One-quarter of those who live past 80 will live with poor health 4. According to estimates, people in the Region live on average 9 years with functional limitations or disability 5. An increased lifespan, but with longer periods of illness and dependence on care provided by others, is a great burden for States, societies, and families, and a significant challenge for public health. Halfon and colleagues define health throughout the life course as a dynamic process that begins before conception and continues for an entire lifetime 6.
This concept, even in evolution, is based on bio-psychosocial and post-genomic models, in which health is considered a process that is integral to complex systems 7. Acting upon that vision of health requires going beyond interventions targeted to specific diseases and their consequences and instead treating health as an essential resource in producing and maintaining capacities and reserves in individuals and populations, throughout the life course.
Health is a dimension and a marker of sustainable development, since it reflects the combined effects of social, economic, and physical living conditions on the population. A healthy population displays greater labor and economic productivity, leading to more inclusive and sustainable growth 8.
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The life course comprises the succession of events that occur throughout the existence of individuals and populations. These events interact to influence health from preconception until death, and may extend even further to affect future generations. The life course perspective provides a basis on which to predict future scenarios in health.
Trajectories, temporary conditions, transitions, critical periods, the interconnection of lives, and cumulative effects form a conceptual platform that, as part of the available scientific evidence, can be used to model scenarios in health 9, There are longstanding efforts to transcend the narrow vision of health as merely the absence of disease. However, these efforts have been limited to philosophical definitions, conceptualizations, and theoretical models of public health 11, Building health means investing in the creation of a capacity or resource that enables individuals and populations to develop according to expectations and the demands of their environment It provides necessary tools not only for their development, but for their adaptation to unexpected situations such as natural disasters, infectious disease outbreaks, or violent events, or to challenges that can persist a long time, such as climate change, chronic diseases, disabilities, human rights violations, lack of job security, or violent situations Under the leadership of the World Health Organization WHO , during a conference in Ottawa, Canada, health promotion was defined as a process aimed at:.
Building health implies not only preventing disease, but also promoting the development and sustainability of physical, mental, and social capacity throughout life. The life course concept includes the influence of the determinants of health on individuals and populations. According to this approach, these determinants not only can lead to disease and death, but also are decisive in building health. Understanding this can contribute to greater clarity about the influence of health on the model of life trajectories and on human development, and about the real impact of investments in health in the short, medium, and long term.
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Furthermore, it demonstrates that in health, both action and inaction have consequences. This vision of public health provides a more realistic view of the problems and sharpens the focus on the priorities and needs of the population. In the Americas, health must be considered in an increasingly diverse population context. For the first time in history, five generations are alive at the same time These generations have had different life trajectories: the first was born without access to vaccines or antibiotics; another experienced the double burden of malnutrition undernutrition along with overweight ; still others started out with high levels of illiteracy and today must adapt to global connectivity and coexist with other generations that are growing up and becoming educated in this new world.
Some people are born and move through their lives with certain health protections, only to lose them in later stages of life, which poses new challenges of adaptation.
Family Violence in Japan - A Life Course Perspective | Fumie Kumagai | Springer
All this represents a challenge for public health, and any future design of universal health must take into account these generational differences. They are added to the amply documented, but largely unresolved, inequities associated with ethnicity and gender and with the different geographic and social contexts where people live. Inequities in the Region of the Americas have been the main cause of failures related to health, and over the next decade will continue to be a barrier to progress. Health inequities that affect some subgroups are not limited to a single health problem, nor confined to narrow, transitory environments, but exert pernicious and pervasive effects throughout the life course The dynamic conception of health is grounded in solid theoretical and philosophical arguments.
However, the aspiration to place people—and not diseases—at the center of health policies will not be realized until practical ways to carry out the life course approach are designed and implemented. Building health is a continuous process, one in which interventions and results are not isolated but cumulative over time, with periods of stability and of transformation.
This interaction shapes trajectories that may be regarded as health pathways, at both the individual and population levels. The analysis of this process reveals both the needs and the influence of protective factors, as well as their impact on the development and maintenance of the capacities of persons and populations. The health sciences, which for centuries have sought to understand the trajectories of diseases, will need to focus in the coming years on understanding life trajectories and, specifically, the health trajectories of individuals and populations. It is important to emphasize that health is not innate; it is built over time.
All individuals are born with a genetic capacity that underlies their personal potential and influences their health and longevity.
Contemporary genomic medicine already has a knowledge base concerning the genetic capacity of individuals and how to influence or manipulate it. This has improved the ability to diagnose genetic errors and genetic diseases, making it possible to predict clinical symptoms long before they appear and physiological changes in individuals before they occur It is also possible to predict which patients will be sensitive, or not, to a given treatment.
These discoveries and others associated with biotechnology, nanotechnology, and pharmacology are part of an important group of interventions known as precision medicine, which will influence clinical practice in the coming decade Public health authorities in the countries of the Region should seek to understand the impact of these interventions and the ethical dilemmas they pose.
For example, the decision of whether to intervene based on genetic risk 25 must take into account the high costs of such interventions and their potential effects on health coverage, as well as questions of access and financing Advances in epigenetics explain how gene expression can be modulated in response to environmental signals and how these changes can persist across several generations A growing body of evidence makes clear that this plasticity is present not only in the early stages of life, but at other points during the life course, a finding that will have a great impact on medicine and public health 2, In their adaptive response, human beings exhibit a high degree of plasticity the capacity to modify developmental biology in response to environmental stimuli that enables them to cope with the changes and different circumstances that they face However, the greatest advances in increasing life expectancy and improving health indicators are due to interventions that influence the life trajectories of individuals.
The vast majority of the actions implemented in the Americas to date that have proved highly effective and efficient are related to health promotion. They include immunization, proper nutrition, physical activity, and the crusade against tobacco use, among others.
There is great scope for increasing actions aimed at promotion and prevention. The barriers imposed by poverty and, especially, inequality, as well as the high costs associated with technology, will continue to limit access to new advances in public health and medicine for the vast majority of the population.
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This chapter and others in this report highlight this reality and its influence on the health situation in the Americas. The impact of events on the life course is not uniform. A single stimulus—negative or positive—can have different impacts, depending upon the time of life when it occurs During particularly sensitive periods, such as the prenatal stage, childhood, and adolescence, these stimuli can trigger adaptive responses in the individual and in populations, with long-term effects that extend to other stages of life.
A reduced growth rate in utero and after birth has been associated with an increased risk of cardiovascular diseases and diabetes Pregnancy and maternal health. With adolescent pregnancies in the Region at alarmingly high rates already, there is evidence of a new and troubling phenomenon: the increase in pregnancies among girls 14 years of age or younger in some countries There has also been a relative increase in pregnancies among women 35 years of age or older, with a consequent rise in complications and mortality associated with assisted reproductive technology practices.
The current functional relationship between maternal mortality and age results in a U-shaped curve, whose upper ends correspond to girls under 15 and women over 35 The Region of the Americas is experiencing an obstetric transition that recalls the classical epidemiological models of demographic and epidemiological transitions. Although some less-developed countries and territories still have high rates of births and of direct maternal mortality, the predominant situation across the Region is a smaller number of births, a reduction of maternal mortality, and greater life expectancy for women.
In this context, maternal mortality is linked to indirect obstetric causes and to the increased number of pregnancies that occur in complex circumstances, such as in women with noncommunicable diseases, transplants, and similar health problems. These different scenarios, shaped by economic, social, and cultural factors, will need an appropriate response from the health sector in the coming years.
The goals and strategies for ending preventable maternal mortality require a specific and realistic framework to guide strategic planning. Furthermore, they should be sufficiently flexible so they can be interpreted and adapted effectively in various national contexts, and especially in the local contexts where they are applied. Ample evidence exists that an inappropriate intergenesic space has an unfavorable effect on both the woman and her offspring. To ensure that a woman begins her pregnancy in the best circumstances, it is key to intervene with accurate information, while strictly respecting her self-determination This perspective, which is not yet widespread in the Region, is linked to a focus on preconception, which in the coming years should be accorded the importance it deserves, just as occurred with prenatal care in last century The impact of adverse conditions during pregnancy can be reduced through preconception care that is based on the provision of biomedical interventions and on the promotion of favorable habits and socio-environmental conditions, directed both to women and to their partners.
The evidence suggests that births in disadvantageous conditions are often due to poor health behaviors, exposure to harmful environmental factors, and lack of access to health care Newborn health. Health at birth is a factor that helps to predict long-term results, such as education, income, and disability. Both low birthweight and prematurity require prenatal care, which is provided to Regionwide, There is steadily increasing knowledge available about the protective effect on fetal health of various interventions, including expanded coverage of influenza vaccination—which helps prevent premature birth—as well as expansion of complementary nutrition, improvements in environmental health, reduction of violence against women, increased use of conditional cash transfers, and better understanding of maternal and fetal health The association between the height of the child and of the mother, or between low birthweight in girls and the body composition and intrauterine growth of their eventual offspring, demonstrates the intergenerational effect of these influences High-quality care at the time of birth means achieving adequate coverage of the interventions with proven effectiveness, those that have a positive effect on maternal and newborn health.
Examples of these interventions are timely clamping of the umbilical cord, early skin-to-skin contact, immediate initiation of breastfeeding, neonatal screening tests, and maternal-infant bonding to promote early development. A good beginning means that the woman is attended by skilled personnel and that her delivery takes place in an appropriate institution and surroundings. Society still does not provide a favorable and enabling environment to the majority of women who wish to breastfeed.
Successful breastfeeding should be regarded as a collective social responsibility, involving health systems, families, communities, and workplaces. Rates of breastfeeding and indicators of adequate complementary feeding can be improved considerably in a very short time. Policies and programs to support nursing mothers in health centers, homes, and workplaces have a greater effect if they are designed and implemented as part of a package of interventions, but they require financing and political will According to the United Nations Convention on the Rights of the Child, all children have the right to achieve their full development potential and enjoy maximum health Healthy children have greater opportunity to grow and develop into adults who are healthy and productive.
The child population has particular characteristics and health needs that require specific responses and actions. The recognition of factors that promote their health and growth requires an understanding of the demographic, socioeconomic, and equity conditions that shape their lives, as well as factors related to family and social cohesion, health promotion policies, nutrition, the environment, and access to and utilization of services, among others Preventing disease and death is not sufficient to ensure a healthy childhood.
Family Violence In Japan: A Life Course Perspective
It has been recognized that early childhood development provides a solid basis for the formation of human capital 22, Today it is known that the foundations of brain architecture are laid and consolidated in the first years of life, through a dynamic interaction of genetic, biological, psychosocial, and environmental influences.
In , Britto and colleagues 49 proposed three packages of effective measures aimed at creating opportunities for every child to achieve his or her maximum development potential: a a package of measures to support and strengthen families; b a package of multigenerational nurturing care measures; and c a package of early protection and learning measures Figure 1. The challenge is to ensure that families and children benefit from these interventions, particularly children affected by multiple disadvantages.
Domains of nurturing care necessary for children to reach their developmental potential Reprinted with permission from The Lancet.
The environment does not change DNA, but it produces chemical changes that affect the development and neurocognitive-motor performance of the child. Moreover, these chemical signals can be transmitted from one generation to the next. The dynamic interactions between the environment and genetics place children on different trajectories that affect their health throughout life, along with their cognitive abilities, behavior, and social functioning, and those of future generations The current literature on early childhood development emphasizes the need to adopt a broader approach to the physical, emotional, cognitive, and social development of children This is a topic with intersectoral implications, encompassing health, education, nutrition, well-being, and social protection, among other areas The interactions between children, their parents, and other caregivers—including those who provide health and social services—constitute the most important external influence, together with the exposure to environmental risks in the home and community.
Parents and caregivers, both women and men, can help offset the negative effects of possible disadvantages by providing health care, nutrition, nurturing, security, and early learning-if they receive support to help them provide an appropriate upbringing to children. In the Region of the Americas today, we have the necessary knowledge to eliminate infant mortality due to preventable causes, as well as to greatly improve the health and well-being of children and carry out the transformations needed to ensure a more prosperous and sustainable future As discussed, the life trajectories of individuals and populations contain transitions that are milestones in themselves and that constitute moments of change.
These transitions can be biological, psychological, social, economic, political, or even geographic in origin, and they are not necessarily predetermined nor always foreseeable: examples include retirement, menarche, menopause, school entry, the beginning of working life, and migration. Other changes that can be mentioned include changes in social roles or, from the biological perspective, the acquisition or loss of functions that accompanies the beginning or end of physiological processes Adolescence represents the most documented example of the life course concept.
It is one of the life stages with the most complex transitions and also one of the most sensitive periods of human development, during which behaviors are modeled and habits and lifestyles are adopted. The development of the human brain continues throughout life through a process known as neuroplasticity. Research suggests that the brain transformations taking place in adolescence are quite different from those that occur in childhood.
During childhood, the focus is on dendritic outgrowth and synaptogenesis or synaptic growth, which permits the brain to increase substantially in size and weight. The evolution of the brain during the second decade of life and into early adulthood seems to concentrate on synaptic pruning, in which the process of eliminating weak or irrelevant synapses is necessary in order to obtain greater brain efficiency.
Synaptic pruning is believed to depend on the responses of neurons to environmental factors and external stimuli. As a result, this stage is regarded as a critical period in which the individual is highly receptive to environmental stimuli, which in turn has enormous consequences for the neurological development of adolescents.
This explains the adaptive form of learning and the rapid acquisition of interpersonal and emotional skills during adolescence An analysis of this process points to the importance of ensuring a secure and stable social environment for adolescents in order to support optimal development of the brain functions that are essential for longevity and for social and emotional well-being in adulthood 56, 57, 58 Figure 2.
Although the family can provide the primary structure of protection and security during this period, adolescents by nature are exposed to and sensitive to many other influences, such as friends, school, communications media, the community, and the world of work. This sensitivity that is so characteristic of adolescence implies that the communications media can influence the attitudes, values, and behavior of the individual more than during any other stage of life.
The digital revolution has facilitated exposure to new ideas and contacts with like-minded people, but it also carries new risks, such as the marketing of unhealthy products and the promotion of fixed consumption habits. Figure 2. Ideal model to promote healthy development in adolescence. Young people leave the educational system and enter the world of work, where they assume steadily increasing responsibility for their own decisions, including those that influence their health. This is the time of life when the human body acquires the capacity to reproduce, and it is also the stage when young people typically encounter tobacco, alcohol, and other possible health hazards for the first time The effects of this relationship are documented: for example, the scientific evidence, although limited, suggests that communication between parents and adolescents-especially between mothers and daughters-on sexual subjects helps delay the beginning of sexual relations and promotes the use of contraceptive methods In the next decade, efforts to provide comprehensive care to people in midlife should be reoriented to the health needs of people, rather than to diseases.
The health issues of men and women in the post-reproductive stage of life have not received the necessary attention. These middle generations are subject to major social and family pressures related to caregiving, extension of the retirement age, and the implications of being viewed by health providers as bearers of diseases or risk factors. It is urgent to evolve toward a holistic vision of the person, using a life course approach.
Mental health is the result of interaction between protective factors and risk factors throughout the life course, including the prenatal period and intergenerational transmission.