COVID-19 continues to exacerbate existing inequalities and place a disproportionate burden on women, including in health-care settings. Women health workers are faced with increased workloads, a gender pay gap, shortages of personal protective equipment that fits them, and harassment and violence as they respond to the pandemic on the frontlines.

Although women make up 70% of the health workforce, they hold only 25% of senior roles.

“The pandemic has been a setback to the advancement and progress of women. Many women find themselves in an impossible situation of having to assume multiple care responsibilities at home and outside the household. We are extremely concerned about the impact that the pandemic has had on the mental health and well-being of women in the health workforce and beyond,” says Dr Natasha Azzopardi-Muscat, Director of the Division of Country Health Policies and Systems at WHO/Europe.

Here, 4 women holding influential leadership positions across the WHO European Region share their experiences and call for change.

“Life had to be changed in a day”

Dr Marija Zdravkovic is Chief Executive Officer (CEO) of the University Hospital Medical Center Bezanijska Kosa in Belgrade, Serbia, where she has worked for over 22 years. In her role, she has not only witnessed but also managed first-hand the challenges posed by the pandemic in a health-care setting.

“In June 2020, our hospital started working as a COVID-only centre, and this period has been very challenging for all staff at the hospital and, of course, for me as the CEO. Once we moved to full COVID mode, we had less than 24 hours to move 248 non-COVID patients to other hospitals and make all epidemiological preparations to operate as the main COVID centre for the entire Belgrade region. But we did it successfully,” says Dr Zdravkovic.

Health workers have experienced high levels of depression, anxiety, insomnia and distress as a result of responding to the pandemic. Women health workers have been disproportionately affected.

“The main goal was to organize work. In order to make an optimal organization, we set working hours of 6 hours in standard care and 4 hours in the intensive care unit. This was important because we wanted to have doctors and nurses completely concentrate on the patients and avoid exhaustion, because we didn’t know how long it would all last. Life had to be changed in a day,” explains Dr Zdravkovic.

Dr Zhamilya Abeuova, Director of the Enbekshikazakh Multidisciplinary Interdistrict Hospital in the Almaty Region of Kazakhstan, echoes Dr Zdravkovic’s experiences. “The pandemic has created an unprecedented health system environment. In a short time, we retrained the entire medical staff of the polyclinic, hospitals, primary health-care centres and the infectious diseases department,” she says.

“Our work has become more intense because we are now mainly prioritizing emergency surgeries and more complex operations. The pace of change was fast and we are constantly learning and adapting,” says Dr Deborah McNamara, Consultant General and Colorectal Surgeon at the Beaumont Hospital in Dublin, Ireland.

“I have also been involved in designing national policies to help surgeons through this period, to ensure they and their teams are safe, and keep our patients safe. I am still motivated by every patient that I see, and being able to do something to radically change and improve their life,” Dr McNamara adds.

Breaking stereotypes

Gender inequality and patriarchal attitudes and stereotypes in medical training, at work and across society mean that women in health care earn less and are less likely to advance in their careers, often due to having multiple care responsibilities.

As Chair of Ireland’s Royal College of Surgeons working group on improving gender equality in surgery, Dr McNamara and her team found multiple barriers to women’s career progression in surgery, which remains a male-dominated field. Currently, women make up only 7% of surgical consultants in Ireland.

“We found that even students in school have a clear perception about who is a surgeon and what a surgeon looks like. And often they are not thinking of women when they think of a surgeon. Many women medical students didn’t even consider a career in surgery,” she says.

Yet Dr McNamara points out, “In the last couple of years, I’ve had the pleasure of seeing women consultant surgeons appointed around the country, including in my own hospital. It has been superb to see that women have progressed, supported by the work that we’ve done investing in measuring the gender gaps as well as training and mentoring.”

While there has been progress, the pace of change for gender equality continues to stagnate.

“The media plays a major role and needs to do more to promote women’s leadership and to avoid inappropriate and misogynistic comments. We need to start promoting gender equality at an early age, starting from kindergartens, schools and universities, including in health management education,” notes Dr Zdravkovic from Serbia.

Strengthening women’s voices in leadership

Women deliver global health while men design and lead it. Women remain largely absent from national or global decision-making on the COVID-19 response.

“Here, women are represented at all levels, from practical to mid-level executives. However, this is not the case in all areas – in the management system of the civil service in Kazakhstan, women traditionally occupy grassroots positions, while men are widely represented in managerial positions,” Dr Abeuova says.

“And if our society values typical male leadership, it is very hard for women’s leadership to be heard because of the norms in our societies,” adds Dr McNamara, who has been a mentor and an inspiring figure for fellow women surgeons throughout her career. “The visibility of women in leadership positions and being prepared to stand up for younger colleagues who may be facing difficult times in their career are important.”

“We need women and men in leadership together because we bring different experiences and perspectives around the table. We need women in leadership at all levels of management, from local to regional, national and global – in all sectors. This is especially important in public health, where we make decisions affecting the lives of millions on a daily basis,” Dr Natasha Azzopardi-Muscat concludes.

World Obesity Day is on 4 March, and on this occasion WHO/Europe raises the urgent need for promoting healthy eating habits among children. This recommendation is based on the results of round 4 of the WHO European Childhood Obesity Surveillance Initiative (COSI), which were recently published in an article in the journal Nutrients and in a WHO/Europe factsheet which summarizes the data.

Children’s eating habits

According to the findings, which present the dietary habits of 132 489 children, 78.8% of children eat breakfast, 42.5% consume fresh fruit every day and 22.6% consume vegetables every day. 10.3% of children consume sweet snacks and 9.4% soft drinks on a daily basis. However, there are significant differences between eating habits from country to country.

Overall, the WHO findings from this study highlight that action is urgently needed to promote healthy eating habits among children in all the countries of the European Region, especially to increase daily consumption of fresh fruits and vegetables.

“A healthy diet includes high consumption of fresh fruits and vegetables, daily breakfast consumption and discouraging routine consumption of nutrient-poor foods that are high in sugars, saturated fats, trans fats and salt,” said Dr Kremlin Wickramasinghe, ad interim Programme Manager, Nutrition, Physical Activity and Obesity, WHO/Europe.

Nutrition for a healthy life

Healthy nutrition is one of the pillars of noncommunicable disease (NCD) prevention. Poor diets, overweight and obesity are major risk factors for cardiovascular diseases and cancer, the 2 main killers in the WHO European Region.

“A healthy diet is especially important for primary school-aged children. Establishing good nutrition habits early in life can substantially decrease risks of child obesity and overweight, and can lead to better health for years to come,” said Dr Carina Ferreira-Borges, ad interim Head of the WHO European Office for Prevention and Control of Noncommunicable Diseases (NCD Office) and Programme Manager, Alcohol, Illicit Drugs and Prison Health.

To contribute to healthy childhood growth and development in the European Region, the NCD Office created a factsheet to summarize the paper on the dietary habits of children aged 6–9 years. The research drew on data from 23 countries participating in the 2015–2017 4th round of COSI, the largest initiative of its kind globally.

Promoting healthy childhoods

Healthy nutrition during childhood is a fundamental priority for the future of the Region. Policy-makers can promote healthy growth and development among children by:

• regulating marketing of unhealthy foods and beverages to children;
• implementing WHO-recommended labelling rules for nutrition producers;
• incentivizing reformulation of foods high in sugar, fat and salt;
• introducing fiscal incentives such as implementing a tax on sugar-sweetened beverages;
• facilitating access to healthy and nutritious food in schools, other public institutions – through implementation of healthy public food procurement and service policies – and in under-served communities;
• supporting monitoring initiatives of children’s eating habits, anthropometric measurements and food environments to monitor policy impacts.

Helping countries to promote healthy nutrition as an effective measure to reduce NCDs is one of the priorities of the European Programme of Work 2020–2025, signed by all Member States of the WHO European Region, which promotes united action for better health while ensuring well-being for all at all ages.

Norway: Pilot study reveals staggering amount of unhealthy food and beverage marketing to children and adolescents

According to a new study conducted by the Oslo Metropolitan University (OsloMet), 8 out of 10 food and drink advertisements aimed at children in Norway violate WHO guidelines and promote unhealthy nutrition. The research used the CLICK framework – a tool that helps monitor and restrict marketing of unhealthy products to children, developed by the WHO European Office for the Prevention and Control of Noncommunicable Diseases.

Researchers have mapped the current digital marketing landscape of food and drinks directed at children aged 3–17 years in Norway, revealing that the majority of the products advertised were foods and beverages high in fat, salt and sugar. While most of these should not be promoted to a young audience, according to WHO guidelines, only 9% of them were deemed unacceptable under the guidelines currently in effect in Norway.

“Protecting children and adolescents from marketing of harmful products online is critical,” underscores Professor Knut-Inge Klepp, Executive Director of Mental and Physical Health at the Norwegian Institute of Public Health, “This report demonstrates that many children and adolescents are not sufficiently protected by current guidelines in Norway, and the study results can be used to inform and adjust national regulations.”

Digital marketing contributes to unhealthy eating habits in children

The WHO European Region continues to struggle with high rates of childhood obesity in many countries. There is overwhelming evidence that the marketing of foods and beverages high in saturated fat, trans-fatty acids, free sugars or salt (HFSS) influences a child’s knowledge, attitudes and food preferences. Consumption of these promoted products is associated with increased risk of overweight and obesity. Obesity in children is a risk factor for noncommunicable diseases, many of which are preventable if major risk factors and behaviours are addressed during childhood.

Childhood obesity is a growing challenge in Norway, where approximately 24% of boys and 22% of girls in primary school live with overweight or obesity, as do around 25% of adolescents in the country. Moreover, the prevalence of overweight and obesity in children has not decreased over the past decade, and health authorities are interested in identifying the role that marketing of unhealthy products plays in this regard.

“Authorities should review the regulations and the age limits,” says Kamilla Knutsen Steinnes of Consumption Research Norway (SIFO), OsloMet. “Norway’s guidelines should be better aligned with WHO guidelines. Today, only children under the age of 13 are protected by current guidelines, whereas it is actually adolescents over the age of 13 who are most frequently subjected to advertising. All children need to be protected online.”

Pilot study with impressive results

The study conducted in Norway uses the CLICK monitoring framework, developed by WHO/Europe, which comprises five steps, adaptable to national contexts. Norway is the first of the participating countries to successfully complete the third step of the framework (Investigate exposure) by collecting data on paid advertisements directly from devices used by children.

“Since the digital landscape is constantly changing, it is difficult to gain good insight without monitoring the children”, says Vilde Haugrønning from OsloMet. “We have used the best method available at present.”

The results of this pilot mapping of advertisement data from the mobile phones of 47 participating children show that 1 in 10 out of the total 5076 captured advertisements promoted food and drink products, primarily unhealthy ones, and that the children spent an average of 13 seconds viewing an advertisement.

While this study focuses only on the impact of paid advertising, the CLICK monitoring framework also offers additional protocols to monitor indirect marketing, such as advertisements made by celebrities and social media influencers. Indirect advertising of unhealthy products to children by influencers with an immense reach is often difficult to recognize as marketing, which makes it highly problematic. It could mean that the extent to which children are being subjected to advertisements of unhealthy products is even greater than described in the report.

“This new study completed by Norway using the WHO/Europe CLICK framework provides some of the most convincing data we have seen so far to demonstrate the extent of this issue,” says Dr Kremlin Wickramasinghe, Acting Programme Manager for Nutrition, Physical Activity and Obesity, WHO Regional Office for Europe. “It reminds us that we must consider how suitable the current policies are for protecting children in the WHO European Region from marketing pressure.”

The report suggests that Norwegian guidelines should be better aligned with WHO guidelines through redefining and improving regulation to protect children from unacceptable promotion of unhealthy products online. In early March the report will be presented to government officials in a meeting hosted by the Ministry of Children and Families in Norway.