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WHO/FCH/CAH/02.13
Growing in
Confidence
Programming
for adolescent
health and
development
•••*
Lessons FROM EIGHT COUNTRIES
■; -
WORLD HEALTH
ini'iimwffirWWB ■
OB) ORGANIZATION
Department of Child and Adolescent Health and Development
WHO/FCH/CAH/02.13
Distribution GENERAL
Original ENGLISH
Growing in
Confidence
Programming for adolescent health
and development
Lessons from eight countries
WHO
Contents
Foreword
Showing it can be done
1
Introduction
Generation of hope
3
Costa Rica
A nationwide programme built on
respect for young people’s rights
6
An holistic approach to promote
healthy development
10
Facing the challenge of reaching
the hard to reach
14
Supporting adolescents to develop
coping skills
18
Breaking down the barriers
for a ‘talk about it’ culture
22
United Republic
of Tanzania
Peer educators put life skills
to the test
26
Thailand
Survey will set a baseline
for skills of young people
30
Network of centres for students
in school or in college
34
Successful programming is evidence based
Problems are connected—solutions must be too
Strong political leadership needed
The involvement of young people is crucial
Many components — one common purpose
Capable of ‘going to scale’
Using existing resources and staff
Address the broader community
Completing the journey
8
12
16
20
24
28
32
36
38
Malaysia
Mexico
The Philippines
South Africa
Tunisia
Good
Practice
Lessons!
Foreword
Showing it can
be done ...
his publication is about 1.2 billion people - young people
T
in their second decade of life. It’s about helping them
through the extraordinarily challenging time of
adolescence. It's about sharing what we know works - to help them
grow in confidence and to increase their chance of living a long and
healthy life.
During the 1990s, WHO and its partners in health and
development made a strong case for more attention and resources
to be devoted to adolescents. We highlighted the problems - for
example 7,000 young people become infected with HIV every day,
90,000 adolescents commit suicide every year. But we also stressed
the opportunities - adolescents are a critical asset and at the centre
of social development.
We know what needs to be done. We know how to do it.
We are now witnessing significant increase in programmes
promoting adolescent health. Alliances have been forged which
have focused attention on the problems faced by adolescents and the
resources needed to combat them.
Countries are now taking adolescent health seriously. As
Growing in Confidence demonstrates, they are developing and
implementing policies and programmes from different entry points,
working through a number of sectors, and being supported by a
wide range of partners.
The international community has also accepted the challenge.
The focus on adolescents in the UN General Assembly Special
Sessions on Drugs (1998), HIV/AIDS (2001) and Children (2002)
bears witness to the growing awareness and concern from
governments, and their willingness to commit to effective action.
And in Stockholm at the Global Consultation on Child and
Adolescent Health and Development in March 2002, government
leaders, health experts, NGOs, and children’s advocates committed
themselves to a world where adolescents enjoy the highest possible
level of health.
If we are to succeed in the wider application of what we know,
we need to develop stronger alliances between the public, NGOs,
private and international bodies and with the adolescents
themselves. Above all we must listen to their voices. We must learn
and be inspired by the success stories highlighted in Growing in
Confidence.
We know what to do. We must not allow this opportunity to
evade us.
Dr Tomris Turmen
Executive Director
Family and Community Health
World Health Organization, Geneva
2
Growing in
Confidence
Generation of hope
here are today more adolescents than at any time in history — a
vibrant generation who will play a crucial role in the next period of
human development. The 1.2 billion people aged 10 to 19 make up
about 20% of the global population. As they progress to adulthood,
these young people represent an enormous energy and potential for change.
For most young people, adolescence is a period of hope and optimism when
they grow in confidence to adulthood. But it is also a time when unsuspected
dangers and confusing messages dash hopes. As each young person matures
sexually, physically and psychologically, many are uncertain of their role in society
or what is expected from them. They have left behind the perils of early
childhood, but are, in many ways, at their most vulnerable.
It is widely acknowledged that young people face
challenges on a personal and collective level that
go beyond those faced by their parents and
grandparents, as traditions that governed how
people grew up and behaved begin to change. For
example, many of today’s adolescents will marry
at a later age. Every young person needs an
Programming
for adolescent
health and
development
effective strategy to survive and flourish during a
period when young people experiment with adult
behaviour. Without it, many are at risk from
unprotected sex, and from the dangers of alcohol,
tobacco or other substances. Adolescents are also
at risk from violence, including sexual violence.
For others, lack of nutrition during adolescence
can damage the process of development. Life
circumstances or lack of a supportive
environment leads many into depression, which
can expose adolescents to other risks, including
the tragedy of suicide. This is the time when
young people most need support and guidance,
but is also the time when tensions or social taboos
may inhibit them from communicating with
their family or with other adults.
This account
shows how
programmers who
support adolescent
health and
development are
growing in
confidence as they
engage with young
people and their
communities to
make programmes
relevant and
acceptable.
The concerns of policy makers
- and of young people
Policy makers all over the world are concerned about adolescents. They
understand that this generation is crucial for the futures of their countries. They
see that the problems of adolescents, if not addressed, can ruin individual lives and
undermine communities and national development. Policy makers look at the
number of young people who leave school early, without education, skills or
training. They see young people living on the streets, because they have no safe
and stable home. They see an increase in those whose lives are disrupted by
substance abuse, including alcohol or drugs. They note the number of young girls
who become pregnant when they should still be enjoying their own childhoods.
They see young people drawn into violence. They see the scourge of H1V/AIDS as
a massive threat to this generation.
This justified concern should come with an understanding that adolescents
are not only a future resource, but should be valued for who they are today.
Adolescents may be the future, but they live in the present. Programmes aimed at
helping adolescents to acquire vital knowledge and skills must therefore be
relevant to their lives and their understanding today, as well as being designed to
protect them for tomorrow.
Many adolescents grow up with a sense of hope and a desire for justice, but
feel they inherit an unjust world where success or failure can be a lottery.
Meeting the challenge for adolescent programming
Adolescents are urged to work hard, but there
The best way for
may be no secure and viable employment when they
adolescents to
grow up. They are told to be peaceful, yet grow in a
protect their
world where there is conflict and war. They are told
health, is to
to honour their father and mother, but may find the
understand the
family structure crumbling under the pressure of
world around them
survival and social change. Support for adolescents is
often inadequate, and many services are judgmental
and interact with it.
and unsympathetic. Often, adolescents turn their
Successful
backs on services that providers believe will help
development is the
them. Instead of using government health clinics,
best route to
they turn to street vendors, to traditional forms of
3
adolescent
health.
medicine or to friends.
Policy makers understand that they cannot build walls around young
people to keep them safe from harm. Sooner or later, adolescents will confront
the dangers in society. Instead countries are trying to build coherent programmes
that help adolescents to develop the knowledge and skills to protect themselves.
They are working with others to put relevant services into place, and to create a
supportive environment that will encourage young people to use the services.
The policy makers who are most successful are not those who see adolescents
as problems and try to constrain them, but those whose programmes help young
people to find solutions. The best way for adolescents to protect their health, is to
understand the world around them and interact with it successfully. Successful
adolescent development is the best route to adolescent health.
Learning the lessons
This account shows how programmers who support adolescent health and
development in eight countries across the world are growing in confidence as they
engage with young people and their communities to make programmes relevant
and acceptable. The programmes described in these pages are work in progress in
the real world, complete with loose ends, contradictory trends and some unsolved
problems. What they have in common is that they have learned from past efforts,
failures as well as successes. And these are not isolated examples, but part of a
worldwide trend. Other countries could tell the same story.
These examples show that programming for adolescent health and
development is growing up fast, even in a tough economic climate for social and
health programmes. With international support these programmes will reach their
own maturity to help adolescents to protect themselves for generations to come. ■
5
A nationwide
osta Rica has a strong programme for adolescents based on a solid
C
political, legislative and social structure. With a health care system
developed over the last 50 years and success in reducing child and
maternal mortality, policy makers turned their attention to
adolescents more than a decade ago. The National Adolescent Health Programme
(PAIA) was launched in 1989 within the national Social Security system. More
recently legislation proposed by the Ministry of Health was passed to guarantee
every adolescent access to free health care.
PAIA began with a strong focus on services in clinics and hospitals, with the
aim of providing comprehensive services to all young people between the ages of
10 and 20. Today the focus is increasingly on developing appropriate responses
from primary health care teams, and on developing a leadership of health
educators from amongst adolescents themselves.
Each primary health care team, made up of a doctor, nurse and primary care
worker based at a health centre, looks after the health of 4,000 people, about 800
of whom are adolescents. The primary care worker ensures that the team monitors
adolescent growth and development, going out into the community and knocking
on doors to make sure that nobody slips through the net.
Costa Rica
Two years ago primary health care teams began to
screen for psychosocial risk factors through a
questionnaire. This is uncovering high levels of need for
counselling, the major risk markers being depression
and problems with alcohol, often amongst adolescent
boys who are unable to find work.
Health centres offer counselling in relation to
sexuality and sexual and reproductive health. They also
host workshops to build self-esteem, including sessions
on the rights of young people. Adolescents are recruited
to train as peer health promoters, and some are in turn
selected to represent the views of young people on
divisional and national groups.
The primary health care team can refer adolescents
for specialist counselling or treatment to one of ten
special clinics. However, there are long waiting times,
and the national priority is to improve the capacity of a
primary care team to offer direct support. PAIA has
started training all 30,000 health workers in counselling
and adolescent issues using a variety of methods,
including distance learning, to reach the whole country.
The national adolescent programme in Costa Rica
seeks to provide a quality service to all young people
based on a strong rights agenda. One priority is to
ensure that primary health care teams provide for under
served groups - including adolescent males.
Young people are increasingly playing a more
active role through peer approaches. For example, in
the small northern town of Guatuso a youth group set
up a postbox where adolescents could post questions.
The young health peer-educators answer questions
themselves or seek information from a doctor or nurse.
Surveys show that one in five births is to girls
under 20, although the rate is now falling. The
Department of Health takes the lead in implementing a
law to support pregnant adolescents, offering a sixmonth skills programme before the baby is born.
✓
'
Key Facts
• This is a
comprehensive
service covering
the whole country.
• There is broad
political
commitment to the
needs of
adolescents.
• A national training
programme is
being implemented
for health workers.
• Young people
receive training to
provide leadership
on health.
• Costa Rica is
supporting efforts
to build adolescent
programmes in
other countries.
...built on
respect
for young
people’s
SUCCESSFUL PROGRAMMING
Successful programming is.BO
evidence based
✓ Successful programming is based on data which shows,
not only the main causes of illness or death, but also
describes what adolescents are doing and thinking.
✓ Surveying the views of adolescents is a way of looking
at their world through their eyes, and the beginning of a
journey to involve adolescents centrally in programming.
✓ Finding out about the environment in which young
people live is a step towards discovering risk factors and
the protective factors which support healthy lifestyles.
✓ Finding out what young people do when they are
concerned about their health turns a spotlight on gaps in
existing services.
✓ Surveying what their parents do and think helps policy
makers support families.
✓ Finding out about teachers’ attitudes ensures that school
health programmes are grounded in reality.
■
8
lessons from around the world
Costa Rica
Costa Rica
■•
Surveys also reveal an increasing number of
deaths and injuries from traffic accidents, suicide or
other violence, often involving alcohol or drugs.
The school health system has been strengthened.
Many school nurses are trained to offer counselling.
Sexuality education has been integrated into the school
curriculum. The linkages between health services and
schools are being strengthened.
A telephone hot line - Cuenta Conmigo (Count on
Me) - opened for young people in 1996. 1,500 to 2,000
adolescents call each month. Parents also call for advice
about relationships with their children. The line is open
at no cost to callersl5 hours a day on weekdays and 12
hours a day at weekends. Cuenta Conmigo is also
launching an Internet service, while technical
information about adolescents is available on-line for
professionals and for parents - a virtual national library
on adolescent health. Some districts started ‘parents
school’ to help parents communicate with their
adolescent children.
Dr Julieta Rodriquez, Director of the National
Health Programme for Adolescents, says that primary
care teams have to be creative to cope with the extra
demand from young people, and the country still needs
support from outside agencies such as PAHO and
UNICEF. However, there is a strong national consensus
that working with adolescents is a priority.
“We have a health care system that developed over
50 years. We have advanced legislation for young people,
and we are very open with young people and encourage
them to participate. Because we have succeeded in other
things we are able to make this a priority.”
The whole region is taking note of this adolescent
health and development programme. Costa Rica is now
cooperating in spreading the benefits of its approach
beyond its own borders.
‘We are
very open
with young
people and
encourage
them to
participate?
Costa R ica
built a
national
programme
based on
respect for
adolescent
rights
9
An holistic
approach...
BX
ICX
I
B
/I alaysia’s holistic approach to adolescent health and development
//■ includes policies to promote good mental health, nutrition and
I sexual and reproductive health, and a programme to promote
W adolescent friendly health services. Programmes in schools and
the community promote healthy lifestyles and aim to reduce smoking, alcohol and
drug use, and to prevent injury. Treatment is increasingly delivered at clinics which
meet adolescent standards for quality and confidentiality.
The national adolescent policy was launched by the Deputy Prime Minister in
October 2001 to promote healthy development and to bring adolescent issues into
the mainstream. The Government was prompted to take action after University
research in 1994 identified lepak (‘loafing’) as a problem among adolescents. In
1996 a national survey on adolescent sexual and reproductive health by the
National Population and Family Development Board showed that adolescents
were engaged in risky behaviour that could jeopardize their health.
The Rakan Muda (Friends of Youth) programme was introduced by the
Ministry of Youth and Sport, to enrol young people in clubs for sports and
recreation and to encourage a healthy lifestyle. Youth development was also
included in the 7th Malaysia Plan and the National Social Action Plan (PINTAS).
— Malaysia
Malaysia
Programming to support adolescent development
is guided by policy, research findings and programme
experiences. A baseline survey on protective factors and
risk factors and was carried out in Terengganu State.
Protective factors included good self-esteem, feeling
connected to parents, and positive peer influences. Risk
factors included lack of communication skills, parents
who did not act as role models and friends who were
getting into trouble. Risk behaviour included missing
school , substance abuse and violence. The Terengganu
experience was shared with other states.
School health and health promotion
Health promoting schools were introduced in October
1997 by the Ministry of Education and Ministry of
Health. These schools set a broad school health policy
covering the physical environment, the social
environment and personal health skills. They mobilise
local communities to support young people’s health.
School health services screen the nutritional status
of young people, and alert authorities to cases of
dengue. They offer immunisation, dental health checks
and treatment. They address the mental health needs of
adolescents and address issues leading to violence.
The Ministry of Education, in partnership with a
range of national bodies, added a sexuality module into
school family life education. Staff or volunteers from the
Family Planning Association of Malaysia (FPAM)
deliver these lessons, where teachers lack the skills or
confidence to do so. FPAM has also developed a
reproductive health adolescent module to target
adolescents through peer education.
The Prostar project has trained 32,000 peer
educators since 1996 as a source of accurate
information about HIV/AIDS in schools information and advice for young people
from young people.
Key Facts
• Malaysia aims for
holistic services
and an integrated
approach.
• Programmes are
based on evidence
of risk and
protective factors.
• Political leadership
ensures good
co-operation
between
government
departments.
• Innovative ways of
reaching young
people include
strong school
health programmes
and peer
educators.
• Health services are
becoming more
adolescent friendly.
...to
promote
healthy
development
u
Health services
The Ministry of Health has launched
interventions to promote self-care
and provide holistic, personalised
care close to home. A survey
in Kota Tinggi District, one of
eight target sites for improving services
to adolescents, showed that young people
expect quality health services to be provided in good physical conditions and for
confidentiality to be respected. Providers at local health centres set out to improve
quality of care, by improving staff skills, the physical condition of the centres and
the referral network. They took steps to advertise the clinics to adolescents and to
provide health promotion. •••>-
SUCCESSFUL PROGRAMMING
Problems are connected — solutions
must be too
✓ The problems that concern policymakers are inter
connected. When researchers look at one risk factor
they commonly find another.
✓ Young people who are at risk in one aspect of their lives
are more likely to be at risk in another.
✓ Risk factors are linked to relationships with family and
friends.
✓ Life skills and links to supportive adults provide
‘protective factors’ which reduce a range of risks.
Research has demonstrated that solutions, as well as
problems, are connected.
✓ Protective factors verified by research include a strong
connection with at least one trusted adult, liking school
and having clear boundaries and expectations.
lessons from around the world
12
—
Malaysia
Malaysia
Paramedic assistants and public health nurses
started regular wellness and outpatient clinics with a visiting
doctor. Adolescent attendance rose by 62% between 1997 and
1999. The most common condition for treatment is upper
respiratory tract infection. Centres offer counselling as well as
health promotion. Staff are developing their ability to detect
hidden problems, such as depression, that adolescents do not
mention when they first attend.
Taking advantage of Malaysia’s Multimedia Super
Corridor, a Telehealth project is being launched during 2002
using television and the Internet to offer individuals a
‘wellness lifetime health plan’. Specific health plans for
adolescents are being developed, covering growth and
development, sexual and reproductive health, mental health,
injuries and violence and nutrition. Adolescents can sign up
to a web-site, www.telehealth.com.my and from June 2002,
when the adolescent specific material will be posted, young
people will be able to carry out an interactive health
assessment on-line.
‘Staff are
developing the
ability
to detect
hidden
problems that
adolescents
do not mention
when they first
attend?
The future
The national adolescent policy took three years to develop,
during which time a number of government and non
government bodies arrived at a consensus the way forward.
The Ministry of Health reviewed policies for health in
conjunction with the Ministries of Youth and Sport,
Education, Welfare, Religious Affairs and with
representatives of professional bodies.
Ministries and professional bodies are
working to develop further programmes for
adolescents.
The Ministry of Health takes the lead
in health related issues, in developing life
skills and in ensuring that hospitals, health
centres and other health facilities provide a
safe and supportive environment for
adolescents.
An holistic
approach to
health and
development
i
13
Facing the
challenge...
exican health services are mobilising families and communities
across the country to take an active role in protecting the health
of adolescents. Programmers believe that families and
communities can help young people to become resilient - able to
deal more effectively with the challenges of growing up, without being
overwhelmed by set-backs. At the same time the Mexican authorities are finding
innovative ways to provide services for young people who are not in school or who
live in remote rural areas.
The Ministry of Health started the national adolescent programme in 1994
with an emphasis on sexual and reproductive health and on problems associated
with drug addiction and substance abuse. Adolescents have free access to health
care both at the primary level and in hospitals. Each of the 240 health authorities
in Mexico has established at least one specialist adolescent clinic.
A major strategy to increase coverage, particularly amongst younger
adolescents, is to deliver services and health promotion through schools. This
service monitors the health and development of 10-19 year-olds, provides
vaccination and offers folic acid supplements to girls. Issues connected with sexual
and reproductive health and substance use have been included in the curriculum.
I
Mexico
Mexico
The school health service and the national network
of adolescent friendly health centres helped to reduce
birth rates among 15-19 year-old girls by more than
17% between 1990 and 2000. Although birth rates fell,
an evaluation showed that adolescents still had limited
knowledge about sexual and reproductive health.
Moreover, the network of clinics was reaching only 7%
of the adolescent population, mainly because many of
the 22 million adolescents live in remote rural areas and
only 60% are in school.
In 1997 the programme IMSS-Solidaridad
introduced CARA (Rural Health Centres for Adolescents)
to bridge the gap in rural areas. These primary health
care services concentrate on meeting adolescent needs
for information, counselling, health education and selfcare. It is estimated that CARA now reaches more than
five million rural adolescents. In addition, health
education material has been added to the informal
education programmes that target people in rural areas
through TV and radio.
In each of the 32 states, religious groups, scouts,
sports groups and others who have an interest in
adolescent development are being brought into the
programme. For example, sports coaches are being
trained to counsel young people. Many adolescents turn
to their coaches for advice and this is an effective way of
reaching the huge number of boys who play soccer,
baseball and basketball. One important aim is also to
increase the number of girls who play sport regularly.
The migrant population poses a special challenge
for the health system - 60% of the three million people
who leave Mexico each year are under the age of 20. A
MAIS ‘go healthy’ campaign was launched in 10 states to
offer health checks. The campaign also works with
providers in the United States to reach Mexican
migrants who need health care.
Key Facts
• Mexico is
mobilising families
and communities to
protect
adolescents.
• Adolescents have
the right to free
health care.
• The school health
service monitors
development.
• One special
programme is
targeted on
adolescents in rural
areas.
• Health screening
and health
promotion is also
targeted on 1.8
million people
under the age of 20
who leave Mexico
each year.
...of
reaching
the hard
15
SUCCESSFUL PROGRAMMING
Strong political leadership needed to
support mwEti sectoral programmes
✓ Sustainable programmes have high level political
commitment to overcome problems and to ensure
adequate resources.
✓ Political leadership and media support helps to create
public backing for programmes.
✓ Many countries demonstrate a link between political
commitment in the office of the President or Prime
Minister and a legislative framework that supports young
people and programmes.
✓ National leadership is needed to bring government
departments, other national bodies and non
government organizations together, to overcome
bureaucracy and to finds ways of reaching a consensus.
lessons from around the world
16
Mexico
Mexico
Health programmes for the national
strategy are being designed to meet needs identified
in epidemiological data from Mexican institutions.
Services for sexual and reproductive health will
include information, skills and counselling. The
national programme will also be directed at a broad
range of health issues, including high levels of
violence and at specific medical problems.
One initiative is to offer early treatment to
adolescents who develop leukaemia and other
cancers, where early diagnosis makes a significant
difference to the chances of a successful treatment.
Young people themselves will also play a greater
role in communicating with their peers and in
helping the authorities to plan services. Across the
country 60 focus groups of adolescents discuss health
issues and feed their views into the planning process.
Regional and national groups of adolescents raise the
level of participation.
The major challenge is to expand the
programme to reach adolescents over the whole
country. Nationally in Mexico over $1,500 a year is
invested per child up to the age of 9, while
investment in health and social welfare falls to $30 a
year between the ages of 10 and 19. There is a short
term commitment to raise the amount allocated for
adolescents, and a long term aim to allocate the same
amount as for younger children.
Dr Juan Pablo Villa Barragan, Director of
Human Development for the Ministry of Health, says
that adolescent programmes must involve the whole
community. “You cannot wait for people to come to
the services. The services must go to the people. The
people are taking responsibility for caring about the
health of adolescents. The family group is still very
important in Mexico and the family can protect
adolescents.”
cThe family
group is
still very
important
in Mexico
and the family
can protect
adolescents.’
Meeting
the
challenge
of
reaching
the hard
to reach
17
Supporting
aaol
he Philippines has one of the fastest growing and youngest
T
populations in the Western Pacific and is making strenuous efforts
to protect its young people from threats to healthy development.
Although death and disease is lower in the adolescent age group
than for young children or for old people, many deaths in this age group are
avoidable. There are warning signs that poor nutrition could cause serious health
problems in later life. A third of adolescents are underweight for their age, and
there is a high level of anaemia and goitre.
Social problems, including a rising wave of drug use, smoking and alcohol
use, are ringing alarm bells. There is a high level of violence and sexual abuse,
most of it directed at young girls between the ages of 11 and 17. Accidents and
violence are the largest cause of death in the adolescent age group.
Although survey figures vary, about a fifth of adolescents say they have had
premarital sex, often unprotected. Adolescent girls account for one in six
abortions, while sexually transmitted infections and H1V/A1DS are a national
concern. Yet the surveys suggest that many adolescents who fear they have sexually
transmitted diseases go to unqualified traditional healers or to drug hawkers
without proper diagnosis.
The Philippines
The Philippines
The Philippines has adopted laws to protect the
rights of children and adolescents. The President of the
Philippines is active nationally and internationally in
leading campaigns against the sexual exploitation of
children and young people.
Now the Department of Health has launched an
Adolescent and Youth Health and Development
Programme, a ten-year strategic plan aimed at reducing
the risks for young people and protecting their health.
The plan will involve adolescents in campaigning for
their own rights, including those of survival,
development and participation.
The Department of Health has adopted a twin
track approach to promoting healthy development
among young adults. The first is to support adolescents
to develop coping skills and positive values and to try to
create a safe and supportive environment in which they
can grow.
The second is to provide high quality gender
sensitive health information and services. Health staff
will be trained in providing a respectful and
sympathetic service to young people. The plan aims to
ensure that 70% of health facilities will, by 2004,
provide basic health services and counselling for
adolescents and youth.
The health and development programme will
target young people in and out of school. It will pay
particular attention to those who are at most risk,
including young people exploited in the sex industry,
and adolescents living on the margins of society.
The programme is strongly based on research
findings. A survey in 1997 confirmed an increasing rate
of unwanted teenage pregnancies, substance abuse,
violence and STDs. It showed that young people were
hesitant about using health facilities because they did
not feel that they were intended for their age group.
Key Facts
• The Philippines
has adopted laws
to protect young
people from sexual
exploitation.
• The Department of
Health has
launched a
programme aimed
at reducing risks.
• It supports young
people to develop
skills and aims to
create a supportive
environment.
• Youth health
centres are being
developed at
hospitals.
• ’One stop’ youth
centres will open in
schools and
shopping malls.
...to
develop
coping
skills
19
SUCCESSFUL PROGRAMMING
The involvement of young people is
crucial
✓ Successful programmes build the skills and self
confidence of young people, treating them as partners
and taking their views seriously, trying to see how the
world looks through their eyes.
✓ Adolescent friendly health services are sensitive to the
feelings of young people. Peer to peer approaches
promote the abilities of adolescents. Programmes that
involve young people in design and planning are more
likely to be relevant and to gain legitimacy.
✓ Broad participation by adolescents makes it more likely
that programmes reach young people of both sexes and
include minority ethnic groups.
lessons from around the world
The Philippines
The Philippines
•■
The process of drawing up the health and
development programme involved extensive
collaboration by the Department of Health with
other agencies focusing on aspects of adolescent
development. Agencies include the National Youth
Commission, based in the office of the President, as
well as Departments of Education, Labour and
Employment, Local Government and Social Welfare.
The process drew in the Commission on Population
and other specialist organisations, including WHO.
Doctors and nurses in 50 government hospitals
will be trained in adolescent friendly skills. They will
then pass on these skills to health workers in all 16
regions of the Philippines.
If given enough financial and human resources,
youth health centres will be developed at hospitals,
separated from other hospital departments. A young
health care provider will provide basic services and
will be able to call on specialists for medical services
if necessary.
'One stop shop’ adolescent and youth centres
will also open in schools and shopping malls where a
professional health care giver can offer services and
counselling. Some reproductive health units will
open at local barangay (parish) level to give basic
services and to help adolescents access other health
services.
Dr Debbie Capuchino, medical specialist in the
Department of Health, says that training health
workers to be adolescent friendly is vital. “Health
providers must be patient, understanding, and
empathetic and get to the level of adolescents. We
want the adolescents to be empowered to improve
their health seeking behaviour. There is more
emphasis on information and skills and less on
clinical issues. I am really very optimistic.”
■
‘Health
providers must
be patient and
empathetic
to get
to the
level of
adolescents?
'One stop
shop’
centres
open in
schools Sr
shopping
rnalls
Breaking down
the barriers ...
outh Africa looks to the future of its young people as the first post
S
apartheid generation rapidly approaches adolescence. A huge collective
effort is under way to address the problems bequeathed by generations
of poverty, unequal development and political oppression. In a country
where the majority population for so long had no say its future, young people are
learning they have a real choice in determining what happens to them as
individuals and as a society.
The 8.8 million adolescents have many obstacles to overcome: sexually
transmitted infections, especially HIV/AIDS, sexual abuse, physical violence,
accidents and substance abuse. Sexual activity often starts in the mid-teens, but
knowledge of reproductive and sexual information remains low. By the age of 20,
one in three girls in South Africa has had a baby. HIV is estimated to be infecting
1,500 people a day, half of whom are young people.
The Department of Health developed policy guidelines for youth and
adolescent health after extensive consultation with the young people. The national
guidelines seek to open public discussion on areas of life that were taboo, and
increase dialogue and understanding between generations and sexes.
1 ---
South Africa
South Africa
Many programmes are partnerships between the
Government of South Africa, which sets national policy,
and NGOs which help to implement it.
One example is Soul City, a combination of prime
time TV, multi language radio shows and easy to read
booklets. Soul City integrates health and development
issues into a lively and popular drama. Launched in
1994, Soul City is in its fifth season of programmes with
a sixth in production. Evaluation shows that series four
reached more than 16.2 million South Africans, two
thirds of whom were between the ages of 16 and 24.
Soul City makes information on health issues
popular and accessible, and encourages its audience to
make healthy choices, both as individuals and as
communities. As it entertains, Soul City encourages
them to reflect on their own attitudes and behaviour,
leaving them with a sense that they have a choice in
determining their behaviour and the impact it has on
their lives and those of others. Soul City also influences
social attitudes to violence, HIV, ‘sugar daddies’ and
other issues.
Soul City has played a major role in increasing
accurate knowledge about HIV/AIDS, in stimulating
dialogue and in shifting people’s attitudes. It has been
influential in reducing resistance to condom use among
young people and in raising public debate over violence
against girls and women. The latest story lines include
the care and support of people living with HIV/AIDS
and the impact of rape on victims.
South Africa is also the home of loveLife, a
nationwide effort to influence adolescent sexual
behaviour. This broad based campaign uses media and
popular culture to advocate a new lifestyle for young
people based on informed choice, shared responsibility
and positive sexuality. loveLife argues that young people
can shape their futures by adopting positive lifestyles
Key Facts
• The first post
apartheid
generation is
nearing
adolescence.
,
• They face many
problems, but
public debate is
now more open.
• Young people are
being taught that
society and
individuals can
make choices.
\
'
• Mass media help
change attitudes
to positive and
negative behaviour.
• Adolescent friendly
health services are
being promoted.
...for a
‘talk
about
it’
culture
23
SUCCESSFUL PROGRAMMING
Many components — one common
purpose
✓ Successful programmers address a range of
interventions targeted at the broader community as well
as on adolescents.
✓ Most address more than one audience — a programme
directed to adolescents may also have a component to
address the concerns of their families.
✓ Effective programming is coordinated to make good use
of resources. Preventing behaviour that leads to key
public health problems involves the same actors, the
same interventions and the same settings.
✓ There is no ‘magic bullet’ solution for adolescents.
• Information is essential, but young people need to
develop skills to find and use information that is relevant
to their lives.
• Life skills are crucial, but may not be enough if a
young person needs treatment that is not available.
• Services are vital, but only those services that are
sympathetic to adolescents and acceptable to their
communities are truly accessible.
All these components are necessary if adolescents are
to learn about risks, to know what support is available
and how to access it, and to be able to access it.
lessons from around the world
24
. ....... South Africa
South Africa
■•
based on informed choices, by sharing
responsibilities in relationships and through a healthy
approach to sexuality. The loveLife tagline ‘talk about it’ aims
to get South Africans, particularly 12-17 year-olds, talking
more openly about their attitudes to sexual behaviour.
loveLife, implemented through a consortium of NGOs
working in conjunction with the Government, supports
telephone hotlines for young people and for parents, and a
network of youth centres for sports and leisure where 18-25
year-old volunteers provide counselling services.
Adolescent friendly sexual health services are one vital
element. The Department of Health and loveLife launched the
National Adolescent Friendly Clinic Initiative (NAFCI) in
South Africa to make health services more acceptable to
adolescents. Clinics sign up to a Going for Gold programme
under which they assess themselves against a range of
adolescent friendly criteria. To meet the standards staff must
have the skills and knowledge to manage common sexual and
reproductive problems, agree to treat adolescents with dignity
and respect and provide non-judgmental counselling.
Clinics must open when young people want to use them,
provide accurate information that is appealing to young
people and include adolescents in planning and developing
services. They must offer adolescents a package of services and
meet guidelines for ongoing care and support. Going for Gold
clinics support the rights of adolescents and have effective
staff training programmes.
Soul City, loveLife and the National Adolescent Friendly
Clinic Initiative will not by themselves resolve the health and
development problems that young people face in South
Africa. However, they represent a concerted effort by
government, by NGOs and by communities to address urgent
and pressing issues effecting the youth of the country.
Through mass media and popular culture, these programmes
are opening a public discussion and changing the cultural
climate in which it takes place.
'Staff must
have skills and
knowledge and
agree to treat
adolescents
with dignity
and respect/
Mass
media Sr
popular
culture
are
opening
a public
discussion
25
Peer educators
put life skills to
the t
anzania will discover this year whether a community based drive to
help young people protect themselves against HIV/AIDS, other
sexually transmitted diseases and unwanted pregnancy has
succeeded. It is already clear that MEMA kwa Vijana (Good things
for young people) has succeeded in raising the knowledge and awareness of
adolescents and is well accepted by parents and the local community. The project
is making local health facilities more friendly and welcoming to young people.
MEMA kwa Vijana is run by local education and health services with support
to make this an effective research trial. It has so far included more than 20,000
adolescents aged 12 years and above and will expand in January 2003 to take in
more villages and schools if the results are positive.
MEMA Kwa Vijana was launched in January 1999 in 62 primary schools and
their surrounding villages and health centres in rural Mwanza to bridge the gap
between what was expected of young people and the reality of what was
happening. In theory, young people abstain from sex until they are married. In
fact, many become sexually active by the time they are 15. In school, young people
were told about abstinence, but could see that many adults have sexual
relationships outside marriage.
United Republic of Tanzania
United Republic of Tanzania
Parents find it difficult to talk to their children
frankly about sex. Negative pressure in the community
was applied not so much to sexual activity, but more to
the use of condoms. Many girls left school early because
they were pregnant.
The project has a number of complementary
strands. It trained three teachers in each school to teach
about sexual and reproductive health, and how the
students could keep themselves safe, and also developed
teaching aids. Six students in each class were trained as
peer educators, able to advise fellow pupils and act in
short dramas to start discussions within sessions. The
main benefits often emerge through informal
discussions between peer educators and classmates.
The first peer educators were trained by trainers
from the local community but as the project developed
teachers took over this training role. More than 1,800
peer educators were trained over a three year period.
MEMA kwa Vijana clubs started at each school. In
some schools members meet regularly and hold special
activities and discussions. At other schools the main
focus for club activity is MEMA kwa Vijana week, when
young people perform drama, songs and rap and take
part in games and competitions against other schools.
When the MEMA project began some parents were
shocked, believing that their children were being ‘taught
how to have sex’. Over time, opinions changed. The
project is welcome in the community, lessons are
popular with the students and class peer educators
have respect and status. Parents are relieved that
teachers are talking to young people about
sensitive issues that they themselves find
difficult to raise. An annual test
carried out by the schools has
shown that adolescent knowledge
has increased significantly.
Key Facts
• Young people in
Tanzania are trying
to reduce HIV/
AIDS, sexually
transmitted
infections, and
unwanted
pregnancies.
• School teachers
train pupils as
class peer
educators.
• MEMA kwa Vijana
clubs create ways
to spread
information about
staying safe.
• Health providers
are trained to be
more friendly to
adolescents.
• The impact of this
project will be
known later this
year.
27
SUCCESSFUL PROGRAMMING
Capable of ‘going to scale’
✓ Countries wish to address the needs of millions of young
people. They need to go beyond small-scale exemplary
projects that work well for small numbers of people.
Because of cost, it is usually unclear how such projects
can expand.
✓ The examples highlighted in these pages are either
large scale programmes or have a clear pathway to
expansion, the ability to ‘go to scale’.
✓ In all cases the programmes are run by or engage with
government. Where programmes are run by NGOs
these are jointly planned with government services and
fit in with government policies and strategic planning.
✓ Small ‘beacon’ projects play a positive role in
pioneering innovative ways of working, but are not
themselves the solution for large populations.
✓ Most individual projects last a maximum of five years.
Adolescents need national programmes that will survive
and adapt to the emerging needs of generations of
adolescents over decades. Only government services
have the capacity to spread good practice countrywide.
lessons from around the world
28
United Republic of* Tanzania
United Republic of Tanzania
The project is also active outside the
school setting. Workers at health facilities have been
trained in adolescent friendly techniques, including the
creation of a confidential area where young people can be
seen. An informal network has developed to sell affordable
condoms in villages.
In December 2000, young ‘simulated patients’ went to
health facilities and asked for help, secretly tape recording the
outcome. Although privacy, waiting times and provision of
supplies were still problems, staff in the intervention facilities
were much more friendly and non-judgemental.
The unique feature of MEMA kwa Vijana is that it will
rigorously test whether it meets its aims, measuring levels of
knowledge, attitude and sexual behaviour among 5,000 young
people in the project area and another 5,000 in villages where
the project has not intervened. Researchers will test for HIV,
chlamydia, gonorrhoea, syphilis, genital herpes and
trichomonas. They will test adolescent girls for pregnancy
and record the drop-out rate of girls from school.
This study will evaluate whether improving knowledge
and skills delays the onset of sexual experience, decreases risk
behaviour and reduces HIV, other STIs and unwanted
pregnancies.
The MEMA kwa Vijana project is a partnership between
the Government of Tanzania, The African Medical and
Research Foundation, the London School of Hygiene and
Tropical Medicine and the Tanzanian National Institute for
Medical Research.
Government staff implement the programme as a
routine part of education and health systems. Project
material is based on the curriculum of the Tanzanian
Ministry of Education and Culture and the policies
of the Ministry of the Health and National AIDS
Control Programme. In 2003, the project
will expand to villages that were used as control
during the trial phase.
c
The study
will evaluate
whether knowledge
and skills
delay the
onset of sexual
experience,
and reduce
STIs and unwanted
>
pregnancies.
Mema
kwa
Vi iana
trains
teachers
29
Survey
will
set a
baselin
hailand has a range of programmes in place that reach millions of
young people in schools, hospitals and the community. The focus
today is on improving the quality of what is being done and in
discovering as much as possible about the skills and competencies of
young people. The results of a ground breaking national survey on protective
factors and life skills will be published later this year, and the findings are likely to
be useful across the whole region.
National concern over the number of young people who face serious health
and social problems brought together the Ministries of the Interior, Education and
Public Health. One priority action for the Department of Health was to tackle the
problems of reproductive health. A national survey showed that almost half of
boys and between a 23% and 37% of girls have had sex by the age of 18. This
survey included married as well as unmarried young people, but it showed that the
average age of first sex is falling, and that more than half of first time sex is
unprotected. Young people make up a third of those who acquire sexually
transmitted infections, and one in eight of those who are infected with HIV.
In 1998 the Department of Health introduced the concept of the
Health Promoting School to help children to make decisions and gain
T
Thailand
Thailand
control over circumstances that affect their health. More
than 10,000 schools (a third of the schools in the
country) are now taking part and 30% of these have
met the national criteria.
In 2001 a working team of health specialists
submitted guidelines for sex education in schools to the
Ministry of Education. As a result, Family Life
Education has been integrated into school health
education. The Department of Health developed a
teaching manual on sex education to help teachers to
overcome their shyness in dealing with this topic, and to
encourage two way communication with young people.
A regional network of trainers begins training teachers
this year.
A life skills programme for AIDS prevention has
been implemented. Regional health staff are training
teachers and health workers to deliver this to young
people, focusing on the skills needed to prevent HIV
infection and to promote safe and responsible sex.
Material is targeted at 11-20 year-olds in school, and to
young people who are not in school, through the
informal education system. At least one teacher has
already been trained in half of the 34,000 schools in the
country, giving five million children access to one sex
education lesson a week.
In November 2001, several thousand young people
aged 10-18 across the country took part in a national
survey to measure protective factors, such as
connectedness with parents and other family factors.
The survey also measured life skills under 12 headings,
including self-esteem, social responsibility, coping with
stress, effective communication, relationships, critical
thinking and problem solving.
The results of the survey, available later this year,
will set a base line against which to measure changes in
young people’ life skills.
✓
..................
Key Facts
>
• Programmes reach
young people in
school and in the
community.
• Teachers are being
trained to deliver
life skills to prevent
HIV infection and
promote safe and
responsible sex.
'
• A national survey
will set a baseline
for protective
factors, including
life skills.
• Hospitals are
introducing youth
friendly services.
• Friend Corners in
the community
draw young people
into contact with
services
v ,,,,
... for
skills of
young
people
SUCCESSFUL PROGRAMMING
Use existing resources and train
existing staff
✓ Shedding light on the critical role that adolescents play
in a country’s development makes a strong case for
increased resources.
✓ Although additional resources are indeed needed, the
main resources already exist.
✓ Existing health staff can be trained to become
adolescent friendly; existing teachers can be shown how
to educate adolescents about reproductive health;
existing community based staff can re-focus their work
to engage with young people.
✓ Some specially created posts may be necessary as
catalysts and to set the standard for training. However, it
is more cost-effective to train existing staff than to start
again from scratch.
✓ Training and support will give staff who enjoy working
with young peop|e a new sense of mission and
accomplishment
Thailand
Thailand
Health services & Friend Corners
The Ministry of Public Health began to introduce Health
Promoting Hospitals in 1998 to make health services more
user-friendly. There are now 350 such hospitals, committed
to health promotion and responding to local communities.
A number have begun to introduce youth friendly health
services.
The Department of Health has adopted an outreach
approach and in 2001 began to introduce Friend Corners in
local shopping malls and community housing areas in 24
provinces. Another 24 provinces will join the initiative this
year.
Friend Corners are open outside school and college
hours and are designed for all youth, not only those with
problems. The first point of contact for adolescents coming
to a Corner will be with other young people trained as peer
counsellors. Health staff are also on hand to provide
counselling, basic primary care or referral to specialized
services as necessary.
The Friend Corner concept is being popularized
through a series of promotional activities. The Department
of Health won an award for its Friend Corner web site
which includes music and fashion as well as health
information.
Dr Suwanna Warakamin, Director of the Family
Planning and Population Division in the Department of
Public Health, said that the Friend Corner approach would
break down barriers.
“We tried for more than ten years to bring young
people into the reproductive health service but it never
happened. Now the first line of contact is with adolescents
themselves. This should be the entry point, which will then
bring adolescents into the government health services. I
hope that Friend Corner will work, because youth are the
future of the world. Whatever kind of future you want,
you cannot create it without them.”
Youth are the
future
of the
world.
Whatever
future you
want, you
cannot create it
without them.’
Friend
Corner
attracts
youth
to use
government
services
33
Network
of
centres
for
students. .T
unisia has a long tradition of school health services and a network of
T
family planning clinics across the country. In 1990 the School and
University Medicine Service was given lead responsibility for
adolescent health in the country. Doctors and nurses at 2,000 health
centres deliver services to 9,000 schools and colleges, (almost 2,000 of which
include adolescents on their rolls). They monitor young people’s health, provide
immunization, advise on nutrition and personal hygiene and monitor healthy
growth and development.
This service has revealed some of the hidden pressures on young people, who
often did not seek help when they were worried. Girls who became pregnant were
silent about their condition until the third month of their pregnancy, beyond the
limit of legal termination. Depressed young people would not seek help, but an
increasing number were attempting suicide. Another indication of depression
came from students asking to be excused from their studies on medical grounds.
Tunisia was part of a multi-country research project, supported by WHO, to
investigate how accessible adolescents in schools and colleges find sexual and
reproductive health services, and how they use them. The research reveals that
most adolescents go to private clinics, or do not use any services at all.
- —
Tunisia
Tunisia
Family planning services in Tunisia were designed
to meet the needs of married couples, but there is a
trend towards much later marriage and the sensitivities
and needs of the younger sexually active age group were
different. Of the small number of young people who
came for consultations, some had had unprotected sex.
Pressure for change came from young people
themselves. A three-year programme to improve their
knowledge about sex showed that information on its
own was not enough. Young people needed skills and
support to find and to use the information. Above all
they needed appropriate services at critical moments.
The student health service set out to increase
contact between students and health services. For three
years, doctors and nurses have set aside a day a week to
see students, offering them counselling, advice and
information and referring them for specialized
counselling or treatment if necessary. A reproductive
health service was included for the first time, supported
by midwives and gynaecologists from the student health
centres.
This approach is based on the principal that young
people most often need information and the
opportunity to discuss their situation with a trained
health professional who will listen to their concerns.
When necessary, prevention and other services are
available nearby.
The programme involves close collaboration
between the National Office of Family Planning and
Population, the Student Health Service, and with NGOs
such as Jeunes Medecins Sans Frontieres, the Tunisian
Association of Family Planning and the Scouts.
Today in Tunisia, every major town has several
health centres, a family planning centre and a centre for
student health, offering specialist services increasingly
designed for students and for single people.
Key Facts
• Tunisia has a well
established
network of student
health services.
• These reveal
hidden pressures
on young people.
• School health
services offer
information and
counselling on
sexual and
reproductive
health.
i
• More adolescents
now use the
service.
• The major change
has been to
improve the
welcome from
health providers,
to reach out to
young people.
...in
school
or in
college
35
SUCCESSFUL PROGRAMMING
Address the broader community
✓ Young people need a supportive environment in which to
grow and develop.
✓ Successful programmes have an element that
addresses the beliefs and concerns of parents or the
wider community, or which opens up communication
between the generations.
✓ These efforts strengthen the role that parents and older
community members can play in providing guidance and
stability for adolescents.
✓ They create space for adolescents to articulate their own
concerns and needs.
✓ Programmes that are acceptable to communities are
more accessible to young people who want to use them.
✓ Health care providers, teachers, religious leaders and
other crucial adults are part of the wider community.
They are better able to deliver programmes that they
believe in, and which have high levels of public support.
✓ Without community support, adolescent health and
development is subject to sudden changes in policy, and
likely to remain marginal.
lessons from around the world
= Tunisia
Tunisia
•’
The Medical Director of the Bardo Centre
for Family Planning in Tunis, is responsible for
implementing national policy on reproductive health in
the capital city. The Bardo Centre was for married
couples, but since January 2000 includes a free
information service for students and single people.
A social worker greets young people. She is skilled
at helping them to discuss problems, and if necessary,
she offers counselling or accompanies them to their first
consultation with the doctor or midwife.
As this service becomes better known, more young
people use it. In the year 2000, 436 young people used
the Bardo service. This doubled to 915 young people in
2001, and the early indications are that 2002 will see
another increase in excess of 40%.
Although some extra resources were necessary to
develop youth services in Tunisia, the major change has
been to improve the welcome from health staff. Staff
reach out beyond the clinical setting to offer services to
schools and colleges. There has been a willingness to
change to meet the needs of young people, and to train
school health teams.
The family planning programme includes a peer
education scheme. Research is now needed to
distinguish the different needs and behaviour of
adolescents at different ages and in different conditions.
This will enable information, skills and services to be
targeted on adolescents who are not in school or
colleges and who outside the system.
The Medical Director of Student Health in Tunisia is
optimistic. “We are offering a service that is responding
to the needs of adolescents. As the centres are free there
are no barriers to students using them. Young people are
already accustomed to going to these centres for their
other health needs, so it is easier for them to take
concerns over reproductive health there.’'
£We are a
service
responding
to the
needs of
adolescents.
There are
no barriers
to students
using them/
The major
change
was the
welcome
from
health
staff
37
11
■
SUCCESSFUL PROGRAMMING
Completing the journey
Many countries — not only those featured in these
pages — are on a journey of discovery, finding out what
works for adolescent health and development.
Not all of the problems are yet resolved — this remains
an area of work where programmers still have a lot to
learn. However, countries are indeed growing in
confidence and they find common denominators
for success.
✓ They base programmes on a clear understanding of the
problems faced by adolescents.
✓ They adopt a multi-sector, multi-disciplinary approach,
understanding that there is no single solution.
✓ They pay attention to how, when and where services are
provided, and they ensure that programmes are
acceptable to young people and to communities.
✓ They pay attention to the social environment in which
young people grow and respect cultural values.
However, they also challenge social customs which limit
the ability of adolescents to develop successfully.
✓ Many programmes monitor outcomes to demonstrate
that what they do makes a real difference.
✓ National programmes demonstrate that a network of
complementary services can support adolescents to
protect their health and to find solutions to problems.
✓ Health workers who find that their services are used and
appreciated; teachers who develop respect amongst
students; peer educators who raise their own self
confidence; they all feed off success and want to
continue their work.
lessons from around the world
38
Acknowledgements
The information in this booklet is based on documents
and reports available to WHO Department of Child and
Adolescent Health and Development and WHO regional
offices as well as interviews with and reports from
government officials and partners working in the
countries. WHO is grateful to all who contributed time
and provided information.
Special thanks are due to Peter McIntyre of Oxford, UK,
who conducted interviews and wrote, edited and
designed this document.
Photos in this publication were
provided by the following:
World Health Organization Picture
Library, Geneva, Pages 3.6,8.14,16,30;
Associated Press 11, 12, 32;
World Health Organization Regional
Office for the Western Pacific, Manila,
18,20;
Soul City, South Africa 22, 24;
David Ross Contents page. 26. 28;
Anita Kolmodin 34;
Peter McIntyre 36.
Pholo copyright remains with the above.
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