary prevention as a way to reduce the burden of chronic diseases
- patient empowerment
- tackling functional decline and quality of life as the main consequences of chronic diseases
- making health systems sustainable and responsive to the aging of our populations associated with the epidemiological transition
Malta participated in two work packages which involved the implementation of the Toybox best practice (as mentioned above) and a policy dialogue to increase free water availability in public areas such as children’s playgrounds. All church and independent kindergarten schools in Malta and Gozo were invited to participate in the implementation of the ToyBox intervention, which consisted of activities to improve energy-related behaviours and oral care among children aged 3-4 years of age. Parents were also involved in this project through the distribution of informative material and their participation in a questionnaire.
Work has also begun on a project ‘Establishing a National Platform to address Social Determinants of Health’ which embarked on structured awareness building among all stakeholders in promoting healthier lifestyles in various settings such as schools, community, homes, work. The project offers specific capacity building sessions in intersectoral and cross sectoral collaboration. Tackling social determinants will reduce health inequalities through a Health in all policies whole-of-government and a whole-of-society approach, which is dependent on awareness among all sectors – policy makers, government, civil society and general public.
Actions of this project include:
- extensive review of health inequalities status in Malta, leading to development of a national action plan to promote healthier lifestyles and health and safety at work using different mediums.
- Establishment of partnership and network - working with a wider range of partners increases commitment towards tackling health inequalities
- Up-skilling and updating knowledge of professionals working within Health and care sectors through training.
The area of Health Education includes Physical Education and Sport and Personal, Social and Career Development (PSCD) as well as aspects of Home Economics. The learning experiences that take place during health education activities aim at equipping learners with the necessary knowledge, competencies, skill, attitudes, and values which they need to maintain, promote and enhance physical, emotional, psychological and social well-being throughout their school life and as lifelong learners. Educators are encouraged to collaborate with parents and the wider community to ensure meaningful and long-lasting experiences in order to inculcate a deep understanding of ‘self’, ‘other’ and the impact of choices and actions upon individuals, communities and the environment. Health Education lays the vital foundation for dispositions necessary for lifelong learning.
• actively and enthusiastically participate in activities to develop important physical skills in an enjoyable way.
• learn the skills and rules of collaborative play, sportsmanship, leadership and competitiveness.
• participate in teamwork and develop team spirit.
• begin to appreciate the importance of a healthy body and physical well-being.
• become aware of and appreciate the changes that take place physically as they grow.
• experience activities that encourage social interaction, promote self-awareness, reflective behaviour, decision-making processes and consequential thinking to develop the necessary skills of emotional and social intelligence.
• begin to become aware of the importance of a healthy mind and body.
• understand the importance of nutrition and eating in a healthy way.
• discover their strengths and weaknesses.
• learn to understand and manage both positive and negative feelings.
• develop the important dispositions of active thinkers and learners especially during key transitions.
The legal basis for the Maltese National Minimum Curriculum can be found in the Education Act. Education on Human Sexuality, Strengthening of Gender Equality and Wise Choices in the Field of Health are three of the Educational Objectives listed in the National Curriculum Framework for All which indicated the knowledge students and young persons needed to acquire and the skills and attitudes they needed to develop. The National Curriculum Framework for All continues to emphasise the need that students and young persons are equipped with the necessary knowledge, attitudes and skills which they will need to maintain, promote and enhance physical, emotional, psychological and social well being throughout their school life and as lifelong learners. The delivery of Sexuality and Relationship Education (SRE) lessons is also guided by the Guidelines on Sexuality and Relationships Education in Maltese Schools, which highlights the skills, competencies and knowledge students should be exposed to for an effective SRE programme.
The delivery of sexuality and relationships education in Maltese Colleges and Schools is guided by the following principles:
- The acknowledgement that children and young persons are sexual beings and develop at different rates.
- The provision of a safe, caring, inclusive and non-judgemental environment that is conducive in promoting a positive attitude towards sexuality.
- The provision of a comprehensive and inclusive curriculum which takes into account the gender, age, orientation, cultural, religious, social and geographic backgrounds of children and young persons.
- The promotion of the importance of healthy relationships in the context of respect, intimacy, readiness, love and the law.
- The promotion of abstinence and postponement of sexual activity and sexual intercourse for children and young persons.
- The provision of age appropriate and scientifically correct information about harm reduction strategies to minimize the risks associated with promiscuous behaviour and drug use.
It is important to point out that SRE lessons in PSCD start in the primary sector with year 4 students (9 year old) and continue till the end of compulsory schooling (16 years old). Specific workbooks have been developed throughout the years to encourage parents or caregivers to have a greater role in the Education of their children in issues related to health and growing up.
In Malta, PSCD teachers are specifically trained at initial professional tertiary education training and qualify as PSCD teachers with a bachelor’s degree (B.Ed Hons) or post-graduate certificate in education (PGCE). All PSCD teachers teaching in State Schools must have received this mandatory training. They are also obliged to attend training which is regularly organized by the Education Officers. This a list of the training carried out during the years in relation to SRE.
- 2007- 2008 - The Health Promotion Department coordinated and delivered a training course entitled ‘ Issues in Health and Sexuality’. Guest speakers covered the topics related to Sexual Health, STI’s and the GU Report of 2006 and Contraception including Family Planning
- 2010 - A seminar ‘Should I say that? Sexual Health Related Issues?’ was organized for all PSD teachers and other stakeholders in conjunction with the PSD association.
- 2011 - The University of Malta delivered a seminar to all primary PSD teachers as part of their continuous professional development sessions on ‘Issues related to Sexuality Education in Primary Schools’
- 2014 - A four day seminar on various issues related to SRE organized in conjunction with the Health Promotion Unit as part of the Strategy for Sexual Health
- 2016 - A three day inset course entitled 'Reflecting on Sexuality and Relationships Education Issues' for secondary PSCD, Religion and Science teachers.
- 2017 - Three day inset course entitled 'Reflecting on Sexuality and Relationships Education Issues' for secondary PSCD, and Religion teachers.
The main pedagogical tool used by teachers are the reflective workbooks for the different years. These compliment the resources and material used by teachers themselves. They also help to assess whether learning outcomes have been achieved.
The teachers are supported by continuous visits in class and lending of resources which they can use with their students. Resources include 'Contraceptive Kit', 'Testicular Cancer Kits' and 'Breast Cancer Kits'. The teachers can also make use of the PSCD website which is continuous updated and uploaded with resources which teachers might find helpful in class. Additionally, teachers also make use of the FRONTER VLE. On FRONTER, the PSCD room is used as electronic information repository from where teachers can have updated, important resources for them to download such as curricula and syllabii.
There are currently no top-level guidelines, programmes projects or initiatives facilitating or relying on peer-to-peer education.
There is no legal framework for collaboration with other entities however the had closely collaborated with the Ministry for Health, Elderly and Community Care to develop a Health Strategy 2011. As a result, various initiatives were taken up such as the training of educational personnel on issues related to SRE.
Raising awareness on healthy lifestyles and on factors affecting the health and well-being of young people
The Directorate for Health Promotion and Disease Prevention in the main public authority responsible for disseminating information about health which is generally targeted at population level, however includes aspects that are more commonly youth health related areas, such as sexual health.
No specific contact point exists which specifically targets young people and where young people can access to receive information.
No top-level framework exists for youth information and counselling structures other than through the support of Aġenzija Żgħażagħ.
Currently there are no major, largescale, youth-targeted information campaigns on healthy lifestyles and factors affecting the health and well-being of young people. These only exist at population level, targeting all age-groups, including young people.
Initiatives targeting the population at large are on-going and these include:
- Campaign to promote a Mediterranean diet
- Campaign on the benefits of drinking water
- Weight Management classes including aerobics, life skills and nutritional advice
- Smoking cessation classes
- Community outreaches throughout the year that target different areas of health such as anti-smoking and on sexual health
- Talks on depression given to health care workers, in conjunction with Mental health services
- Outreaching at University fresher’s week on sexual health