Young and Healthy?

This issue is co-published with NHS Health Scotland and IPPF European Network YOUNG AND HEALTHY?

THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No.69 - 2009 Contents The European Magazine for Sexual and Reproductive Health Editorial Rachel Hanretty 3 Entre Nous is published by: Country Policies and Systems Unit Investing in Young People: UNFPA’s Commitment to Advancing the Rights WHO Regional Office for Europe of Adolescents and Youth in the eastern Europe and central Asia (EECA) Scherfigsvej 8 Region DK-2100 Copenhagen Ø By Thea Fierens 4 Denmark Tel: (+45) 3917 1602 Accelerating action for adolescent health in the European Region Fax: (+45) 3917 1818 By Valentina Baltag, Gunta Lazdane, Venkatraman Chandra-Mouli and Bruce Dick 6 E-mail: [email protected] www.euro.who.int/entrenous A guide for developing national policies on young people’s sexual and reproductive health and rights Chief editor By Elizabeth Bennour and Irene Donadio 8 Dr. Gunta Lazdane Editor Adolescents, the internet and new technologies: a cyber-wonderland? Dr. Lisa Avery By Pierre-André Michaud 10 Editorial assistant Dominique Gundelach Sexuality education programmes and sexual health services: Layout links for better sexual and reproductive health (SRH) Sputnik Reklame Aps, Denmark. By Dan Apter 12 www.sputnikreklame.dk Print Valuing young people: Scotland in context Zeuner Grafisk as By Shirley Fraser 14 www.zeuner.dk A personal perspective: sexual bullying Entre Nous is funded by the United Nations By Kalle Johannes Rose 16 Population Fund (UNFPA), New York, with Engaging and involving young people in sexual and reproductive health the assistance of the World Health Organiza- By Nuala Healy 18 tion Regional Office for Europe, Copenha- gen, Denmark. Croatian school health services and adolescents’ reproductive health pro- Present distribution figures stand at: 3000 tection: human and organizational capacity English, 2000 Spanish, 2000 Portuguese, By Marina Kuzman and Ivana Pavić Šimetin 20 1000 Bulgarian and 1500 Russian. Developing youth friendly primary care services in Bosnia & Herzegovina Entre Nous is produced in: By Anne Meynard, Daliborka Pejic, and Dagmar M. Haller 22 Bulgarian by the Ministry of Health in Bul- garia as a part of a UNFPA-funded project; Healthy Respect – a national demonstration project on sexual health and Portuguese by the General Directorate for young people Health, Alameda Afonso Henriques 45, By Moray Paterson 24 P-1056 Lisbon, Portugal; Russian by the WHO Regional Office for Walk the talk: supporting the delivery of youth friendly health services in Europe Rigas, Komercfirma S & G; Scotland Spanish by the Instituto de la Mujer, Minis- By Nuala Healy 25 terio de Trabajo y Asuntos Sociales, Almagro Quality of care in Estonian youth clinics 36, ES-28010 Madrid, Spain. By Kai Part, Triin Raudsepp and Helle Karro 26 The Portuguese and Spanish issues are dis- tributed directly through UNFPA representa- Reaching most at risk adolescents and youth – Tajikistan’s experience tives and WHO regional offices to Portuguese By Nisso Kasymova 28 and Spanish speaking countries in Africa and South America. Resources By Lisa Avery 30 Material from Entre Nous may be freely trans- lated into any national language and reprinted in journals, magazines and newspapers or placed on the web provided due acknowl- The Entre Nous Editorial Advisory Board 2 edgement is made to Entre Nous, UNFPA and Dr Assia Brandrup- Jane Cottingham Ms Nell Rasmussen the WHO Regional Office for Europe. Lukanow Coordinator, Gender, Repro- Senior Consultant, Danish Articles appearing in Entre Nous do not Senior Adviser to the Health ductive Rights, Sexual Health Centre for Research on Social necessarily reflect the views of UNFPA Matrix Network and Adolescence, Vulnerability or WHO. Please address enquiries to WHO headquarters, Geneva WHO headquarters, Geneva Dr Peer Sieben the authors of the signed articles. Mr Bjarne B. Christensen Dr Helle Karro UNFPA Representative for For information on WHO-supported activi- Secretary General, The Danish Professor, Head Turkey and Country Director ties and WHO documents, please contact Family Planning Association Department of Obstetrics and for Armenia, Azerbaijan and Dr. Gunta Lazdane, Country Policies and Ms Vicky Claeys Gynaecology Georgia Systems unit, office T-316 at the address Regional Director Medical Faculty Dr Robert Thomson given above. International Planned Parent- University of Tartu Member, Geneva Foundation Please order WHO publications directly from hood Federation, European Estonia for Medical Education and the WHO sales agent in each country or from Network, Brussels Dr Evert Ketting Research Marketing and Dissemination, WHO, Senior Research Fellow CH-1211, Geneva 27, Switzerland Radboud University Nijmegen Department of Public Health ISSN: 1014-8485 ,, Rachel Editorial Hanretty A young person’s perspective on sexual and reproductive health

lthough it fulfils an indulgence in with health professionals who are friendly As young people we need to be proactive stereotyping, as a young female I and unassuming. Development of quality and involved with the decision making do spend a lot of time worrying youth friendly health services, whether process at all levels. We need to be our overA and considering my appearance; tak- they are part of school services, exist- own advocates so that our voices are ing a moment aside to view one’s figure in ing clinics or stand-alone facilities, are heard and our needs are recognized. We the mirror is not uncommon. However, an essential step towards breaking down need to be involved in open dialogue with as a young female, taking a moment to the barriers that exist between young all key stakeholders and communicate ef- review my own sexual and reproductive people and access to health services and fectively to promote positive understand- health (SRH) and checking that every- advice. Some might argue that the barrier ing when it comes to the SRH of young thing is okay is so uncommon that it is between young people and older genera- people. We need the appropriate life skills often badly misinterpreted by others. tions has widened with the global spread and tools to empower us to make in- This is largely because it is assumed that of networking sites, SMS messaging and formed decisions about all aspects of our a young person who goes to a SRH clinic wired in earphone and ipod accessories. health, for the behaviours we learn in our must be going with a negative purpose: an The Internet and the other media facets youth can have significant impact on both experience of unprotected sex, suspected that are becoming part of daily life can our present and future health. Perhaps pregnancy or a possible case of a STI, all be utilized across Europe in order to pro- most importantly we need to be seen as of which carry a burden of embarrass- mote good health amongst young people. partners throughout this entire process. ment and a scathing, judgemental look Old methods aren’t working. Posters and Meetings such as the “Meeting on from the receptionist at the clinic. Rarely fliers are all very well but young people youth friendly health policies and is it assumed that we might actually be are changing and it’s time that health services“ held in Edinburgh, Scotland, being proactive with our SRH, seeking services worldwide moved with the tides. are one such forum that enables young information, advice or access to care that In Scotland attempts at adopting this people, SRH experts, policy makers and will enable us to live healthy sexual and informal and friendly approach have key stakeholders to come together with reproductive lives. proven successful, as is the case with ‘The the goal of promoting and improving the As part of a group of young people who Corner’ youth facility in Dundee (see SRH of young people. I commend the form a Public Partnership Forum, work- pages 18-19 for more details). Here young sponsors (NHS Health Scotland, WHO ing with NHS Education for Scotland, we people don’t need to be ashamed of drop- Regional Office for Europe, IPPF EN, have put forward communication issues ping in because it is a centre that deals European Training for Effective Ado- as one of our top priorities. We have all with young people’s overall welfare, not lescent Care and Health, UNICEF and talked about how one raised eyebrow just SRH. Qualified nurses are available UNFPA) and all those involved for taking or unfriendly comment can put young to talk about everything and anything the steps to address the SRH and needs people off from seeking medical help. without any stuffy pretentiousness or of adolescents and in doing so working Why would a young person seek a SRH established protocol and peer-educated towards ensuring that positive SRH of check up - without an immediate sexual volunteers can talk to young people on young people is recognized as a basic problem - if the health professional is the same level without a ‘should-have- human right. suspecting the worst from a presenting known-better’ tone of voice. patient and ready to cast judgement? Wherever in the world you look, young Rachel Hanretty, Young people need to be understood people hold an increasingly prevalent young person in a friendly, approachable manner and reputation of being tough, confident and Public Partnership Forum 3 Scotland where SRH is concerned, it should be the outspoken. Yet, this is also a time for case that going to a clinic should not be us when we can feel vulnerable – faced shameful. We need to know it will be okay with new emotions, development and to talk about sex and sexuality. behaviours. In reality we are often scared In order to gravitate towards some mu- of being proactive about our SRH because tual understanding between young people the positive SRH of young people is often and medical professionals the Public Part- challenged by many societal and cultural nership Forum in Scotland is holding our taboos. As a young person, this is what I own event – The Sex Factor – for school feel ultimately must be addressed and re- age pupils to come and learn in one day versed. Governments at all levels need to what they are too afraid of asking adults. create and implement policies that recog- We want them to see that beyond the nize our right to positive SRH, including context of a doctor’s clinic, services can be the development of quality youth friendly developed that are youth friendly, staffed health services and sexuality education.

No.69 - 2009 Investing in Young People: UNFPA’s Commitment to Advancing the Rights of Adolescents and Youth in the eastern Europe and central Asia (EECA) Region

Investing in young people is and employment programmes, an investment in the fu- • uphold the rights of young people, especially girls and marginalized ture. Yet more than half of groups, to grow up healthy and safely young people throughout to receive a fair share of social invest- ments and, the globe live in poverty. • encourage young people’s leadership Impoverished youth are and participation in decisions that affect them, including the development particularly at risk of gen- plans of their countries. der discrimination, poor have been the emerging good practices UNFPA’s work in eastern Europe related to youth participation and youth schooling, unemployment and central Asia Region empowerment through Y-Peer, the Youth and poor access to health In the eastern Europe and central Asia Peer Education Network, and RHIYSC, Region, UNFPA advocates, with national the Reproductive Health Initiative for services. They are also less governments, for an essential package of Youth in the South Caucasus. They are likely to know of, claim and social protection interventions for young successful because these initiatives give people. An important component of our young people the power to make their exercise their rights to re- work includes creating an environment own choices. productive health informa- in which adolescent girls and boys are encouraged to delay childbearing. Delay- Youth participation tion and services. ing childbirth directly saves lives - the life Y-PEER is a network of more than 500 of the mother as well as the child. Babies non-profit organizations, associations and The rights of adolescents to reproduc- with adolescent mothers are 1.5 times governmental institutions. Its member- tive health information and services has more likely than those with older mothers ship includes thousands of young people, been upheld by numerous international to die before their first birthday (1). High active peer educators, trainers and youth agreements and global forums, includ- rates of early childbearing are directly advocates for adolescent and reproduc- ing the Convention on the Rights of the linked to the practice of early marriage tive health. Y-PEER links more than 5000 Child, the 1994 International Confer- in many countries. It is important to members from 39 countries in the eastern ence on Population and Development highlight that in many countries in the Europe and central Asia Region, as well and the 1995 Fourth World Conference eastern Europe and central Asia Region, as the middle East and north Africa on Women in Beijing, among others. Yet marriage before the age of 18 is permitted and continues to grow to date. Y-PEER there remains a huge gap between rights by law (2). employs a rigorous system of training guaranteed in international conventions, During the past fifteen years, UNFPA’s for peer educators while maintaining and the enforcement of these rights at the eastern Europe and central Asia Region an “edutainment” component, using national level. has gained vast experience in working for interactive methodologies and a process and with young people to address their that is entirely owned by young people. The role of UNFPA growing needs for comprehensive sexual These proven peer education methodolo- 4 UNFPA seeks to address the rights and reproductive health information, gies have been deemed so effective that of adolescent and youth through the education, services and supplies. UNFPA they are now included in the National framework of poverty reduction. In this has generated baseline sexual and repro- Programme on the Prevention of HIV manner, UNFPA and its partners propose ductive health data for national planning Epidemic and its Social and Economic a holistic and multi-sectoral approach in and programming, and developed a Consequences in Kyrgyzstan. At a policy order to: strategic framework for adolescent sexual meeting in Kyrgyzstan it was noted that • empower adolescents and youth with and reproductive health in the region. We “Peer education standards developed by skills to achieve their dreams, think have developed the technical capacities Y-PEER were adopted and introduced critically and express themselves of healthcare professionals and govern- to stakeholders and approved by the freely, ment officials involved in adolescent and Government and Civil Society. They serve • promote health, by giving them access young people’s health, and worked with as a baseline for the standardization of the to sexual and reproductive health national counterparts to advocate for the informal education in the country (3).” information, education commodities integration of sexual and reproductive The Reproductive Health Initiative for and services, health education into national curricula. Youth in the South Caucasus funded by • connect young people to livelihood Critical to our successes in the Region the European Commission and UN- Investing in Young People: Thea Fierens UNFPA’s Commitment to Advancing the Rights of Adolescents and Youth in the eastern Europe and central Asia (EECA) Region

FPA seeks to advance the reproductive cultural and traditional taboos related to Thea Fierens health and rights of youth in Armenia, sexual and reproductive behaviour and Regional Director Azerbaijan and Georgia. Young people limited support for a youth agenda by na- Eastern Europe and central Asia in these countries are joining efforts, tional governments. The current financial Regional Office working together, and learning from crisis may further limit government’s abil- UNFPA each other. Activities provided in the past ity to provide needed health care services [email protected] by RHIYSC include the establishment and infrastructure, at the very moment of youth friendly health services, social when demand for health services, due to References marketing of condoms and free of charge worsening poverty, will be more acute. 1. UNFPA. State of World Population contraceptives, promotion of parental Without sustained investment in youth, 2008. Reaching Common Ground: cul- involvement in the removal of barriers to it will be impossible to meet the Mil- ture, gender and human rights. New access for sexual and reproductive health lennium Development Goal (MDG) on York: UNFPA, 2008. services and promotion of dialogue and poverty reduction. Nor will it be feasible 2. Rangita de Silva de Alvis. Eastern experience sharing with partners and to attain MDG 2 on education, MDG 3 Europe and Central Asia Regional Leg- stakeholders throughout the Region. on gender equality, MDG 5 on maternal islative Analysis: A Review of CEDAW 5 health, or MDG 6 on HIV prevention. As Compliance. New York: UNFPA, 2009 Conclusion indicated by a Bulgarian youth advocate, 3. Declaration on promotion of SRH Despite these initiatives, adolescents and “treating social problems is not only a and rights, 20 November, 2009, youth face many obstacles to sexual and matter of personal responsibility – it’s also Bishkek, Kyrgyzstan (National reproductive health information and part of belonging to a global network with Conference on presentation of Peer services that are compounded by their shared responsibility to the young people Education standards and National low social status in many cultures as throughout the world.” Forum on presentation of Y-PEER young people. Youth may be reticent to programme for youth NGO’s/associa- seek reproductive health services due to tions, young leaders, National Com- stigma or mistrust of health care provid- mission on Youth Policy, relevant ers. In countries where fee-for-health ministries and counterparts, donor services are required, youth may not have community) the resources to pay for required services. Advocates for youth often confront

No.69 - 2009 Accelerating action for adolescent health in the European Region

Two recent developments small expenditures would be catastrophic. Reforming services to deliver for young people’s health are of major importance for In a number of countries, with the current financial crisis and the diminished Poor quality of services for young people shaping the public health employment opportunities for young peo- remains a main challenge to be addressed agenda in the European ple, the period is increasing between the in service delivery reforms. Low effective- end of their insurance status as a child, ness, especially in select outdated models Region for years to come: and the beginning of a career. of school health services (SHS), is another primary health care (PHC) Cross-border mobility is increasing in one. The third challenge is the fact that the region. EU mechanisms for cross- with the waves of health systems reforms renewal (1) and the Tallinn border health care try to address the and the trends of a shift towards the needs Charter (2). issue of patient mobility, but migrants of an increasingly ageing population, from outside the EU, many of who are young people’s needs tend to be over- The Tallinn Charter outlines directions young people, continue to fall through looked and neglected. for health systems development in the the cracks. For example, in Luxembourg Health systems that existed in the WHO European Region if they are to ef- almost 40 % of young people are from past were often biased towards detecting ficiently contribute to health, wealth, and other EU Member States, and more than health problems and providing curative social well-being. The World Health Re- 15% of young people in Spain were non- health services rather than addressing port 2008 makes the case for global PHC EU citizens (3). preventive measures. They also tended to renewal, outlining the four sets of reforms Boys are generally much less likely be fragmented with specialists focus- that are needed to meet the expectations to use health services, even if there are ing on particular organ systems (e.g. in of citizens in the modern world: universal specific initiatives to reach adolescents. many countries, there were adolescent coverage, service delivery, public policy Age per se may be a factor of exclusion. gynaecologists) rather than on the holistic and leadership. The two documents Traditionally designed health systems needs of individuals. As a result of this, share similar values and principles, and were built to serve the needs of ill and health services are often of poor qual- describe similar approaches for achieving disabled people, while adolescents are ity both in the way in which they are the improvements that are required. more in need of preventive oriented provided, and in the way in which they This paper analyses their implications services. Sexual and reproductive health meet the expectations of young people. In for adolescent health programmes in the service delivery is particularly “age sensi- some countries systems to improve and Region. tive”, with some societies limiting their maintain quality are weak or nonexistent, provision to adolescents. and there is no commitment to dealing Universal coverage for young Marginalized groups of adolescents are with this. Involving users in the design people’s health frequently not reached by health services of health service provision to ensure that There are many challenges in the Euro- even where efforts are under way to make it meets their needs is not yet a routine pean Region that hinder progress towards them “adolescent friendly”. In the past, practice in many countries. universal coverage of young people with many countries of the Region made con- The health system reforms provide an effective interventions. These include certed efforts to bring everyone into the opportunity to reorient health service young people’s financial vulnerability, mainstream, with virtually no efforts to delivery systems to respond to the needs cross-border mobility, patterns of exclu- provide those few individuals and groups of adolescents. However, in many places, 6 sion because of a range of factors includ- who were not part of the mainstream with these reforms tend to be blind to the ing sex and age, and the specific needs of health and social services. needs of adolescents. For instance, the marginalized and vulnerable groups. However countries are moving for- recent transition to family medicine in Concerning the financial vulnerability ward. The Republic of Moldova recently many countries of the Region did not of young people, there are a number included YFHS in the list of services take into account that adolescents are as of countries where adolescents are not covered through mandatory health insur- much members of a family as children covered by health insurance schemes or ance scheme. There are efforts to respond and the elderly. Consequently, profes- specific budgetary allocations. In some to the special needs of males, for example sional capabilities of PHC providers to countries where youth friendly health by setting aside dedicated clinic times deal with specific needs of adolescents are services (YFHS) have been developed, the as in Estonia, or to reach marginalized extremely limited, and the “age appropri- services that are provided rely on time- adolescents, such as injecting drug users, ateness” of PHC services is very low. SHS limited project funds. For certain groups as in Tajikistan. – a particular type of PHC services - have of young people, for example, those fallen between the cracks in health sys- whose parents are working abroad and tems reforms. They continue to abound have left their children behind, relatively with non-effective interventions, to focus

Valentina Gunta Venka- Bruce Dick Accelerating action for adolescent Baltag Lazdane traman Chandra- health in the European Region Mouli

on treatment rather than health promo- Often support for actions in health be a litmus test for their implementation. tion and are seen as less prestigious than facilities and communities is completely On the other hand, adolescent health other PHC professions. missing at the sub national level. Al- programmes should use the opportunity However, progress is being made in though evidence about decision making of both the PHC approach and Tallinn many countries in the Region in trying in public health are inconclusive, some charter to accelerate the energy for their to match services with needs. The United from the European context revealed that implementation. Kingdom is implementing the National setting priorities is consistently related to Service Framework for Children, Young population health status, epidemiological Valentina Baltag, MD, PhD People and Maternity Services. Several data, burden of disease and, often, scope Technical Officer countries – i.e. the Republic of Moldova for prevention (4). Economic argument is Adolescent SRH including HIV and PHC and Kyrgyzstan - are making efforts in increasingly appealing. As adolescents are Country Policies and Systems setting nationally agreed quality stand- often a relatively healthy segment of the WHO Regional Office for Europe ards for YFHS so that any facility may population, reliance on epidemiological [email protected] be “measured” against them. Denmark, data of disease incidence and preva- Belgium, United Kingdom and Croatia lence for priority settings becomes less Gunta Lazdane, MD, PhD are just some of the countries that have relevant. Rather, the scope for prevention, Regional Advisor, reoriented SHS from a medical care para- economic argument, ethical and human Country Policies and Systems digm to a social care paradigm over the rights considerations should be used in WHO Regional Office for Europe last decades. The Republic of Moldova, obtaining buy-in from leaders of various [email protected] Ukraine and Albania also recently em- sectors. barked on this process. In the framework of the implementa- Venkatraman Chandra-Mouli, MD Coordinator, Adolescent Health and tion of the European strategy for child Public policy reforms Development and adolescent health and development Department of Child and Adoles- The “health in all policies” call of the (2005), 12 countries started the develop- cent Health and Development renewed PHC acknowledges the impor- ment of their national strategies. While WHO headquarters tance to address socio-economic determi- a positive sign of leaders’ increasing [email protected] nants of health, as does the Tallinn Char- awareness and commitment to adolescent ter. In many countries, sectors other than health needs, there is a risk that these Bruce Dick, MD health do not make the needed important strategies will not be implemented unless Medical Officer, Department of contributions, or do so but their activities concerted efforts are made to translate Child and Adolescent Health and are not well coordinated. the actions proposed into existing work Development Per se, “health in all policies” will not plans and budgets. WHO headquarters [email protected] address the specific needs of young people unless there is a “young people’s health in Conclusion References all policies” standpoint. The creation of The adolescent health programmes, by opportunities for girls to study or work the nature of their beneficiaries’ needs, 1. The World Health Report 2008. Pri- as a means of reducing early pregnan- are consistent with the PHC renewed mary Health Care – Now More than cies, the decriminalization of needle and approach and the Tallinn charter. They Ever. Geneva: WHO, 2008. http:// syringe exchange programmes, actions to advocate for, and make concrete actions www.who.int/whr/2008/en/ 7 reduce road injuries and violence due to in, ensuring universal coverage, reform- 2. WHO European Ministerial Con- alcohol use, and actions to protect young ing services to make them youth-friendly ference on Health Systems “Health people against aggressive marketing of and make them part of overall health Systems, Health and Wealth”, Tallinn, the tobacco industry are just some of the systems reforms. They advocate for Estonia 25–27 June 2008. Report. Co- examples where the fact that a person is public policy reforms along the “young penhagen: WHO, 2009. http://www. young requires tailored interventions. people’s health in all policies” paradigm. euro.who.int/InformationSources/ Multi-sectorial interventions should also Finally, they advocate that leaders from Publications/Catalogue/20090122_1 address the issues of health care seeking all sectors consider the youth dimen- 3. EU Youth Report. EC, Brussels, 2009 behavior. sion in their policies. In these aspects, 4. Allin S, Mossialos E, McKee M et al. adolescent health programmes provide Making decisions on public health: a Leadership reforms a very useful practical application of the review of eight countries. WHO, 2004 National level leaders in many countries PHC renewed approach and the Tallinn on behalf of the European Observa- are not committed to meeting the needs charter – documents that are merely po- tory on Health Systems and Policies. and fulfilling the rights of adolescents. litical and directions’ setting – and might

No.69 - 2009 A guide for developing national policies on young people’s sexual and reproductive health and rights

PPF European Network (IPPF EN) comprehensive, rights-based approach to trust and ownership building is essential has been a lead advocate for young young people’s SRHR. It recognizes that to bring about the ‘change’ of political people’s sexual health and rights while there are basic underlying princi- attitudes and social norms necessary to (SRHR)I over the years and its Member ples that should be a common thread for achieve better SRHR policies for young Associations have piloted initiatives to policies, policy implementation will vary people. Moreover, it is crucial that in the provide sexuality education, informa- depending on national legislation and po- policy making process the capacities and tion and services and promote a right litical setting, service structures and other aspirations of the stakeholders themselves based approach towards the SRHR of national considerations. Box 1 outlines are valued and respected. young people. IPPF EN and like-minded cross-cutting elements of policy making In determining the stakeholders it organizations consider that sustainable in this field. is important to consider who will be gains in ensuring young people’s SRHR The SAFE partners selected five policy affected by the desired change and how, can only be obtained if there is a solid areas considered to be key in ensuring and what needs to be done to ensure that framework of sound and comprehensive the SRHR of young people (see Box 2). A an enabling environment is created to policies. Therefore building on evidence, separate chapter for each of these areas bring about change. In the case at hand, research and our expertise we developed, provides a detailed discussion of the is- the primary stakeholders were the young together with WHO, a set of tools to assist sues and principles at stake, followed by people themselves, and the key stake- policy and decision makers in providing a checklist for action by national and/or holders were the networks supporting such a framework. regional governments/agencies. them: families, teachers/schools, medical In 2004-2007 IPPF EN implemented professionals, judges, social workers, the Sexual Awareness For Europe (SAFE) Stakeholder involvement: an essen- police, media, opinion leaders and role project in partnership with 26 of its tial element in policy development models for young people, local authori- and implementation Member Associations in Europe, the ties, parliamentarians, religious groups, WHO Regional Office for Europe, which IPPF EN firmly believes that in order to specialized agencies of service providers, coordinated the partnership with health introduce policies to promote and ensure advocates and researchers. In our field in ministries, and Lund University (Sweden) the SRHR of young people, it is essential particular it is of crucial importance that which was in charge of the research com- to have multi-stakeholder and multi- all the groups that might be affected in ponent. One of the major achievements agency involvement and support. Greater some way, that feel they have a legitimate of SAFE was the Guide for Developing information and broader experiences and stake in the issue or will have a role in the Policies on the Sexual and Reproductive support make it easier to develop and process, are properly involved and given a Health and Rights of Young People in implement realistic policies and plans, voice, space and some power to contrib- Europe. The policy guide is the fruit of allow new initiatives to be embedded into ute/decide. the cooperation with representatives of existing legitimate local institutions, en- An example of best practice is Scot- health ministries of the countries partici- able less opposition and greater political land’s experience in developing and intro- pating in the SAFE project and allowed leadership, and develop local capacities. ducing a national sexual health strategy. us to work closely with decision makers Stakeholder involvement can be clas- and implementers. It created a platform of sified into three types: i) instructive, ii) Taking up the challenge experts that looked in depth at challenges consultative and iii) cooperative. Instruc- IPPF EN and its partners are currently and possible solutions. This collaboration tive involvement is where government preparing to embark upon SAFE II. One 8 also permitted a constructive dialogue makes the decisions but mechanisms exist of the main work streams under this with governments, the creation of trust for information exchange. Consultative new 3-year project will include focused between different actors, wider ownership involvement is where government is the advocacy in several European countries and political momentum. Furthermore decision-maker but stakeholders have for government adoption of comprehen- a key element for the development of the a degree of influence over the process sive policies on young people’s SRHR guide was youth participation and the and outcomes. Cooperative involvement using the SAFE policy guide as a tool. involvement of the young people from is where primary and key stakeholders These efforts will be undertaken in close IPPF EN’s youth network (YSAFE). The act as partners with government in the collaboration with young people and guide complements the WHO European decision-making processes. key stakeholders from among the groups Strategy for Child and Adolescent Health In the field of young people’s SRHR mentioned above, and will also involve and Development. Other tools include key stakeholder involvement is essential representatives of relevant ministries and a policy brief (1) and four fact sheets because of the controversy attached to government agencies (e.g. health, educa- on good practice in addressing young young people’s SRHR and because of the tion). A compendium on the state of people’s SRHR. intended social change. Furthermore, policies on young people’s SRHR in 24 EU The Policy Guide takes a positive and cooperative involvement, negotiation, Member States will also be developed

Elizabeth Irene Bennour Donadio

What makes a successful youth-friendly SRHR policy? A youth-friendly SRHR policy respects diverse values held by a • Protection policies for young people wide range of groups, provides age-appropriate information Young people have the right to physical, psychological and social that addresses the realities of young people’s lives and takes protection, particularly those with special needs, such as sexually the perspective that sexuality is a positive force and not some- abused and trafficked young people, teenage mothers, young people thing to fear. It should also take into account and integrate a with disabilities, young people with HIV, and victims of female genital number of essential cross-cutting issues and principles related mutilation. The legal systems should provide an adequate framework to young people’s SRHR, including: for young people’s SRHR that is protective and supportive. • Involvement of young people • Multi-sector support The participation of young people in policy development ensures that The SRHR of young people is not purely a health issue, nor only the policies and programmes meet their real needs. Policymakers are urged responsibility of health workers. Government ministries should develop to call on youth councils or to create youth advisory panels on SRHR to a national strategy to ensure multi-sectoral collaboration, including participate in the policy process. publicly-funded structures and primary and secondary stakeholders in- • A gender focus cluding youth organizations, non-governmental organizations (NGOs) and community-based groups in both the national strategy develop- Boys and girls have a variety of different needs and risks. Women, ment and its implementation. especially young women, are biologically more vulnerable than men • Effective monitoring and evaluation to diseases related to the reproductive system. Both sexes are at risk of sexual abuse and exploitation. Young gay men and lesbians are particu- There is a lack of data on the SRHR of young people in Europe, particularly vulnerable to discrimination. larly comparative data. To have a better understanding and be more • Recognition of diversity and effective, all countries should improve comparative data collection. vulnerability The Health Behaviour in School-aged Children survey is one important tool that does this. NGOs and young people have a key role to play in Young people come from a broad range of social, economic, ethnic and conducting formative research, interpreting results, developing and cultural backgrounds and have different sexual identities. Flexible and implementing programmes, and being engaged in the monitoring and creative approaches are needed to reach marginalized young people or evaluation of policies and programmes. those with special needs, and to accommodate the different settings in which they live. Box 1 Box 2 Five Key Policy Areas Policy area 1: High-quality information and comprehensive sexuality education equips and disseminated. The compendium Information, young people with the knowledge, skills and attitudes needed for will be designed around the checklist for education informed choices now and in the future. and commu- action in each of the five key policy areas nication outlined in the policy guide. Policy area 2: Youth-friendly services are those that attract young people, respond to Health serv- their needs, and retain young clients for continuing care, based on an Elizabeth Bennour ices understanding of and respect for the realities of their diverse sexual and Director of Programme & Advocacy, reproductive lives. Regional office, IPPF EN, Brussels Policy area 3: Access to contraceptives is an integral element of any strategy for [email protected] Access to reducing rates of unwanted pregnancies and is a demand of the youth contraception movement. Irene Donadio Promoting regular and effective use of contraception cannot be addressed simply by making contraception available. Programmes must Advocacy Officer also include information and education on a wide range of issues, such as Regional Office, IPPF EN social values, gender equality, personal relationships, and drug and alco- Brussels hol use and aim to create an empowering environment for young people. [email protected] Young people often have limited financial means and, therefore, difficulty 9 purchasing contraceptives. This should be addressed in national strategies on SRHR. References Policy area 4: Reported rates of STIs are increasing across Europe with young people at 1. Developing Policies on the Sexual STIs and HIV/ increased risk. The importance of STIs/HIV prevention in youth needs to and Reproductive Health and AIDS be addressed. Positive prevention should increase the self-esteem and Rights of Young People in Eu- confidence of HIV positive individuals to protect their health and build healthy and happy relationships and families. rope http://www.ippfen.org/en/ Policy area 5: At a time of life when fertility is high and young people have limited Resources/Our+publications/ Unwanted experience using contraceptives, there is a greater risk of unintended or SAFE+Policy+brief.htm pregnancy unwanted pregnancies. 2. WHO. Safe abortion: technical and and safe Sexuality education, the availability of contraceptives and youth-friendly abortion services should all be components of a comprehensive approach to SRHR policy guidance for health systems, which should also lead to reducing unwanted pregnancies and abortion. Geneva: WHO, 2003. Nevertheless, it is not possible to completely eliminate unwanted pregnancy because of the multiple causes and factors involved with it. When performed by a trained healthcare provider with the proper equip- ment and under safe conditions, abortion is one of the safest medical procedures (2).

No.69No.61 - 20092005

Adolescents, the internet and new technologies : a cyber-wonderland?

The way in which the Inter- Adolescents are great users of tools such interactions which can be very stimulat- net and new technologies as mobile phones, electronic diaries, ing and builds on the natural interest and i-phones and personal computers: on one needs of adolescents’ to engage them- will affect our existence in hand, they familiarize themselves with selves in the exploration of their environ- the future remains to be any new technology much quicker and ment and of the world, as well as, the more easily than adults do; on the other construction of ideals (2). recognized, but already hand, all these devices are so appealing to For handicapped young people and there are lessons that can young people, that they represent a highly those suffering from chronic conditions, appreciated – if not naively exploited - the cell phone and the computer consti- be learned from the last ten target for the sale of such tools. It should tute a mean to – at least partly - overcome to fifteen years, particu- also be mentioned that, in low income the isolation linked with their impair- countries, compared to traditional paper ments. There are sites which allow for larly where adolescents and documents and land lines, the wireless exchanges between youngsters suffering health are concerned. connection as well as access to the web from specific diseases or who are hospi- allows quick and easy access to informa- talized. Also, for older adolescents, the tion; it follows that this huge technologi- web is a potential source of information cal leap will help these countries to close on their disease, on new treatment, or on the gap they faced in the past. Indeed, the normal course of their illness. It thus while nowadays the vast majority of may empower them, providing a sense of adolescents, in developed countries, are control over their condition. Finally, more connected in one way or another, the and more health professionals use the cell percentage of young people in low or phone as a reminder tool to increase ther- middle-income countries having such apeutic adherence, to remind youngsters access is increasing rapidly. of their appointment, or to communicate Often, parents, educators, health pro- the results of lab tests (3). fessionals or politicians tend to demonize new technologies arguing that they may Information, prevention and advice contribute to the spread of violence, por- Several informative websites have been nography, or make adolescents depend- developed, which aim to provide young ent (1). While this may be the case for a people with health information, preven- minority of more vulnerable individuals, tive messages or specific advice. They most adolescent girls and boys cope fairly currently exist in different languages such well with all these new tools. This brief as English, French, Spanish or Russian. review will discuss these new technolo- Many of the quality websites are run, or at gies potential impact on the learning and least supervised, by health professionals. socialization processes of adolescents, as A non-governmental agency located in well as, how they can affect their health. Geneva, Switzerland, named Health on 10 the Net can validate the quality of such Promoting education and learning websites. Some sites offer the possibility In the field of education and learning, the for users to ask their own questions and Internet constitutes a unique source of in- receive specific answers. It is possible to formation for all adolescents. It stimulates access to the whole range of questions their curiosity and assists them in the asked and answers provided, and thus preparation of documents. The condition provide an illustration of the wide range for proper use requires adequate support of preoccupations which teenagers have and assistance from adults and teachers. at various periods of their life, including Along the same line, the Internet is an growth and puberty, sexual life, nutrition, appealing socialization tool that allows mental health and depression, substance for exchanges not only with close mates use, etc. Furthermore, these sites consti- and friends, but also with correspondents tute a useful teaching device for doctors from all over the world. In this respect, in-training, who can learn more on how the existing chats and forums allow for young people express their questions or Pierre- Andre Michaud

opinions regarding their health, and how disorders, or even suicidal conducts (6). Pierre-André Michaud, MD Professor, Multidisciplinary Unit for to address these issues in a simple, acces- As a result in some countries – notably in Adolescent Health sible but accurate language (4). Scandinavia - schools have already imple- CHUV/University Hospital Lausanne mented formal curricula that attempt to [email protected] Potential negative consequences educate young people in the appropriate There are of course also several pitfalls use of all these technologies, but this is far linked with the use of new technologies. from being the rule. References One of the main concerns is the lack of Another area of great concern is the control of any formal agency on the qual- issue of the amount of time spent on 1. David-Ferdon C, Hertz MF. Electron- ity and the content of Internet websites the Internet by adolescents. It is virtu- ic media, violence, and adolescents: (1). This is why it is important for parents ally impossible to define the boundary an emerging public health problem. to monitor, especially among children between adequate and excessive use of J Adolesc Health 2007; 41:S1-5. and younger adolescents, the use of the new technologies as it is not only a ques- 2. Williams AL, Merten MJ. A review of computer and of the cell phone. Indeed, tion of numbers of hours, but also type online social networking profiles by for some of these young users, it is dif- of use, as well as reasons for using the adolescents: implications for future ficult to differentiate between the virtual computer. Young persons who utilize the research and intervention. Adoles- and the real world. In other words, adults computer to chat with others, to discover cence 2008;43: 253-74. have a responsibility not only to survey new fields of interest, or to construct new 3. Marsch LA, Bickel WK, Grabinski MJ. what the young people see, but also to spaces are probably much less destined to Application of interactive, computer discuss openly with them the meaning of become dependent than those who use technology to adolescent substance the information, images and proposals the computer for the thrill brought by abuse prevention and treatment. Ado- they have access to. the game and the satisfaction to win. In lesc Med State Art Rev 2007;18:342- Several specific potential threats to this regard, one of the biggest threats to 56, xii. the health and well-being of adolescents health is linked with the existence of so- 4. Gray NJ. Adolescents, the Internet, should also be mentioned: cyber-bullying called MMORPG (Massively Multiplayer and health literacy. Adolesc Med State has recently been recognized as a subtle, Online Role Playing Game) in which Art Rev 2007;18:370-82, xiii. but destroying, way for adolescents to users become dependent on the extent of 5. Smith PK, Mahdavi J, Carvalho harass or repeatedly menace their peers, their time involvement to gain credits and M, Fisher S, Russell S, Tippett N. with clear harmful consequences for the esteem from the other players, spending Cyberbullying: its nature and impact victims in terms of mental health and more and more time on their computer. in secondary school pupils. J Child self-image (5). Pornography and violent Psychol Psychiatry 2008;49:376-85 scenes can be quite disturbing for young Conclusion Norris ML, Boydell KM, Pinhas L, unprepared adolescents, especially if As can be understood from this discus- 6.Katzman DK. Ana and the Internet: this access is not supervised by adults sion, the Internet, the cell-phone and a review of pro-anorexia websites. Int and thus not accompanied by a “debrief- other new devices represent two sides of J Eat Disord 2006;39:443-7. ing” discussion. The transfer between the coin. They signify access to a huge adolescents of erotic images, obscenities amount of health information and a Examples of health websites for young or verbal attacks of individuals through fantastic means for positive exchanges people: 11 SMS is a recent phenomenon which and connectedness, but at the same time http://www.ciao.ch/ exemplifies the lack of capacity of young represent a threat to some adolescents’ http://www.goaskalice.columbia.edu/ people to discriminate between the health and development. The objective http://www.teenhealthfx.com/answers/ private and public arenas, as well as, their of our society thus is to set-up, in as health/index.html ignorance of the legal regulations in this many settings as possible, an appropriate domain. The exchange of information, sensitization of adults and of adolescents Examples of training websites for health addresses, or of invitations, as well as, the on the limits, the pitfalls and the potential professionals organization of encounters through the harmful effect of the inappropriate use http://www.euteach.com internet with persons who are unknown of the web and of cellular phones. Health http://ec.europa.eu/education/pro- to the adolescent user can potentially professionals, in particular, are well posi- grammes/newprog/index_en.html lead to dramatic events, such as extreme tioned to increase the awareness of the all www.usc.edu/adolhealth violence or sexual abuse. Finally, there are concerned adults on the challenges posed certain websites that encourage the adop- by new technologies. Foundation Health on the Net : tion of harmful behaviors such as eating http://www.hon.ch/

No.69 - 2009 Sexuality education programmes and sexual health services: links for better sexual and reproductive health (SRH)

RH for adolescents is based on atmosphere, where young people can feel 30 Abortions three fundamental components: welcome and comfortable. Unquestion- 25 Deliveries 1) recognizing sexual rights, able confidentiality is very important. 20 2)S sexuality education and counselling The providers must not moralize and 15 and 3) confidential high quality services. judge the adolescents, but have a positive These components all need to be con- attitude in changing risk behaviour and 10 sidered together. The closer sexuality treat adolescents with respect indicat- 5 0 education programmes and sexual health ing that young people are important. In 75 85 91 93 95 97 99 01 03 05 07 services (SHS) work together, the better this way self-esteem is strengthened, and 80 90 92 94 96 98 00 02 04 06 08 the results. adolescents learn to respect and take care Figure 1 In Nordic countries the SRH of young of themselves and others. Abortions and deliveries per 1000 girls people is relatively good when com- Health care in Finland, as in many 15-19 year old in Finland 1975 to 2008 (2). pared internationally, with relatively low other countries, is organized into different numbers of unintended pregnancies, levels: primary, secondary and tertiary Changes in education and health abortions and sexually transmitted infec- health care. Primary health care (PHC) care during previous economic tions (STIs). This situation has of course provides the basis of the health care or- depression evolved over time. Sixty years ago the ganization and school health care (SHC) During the early-mid 1990’s, due to the situation in Finland was quite different: is an essential part of it. Finland has not economic recession, resources for health illegal abortions and STI’s were com- set up a network of youth clinics; specific and social services were cut in Finland, mon, sex education was non-existent and clinics for adolescents exist only in some and many municipalities “saved” by attitudes towards sexuality and contra- of the biggest towns. On the other hand, reducing the number of people employed ception were negative. In general, the SHC is an essential part of PHC. It is in health care. Cuts were carried out in overall development in society - gender provided in all municipalities and covers all health and social care, but preventive equality, equal education opportunities health care free of charge for the pupils health care, such as SHC, was particularly for boys and girls, development of the in primary and secondary education. hard hit. In addition, in an attempt to cut health care system and positive attitude Thus, clientele of SHC consists of almost costs, education also shifted towards a changes of the state and church have all the entire population from ages 7 to 16. more decentralized system. As a result, made it possible to reach the present Its aim is to promote healthy growth and from 1994, sexuality education became an situation through extended provision of development of the child and adolescent. optional subject, with each school decid- sufficient and reliable sexuality education, Health education and counseling are key ing by itself if and how to teach it. This confidential and high-quality services and elements of SHC. Recognition of possible led to a marked deterioration in both the wide selection of contraceptive methods problems and health risks, screening and quality and quantity of sexuality educa- (1). advice for healthy ways of living belong tion provided in schools (3). Assumingly, Many of the problems of adolescence to preventive health care. SHC also the simultaneous reductions in health and are related to the unwillingness of our embraces a holistic approach, collaborat- education led to the 50% increase seen in culture to adapt to the structurally changing with parents, teachers, psychologists, adolescent abortions in the latter part of ing position of adolescents in society. In physiotherapists and nutritionists. 1990’s (Figure 1). At the same time, until modern society, young people develop The other basis for good SRH is sexual- 2002, the number of detected Chlamydia 12 physically and emotionally at a rather ity education, which needs to be continu- infections increased markedly. Annual young age, yet it is several years later ing, well planned, and adapted to the de- school health surveys by Stakes (National before they are ready to start a family. For velopmental stage of the child. Sexuality Institute for Health and Welfare) started example, the mean age at first intercourse education became obligatory in schools in in the late 1990’s (every even year in the for females in Finland is close to 17 years Finland in 1970 and the quality and con- eastern part of Finland and every odd of age, mean age at first marriage 27, tent slowly developed. In most schools, year in the western part of Finland) and and at first delivery 28 year of age. This there was a close connection between covered the whole country. The large growing gap between physical maturity sexuality education and SHC support- questionnaire included questions about on the one hand, and “social maturity“ on ing each other and promoting the same sexual behaviour and contraceptive the other causes many of the problems of messages. Together, in combination, these use. As seen in Fig 2A, in the late 1990’s adolescent sexuality. improved SRH, increased contraceptive the percentage of girls starting to have SRH services for adolescents can be use, and contributed to the decline in intercourse at an early age (age 14 and 15) provided in various settings, as long as adolescent abortions and deliveries from increased, while at the same time until certain basic principles are observed. The 1975-1995 shown in Figure 1. 2002, the percentage who used no contra- services should have a youth-friendly ception increased as well (Fig 2B). ` Sexuality education programmes and Dan Apter sexual health services: links for better sexual and reproductive health (SRH)

25 contraception. 40 20 Conclusion 30 15 Since 2004, with the improvement in 20 10 quality of sexuality education, there has 10 5 been a continued improvement in the 0 0 SRH of adolescents in Finland. Both 1998 2000 2002 2004 2006 2007 1998 2000 2002 2004 2006 2007 the percentage of girls starting to have 8. grade 9. grade 8. grade 9. grade intercourse at an early age, during grade Figure 2A Figure 2B 8 or 9 (aged 14-15) (Figure 2A) and the % of girls who have had intercourse (A), and % of girls who did not use any contracep- percentage that used no contraception tion at last intercourse (B), grade 8 (mean age 14,8) and 9 (mean age 15,8), Finland has decreased (Figure 2B). There has also 1998-2007 (4). been a marked decrease in adolescent conditions at school, to teach health abortions from 15.7 per 1000 in 2004 to Recent developments with sexual- education of the pupils, to network 12.3 per 1000 in 2008. During the same ity education and to access continuous education time, a smaller decline also took place in Slowly, based on the above information, of their own. At school a school psy- delivery rates (Figure 1). There also seems the education system was changed and chologist and a social worker should to be a cohort effect, with a carry over the National Board of Education actu- also be available. of a higher abortion rate to the older age ally developed guidelines for sexuality 2. The workrooms reserved for SHC groups with time. education that were quite good. These should be appropriate. In conclusion, when adolescent were based on a holistic approach to 3. In each health district there should sexuality is not condemned but sexuality sexuality. A new subject called “Health” be an identified doctor whose specific education and SRH services are provided was included. Teaching started in most responsibility is SHC. S/he is respon- instead, it is possible to profoundly im- schools in 2003-2004, and has been sible for the overall planning of SHC prove adolescent SRH with comparatively obligatory in all primary and secondary and ensures that SHC has sufficient small costs. Each year new groups of schools since 2006. Teachers are trained, possibilities to operate and that new young people mature, requiring new ef- and one teacher per school is responsible workers will be adequately trained to forts. Education, counselling and services for coordination of the topic. In grades participate in SHC. In larger munici- are all needed. If the resources are not 7-9, sexuality education is provided for palities a school nurse is also needed provided or alternatively, reduced signifi- at least a mean number of 20 hours. A to co-ordinate SHC. Special respon- cantly, as recently occurred in Finland, detailed study has been done by Väestöli- sibilities are taken into account in the negative effects are soon evident. itto, Family Federation of Finland, on the salaries of the staff involved. content of sexuality education provided 4. The staff should use an equivalent of Dan Apter, MD and the SRH knowledge of 8 grade pupils. at least 10 working days for continu- Director Particularly for boys, school sexuality ous education regarding SHC. The Sexual Health Clinic, Väestöliitto (Family Federation of education influenced knowledge (3). SHC is a part of the school commu- Finland), nity. Its aim is to ensure that the school [email protected] Basic prerequisites for good SHC provides an environment for its pupils 13 In Finland, the basic prerequisites for that promote their physical and emo- good SHC have been discussed and de- tional health and well-being. SHC actively References fined. These are listed below. participates in health education at school. 1. Lottes I, Kontula O. New Views on 1. SHC should have a sufficient amount The school nurse follows each pupil’s Sexual Health: The case of Finland. of staff. A full-time school nurse development and health by yearly check- Väestöliitto D37, Helsinki 2000. should be responsible for the care ups. An extended check-up by the school 2. http://www.stakes.fi/FI/Tilastot/ of not more than 600 pupils. If she doctor and the school nurse is performed Aiheittain/Lisaantyminen/raskau- works in more than one school, the when the pupil starts school, and at grade denkeskeytykset/index.htm amount of pupils should be less. A 5 and 8 when s/he is aged 11 to 12 years, 3. Kontula O, Meriläinen H. Koulun sek- school doctor should have at least one and 14 to 15 years according to an Act suaalikasvatus 2000-luvun Suomessa. working day per week per 1000 pu- of Parliament in May 2009. Counselling Väestöliitto Väestöntutkimuslaitos pils. In addition to clinical work, the about sexual health including pregnancy Katsauksia E 26/2007 staff should have time to plan SHC prevention is particularly mentioned. 4. http://info.stakes.fi/kouluterveysky- activities, to supervise the working The school nurse can also start hormonal sely/EN/index.htm

No.69 - 2009 Valuing young people: Scotland in context

cotland is one of the four countries led by young people, is committed to The overarching and interdependent that make up the United Kingdom. ensuring that the voice of young people is aims of the action plan are: It has a population of 5.16 million, listened to by all decision makers. • providing better services by improv- ofS which 18% are under the age of 18. ing the quality, range, consistency, The devolved Government for Scotland is Sexual health policy in focus accessibility and cohesion of SH serv- responsible for most of the issues of day- Respect and Responsibility: Scotland’s ices that are safe, local and appropri- to-day concern to the people of Scotland, Strategy and Action for Improving ate; including health, education, justice, rural Sexual Health • promoting respect and responsibility affairs, and transport. There are 14 health The Scottish Government’s commit- by supporting everyone in Scotland to authorities and 32 local government ment to address Scotland’s poor record acquire and maintain the knowledge, areas. Key public health concerns include on unintended pregnancies and STI’s, skills and values necessary for good coronary heart disease, alcohol/drug mis- including HIV/AIDS, was first flagged in SH and well-being; and use, mental ill health including suicide, “Our National Health: A Plan for Action, • preventing STI’s and unintended smoking and sexual ill health, as well as, A Plan for Change (2001)” with a com- pregnancy by positively influencing health inequalities. mitment to developing a national strategy the cultural and social factors that made in “Improving Health in Scotland: impact on SH. Young people the Challenge (2003)”. The issues to be To achieve these aims, actions are There is a cross government commitment addressed included: directed to key national and local health to improving the lives of young people in • a general decline in the overall care and local government statutory agen- Scotland with a focus on: pregnancy rate in adolescent’s under cies as well as to Scottish Government. • ensuring that all young people have 16 but still the highest in western Central funding of £5 million per year the support they need to achieve their society; was provided and strong visible leader- potential; • significant links with economic depri- ship and direction provided through: • positive opportunities for and positive vation and sexual ill health; • the Minister for Health and Com- engagement with young people; and • use of condoms primarily for preven- munity Care chairing a national SH • early intervention to nurture potential tion of pregnancies rather than for advisory committee; and offer support at an earlier stage in protection against STI’s; • lead clinicians in SH appointed in a young person’s life. • increasing diagnoses of STI’s, espe- each local health agency to guide lo- In 2009, the Scottish Government with a cially Chlamydia and HIV; and cal implementation; range of National Health Services (NHS) • rising rates of induced abortions and • learning from the robustly evalu- and non NHS partners launched “Valuing repeat induced abortions in women ated national health demonstration Young People: Principles and Connec- over 25. project on young people’s SH, Healthy tions to support young people achieve In the summer of 2003, the Minister for Respect, being shared throughout their potential”, which provides a com- Health and Community Care commis- Scotland; mon reference tool for any professional sioned the former Public Health Institute • clear and transparent reporting mech- delivering services to young people. of Scotland to lead the development of a anisms with progress and funding Youth friendly health services is one of draft strategy. Following an analysis of published; and the nine delivery ‘pillars’ identified to help sexual health (SH) strategies internation- • clear targets identified for reducing young people achieve the 4 capacities ally and in other UK countries and a two- unintended pregnancies (reducing 14 (successful learners, confident individu- year period of policy development and pregnancy rate in 13-15 year olds als, effective contributors and responsible engagement with key partners, “Respect from 8.5 per 1000 in 1995 to 6.8 per citizens) outlined in the National Delivery & Responsibility”, Scotland’s first SH and 1000 by 2010). Plan (see figure 1). relationships strategy, was published in During the period 2005-2008, progress The Scottish Government supports the January 2005. This strategy provided an was particularly made in: provisions of the United Nations Conven- evidence-based national action plan for • more integrated SRH services; tion on the Rights of the Child and Scot- improving SH and relationships across all • increased focus on opportunistic test- land’s Commissioner for Children and ages. Underpinned by the WHO defini- ing and treatment of key STIs among Young People has developed resources tion of SH, it promotes the principles of young people, including antenatal designed for young people to help them respect for self, respect for others and HIV testing; know their rights (available at strong relationships. In recognizing the • the promotion of drop in services for http://www.sccyp.org.uk/webpages/cypr. diversity of lifestyles in the population of young people and service standards; php). Scotland also has its own Youth Scotland, the action plan seeks to improve • the development of quality standards Parliament with subject committees, access to information and services whilst for SH services; including health and education. The enabling flexibility for local services to • improved national data collection Scottish Youth Parliament, designed and respond to local needs. through monitoring of key clinical in- Shirley Fraser

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- The promotion of In 2007, NHS Health Scotland, in joint longer-lasting reversible collaboration with the Scottish Govern- contraception (IUS, IUD ment, commissioned an evaluation of NHS Boards and their stakeholder part- and implants) as a means of reducing “Respect and Responsibility” with a view ners are working towards achieving these unintended pregnancies and repeat to assessing whether the actions were in outcomes in their own areas and are sup- terminations in all ages – released in the right direction or if a renewed focus ported at national level through the provi- July 2009; was required. This review highlighted the sion of training, resources and quality - The testing of approaches around need to continue support for SH service standards. Annual visits by the Scottish HIV prevention with men who have provision but also emphasized the need Government are undertaken to ensure sex with men (and then with African to influence the sexual wellbeing culture progress is maintained on achieving the communities) – release in early 2010. of Scotland. It also indicated a need greatest impact on poor SH outcomes but All of this work is being informed by for a smaller national committee with a also to identify where further national attitudinal research with the target audi- continued focus on sexual wellbeing but support may be required. ences. In addition, the Scottish Govern- with the inclusion of HIV issues. The As indicated, there is a greater focus on ment has made a commitment to provide Minister for Public Health and Sport has HIV issues, particular in relation to the better access to independent SH informa- demonstrated continued commitment for prevention of HIV transmission and the tion including: this topic by chairing this group. co-ordinated and consistent delivery of • a dedicated public website which aims Further actions are identified in high quality care and treatment for people to provide information on sexual ill “Respect and Responsibility: delivering with HIV in all parts of Scotland. The health, direct users to services and improvements in sexual health outcomes Scottish Government is currently engag- other support mechanisms – www. 2008-2011” with the following specific ing with key stakeholders on its draft HIV sexualhealthscotland.co.uk; long term outcomes: Action Plan and the central aims of this • a series of standardized leaflets on • reduced levels of regret and coercion; plan are to: STI’s and vaginal health (produced by • reduced levels of unintended preg- • prevent HIV infection where possible, NHS Health Scotland and available 15 nancy, particularly in those under • detect infection early, in nine core languages) to ensure 16 but also to see a reduction in the • provide high quality treatment and consistency across Scotland – will number of repeat induced abortions ongoing support to those who need it. become part of downloads from the in all ages; electronic data collection system and • reduced levels of STI’s, recognizing Improving the sexual health and text replicated on website; and that there will first of all have to be an wellbeing culture of Scotland • a Scottish identity for SH services increase due to increased testing; Whilst “Respect and Responsibility” – Sexual Health Scotland – and an • increased access to SH information aimed to promote positive sexual wellbe- expectation that local areas will adopt and uptake of services; ing, it was recognized that the initial this. • reduced levels of HIV transmission, implementation has focused primarily particularly amongst men having sex on actions to reduce sexual ill health. In Shirley Fraser with men; and the next three years, there will be specific Health Improvement Programme • reduced levels of undiagnosed HIV, actions focused on the culture around Manager NHS Health Scotland particularly amongst men having sex relationships and SH, such as: [email protected] with men and African populations. • a broad-based social marketing

No.69 - 2009 A personal perspective: sexual bullying – a downside of liberalism and individualism

In many northern and Previously the time period of childhood school, secondary school and high school western European countries went from birth to the end of the teenage with curricula that allowed for active years. Now children are already forced to engagement in simulated bullying situa- during the last years chil- align themselves with a specific sex and tions, combined with background history dren have been increasingly gender, often as early as the age of 5-6, on sexual bullying and the psychological largely as a result of society’s pressure effect on children. While this method pushed to identify them- for uniqueness and individualism, the has been used with some success in some selves as select sexes with goal being to automatically recognize countries it has been shown not to be and respect each human being as unique enough to tackle the problem. The discus- select gender roles. Society as soon as the sign of self-developed ac- sion that followed at the meeting showed and parents often put pres- tion appears. The effect of putting such great initiatives from each country, which decisions upon a child’s shoulders at together holds the promise of an effective sure on children to assume an age when the child is not adequately solution. Examples of various initiatives the primary ideas of indi- developed at the demanded psychologi- included: cal stage, forces the child to do what s/he • In Norway, in a town just outside vidualism. As a result the cannot. Therefore the outcome of such an Oslo, a high school teacher has been defined childhood period of evolution tends to be that a child seeks experimenting with a new teach- the answer to fulfil the expectations of ing method for educating students unity, where sex and gender society by copying those who have given about sex and sexual rights. Rather are not the primary focus, the child answers to all other questions, than formal lectures she focused on the grown ups. Due to this outside pres- interactive education, setting up dis- but social interaction of the sure children take in words, actions and cussions in class and between classes group is considered top pri- behaviours that are related to the different on subjects taken from the IPPF sexes and gender roles, but without know- statements on sexual rights. Students ority, has been lowered. ing the meaning or consequences. learned by being involved - preparing As a result of the evolution mentioned projects and activist campaigns on above, schools, particularly in northern these subjects impacted significantly and western European countries, have on how the youngsters behaved in seen increased, intensified bullying based front of each other and helped to on the sex and gender roles of children lower the rate of sexual bullying. and youngsters from the age of 5 all the At the same time the participating way to the end of high school. students also signed up for YSAFE, which gave them a sense of serious- Previous experiences ness and importance. High school As a steering committee member of students have an urge to be a part of YSAFE (“Youth Sexual Awareness for an assembly with a goal to show their Europe” a youth network on sexual and own capacity of doing something real. reproductive health and rights established This could be a great way to address 16 as a project of the International Planned the problem of sexual bullying at a Parenthood Federation European Net- high school level, in combination work (IPPF EN)) I participated in the with education of teachers, and par- Regional Council meeting of IPPF EN in ticipating students for peer education. Madrid this summer of 2009. There I had the pleasure of discussing this subject of • In Denmark there has been national sexual bullying with other representatives interest to stop sexual bullying. With from northern and western European support from local NGO’s, radio countries, where the problem is progress- stations, youth television, movie stars ing rapidly, with problematic negative and musicians, Denmark launched development for those involved. Everyone a stop bullying campaign, focused at the steering committee felt strongly primarily on students at the second- that one way to handle the issue of sexual ary school level, but also on primary bullying would be through the education school students. Education sessions of teachers from kindergarten, primary were specifically designed to teach Kalle Johannes Rose

educators how to address bullying constant dialog with the parents can help issues from the kindergarten level Definition of sexual bullying from the process. onwards. Parents were also provided WOMANKIND, with educational sessions on how to (http://www.womankind.org.uk/sexual- Conclusion bullying-definition.html) minimize bullying. There has even To stop, change or slow down a process been discussion about developing a Any bullying behavior, whether physi- such as sexual bullying, steps have to be cal or non-physical, that is based on a certification system, where schools person’s sexuality or gender. It is when taken at national, regional and local lev- are graded in public on the educa- sexuality is used as a weapon by boys els, ideally synergistically. I hope that one tion of teachers in the handling of or by girls. It can be carried out to a day there will be a possibility to create a person’s face, behind their back or by bullying. In addition, the music TV/ use of technology. pop culture, which fights against bullying radio station “The Voice” had famous For example: and sexual bullying, to secure harmony, young musicians make statements social interactions and positive psycho- • Using words that refer to someone’s about bullying and young celebri- sexuality as a general put down (like logical progresses for the new generation ties made statements on youth used calling something ‘gay’ to mean that of youth of all countries. websites. Addressing the youth it is not very good) through this type of media to try and • Using sexual words to put someone Kalle Johannes Rose, young down (like calling someone a ‘slut’) influence behaviour had very positive person outcomes. Finally, a new method of • Making threats or jokes about serious Steering Committee Member of and frightening subjects like rape YSAFE using mobile technology to teach • Gossiping about someone’s sex life - Master in Business Administration youth about sexual rights and sexual including the use of graffiti and Commercial Law education way is being explored by • Touching someone in a way that Copenhagen Business School the Danish Member Association of makes them feel uncomfortable [email protected] IPPF, perhaps in the form of a mobile • Touching parts of someone’s body telephone game. Former computer that they don’t want to be touched games for youth, that combined fun • Forcing someone to act in a sexual and sexual education, have previ- way ously been successful in Denmark at the end of the 1990’s. Regardless of whether the focus has been on ordi- that each country, region and town holds nary bullying or on sexual education, different cultural, economical, religious the two are not completely separable and social beliefs and behaviours. and actions on each approach have My own advice for addressing the shown and should show an effect on issue of sexual bullying would take into the other. account the above and consist of the following: use the Norwegian experience Solutions and ways forward and make the theme of sexual rights and Psychologists, teachers, professors and health services a part of the high school volunteer workers all agree that the way volunteer services; use youth participat- to fight a problem like sexual bullying is ing as activists to go out into secondary 17 by providing information and education schools and become peer educators; teach about the issue at all levels, in a format about general human rights and sexual that is relevant for the target audience. rights and services in the form of projects That is why it is extremely important to and discussion forums, not as lectures. If include peer youth educators to teach the possible the use of youth media should youth in a “language” they understand. and can have a positive effect on behav- Using the language and slang of the youth iour, as long as the use of communicators helps establish equality and rapport. stays within the line of people that youth/ What remains more challenging is trying children respect. For children at primary to establish when specific subject matter school there is a natural reluctance to- related to bullying should by taught, what wards sexual education, but since sexual the content should consist of and what bullying exists even at this age (and where media methods are appropriate to use for it may even be grounded) it will be neces- the task, specifically when considering sary to take steps at this stage. A firm and

No.61No.69 - - 2005 2009 Engaging and involving young people in sexual and reproductive health

In 1994 the International Conference on Population and Development in Cairo cemented the concept that sexual and reproductive health (SRH) is a human right for all individuals, including young people. Since then many countries have developed strategies, policies and programmes that focus on SRH of adolescents and youth, including the development of quality youth friendly health services. Youth involvement is recognized as essential to the successful implementation of the above-mentioned activities. The focus of this article is Scotland’s experience with engaging and involving young people in health service delivery.

Mystery shopping – A novel ap- and quality information and support in services. Most young people in rural proach for youth led assessment of a location that suited them. The MIB has areas want somewhere to hang out and services the aim of working in partnership with something to do. In some rural areas we During the Healthy Respect Demonstra- other key agencies in order to address the may only have 7 teenagers that night but tion work in Lothian (see article page 24), following 5 objectives: it is important to remember that this may a group of volunteers with Lesbian Gay • identify areas of unmet need for represent 90% of the youth population in Bisexual and Transgender (LGBT) Youth young people, that area. As a result numbers are not our Scotland started a project to assess sexual • provide appropriate information and main concern in rural areas. health (SH) services for young people in advice to young people, Currently we are performing a critical the Lothian area. Dubbed the ‘mystery • provide opportunities for self devel- review/consultation of the MIB service shopping’ exercise, nine organizations opment, in Moray to support the ever-changing and eighteen services were assessed in • develop a programme of relevant needs of young people. Findings indicate total, none of which were aware of the as- activity and, that the following factors have been key sessment. The mystery shoppers’ focused • ensure some of these activities are to the success of the MIB: on five key subjects: ongoing and sustainable in the com- • unique (being the first of its kind) • access, munity. unit, that is comfortable and welcom- • appointments and waiting times, The MIB is primarily based within rural ing, • condition of waiting areas, localities, where access to services and • highly trained staff, • staff and, information is not as accessible for young • friendly, welcoming non judgmental • quality and accuracy of information people. Health and community planning environment, provided. workers staff the MIB. This works well as • young people access the bus on their Under each heading was a list of ques- they have the local knowledge and know own initiative, tions, to be answered after every encoun- the young people. It is also an opportuni- • reliable and consistent, it endeavors ter, also referred to as the ‘shop’. In the ty for youth workers to gain much needed to secure effective partnership work- interests of collecting clearly measurable training. ing, and comparable data, these were largely Since it began (in 2000) the MIB has • relaxed and informal atmosphere, of a ‘yes/no’ nature, although almost every visited 6 areas in Scotland including Stra- where young people feel comfortable 18 question encouraged ‘shoppers’ (those thisla, Fochabers, Speyside, Buckie, Forres asking questions. assessing the services) to include any and Lossiemouth. 6269 visits were made • equipped with approved educational significant comments or further expla- by young people between the ages of 12 resources and information that can nation. Three distinct types of services to18 years, providing an opportunity for be carried away, were targeted. These were pharmacies, young people to have somewhere to go, • service users and providers review clinics and the c: card services (a type of someone to listen to them, an activity to and evaluate the service on an ongo- dedicated service that provides condoms join in and an opportunity to take part in ing basis and, to young people free of charge). To read workshops and games. Interestingly, but • recommendations from service users the full report go to perhaps not surprisingly 50% of the activ- and providers are implemented to http://www.healthyrespect.co.uk/ ity is health related (drugs, alcohol, sexual maximize the impact upon most at health). Workshops and health related risk youth, such as those with poor MIB: Mobile information bus in discussions are popular, along with televi- SRH outcomes or disadvantaged rural Scotland sion, music and computer games. socioeconomic status. Young people in rural areas identified The MIB works with communities that they needed and wanted appropriate to identify and sustain young people’s Nuala Healy

The Corner and the Peer Education positive skills, contribute to their com- issues and increase the provision of youth Project munity, achieve accreditation and access friendly health services. This is particu- The Corner Young People’s Health and a wider network of support that promotes larly relevant for Dundee where accord- Information Service is a health and infor- resilience. ing to The Tayside Public Health Report mation agency in Dundee, Scotland that The project continues to develop links 2006/07: provides services to young people aged with young people, parents, commu- • Dundee City has the highest teenage 11-25 years old, funded in partnership nity groups, police, schools, voluntary pregnancy rates in Scotland, with NHS Tayside, Dundee City Coun- organizations and council departments to • 3% of 13 year olds in Dundee City cil and The Scottish Government. The support peer-led health improvement of reported using drugs in the month Corner aims to work with young people children and young people. prior to the report and, in a manner that reflects the principles • in Dundee City, 58% of 13 year olds stated in the ‘-UN Convention on the A ‘VIEW’ to improvement – young and 82% of 15 year olds reported that Rights of the Child-’. It strives to redress people training health profession- they had ever had an alcoholic drink als the inequalities experienced by young (2). people through offering them assistance Young people consistently report barriers to develop skills and confidence and sup- to accessing primary health care services Partnership with Young Scot and port to move forward and make positive as: young people choices in their lives. Services are all free, • concerns about confidentiality, NHS Health Scotland has a unique histor- informal and confidential and include: • lack of information about services, ical partnership with the national youth • full range of contraception and preg- • unfriendly environment and staff and, information agency, Young Scot, which nancy testing services, • language barriers (staff use jargon or enable both organizations to bring evi- • information on a wide range of topics overly ‘adult’ language) (1). denced based and youth friendly health including drugs, housing and train- Recommendations encouraging the messages and advice to young people ing, removal of these barriers have been sup- via a website and phone line. The service • 1:1 support, legal advice, employment ported by the WHO and have led to a call is guided by a panel of young people as services, for the development of youth friendly well as health topic experts to ensure • access to personal computers and health services worldwide. In 2001 the information and advice is up to date and broadband Internet, health services link worker post was cre- youth appropriate. Find out more at www. • events and support/interest based ated at The Corner Young People’s Health youngscotonfoline.org/channels/health/. opportunities (for both mixed groups and Information Service to work with Please note that these are just a few and sex specific groups) focusing on front-line health care staff and ensure examples of how we have engaged youth a wide range of issues and needs, for delivery and development of services that – for more examples please contact the example, drama, multiculturalism are appropriate and accessible for young author. and mental health and, people. This role has a direct partner- • outreach with young people (Corner ship link through Dundee Community Nuala Healy Carry-Out) in schools, colleges and Health Partnership to the public health Health Improvement Programme community bases. practitioner responsible for children Manager (young people) NHS Health Scotland Peer education is a term widely used to and young people. One of the objectives Email: describe a range of initiatives where peo- was to develop a young people friendly [email protected] 19 ple from a similar culture, background, practice within health service settings. age group or social status educate each Various methods of developing and other about a variety of issues. The Peer delivering youth friendly practice within References Education Project was set up to work in the health service across the country were 1. Mcpherson A. 2005. ABC of adoles- specific communities in Dundee as part researched. The outcome of this was the cence: Adolescents in Health Service. of a range of approaches encouraging development of training aimed at front- BMJ, 2005; 330. young people to make positive, healthy line health service staff called the VIEW 2. Scottish Schools Adolescent Lifestyle choices. The project’s approach encour- (Values, RIghts, ConfidEntiality, the and Substance Abuse Survey (SAL- ages a broad range of young people to LaW). Recognizing that primary health SUS) – National Report 2008. Ipsos participate in training and supporting care remains one of the most accessible MORI, ISD Scotland and NHS Health young people to educate their peers. The and available providers of a wide range Scotland, 2009. model developed, which has personal and of health services for young people, the social development at its core, has created aim of the training was to develop health opportunities for young people to acquire workers awareness of youths needs and

No.61No.69 -- 20052009 Croatian school health services and adolescents’ reproductive health protection: human and organizational capacity

n several European countries school and youth programme is oriented toward (RAR) findings (conducted in Croatia in health services for school children young people’s undisturbed growth, 2001/2002) there was a recognized need and university students exist, and physical, mental and emotional develop- for a foundation of youth friendly centres professionalI organizations of the health ment. The main tasks are focused towards that would provide everything at a single care workers involved in these activi- the complex contextual influences in place (for example, guidance centre on ties are united in the European Union childhood and adolescence that shape sexuality, counselling on relationships of School and University Health and development. According to the national and communication problems, gynaeco- Medicine. The Union’s goal is to increase legislation framework in Croatia, organi- logical service). These findings supported awareness of governments and health zation of the specific health care for this the further improvement of the existing service leaders of the importance of population group is rooted in the basic school counselling services. As a result developing and improving health services legislation. The preventive programmes, current sexual and reproductive health to meet the rapidly changing health needs for which the school health services are counselling covers early sexual inter- of pupils and students (1, 2). responsible, embrace different activities, course, promiscuity, sexually transmitted For many decades Croatia has had a such as systematic check ups, vaccination, infections, contraception, condoms use, specialized organization dedicated to counselling, health education and health teenage pregnancy, and sexual identity. the prevention and protection of the promotion. School health services are health of school children and adolescents. available for each child or student during Areas of counselling Called “school medicine”, this medical periods of education, free of charge, with Besides reproductive health and risk specialization was established in 1951 and no referrals required and no ethnic or behaviours, mental health, learning dif- postgraduate studies were developed in other limitations. As school is seen as ficulties, and chronic illness are distin- 1955. The specialization lasts three years a place for learning, living and gaining guished as separate areas of counselling. encompassing knowledge and skills in experience in the life of many people, the According to the Croatian Health Service clinical, as well as, in health promotion contextual meaning of the school envi- Yearbook for 2007 (3) the number of and health education areas. Postgraduate ronment is of crucial importance for the counselling visits for pupils, parents and training lasts 4 months, as an obliga- school health services approach. There- school staff at School Health Services tory part of the specialization. Recently, fore, the activities are mainly planned and grew from 77 843 in 1998 to 186 440 in the new specialization programme provided according to the school system, 2007-2008. This increase is partly due titled “school and adolescent medicine” close to schools and university facilities, to the change in school doctors’ way of recommended the training duration often targeting the class or school as a thinking, knowledge, and approach to be increased to four years. While these unit, using a health promoting approach work that occurred through postgraduate school health services have changed both where the role of school staff, pupils, study in school health and various perma- in content and organizational structure parents and local community is taken into nent in-service trainings. with time, their focus has always been to- account (1,2). The distribution of visits to the guid- wards health promotion and prevention, ance service also reveals which top- particularly during vulnerable periods Sexual health and school health ics pose the greatest burden to youth and events in children and adolescents’ services throughout their life cycle. Problems lifespan. Sexual education in Croatia exists as a connected to chronic diseases, mental cross-curricular subject in the school illness and learning difficulties are the 20 The goals of health care for school curriculum. School doctors and nurses leading issues in counselling primary children and youth provide health education activities on a school-aged children. For high school Rising socio-economic inequalities in regular basis and schedule (sexual matu- pupils, after chronic diseases, reproduc- Croatia and the recent global recession ration at age 11, the growth, development tive health issues were the second most have seen children and young people and sexually transmitted infections at age frequent reason for counselling, whereas exposed to rising school demands, unem- 13-16). The majority of activities occur among university students reproductive ployment, in-loyal competition, dysfunc- in the class setting, either as lectures or health issues were the leading reasons for tional families, violence, abuse and other using interactive approaches such as visits (Table 1). forms of unfavourable life circumstances. group work or guided discussion. The Irresponsible sexual behaviours together most recognizable school health services’ Why perform counselling in school with other forms of risk behaviours have activities are done through the coun- health services? negative consequences not only in youth selling programme, which since 1998 School health services that provide but also have potential long-term effects have been organized within the school counselling hold a unique position in on health later in life. health service facilities. According to the the health system as they are able to have The health care for school children main Rapid Assessment and Response significant impact on the health, includ- Marina Ivana Pavić Kuzman Šimetin

ing sexual and reproductive health, of children and adolescents. Rationale for 70000 Reproductive health this includes: 60000 Chronic diseases 1. Young people may be unaware of Learning difficulties their problems, afraid to seek help, 50000 Mental health Risk behaviours or unable to make positive change 40000 without help. Contact to whole populations of primary, secondary 30000 and university students through 20000 activities such as systematic check ups 10000 and health education provide an opportunity to detect those at need for 0 1999/00 2001/02 2003/04 2005/06 2007/08 1999/00 2001/02 2003/04 2005/06 2007/08 2005/06 2007/08 counselling who by themselves would PS PS PS PS PS HS HS HS HS HS US* US*

not seek help. Therefore, school * Data not available for other years. (Primary School PS, High School HS, and University Students US) health work recognizes two crucial points in care: early detection and Table1 Counselling in School Health Services 1999-2008, number of and reasons for visits. motivation to change. Early detection is improved through guidelines rience has shown that the organization of References development (such as a guideline for counselling services within the frame- 1. European Union for School and obesity prevention (4)) and introduc- work of school health services, providing University Health and Medicine. The tion of new screenings (such as men- competent staff, open access and a youth Dubrovnik Declaration on School tal health screening for high school friendly approach, can have a positive Health Care in Europe, 13th EUSUHM pupils). Also, many school doctors effect on the health of youth. Comprehen- Congress, Dubrovnik, Croatia, 15 and nurses are trained in the short sive research on youth friendly services October 2005 URL: www.eusuhm.org motivation intervention “MOVE” organization and impact concluded that 2. European Union for School and which was introduced in Croatia in for developmental as well as epidemio- University Health and Medicine. 2004 as part of “Strengthening the logical reasons, young people need youth- The Tampere Declaration on Student Croatian Capacity to Combat Drugs friendly models of primary care (7). Health Care in Europe, 14th EUSUHM Trafficking and Drugs Abuse” in col- There is enough evidence, as well as, Congress, Tampere, Finland, 6-9 June laboration with German partners. broad expert consensus (1,2) to recom- 2007 URL: www.eusuhm.org mend that a priority for the future is to 3. Croatian Health Service Yearbook 2. During the period of maturation, ensure that each country, state and local- 2007, Croatian National Institute of reproductive health risk behaviours ity has a policy to encourage provision Public Health, Zagreb, 1008; 172-186 are not an isolated event in the life of innovative and well-assessed youth- 4. Hoppenbrouwers K, Juresa V, Kuz- of young people. According to our friendly services, whether part of existing man M et al (eds.). Prevention of findings early sexual intercourse (at school health services or new stand alone Overweight and Obesity in Childhood: the age of 15 or earlier) was associ- services. A Guideline for School Health Care, ated with complex risk and contextual 2007. URL: www.eusuhm.org; 69-90 factors, some of which are gender Marina Kuzman, MD, PhD 5. Kuzman M, Simetin Pavic I, Franelić 21 specific (5). This multiplicity of health Head, Youth Health Care and Drug Pejnovic I. Early sexual intercourse problems requires a holistic ap- Addiction Prevention Department and risk factors in Croatian adoles- Croatian Institute of Public Health proach to the young person’s mental, cents. Coll Antropol. 2007; 31 Suppl [email protected] emotional and physical health. School 2:121-30. health services are able to provide this Ivana Pavić Šimetin, MD 6. European strategy for child and thanks to the school physicians’ com- Croatian Institute of Public Health adolescent health and development. prehensive approach and education. [email protected] Copenhagen: WHO, 2005. 7. Tylee A, Haller DM, Graham T et Conclusion al. Youth-friendly primary-care The WHO European strategy for child services: how are we doing and what and adolescent health and development more needs to be done? Lancet 2007; (6) recommends youth friendly counsel- 365:1565-1573. ling and health services for reproductive health and other health issues. Our expe-

No.69No.61 - - 2009 2005

Developing youth friendly primary care services in Bosnia & Herzegovina

Family medicine implementation project in Bosnia and Herzegovina (FaMI project)

The Fondacija fami is an organization created with the support from the Swiss Agency for Development and Coopera- tion. Fondacija fami works on rebuilding and reorganizing health services in post- war Bosnia and Herzegovina through the development of a high quality primary care system. First phases of this project (FaMI phase 1-4) focused on training health professionals and implementing family medicine in Bosnia and Herze- govina. Fondacija fami is now focusing on the coordination and integration of health and social services into a coher- ent, cost-effective service provision, with a special emphasis on vulnerable groups (FaMI phase 5). Young people (10-25 years) are considered as a particularly vulnerable group in this country as they face major barriers in accessing health proach (1). In Bosnia and Herzegovina Sanci, an Australian expert in adoles- care. As most preventable causes of mor- family medicine specialization offers cent health primary care was invited to bidity and mortality start in this period education on STI management but no join the project as an advisor (3) . She of life, financing interventions in this age specific training on adolescent health has been leading projects in the field of group can provide long-term health and issues. “youth friendly primary care” for many economical benefits. In addition, eastern Taking the above mentioned elements years. and central European countries face into consideration and building on the societal changes that have great influence World Health Organization’s (WHO) Implementation of youth friendly on young people’s health: unemploy- principles for the development of services and health promotion activities within family medicine practices ment, post-war countries with children of that are available, accessible, acceptable traumatized parents, tobacco and alcohol and equitable for young people (youth Here we describe two projects to illustrate misuse, growing epidemics of sexually friendly health services), Fondacija fami various aspects of FaMI supported activi- transmitted infections (STI’s) and rising decided to support the development of ties in Bosnia and Herzegovina. intravenous drug abuse are just a few of youth friendly family medicine services 22 the main challenges. in Bosnia and Herzegovina (FaMI phase A. Community and school health Bosnia and Herzegovina is mainly a 5) (2). Through a decade-long collabora- education by family medicine teams rural country and access to specialized tion between Fondacija fami and Geneva services remains scarce outside of major University Hospitals, Swiss clinicians and Since 2007, Orasje health centre has been cities. Family medicine services provide researchers became involved in vari- conducting a large project to improve an ideal point of care for the delivery of ous projects as consultants. Physicians youth reproductive health (RH) in the sexual and reproductive health (SRH) of the adolescent health unit in Geneva municipality which consists of 25 000 and other services to young people. As re- University Hospitals not only assisted in inhabitants and 9 family medicine teams. cently highlighted by the European forum developing youth friendly family medi- In April 2008 the project was approved for Primary Health Care, the provision of cine services in Bosnia and Herzegovina, by the Federal Ministry of Health. This SRH through primary care has benefits but also provided educational material for project employs family medicine teams, such as easy accessibility, better coordina- post-graduate education of health profes- other health professionals, the local com- tion in service provision, integration of sionals and evaluated this development munity, parents and young people, as different health related problems within in order to provide essential evidence for well as, school services. Family medicine a consultation and a social-medical ap- use both locally and worldwide. Dr. Lena teams (doctors and nurses) attended Anne Daliborka Dagmar M. Meynard Pejic Haller

modules of continuous education on vari- tion to improve the youth friendliness of changes for further adaptation of existing ous themes (RH and adolescent health family medicine services, in a randomized health care services to the needs of young general topics) and have then been teach- controlled trial using the validated tool. people. ing RH issues in school for 13-15 year old In recent years, members of the De- The trial will begin as these lines are youth (See photo). partment of Child and Adolescent Health published and results will be available by During focus groups, young people and Development at WHO headquarters the second half of 2010. We hope it will highlighted confidentiality issues as main in Geneva have created a toolkit, used contribute to a better understanding of barriers to accessing SRH services or con- internationally for quality control and quality care for young people. doms/contraceptives in this small rural improvement of youth friendliness of conservative area. RH services (4). Adding elements from Anne Meynard The health centre is currently encour- another tool developed for a youth Department of Child and Adoles- aging family medicine teams to register friendly primary care project in Australia, cent and Department of Commu- nity Medicine and Primary Care, more data on youth accessing their and with contribution of an international Geneva University Hospitals and services and opened a counselling centre group of experts, we adapted the WHO University of Geneva also run by family medicine teams which tool, adding new items addressing the includes phone and internet contacts and variety of issues encountered in primary Daliborka Pejic group sessions by school psychologists. care (for example, nutrition, substance Fondacija fami and Doboj Health School teachers will soon be integrating use and injury prevention). centre, sex education in the school programmes. The trial will take place in family medi- Bosnia & Herzegovina Ongoing project evaluation will allow cine services in ten municipalities of the data collection and better understand- canton of Zenica. The multimodal inter- Dagmar M. Haller ing of delivery of SRH services for young vention will include training modules for Department of Child and Adoles- people in the local clinics. family medicine teams, as well as different cent and Department of Commu- nity Medicine and Primary Care, components addressing organizational B. The development of youth Geneva University Hospitals and aspects of the services, such as, confiden- University of Geneva friendly family medicine services tiality and information about services in the canton of Zenica: a cluster offered. randomized controlled trial For correspondence contact: Training of health professionals in Conclusions [email protected] adolescent health is a cornerstone for Bosnia and Herzegovina is facing major development of youth friendly services societal changes and health care reforms. The authors also wish to thank and with now clear expert agreement on SRH delivery for young people is a burn- acknowledge Tajiba Nurkic, Ana Sredic, content and structure of such trainings. ing topic in many community projects Senad Huseinagic , Lena Sanci, Nicolas What makes the difference in the quality including peer education, Internet help Perone and Francoise Narring, whose of services for young people is far less lines, youth clinics, NGO supported contributions were an essential part of the understood. Evaluation of the quality of activities and school health. Accredita- project. services for young people is hampered tion of family medicine services for care by the lack of adequate tools to measure of young people and preventive activities References youth-friendly characteristics in practices. is currently in discussion and could give 1. Ketting EA., Akin A. The role of pri- 23 In order for their project to contribute to additional credit to these activities in the mary care in sexual and reproductive more concrete evidence in the develop- primary health care sector. Community health in Europe. Entre Nous, 2009; ment of youth friendly services, Fon- projects like Orasje’s project where fam- 68:12-13. dacija fami team and their partners from ily medicine teams are providing health 2. McPherson A. Adolescents in pri- Geneva University Hospitals chose to use education in schools maximize the use of mary care. BMJ, 2005; 330:465-7. a randomized trial design to evaluate the existing resources and networks, which 3. Tylee A Haller DM, Graham T et implementation of youth friendly family is especially important in rural isolated al. Youth-friendly primary-care medicine services in the canton of Zenica areas. The research project in the canton services: how are we doing and what which consists of 400 000 inhabitants. of Zenica will actively encourage collabo- more needs to be done? Lancet, The project first focused on the develop- ration between family medicine teams 2007;369:1565-73. ment and validation of a tool to measure and community to increase visibility of 4. Kozhukhovskaya T. Assessing youth- the youth friendliness of services for offered services to the community for friendly health services in the Russian research purposes, followed by the evalu- both young people and adults. It will also Federation. Entre Nous, 2004; 58: ation of the effectiveness of an interven- encourage implementation of system 8-11.

No.69 - 2009 Moray Healthy Respect – a national Paterson demonstration project on sexual health and young people

What was the Healthy approach is the best way to achieve to present and share their own work at Respect Demonstration improvements for young people in sexual network events led to a shared sense of wellbeing. ownership of the network as a whole. Project? Partnership network Communication The Healthy Respect Demonstration A network of all the different partners As well as face-to-face meetings, HR2 Project (www.healthyrespect.co.uk) set involved in HR2 was established. To used a variety of communication chan- out to create an environment that would support this, a charter document was nels to engage network members and lead to long-term improvements in the developed. This established the aspira- share information. These included printed sexual health (SH) and wellbeing of tions, guiding principles and values of newsletters, e-bulletins and online fo- young people aged 10-18 years, using a the partnership, along with how the rums. HR2 learned that communication multi-faceted approach that linked exist- network would operate. In addition, a needed to be two-way, with information ing providers of SH education, infor- separate identity and brand was created going to and coming from partners. HR2 mation and services. This consisted of for the network. The charter and brand encouraged partners to make contribu- two phases. Healthy Respect Phase One highlighted the similarities between all of tions and share information at events and (HR1) began in 2001 and ended in 2004, the organizations, as well as the mutual in news bulletins. However, HR2 found it and Healthy Respect Phase Two (HR2) responsibilities of those involved. difficult to engage professionals in online began in 2005 and ended in March 2008. A key element in the development of forums, and found that professionals HR2 aimed to demonstrate how work- the charter was agreeing on values for the visited their website to access specific ing with young people from specific areas Healthy Respect partnership network. It information rather than to chat. of Lothian (one of the 14 health regions was necessary to negotiate a set of values in Scotland, that encompasses Edinburgh that everyone in the partnership could Moray Paterson City, mid Lothian, east Lothian and west buy into, and identify their individual and Programme lead Lothian), using a multi-faceted approach, organizational place within them. HR2 NHS Health Scotland [email protected] can enable them to develop a healthy re- learned that having explicit values helped spect and a positive attitude to their own in the process of finding common ground Further reading sexuality and that of others. Healthy Re- where there were challenges to overcome. NHS Health Scotland. Evaluation of spect’s approach was evidence-informed, Healthy Respect Phase Two: Interim and linked up-to-date information with Partner agreements Report (Executive Summary). Edin- appropriate education and accessible To formalize relationships, HR2 negoti- burgh: NHS Health Scotland, 2008. services. ated agreements with partner agencies. These agreements outlined key expecta- Working in partnership on SH: tions and contributions from each part- Healthy Respect’s learning what we did ner, and identified lead contacts for each • Organizational re-structuring and To deliver a range of activities across a va- area of work. HR2 learned that it was politics within partner agencies can riety of settings, HR2 developed partner- necessary to build alliances with more influence their capacity to work in ships with organizations and professionals than one person in each agency to engage partnership. Healthy Respect Phase Two (HR2) learned that it was important to who already worked with young people. staff at different levels, and to maintain review partner agreements regularly. These included: communication if a key contact moved 24 • Individuals can move on or leave posts. • local authority partners in education, on. Partner agreements were negotiated HR2 learned that it was important to social work and community learning for three-year periods, and were reviewed have more than one key contact in each and development, annually. partner agency. • NHS partners in general practice, • HR2 learned that the provision of fund- Network events ing could sometimes hamper projects, family planning/SH and school nurs- while those developed out of shared ing, Twice a year, HR2 hosted partner events, visions and shared contributions were • voluntary sector partners in health, bringing together all of the stakeholders often more valued and sustainable. education and youth work and, within the Healthy Respect partnership • partners in advertising and commu- network. These provided an opportunity nications. to reflect on emerging issues and to share experiences. They also created a social A partnership approach was used to inte- space where members could network grate education, information and services, and build relationships with each other. as the evidence suggests a multi-faceted HR2 learned that supporting partners

Nuala Walk the talk: supporting the Healy delivery of youth friendly health services in Scotland

It is now widely acknowl- edged that young people face more complex health issues than their parents’ generation. In 2002, the World Health Organization identified young people Image 2 aged 10-24 as a priority message ‘we keep it zipped’ (see image group for health care pro- 1), which was really appealing for young viders. As a recent paper people who sometimes struggled with the concept of confidentiality and required published in The Lancet reassurance that health care settings highlighted, the need for would respect their rights. Image 1 In 2008, Walk the Talk held a national young people to have for General Practitioners and Nursing, conference for 200 health professionals, youth-friendly models of the national youth work agency and which included inputs from the WHO NHS Education for Scotland (the agency headquarters in Geneva, United Kingdom primary care is now widely responsible for professional education of experts on youth health, as well as, young recognized around the health professionals). people who launched the Youth Voices Walk the Talk provides a series of na- DVD (available to watch on www.walk- world and enough is known tional resources to support youth friendly the-talk.org). A cartoonist recorded the about the barriers they face health services, including an interactive main themes of the day and these images website for professionals, a DVD made can serve as helpful visual aids when edu- to merit policy and support by young people on their experiences of cating healthcare workers on issues and for youth friendly health health services, as well as, a short seven solutions for healthcare and young people step guide to improving practice. The (also available free at www.walk-the-talk. services(1). national website www.walk-the-talk. org) (see image 2). org is a central resource for information, Walk the Talk’s partnership with the Walk the Talk, a national initiative run research, tools and signposting. The site Royal College of General Practitioners in by NHS Health Scotland, aims to support includes an interactive seven step audit Scotland has resulted in the programme youth friendly health services across Scot- for services to assess where improvements becoming a criteria for their Quality land. The initiative aims to embed youth could be made. Visitors can watch a free Practice Award scheme. This will ensure friendly practice within the mainstream short film produced by young people that all general practitioner practices NHS service offered to all Scottish people. on their experiences and expectation participating in this scheme will need to The need for young people to be regarded of health services and this is now being implement Walk the Talk principles to 25 as a priority group was underlined by used as part of a training session with gain their award. the findings of research carried out on healthcare workers. Professionals are then behalf of Walk the Talk (http://www. encouraged to take a seven step audit of Nuala Healy walk-the-talk.org.uk/why-walk-the-talk/ their own service and the website pro- Health Improvement Programme the-research.aspx )and through ongoing vides them with feedback and pointers for Manager (young people) NHS Health Scotland dialogue with young people. improvement. Developing and maintain- [email protected] Walk the Talk recognizes that young ing a central national suite of resources people face a range of barriers in ac- to support practice continues and in 2009 cessing health services and works to Walk the Talk will begin distributing References overcome these barriers in partnership confidentiality posters to all health care 1. Tylee A, Haller DM, Graham T et with young people and professionals. settings. The poster which is the result of al. Youth-friendly primary-care Walk the Talk is supported by a broad extensive consultation with young people services: how are we doing and what partnership steering group including the and health professionals provides an more needs to be done? Lancet 2007; Scottish Government, the Royal Colleges eye catching image of a bunny with the 365:1565-1573.

No.69 - 2009 Quality of care in Estonian youth clinics

he first youth clinics in Estonia clinic services (apart from sexuality a summary of network management were established at the beginning education lectures) and currently the activities and an overview of the volume of the 1990s by local enthusiasts, financing continues as part of a national of services provided by each clinic. Tand were without regular funding. Cur- HIV and AIDS strategy. The quality Each clinic receives feedback in which rently there a network of 17 clinics exists, development stems to a large degree from its actual activities are compared with which offer sexual health services free of the grassroots level. At the beginning of those projected, those of other clinics charge for young women and men up to the governmental financing, the leading and the project objectives. For example, the age of 25 years. Contraceptive coun- staff members emphasized the inner need records are kept of the number of medical selling, gynaecological and andrological for quality control as they felt that “youth tests and procedures conducted and the examination, STI/HIV testing, pregnancy clinics” must comply with measurable number of patients they are conducted related counselling, sexual counselling, standards to justify their name. At the on. Among other data, visitors’ age, counselling after sexual violence and same time, the EHIF wanted to prevent gender and working status is collected, sexuality education lectures are offered the rising incidence of HIV and was inter- which enables us to estimate which part in the clinics. Telephone and online ested in a network of clinics with strong of the target population is met or unmet counselling are also provided. If needed, management in order to form a trustwor- by the service. Data about detected STI’s referral to a specialist or other health care thy partnership. Thus, for the first time and pregnancies helps to analyze the institution (for example for termination the clinics could take steps to achieve purpose of the visits, and to compare the of pregnancy) is provided. effective management of the network and results with the Estonian epidemiologi- improvement of the quality of services. cal situation. STI cases are registered in Work principles Although the clinics operate as different the general Estonian STI registration All youth clinics work according to com- legal bodies (as departments within larger system. If, according to the gathered data, mon principles: to help young people health institutions, as private gynaeco- a clinic’s practice diverges substantially recognize their needs and rights, and logical practices or as practices set up from the others, an analysis of possible to provide trustworthy information especially for this service), they follow the reasons is performed. and counselling. Young people must same quality requirements and perform The founding of new clinics or the feel secure, welcome and respected in the same activities in order to improve the reorganization of existing ones is also as- the clinics. An integrated approach to quality of care. sisted by the ESHA. New staff is provided problems is practiced, providing counsel- with the opportunity of gaining practical ling in medical, psychological, as well as, Quality of care on the network level guidance at one of the well-established social matters. Clinic specialists (doctor, Regular financing enabled the ESHA to clinics. Workgroup members visit the midwife, nurse, and in some clinics also employ a part-time project manager and clinic frequently before it opens as well as social worker and psychologist) work to form a workgroup of volunteers. The afterwards to discuss with the staff mem- together as a team. To encourage visits, workgroup has eight members; among bers issues regarding their work. the atmosphere at the clinics is friendly them are a youth representative, youth In 2008, EHIF ordered an independent and informal with a work routine that clinic managers with long-term experi- analysis of the youth clinics’ services from supports privacy. It has been kept in ence, as well as, the previous and current the centre for policy studies PRAXIS. As a mind that youth clinics should be located project managers. The workgroup plays result, youth clinics’ quality improvement in places accessible to young people, an important part in the planning of activities were set as a good example for 26 preferably separate from other health network management activities and their other health promotion programmes. care establishments. The clinics are open implementation. The activities of the at regular hours suited to young people clinics are regularly monitored, evaluated Quality of care on the youth clinic and at least partly drop-in hours must be and, if necessary, adjusted. ESHA is also level available. responsible for the advertising of the clin- Being part of a network means expecting ics in different media (audiovisual media, the same style and quality of work from Building up a network online-counselling, web-page, schools others. Therefore, written unified quality In the 1990’s the Estonian Family Plan- and other partner institutions). Clinic standards describe the principles of youth ning Association (since 2005 Estonian representatives are welcome to take part counselling and stipulations for their Sexual Health Association, ESHA) took in workgroup meetings. observance (Table 2). Quality standards the clinics under its wing, organized The youth clinics send statistical indi- are always ensured in the establishment of training for the staff, and compiled and cators to the ESHA every quarter, which new clinics, as well as in the assessment of published sexuality education literature. enables the workgroup to analyze each existing ones. The standards are regularly In 2002 the Estonian Health Insurance clinic’s work (Table 1). A joint quarterly amended according to proposals from the Fund (EHIF) began to finance youth report to the funding body includes clinics and the workgroup. Kai Part Triin Helle Raudsepp Karro

Every year 1-2 clinics are supervised males, several clinics provide separate Table 1 by three workgroup members, given hours for counselling for boys/young Some statistical indicators collected quarterly from youth clinics. feedback and recommendations for men. To improve access for non-ethnic necessary changes, keeping in mind the Estonians, a web site and online counsel- common working principles. If a clinic ling are available in Russian. The needs of • Number of visits. is not working in accordance with the school drop-outs, young drug users, and • Distribution of contraceptive counselling/ standards, ESHA has the right to suggest young homosexuals are still not fully met STI testing/ sexual counselling visits. to the EHIF to discontinue the financ- in the youth clinics. Identifying ways to • Number of first time visitors. ing of that particular clinic. New clinics reach these young people is an important • Distribution of visitors by gender, age, are supported with advice from more task for us in the near future. working status. experienced clinics, and an evaluation of Although the activities to improve the • Number of STI tests performed (for Chlamydia, gonorrhea, HIV, syphilis, geni- services is carried out at the end of their quality of care in youth clinics have been tal herpes). first year of activity. divided between different levels in this ar- • Diagnosed cases of STI’s. ticle, the common goal of all the activities Quality of care on the staff level • Number and age of pregnant visitors is the best possible sexual health service (including referrals for abortion, repeat Two directions have been followed in the delivery for young people. abortions). organization of training courses. The first WHO has recently published an ana- • Number of lectures and participants. provides yearly in-service training and lytic case study of Estonian youth clinics, • Number of telephone counselling’s. which is accessible at: http://webitpreview. guidance to existing staff members. There • Advertising activities. is a two-day summer training seminar who.int/entity/child_adolescent_health/ every year on a particular topic, and this documents/9789241598354/en/index. event serves as a social event as well. Ad- html ditionally, regional supervision meetings Table 2 take place 3-4 times a year. The second Kai Part Gynaecologist and youth counsellor Some compulsory requirements for youth provides basic training in youth counsel- clinics in the quality standard document. ling (160 hours) to new workers and has Department of Obstetrics and Gy- naecology, University of Tartu been organized once with the help of Estonian Sexual Health Association ESHA. • Availability of STI/HIV testing & counselling [email protected] and contraception counselling. Quality of care on the client level • Facilities for diagnosing pregnancy. Triin Raudsepp To obtain feedback from young people, • Availability of sexuality education lectures Programme manager in the clinics. regular surveys (1996, 2002, 2007) have Estonian Sexual Health Association • Team consisting of medical doctor and a been conducted to assess satisfaction of Programme for Reproductive Health midwife/nurse. the visitors. Since 2003 young people can Counselling and STI Prevention of • Staff has passed courses on youth counsel- also provide continuous feedback online Young People ling. [email protected] at ESHA’s web page. Feedback from both • Organization of the rooms must support sources (surveys and online) is used privacy. Helle Karro, MD for the development of activities for the Professor • Access for disabled persons. network and for individual clinics. For Department of Obstetrics and Gy- • Clear signs indicating the location of the 27 example, TV and radio has been set up naecology, University of Tartu clinic. in some of the waiting rooms in order to Estonian Sexual Health Association • Services are free of charge. prevent the clients in the waiting room [email protected] • Drop-in hours available. overhearing the conversation in the coun- • Free printed educational materials for the selling room. Additionally, telephone- visitors. counselling hours have been expanded, • Possibility to give written feedback. as the feedback from the clients indicated • Co-operation with ESHA, youth clinics’ such a demand. network, local schools. Different ways to reach several groups whose needs have not been met have been developed. For example, to reach youth living in rural areas, an online counselling service was initiated through the ESHA’s web site. To increase the visits by young

No.69 - 2009

Reaching most at risk adolescents and youth – Tajikistan’s experience

Currently the young people (aged 10-24 as defined by the United Nations) of Tajikistan make up about one third of its population and are an essential component of the countries human capital. The status of the health and well being of the adolescents and youth has serious implications for the future of the Tajik generation. In this respect Tajikistan faces many challenges: high rates of poverty, high youth unemployment, growing con- sumption of injection drugs, trends toward early marriage and poor public awareness of HIV/AIDS and STI prevention methods, coupled with widespread labor migration have created an environment in which HIV/AIDS is rapidly increasing over a short period of time, especially among the young population. While the HIV/AIDS epidemic in Tajikistan is currently a concentrated one, the youth (defined as those between the ages of 15-30 by the Youth Law of Tajikistan) remain most affected with approximately 70% of total numbers of people living with HIV/AIDS between the ages of 15-30 (1). Sentinel surveillance indicates injecting drug users and sex workers are the predominant at-risk youth cat- egory. In 2007, among sex workers, the prevalence of HIV was 1.8%, syphilis 12.6% and hepatitis C 4%. The prevalence of HIV among drug users was 19.4% (1).

In 2006, the Ministry of Education and friendly health services (YFHS) in Ministry of Health of the Republic of existing health sector services (3). The Tajikistan, in collaboration with UNICEF, YFHS supported by UNICEF and CARE CDC Atlanta, WHO headquarters and International operates in five cities. They the WHO Regional Office for Europe, are designed to help achieve the goals of conducted the Global School based the National Strategy to Combat HIV/ Health Survey (http://www.who.int/ AIDS. The YFHS aimed to increase chp/gshs/en/index.html) to gain a better access by a targeted group to informa- understanding of risk behaviours of ado- tion, reduce practice of risky behaviours lescents aged 13-15. The study described among most at-risk adolescents and the risk behaviour tendencies amongst youth (aged 15-24), including sexwork- adolescents and revealed the following: ers, intravenous drug users, men who 1.6% of school children aged 13-15 had have sex with men, street children and experienced injecting drug use, 12.6% of school students and stabilize or reduce 28 students seriously considered attempting the prevalence of STI’s and HIV/AIDS suicide during the past 12 months and among these target groups. Intensive 10. 7% of students were physically forced advocacy based on evidence resulted in into sexual acts. In addition, only 3.7% of significant achievements met during the students’ aged 13-15 had a comprehensive project’s first three years of operation. It level of HIV/AIDS knowledge (able to included the establishment of a legal and answer all five of the survey questions on regulatory framework that enabled at risk HIV/AIDS transmission correctly) (2). youth to have access to the confidential basic health services; the establishment of Using youth friendly health services contacts between health service provid- to combat HIV/AIDS/STI’s ers and at risks group through outreach In national legislation, there are several approach; and the integration of the Uni- documents that address the health of versal Identification Code to keep track young people and adolescents and have of the volume of most at risk adolescents enabled the establishment of youth visits, programme coverage, prevalence of

Nisso Kasymova

STI’s/HIV, use of supplies, and the volume of both life skills based health educa- on these two exercises to adapt and test of voluntary counselling and testing tion in schools, including an HIV/AIDS WHO quality measurement tools. and treatments. Thus, in 2007, 47.7% of component, and access by young people the target group was contacted through to YFHS interventions will double the Nisso Kasymova, PhD, outreach, 26% visited the YFHS and 25% programme impact and help improve cost YPHDP and HIV/AIDS programme received counselling and an STI test (6% effectiveness and efficiency. Currently, specialist UNICEF Country Office, Tajikistan for HIV). In all, 18% of the target group however, most costs of the programme [email protected] were counselled and tested and, if testing are financed by international agencies. positive, treated. 50% of the target group Over the longer term, these will have to References had comprehensive knowledge about be incorporated into national budgets or HIV prevention, while 41% reported con- otherwise covered by national resources. 1. Surveillance Survey on HIV/AIDS in dom use during their most recent sexual As a result, there is a need to define 2007. Ministry of Health, Tajikistan: encounter (4). The prevalence of STI’s sustainability of YFHS scale up within Republican AIDS Centre, 2008. and HIV among those tested were 22.8% the health system. The legal system also 2. Global School based Health Survey and 1.2% respectively (5). needs to be addressed. Current legisla- (GSHS) 2006 in Tajikistan. Dushanbe, 29 tion allows provision of certain medical 2008. Next steps services to juveniles without parental 3. Osipov K. Developing Youth Friendly To date, only pilot activities have been constraint, while at the same time the age Health Services in the Republic of carried out, as described above. This is of consent differs across legislation. In Tajikistan: Legal Aspects. Dushanbe: an important step, but it is definitely not addition, there is a need to repeal legal UNICEF Country Office, 2007. adequate enough to have an impact on provisions for mandatory annual check 4. Currie C et al. (Eds). Inequalities in young people in general. Nonetheless, the ups and screening of all adolescents up young people’s health. HBSC inter- ground has been prepared for the project to the age of 18 years (3). There is also a national report from the 2005/2006 to be scaled up, together with national need to revise the provisional regulation survey. Copenhagen: WHO, 2008. and local authorities and relevant part- governing YFHS operations in light of 5. Peart G. YFHS bottleneck analysis. ners, especially the at risk young people. project experience. The project plans to Experience of Three Pilot Cities in School has to be a part of, as well as, conduct a thorough needs assessment for 2006 and 2007. Dushanbe, UNICEF an entry point for the YFHS programme YFHS, to revise service criteria and stand- Country Office, 2007. target groups coverage. The synergism ards that are currently in place, and based

No.69 - 2009 resources

Sexually transmitted infections among adolescents – the need for adequate health services. Geneva: WHO and GTZ, 2005. A global perspective on STI’s in young people directed towards policy makers, health professionals and adolescents that aims to improve STI prevention and care strategies for youth. Available in English at: www.who.int/reproductivehealth/topics/adolescence/en/index. html

Investing in our future: a framework for accelerating action for the sexual and reproductive health of young people. WHO, 2006. Directed towards programme managers and policy makers, it provides a framework for scaling up critical interventions in order to meet the needs of and improve the SRH of youth. Available in English at www.who.int/reproductivehealth/publications/ adolescence/929061240X/en/index.html

European strategy for child and adolescent health and development. Copenhagen: WHO, 2005. The strategy provides a framework for improvement of child and adolescent health. A toolkit for implementation is also available. Available in English and Russian at http://www.euro.who.int/childhealtdev/strategy/20060919_1

The health promoting school: international advances in theory, evaluation and practice. Copenhagen: Danish University of Education Press, 2005. This book brings together recent international thinking on the links between education and health, and recent research evidence evaluating the processes and outcomes of health promoting schools initiatives. Avaialble in English at http://www.euro.who.int/InformationSources/Publications/Cata- logue/20060419_1

Currie C et al (eds). Inequalities in young people’s health: international report from the HBSC 2006/06 survey, (Health Policy for Children and Adolescents, No.5). Copenhagen: WHO, 2008. A WHO collaborative cross-national study on patterns of health among young people aged 11, 13 and 15 years in 41 countries and regions across the WHO European Region and North America, it remains one of the best sources for comparative data on adolescent health and health behaviour. Available in English at www.euro.who.int/InformationSources/Publications/Cata- 30 logue/20080616_1.

Generation of change : Young people and culture.Youth Supplement to UNFPA’s State of the World Population Report 2008. The third eidtion in a series, the youth supplements highlights the value and importance of recognizing and responding to the needs of youth. Available in French, English, and Spanish at www.unfpa.org/public/cache/bypass/publications/pubs_youth

The Adolescence Experience In Depth: Using Data to Identify and Reach the Most Vulnerable Young People. UNFPA and Population Council, 2009. A series of adolescent data guides that provides decision makers with data on most at risk adolescents. Available in English at www.unfpa.org/public/publications/pid/3346” http://www.unfpa. org/public/publications/pid/3346. Lisa Avery

Investing when it counts: Generating the evidence base for policies and programmes for very young adolescents. Population Council, UNFPA, UNICEF and UNAIDS, 2006.

This guidance document and toolkit presents methodologies that can e be used to develop programmes and polices for adolescents aged 10-14 – a group that is often overlooked. Available in English at www.unfpa.org/public/publications/pid/363” http://www.unfpa. org/public/publications/pid/363.

A reference guide to policies and practice. Sexuality education in Europe. Brus- sels, IPPF EN, 2006. A guide to assist policy makers and governments develop better sexuality education, with data from 26 European countries. Available in English at www.ippfen.org/en/Resources/Our+publications/defaut.htm” http://www.ippfen.org/en/Resources/Our+publications/defaut.htm.

A guide for developing policies in sexual and reproductive health and rights of young people in Europe. Brussels: IPPF EN, 2007. This policy guide provides a series of broad recommendations intended to guide policymakers and programmers in creating a more youth-friendly SRHR policy environment for young people. Available in English at http://www.ippfen.org/en/Resources/Our+publications/ Policy+Guide.htm

These are just a few of the excellent resources available for young people and all those involved with young people. More can be found at the following relevant websites:

IPPF European Network - www.ippfen.org” www.ippfen.org WHO - www.who.int/topics/adolescent_health/en// WHO Regional Office for Europe - www.euro.who.int/childhealthdev UNFPA - www.unfpa.org/public/publications/pubs_youth Y-Peer – www.youthpeer.org Youth Sexual Awareness for Europe – www.ysafe.net 31 Allan Guttmacher Institute - www.guttmacher.org/ European training in effective adolescent care and health (EuTEACH) – www.euteach.com NHS Health Scotland - www.healthscotland.com Web library on sexuality education - www.contraception-esc.com/weblibrary The aim of the web library is to provide background information and educational tools to professionals working in the field of sexual health promotion. It is designed to support best practice and contains a variety of international resources.

No. 69 - 2009 The European Magazine for Sexual and Reproductive Health

WHO Regional Office for Europe

Country Policies and Systems Unit

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Tel: (+45) 3917 1602 or 1451

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