Participatory approaches to reaching the Sustainable Development Goals: San Marino: promoting healthy lifestyles through schools and family

Participatory approaches to reaching the Sustainable Development Goals: SAN MARINO Promoting healthy lifestyles through schools and family 2Participatory approaches to reaching the Sustainable Development Goals Key messages San Marino has the following key messages to share from their experience in utilizing participatory approaches in implementing action to achieve the Sustainable Development Goals (SDGs) of the United Nations 2030 Agenda (1) with the ultimate aim of promoting healthy lifestyles. „ The establishment of intersectoral working groups and collaboration at the international level guarantees stakeholder commitment. Using a strategic platform, such as “Produce health and development” in San Marino, to facilitate collaboration on investment for health through action to prevent disease, address the health determinants, promote intersectoral policies and promote multipartner cooperation, can boost progress towards achievement of the health-related SDGs (1). „ Building a dialogue among departments with different goals is important. The small size of a country, such as San Marino, makes for the easier involvement of a broad range of representatives of civil society and public institutions in a fruitful dialogue. A shared vision of sustainable development is crucial; continuing to foster synergy among stakeholders takes both time and effort. „ Enabling environments are necessary to create powerful systems of prevention and health protection. San Marino’s experience shows the importance of enabling citizens to adopt healthy lifestyles and live in settings where they can make choices conducive to good health and well-being. 3SAN MARINO Summary In San Marino, the intersectoral approach to improving population health is a long-standing tradition. Several intersectoral projects have been underway for some time with a focus on the achievement of the SDGs (1), their overall aim being to enhance population health and well-being. In 2013, the Health and school working group was established to promote a systematic approach to health education. The aim is to create a school system in which everyone involved works together to provide students with a safe and healthy environment and positive experiences, and to promote a more sustainable and fairer lifestyle. Such an environment, involving both families and communities, is needed in tackling the burden of noncommunicable and chronic diseases and their risk factors. The adoption of the 2030 Agenda in 2015 gave San Marino the impetus to create the Intersectoral working group on implementation of the SDGs. Comprising representatives of all government departments, this working group is tasked with preparing the voluntary national review (VNR) for submission to the High Level Political Forum (HLPF) in 2019. San Marino has also set up a strategic platform entitled, “Produce health and development”, to promote intersectoral policies and multipartner cooperation and provide leadership of the WHO Small Countries Initiative in conjunction with the WHO European Centre for Investment for Health and Development, Venice, Italy, of the WHO Regional Office for Europe. The action reported in this briefing is directly linked to SDG 3 (good health and well-being), targets 3.4 and 3.5, and SDG 4 (quality education), target 4.7, and the strategic directions of the WHO European Roadmap to implement the 2030 Agenda for Sustainable Development building on Health 2020, the European policy for health and well-being (advancing governance and leadership for health and well-being, preventing disease and addressing health determinants by promoting multi- and intersectoral policies throughout the life- course, and establishing healthy places, settings and resilient communities) (1,2). Motivation Recognizing that poor lifestyle choices influence a person’s entire life-course and become risk factors for noncommunicable and chronic diseases, San Marino decided to take action to tackle the unhealthy lifestyle trends observed among youth in the country. In 2010 and 4Participatory approaches to reaching the Sustainable Development Goals 2012, San Marino participated in the Italian survey, Okkio alla Salute, which is part of the WHO European Childhood Obesity Surveillance Initiative (COSI) (3,4). According to the 2010 survey, 20.8% of the children in San Marino were overweight and 8.4% were obese (3). The 2012 survey found an increase in the prevalence of overweight and obesity to 22.4% and 9.3%, respectively (3). These surveys also illustrated a negative trend in lifestyle behaviour: in 2010 and 2012, respectively, 6.5% and 8.9% of children were found to be sedentary (3). In 2010, the Global Youth Tobacco Survey (GYTS) revealed that 11.2% of young people smoked cigarettes (5), while the Health Behaviour in School-aged Children (HBSC) study showed that 22% of adolescents had gotten drunk at least one time in their lives (Presentation by Dr Gabriele Rinaldi and Dr Elena Sacchini: Report indagini di sorveglianza sanitaria [Report on health surveillance surveys]. Health Authority for Authorization, Accreditation and Quality of Health Services, unpublished data,17 January 2018). These trends in unhealthy lifestyle among youth served as an impetus in San Marino to boost efforts to engage other sectors in health-promoting activities. To address the issue coherently, in 2013, the State Congress established the Multidisciplinary and intersectoral working group on planning and coordination of health-promotion and health-education activities in schools and streamlining action in three main settings: health, school and family. This working group meets once a month; its tasks include: „ identifying health-promotion and health-education activities being carried out in schools; „ assessing and prioritizing action to ensure an efficient unitary operating plan for all initiatives and proposals related to health promotion and health education in the school environment, compatible with national social-health planning and school education programmes; „ evaluating the coherence of education proposals from extra-school bodies with identified aims; „ proposing training/information events for school and health workers, parents, associations and communities; „ coordinating the working groups focusing on specific thematic areas; „ developing a monitoring system and indicators to evaluate the effectiveness of action taken; „ collaborating with the Permanent Observatory on Youth Condition (in San Marino). 5SAN MARINO Membership of the working group varies according to needs and the issues addressed; it may be supplemented by other experts and collaborators, such as teachers, parents and representatives of civil-society associations. In October 2018, the Government set up the Intersectoral working group on implementation of the SDGs, comprising representatives of all departments, to engage the various stakeholders in the implementation of the 2030 Agenda (1). Each department was assigned tasks according to its strengths, the aim being to develop common strategies and policies based on a whole-of-government and whole-of-society approach. One of the first tasks of this working group involved: mapping out the activities already being carried out in the country towards achievement of the SDGs (1) as a basis to build on in the coming years; identifying which sector(s) should be responsible for each SDG; and creating an official database, using the existing indicators for San Marino. The ministries for foreign affairs, justice, territory, economy, education, and tourism and the Social Security Institute were involved in this work. Impact The intersectoral collaboration provided through the Multidisciplinary and intersectoral working group on planning and coordination of health-promotion and health-education activities in schools has made it possible to carry out joint activities related to childhood obesity, including: „ participation in international surveillance surveys (Okkio alla Salute, HBSC, GYTS, Early Development Instrument (EDI)); „ meetings of health experts (pediatricians, dietitians, etc.), teachers and families to study menus in full-time schools (nursery and primary) and ensure that they are healthy; „ training for kitchen workers on issues related to obesity; „ dialogue with sports structures on encouraging physical activity among children. Some encouraging survey results have emerged, including: „ a reduction in the prevalence of obesity and overweight among 8 year-olds, from 22.4% and 9.3% in 2012 to 18.7% and 7.1% in 2016, respectively (6,7); 6Participatory approaches to reaching the Sustainable Development Goals „ a reduction in the prevalence of sedentary behaviour among 8 year-olds from 8.9% in 2012 to 5.8% in 2016 (6,7); „ an increase in the response rate to the Global Youth Tobacco Survey (GYTS) from 85.7% in 2010 to 95.7% in 2014 (5); „ a reduction in tobacco use from 11.2% in 2010 to 7.4% in 2018 (5). Unfortunately, data on bullying show that it is increasing, especially among 11 year-olds. In 2010, 14.3% of this age group said they had been bullied at least once during the last 2 months. In 2014, the trend had increased to 20.9% (Presentation by Dr Gabriele Rinaldi and Dr Elena Sacchini: Report indagini di sorveglianza sanitaria [Report on health surveillance surveys]. Health Authority for Authorization, Accreditation and Quality of Health Services, unpublished data,17 January 2018). The initial mapping exercise carried out by the Intersectoral working group on implementation of the SDGs highlighted the areas in which each of the 7 ministries were already involved, as well as their key roles. It also illustrated San Marino’s umbrella approach to working towards the SDGs by considering them as one whole goal to be achieved. The group has been working to understand which SDG-related projects might need more support. The mapping exercise also familiarized the group with projects being carried out by civil society and gave its members the opportunity to collaborate on and strengthen their social commitment to the SDGs (1). Lessons learnt San Marino’s small size has made it easier to involve a broad range of representatives of civil society and to achieve a fruitful dialogue between public institutions. The establishment of government-supported working groups, such as the Health and school working group and the Intersectoral working group for implementation of the SDGs, guaranteed the formal commitment of all stakeholders. Participation in surveillance surveys increases awareness of social and health issues if these are well explained through preliminary meetings, for example, with headmasters, teachers, school personnel, children, adolescents and health workers. This leads to the consequent return of data as demonstrated by the increase in the response rate to GYTS in 2014 compared to 2010. To enable better planning, surveillance surveys should be managed by the health and education (school) sectors with the involvement of families (parents and children). 7SAN MARINO Being able to rely on guidance, such as that provided in the 2030 Agenda and through the Small Countries Initiative, is essential in helping small countries, like San Marino, find the best solutions to the challenges they face. References1 1. Sustainable Development Goals. In: Sustainable Development Goals Knowledge Platform [website]. New York: United Nations; 2015 (https://sustainabledevelopment. un.org/?menu=1300). 2. Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe; 2017 (http://www.euro.who.int/__data/assets/pdf_file/0008/345599/67wd09e_ SDGroadmap_170638.pdf?ua=1). 3. Okkio alla Salute. Promozione della salute e della crescita sana nei bambini della scuola primaria [Okkio alla Salute. Health promotion and healthy growth in primary school children]. In: Epicentro [website]. Rome: Istituto Superiore di Sanità; 2019 (https://www.epicentro.iss.it/ okkioallasalute/). 4. WHO European Childhood Obesity Surveillance Initiative. In: WHO Regional Office for Europe [website]. Copenhagen: WHO Regional Office for Europe; 2019 (http://www.euro.who.int/en/ health-topics/disease-prevention/nutrition/activities/who-european-childhood-obesity- surveillance-initiative-cosi). 5. Global Tobacco Surveillance System data (GTSSData). In: Centers for Disease Control and Prevention [website]. Atlanta, GA: Centers for Disease Control and Prevention; 2019 (https:// nccd.cdc.gov/GTSSDataSurveyResources/Ancillary/DataReports.aspx?CAID=1). 6. WHO European Childhood Obesity Surveillance Initiative: overweight and obesity among 6–9-year-old children. Report of the third round of data collection 2012–2013. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/__data/assets/pdf_ file/0010/378865/COSI-3.pdf?ua=1%20). 7. COSI Factsheet. Childhood Obesity Surveillance Initiative. Highlights 2015–17. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/__data/assets/pdf_ file/0006/372426/WH14_COSI_factsheets_v2.pdf). 1 All URLs accessed 14 March 2019. Coordinated and reviewed by: Bettina Menne (Coordinator, Division of Policy and Governance for Health and Well-being, WHO Regional Office for Europe) and Francesco Zambon (Coordinator, Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development, Division of Policy and Governance for Health and Well-being). Authors and contributors: Federico Tirabassi, Gabriele Rinaldi, Elena Sacchini, Sara Pasquali, Alessandra Melini (Health Authority, San Marino); Micol Rossini (State Secretariat for Health, Social Insurance and Gender Equality, San Marino); Francesco Berardi (Head of Department of Public Instructions, San Marino); Laura Gobbi (San Marino University); Andrea Gualtieri (General Director of Social Security Institute, San Marino) and Leda E Nemer (Consultant, WHO European Office for Investment for Health and Development, Division of Policy and Governance for Health and Well-being). Cover: © UN Photo/Cia Pak and © UNHCR/S. Baldwin © World Health Organization 2019 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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