Meeting summary report Meeting aims and objectives
B. Training with simulated patients
be capable of being adapted to countries’ particular needs and situations. They should also be tested among different groups.
Promotion of the standards would be most productive if started in schools, where many children can
•
be reached.
The SHARE programme from United Kingdom (Scotland) offers a positive example that other
•
Member States may wish to explore and emulate. It would be necessary to perform a comparative study, however, before scaling-up the experience among Member States.
It is recognized that school curricula tend to be “crammed”, but significant benefits can accrue for
•
children and young people when innovative approaches are taken to creating time to focus on sexual education within the school curriculum.
There is clear evidence that peer education is a powerful methodology for sexual education among
•
young people. It is important to identify opportunities within primary health care and youth-friendly services, including school health services, to adopt peer-education approaches.
Standards for peer education are most effective when adapted to country needs and approved
•
nationally, possibly to accreditation level.
There may be benefits in scaling-up the peer-education methodology for work within clinical
•
facilities and to explore possibilities within national HIV-prevention programmes.
Workshop 5. Use of technology for professional education and engaging youth: summary A. E-learning in adolescent health – the United Kingdom experience
A wide range of health professionals in the United Kingdom encounter young people in the course of their day-to-day clinical work, but few have received any specific training in adolescent health care. In response to this need, the Department of Health in England funded a project to develop an e-learning package in adolescent health. The project was a partnership involving a number of organizations, including E-Learning for Healthcare, the Royal College of Paediatrics and Child Health and other professional royal colleges.
The “Adolescent health project” consists of over 70 focused e-learning sessions written by specialists from a range of disciplines. The sessions are each intended to take 20−30 minutes to complete and are set at four different levels of complexity to meet the educational needs of different groups of professionals. Content is based on needs analysis and by matching the curricula competency requirements of all doctors and nurses.
The highly interactive materials have been designed to be used on a standard laptop or personal computer via a broadband Internet connection at home or in the work place. The content includes high-resolution images and video clips to enrich the learning experience and increase visual accessibility. The package is currently being disseminated across the NHS.
B. Training with simulated patients
Skills in psychosocial communication with adolescents differ from those required for younger patients and adults, because they include discussing issues such as confidentiality and adolescent risk-taking behaviours.
The use of adolescent simulated patients is a technique that gives the opportunity to the learner (medical students, physicians in training and other health professionals) to be trained in real-life situations in a safe environment. At the end of their “performance”, the learners can receive direct feedback from the adolescent simulated patient.
C. “Cool2talk”: use of technology for professional education and engaging youth
The “Cool2talk” web site is a successful and economical way of reaching young people in the context of other local service provision. “Cool2talk” is an interactive web site through which young people in the region of Tayside, United Kingdom (Scotland) can have their health-related questions answered honestly and accurately. It offers reassurance, encouragement, information and advice on any health-related issue and signposts young people to appropriate services. Its target audience is young people aged 12−18 years.
The questions provide a resource for young people’s workers to get an idea of the current issues that concern young people, as well as a means to evaluate the site. Young people can post a question onto the site and get an answer within 24 hours. When accessing the site, they will be asked to supply quantifiable data such as age, gender and the first part of their home postcode. An overall view of the use of the site can emerge through these data.
The number of questions received varies with the promotion of the site. Promotional packs are available for young people’s workers and teaching staff and promotional events take place across Tayside, with
“Cool2talk” workers available to answer young people’s questions.
Main points from Workshop 5
E-learning opportunities show great promise in enabling health care professionals working with
•
young people to meet professional curricular requirements and improve the health of young people.
Enrolment of currently practising practitioners to e-learning programmes can be encouraged through
•
linking the programmes to web sites frequently used by health care professionals.
The e-learning package in adolescent health in the United Kingdom would have greater perceived
•
value if it had a certification scheme of accreditation.
Initiatives like the “Cool2talk” programme could produce benefits if rolled out nationally while
•
maintaining a local focus (which is considered vital to the success of the programme). The programme could be promoted nationally as a support and educational tool not only for young people, but also for health care professionals.
Greater support for programmes like “Cool2talk” would be likely to arise if an evaluation and audit
•
of the programme was carried out to, for instance, measure the impact of the advice given and to assess the number of users who seek out recommended services.
Any increases in the demand for a service would, in all probability, lead to requirements for greater
•
funding and more staff. Such extra resource would, however, enable the service to develop initiatives such as a real-time chat service and to increase the number of service users through developing and promoting the outreach elements of the service.
As with all such initiatives, young people have an important role to play in service development,
•
feedback and evaluation.
Outcomes and discussions from the workshops are reflected in suggested action areas 6, 20, 31, 33 and 35.
Spotlight session
Youth-friendly services – are we reaching adolescents most at risk?
The session was opened by Nina Ferencic, UNICEF Regional Office for Eastern Europe and Central Asia, who defined most-at-risk adolescents (MARA) as those who are vulnerable due to the circumstances they find themselves in – for example, homeless or institutionalized children, those working in the sex industry, or those coming from disadvantaged communities, such as Roma. Many of these children exist outside the mainstream social, education and health sectors.
Dr Ferencic explained that eastern Europe has gone through a tremendous process of transition in recent years, which is affecting more than 300 million people. Young people have suffered much in terms of rising unemployment, high rates of institutionalization and the rising phenomenon of “social orphans” (where parents abandon their parental rights, due mostly to economic hardship). There is endemic substance misuse and suicides (8 of the top 10 suicide rates in the world are in countries in this region) and an HIV epidemic; 1.7 million people are living with HIV (a 20-fold increase in the last 20 years) and one third of new infections involve 15−24-year-olds. A study carried out in St Petersburg, Russian Federation, in 2007 showed that almost 40% of street children aged 15−19 were HIV infected. Ninety-seven per cent of these young people were also sexually active, 65% of them with multiple partners, leading to a complex picture of risk behaviour.
The HIV epidemic reflects, among other things, the significant problem of injecting drug use among young people, with an estimated 2 million injecting drug users in the countries of the Commonwealth of Independent States and 300 000 in central Asia.
The risk behaviours being seen often begin in adolescence. Dr Ferencic reported on an as-yet unpublished study carried out by UNICEF and the London School of Hygiene and Tropical Medicine which shows the early age of initiation of injecting drug use in the region: in Ukraine, for example, 45% of drug users commence injecting before the age of 15 years, and almost all of them are injecting before the age of 18.
The “pathways of risk” for MARA lead from families, communities and systems, Dr Ferencic suggested.
Families are in economic and social crisis, often leading to children being left without parental supervision as parents move to find work elsewhere. Communities are increasingly facing the problems of high levels of unemployment. And systems, such as education and health, are finding it difficult to meet the needs of young people. To escape the harsh realities of their lives, many children turn to drugs and other substances, and services, which are designed for adults, are not reaching them.
The controversial mix of drugs, sex and minors that MARA represent, Dr Ferencic said, is a mix that no politician wants to touch. In addition, there is very little reliable data on these young people, a huge amount of stigma and discrimination associated with them, parental disengagement and community, social and religious opposition to attempts to develop services for MARA, who many see as “lost causes”. There are also service provision barriers such as legal barriers to access to services without parental consent and necessary documentation, payment and location barriers, and service prejudice towards MARA; these help to make the young people distrustful of services. Those services that do want to help find barriers that stop them from doing so (like a requirement to report drug users to the police). Even NGOs are proving reticent to get involved for fear of being seen as exploitative of MARA.
UNICEF is now working with partners to get MARA on the agenda and to acquire the evidence needed to inform meaningful interventions, Dr Ferencic explained. It is trying to build political and community support and to remove barriers to use of services by MARA.
Dr Ferencic’s colleague, Olena Sakovych, UNICEF Country Office, Ukraine, then provided an example of how youth-friendly services in Ukraine are trying to reach out to MARA. She described MARA as
“the missing face of the health and community response”, in that so little is known about them, few service providers are interested, and there is no strategy to meet their needs. Research carried out by
UNICEF, however, has uncovered some key facts, such as: MARAs’ high levels of HIV-risk behaviour and overlapping risks, which are higher than among their older counterparts; significant service access barriers faced by MARA, with very low service-seeking behaviour and few referrals; and serious concerns about the sexual and reproductive health of MARA girls.
Ukraine now has in place a network of youth-friendly clinics supported by a legislative framework, service standards and certification, in-service and postgraduate training for professionals, strong quality assurance mechanisms, links with social services and youth participation. These youth-friendly clinics now face the challenges of becoming MARA-friendly, reaching and protecting MARA, building the capacity of service providers and overcoming the legal barriers and stigma that stop MARA accessing services. Despite these challenges, youth-friendly clinics provide an emerging opportunity to reach MARA which should not be missed, Ms Sakovych said.
Neil Hunt, Director of Research for KCA(UK), a treatment agency in the United Kingdom, described the youth-friendly ethos that has been developed within the agency as a means of engaging with and encouraging participation from young people who have drug and/or alcohol problems. The agency has a young workforce (most are aged from 20 to early 30s) who are able to talk to young people in a language they understand and share many cultural reference points with young people. Many have experience of drug
The workforce emerges from a range of disciplines, including teaching, youth work, social work and nursing. They are professional, well-informed and able to work equally well with young people who are at different stages of their drug or alcohol use. They work with young people on their terms (stopping drug use is not assumed or required, Mr Hunt explained, but is always considered) and use a range of age-appropriate tools and resources, many of which were developed within KCA by young people. Meetings with young people are arranged when it suits them (perhaps lunch time or after school) and where it suits them (school, cafes, parks etc.).
Mr Hunt explained that parents are involved whenever possible and appropriate, with the young person involved in the decision about how and what they are told. In this way, the KCA worker doesn’t direct the work: it is directed in a partnership involving the practitioner and the young person. It is always carefully explained, however, that the agency’s youth-friendly ethos does NOT override its professional and legal obligations. Obligations to, for instance, share information with youth justice systems and comply with child protection legislation have to be met within the framework of the youth-friendly service.
Mr Hunt drew some contrasts with the situation in the United Kingdom and some countries in eastern Europe that he has worked in. He explained that there are more resources in the United Kingdom for young people’s services, and strategic leadership has not been developed to the same extent in eastern Europe.
Particularly striking is the dominance of the medical profession and medical model in drug and alcohol treatment programmes in eastern European, which contrasts very starkly with service provision models in the United Kingdom, in which medical involvement is the exception rather than the rule. There are also significant differences in the target groups for drug and alcohol services. While the United Kingdom does have street children who misuse drugs and alcohol, it is clearly of a different order of magnitude than some eastern European countries; there is a Roma community in the area in which Mr Hunt provides services, and it is largely integrated into education, health and social systems.
To conclude, Mr Hunt said that youth-friendly services require strong strategic leadership and resources, a robust commitment to youth-friendly services and a willingness among staff and partners to work in different and innovative ways.
In closing the session, Rita Khazayeva, Programme Technical Adviser on Health and Rights in the UNFPA Regional Office of Eastern Europe and Central Asia, summarized that:
dealing with MARA requires policy commitment to address the issue, rather than “turning a blind
•
eye”;
health systems have a great responsibility in the process and are critical components in dealing with
•
the health and social care needs of MARA – there are roles for primary care, for general practice and family doctors, and for youth-oriented and specialist services;
early interventions are important;
•
age-appropriate tools have a role to play, especially in helping to engage MARA in conversations and
•
identifying opportunities for effective interventions;
a knowledgeable and experienced workforce with ongoing training opportunities is needed, as the
•
risks MARA face keep changing;
young people should be able to direct the service; and
•
linkages and referrals between health, social, education and child protection services are critical.
•
The crucial questions that need to be asked of youth-friendly services, Dr Khazayeva suggested, are the following.
Could MARA use the services if they wanted to?
•
Are the services appropriate and accessible?
•
Are they effective – will they make a difference to MARA?
•
Are they being developed with the needs of MARA, and not just children and young people in the
•
mainstream, in mind?
Outcomes and discussions from this session are reflected in suggested action areas 4, 13, 18, 28 and 32.
Meeting day 3
Health care at school: pairing young people with health services
Day 3 was opened by the chair, Olivier Duperrex, Medical Head for School Services for Canton de Vaude, Switzerland. Dr Duperrex described how the geographically short distance of 80 km involved in moving job from Geneva to Lausanne also involved a very large move in culture for him. In his former work, he explained, the school health service (SHS) was based within the education system, while in his new area, it is based in a joint structure involving the education and health departments. Regardless of the particular culture in which SHS are based, however, professionals in SHS have to define a subculture of school health, he said.
Miriam Levi, WHO temporary adviser, then reported on a WHO survey of the organization of SHS in the WHO European Region. Dr Levi reported that the survey was designed to:
generate evidence about SHS’ contribution to priority health and development needs of pupils in
•
Member States;
define SHS content and orientation towards health promotion;
•
identify health system aspects of ongoing reforms in SHS; and
•
identify the need for revision of SHS scope and content.
•
Respondents were government chief nurses and national focal points for child and adolescent health and/
or school health care in the country. The questionnaire was designed in a health system framework, looking at issues of service delivery models, financing, human resources capacity and governance. Responses were received from 33 countries.
Results indicated a general lack of funding, insufficient orientation towards health promotion, a mismatch between priority health problems and services provided, and school health personnel being insufficiently trained to provide appropriate services. The main challenges to SHS were identified as:
lack of adequate funding (79% of respondents);
•
insufficient involvement of families, teachers and communities in health promotion (71%);
•
shortage of (65%), and inadequate training of (50%), SHS personnel;
•
uneven SHS provision within countries (35%); and
•
inequalities in access (29%).
•
Respondents identified important roles for WHO in supporting Member States to strengthen SHS, including developing guidelines and facilitating the sharing of experience among countries. WHO also had an
identified role in advocating for SHS with national authorities. Dr Levi concluded by saying the survey had revealed a big gap between what is provided and what should be provided in the field of health promotion, and a general lack of funding for SHS. Decision-makers have to be made aware of this, she commented, as, to quote UNESCO, “investing in school health is investing in a country’s future”.
Sven Bremberg, Director of the Department of Child and Adolescent Health and Mental Health at the Swedish National Institute of Public Health, then described current trends in the Swedish SHS. He explained that SHS in Sweden are evolving and are moving in the direction of being based on evidence.
National guidelines have been produced, but SHS are funded by local municipalities which are autonomous, so can chose not to implement the guidelines.
The service is effectively completely staffed by school nurses, who are trained? for three years in public health nursing, Dr Bremberg explained. There are 13 school nurses per 10 000 pupils, compared to one physician; this is a higher ratio than is found in any other country. Their main tasks are health promotion, health examinations, open consultations, supporting pupils with disabilities and immunizations. The current trend is to focus more on health promotion and less on health examinations, for which there is little supporting evidence.
Health promotion activities include individual consultations, classroom teaching on health issues and supporting the school as a learning environment. The evidence for focusing individual counselling on
Health promotion activities include individual consultations, classroom teaching on health issues and supporting the school as a learning environment. The evidence for focusing individual counselling on