WHO-EM/WRH/051/E
Promoting adolescent health and development in the Eastern Mediterranean Region Report of a roundtable discussion Manama, Bahrain, 26–28 December 2005
World Health Organization Regional Office for the Eastern Mediterranean Cairo 2006
© World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 670 2535, fax: +202 670 2492; email: DSA@emro.who.int). Requests for permission to reproduce WHO EMRO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to the Regional Adviser, Health and Biomedical Information, at the above address (fax: +202 276 5400; email HBI@emro.who.int). Document WHO‐EM/CBI/051/E/03.06/150
Contents 1. 2. 3. Introduction...............................................................................1 Objectives and methodology ..................................................4 Technical presentations ...........................................................6 3.1 Overview of the draft framework for the strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region ..6 3.2 Promoting adolescent health and development.........8 Country presentations ...........................................................10 4.1 Bahrain............................................................................10 4.2 Egypt ...............................................................................11 4.3 Lebanon ..........................................................................13 4.4 Saudi Arabia ..................................................................15 4.5 Syrian Arab Republic ...................................................15 4.6 Tunisia ............................................................................17 Group work .............................................................................19 Conclusions .............................................................................26 Recommendations ..................................................................28
4.
5. 6. 7.
Annexes 1. Agenda .....................................................................................31 2. Programme ..............................................................................32 3. List of participants..................................................................33
Promoting adolescent health and development in the Eastern Mediterranean Region
1. Introduction
A roundtable discussion for promoting adolescent health and development in the Eastern Mediterranean Region was held in Manama, Bahrain, from 26 to 28 December 2005. The roundtable was organized by the World Health Organization’s Regional Office for the Eastern Mediterranean (WHO/EMRO). The objectives of the roundtable were to: •
•
•
discuss the existing opportunities and challenges in addressing adolescent health and development in the Eastern Mediterranean Region; identify appropriate mechanisms to develop and operationalize the existing and new strategies for improving adolescent health, including the draft regional framework for strategic directions for promoting adolescent health and development; identify programmatic and resource needs to better address adolescent health and development in specific settings.
The meeting was attended by 15 experts from ministries of health and education, the American University of Beirut, the Planned Parenthood Federation (IPPF) and the International Federation of Medical Students’ Associations (IFMSA), the scouts and girl guides movements, and the Bahraini Parliament, as well as WHO staff from headquarters and the Regional Office for the Eastern Mediterranean. Her Excellency Dr Nada Abbas Haffadh, Minister of Health, Bahrain, inaugurated the roundtable. Dr Haffadh emphasized the high level of commitment in Bahrain to the continued investment in and development of human resources in the country, with specific focus on the young people. She noted that raising awareness about healthy lifestyles did not change behaviour of the young people. Instead, improving knowledge levels about important issues related to
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adolescence should always be accompanied by improving the basic skills of the adolescents themselves in order to improve their behaviours. Ministries of health and the concerned governmental and nongovernmental sectors faced major challenges in directing the attention of the public to the hazards of risky practices such as smoking and drug addiction. Nowadays, there was special need for raising the awareness of the family in particular about following healthy lifestyles such as physical exercise and healthy eating habits, so that this knowledge could be proactively used while raising children. Dr Ramez Mahaini, Coordinator, Family and Community Health, delivered a message from Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. In his message, Dr Gezairy noted that the roundtable discussion highlighted priority issues in adolescent health, with specific focus on strategic directions aiming at improving the situation of adolescents of our Region. Although adolescents made up a quarter of the entire population of the Eastern Mediterranean Region, they remained underserved and relatively marginalized. The rapidly changing socioeconomic circumstances in the countries of the Region posed considerable challenges for young people with regard to making a safe transition into adulthood. Many unhealthy practices, such as smoking, risky sexual behaviour and alcohol and drug addiction, had their roots in adolescence. Preventing risky behaviour and promoting healthy choices among adolescents, in particular, resulted in positive health outcomes, not just during adolescence, but also during adulthood. Well‐developed adolescents who were empowered with appropriate life skills had a better chance of becoming healthy, responsible and productive adults, and had better potential for successful productive careers. In 1996, he pointed out, the Forty‐third Session of the Regional Committee for the Eastern Mediterranean had issued a resolution on the health education of adolescents which underlined the importance of adolescence as the critical decade of human life and stressed the need to implement, through all available approaches, health education
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programmes for adolescents. An intercountry workshop in 2002 on promoting adolescent health and development using information, education and communication had also recommended finding creative ways to communicate adolescent health messages and to exercise creativity and responsibility in producing communication tools for the promotion of adolescent development and health. In 2004, an intercountry workshop on adolescent peer education in formal and non‐formal settings had focused on the use of peers in adolescent health promotion, examining the effectiveness of conveying health messages, changing unhealthy behaviour and exploring the full potential of peer education. In order to synergize the efforts made in this respect and guide national programmes on making pregnancy safer, the Regional Office had embarked on formulating strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region. These strategic directions were expected to serve as a guide and model for the national strategies and programmes aiming at promoting adolescent health and development in countries of the Region. Dr Salah Abdul Rahman (Bahrain) and Dr Yahia El‐Hadidi (Egypt) were elected as Chairperson and Co‐Chairperson, respectively. The reporting responsibilities were shared on a rotating basis. The agenda, programme and list of participants are found in Annexes 1, 2 and 3, respectively.
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2. Objectives and methodology
The objectives, mechanisms and expected outcomes of the consultation were presented by Dr Ramez Mahaini, Coordinator, Family and Community Health, who highlighted priority issues related to protection and promotion of adolescent health and development in the Eastern Mediterranean Region. Although adolescents in countries of the Region share many of the universal needs of adolescents of the world, they live in a region that is characterized by its cultural specificities and social and economic impediments – which are mainly the result of economic recession, economic embargoes, intergenerational educational gaps, and conflicts and disasters. Therefore, the health and development of adolescents should be addressed both separately and comprehensively, within the prevailing religious and socio‐ cultural values of the Region. In order to support technically the national efforts to formulate appropriate and effective national strategies aimed at promoting adolescent health and development, the Regional Office has developed a regional framework that serves as a guide and model, entitled “Strategic Directions for Promoting Adolescent Health and Development in the Eastern Mediterranean Region”. To enrich this document, a considerable time was allocated in the meeting for discussing its content and the approaches required for its application in countries of the Region. The roundtable was divided into technical presentations, country presentations and group work. The group work sessions were organized to take place in three groups, as follows: • Group A: Discuss and specify the role of political commitment and policy development in the area of adolescent health and development in the Eastern Mediterranean Region, as well as the challenges facing the
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achievement of political commitment and adequate policy development. • Group B: Identify ways through which effective partnerships can be developed and resources can be mobilized. Discuss the role that effective partnerships and resource mobilization can play in promoting adolescent health in the Region. Group C: Identify the required information, education and communication (IEC) strategies for increasing community awareness and changing behaviour to improve adolescent health in the Region. The group work sessions used the background document of the roundtable, namely: “Strategic Directions for Promoting Adolescent Health and Development in the Eastern Mediterranean Region”, as main guide reference, in this respect. The last day was allocated for a plenary discussion that summarizes your input in this activity and reaching a consensus on major conclusions and recommendations that underlined by you in the roundtable. The participants were reminded that the expected results of the roundtable discussion were that lessons learned on different approaches and methodologies for promoting adolescent health and development in the Eastern Mediterranean Region would have been exchanged and a framework for strategic directions for promoting adolescent health and development in the Region developed.
•
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3. Technical presentations
3.1
Overview of the draft framework for the strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region Dr Abdelhalim Joukhadar and Dr Hossam Mahmoud The World Health Organization defines adolescence as the stage between ages 10 and 19 years, where adolescents are no longer children but are not yet adults. Adolescents constitute a significant segment of society, comprising up to one quarter of the population in the Eastern Mediterranean Region. This makes them key players in supporting the development process in countries of the Region. Adolescence is a period of rapid transformation, which includes sexual development and emotional and psychological changes. In addition, several attitudes and key behaviour patterns that influence health and longevity have their origin in adolescence. These include gender considerations, eating habits, physical activity and exercise, coping mechanisms and risk‐taking behaviours. The document “Strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region” explains the conditions and processes that have led to its development: the progress in strategy development and implementation in most Member States is still lagging behind responding to adolescent health needs. Evidence‐based planning for adolescent health is still insufficient. Rapid changes in the Region require an urgent response to rising needs within a comprehensive approach. WHO headquarters recently finalized global strategic directions for promoting child and adolescent health. Since then, the Regional Office has embarked on examining this global document and
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formulating its own directions based on the specific needs of the Region. The draft framework includes several components: introduction, current situation, strategic directions, conclusion and an annex. The section of current situation of adolescent health in the Region describes the main components of adolescent health and development identified by the Regional Office as main areas of work, within the cultural and religious norms prevailing in the Region. These are sexual and reproductive health, mental health, nutrition and eating habits, lifestyles, and personal hygiene. Some organizations, nevertheless, have focused on certain components of adolescent health (sexual and reproductive health, smoking, basic life skills), overlooking others. This has diverted resources and national efforts into specific programmes at the expense of others. The section also analyses the situation of adolescents in the Region in relation to these defined components, based on research activities undertaken in countries of the Region. The lives of many of the adolescents in the Region are challenged by rapidly changing socioeconomic and cultural environment, intergeneration educational gap, and natural and man‐made disasters. The section on strategic directions for promoting adolescent health and development includes: the main objective, guiding principles, operational approaches and priority actions. The main objective is to provide countries of the Region with strategic directions to plan, implement, monitor and evaluate need‐based gender‐sensitive interventions and programmes with a view to ensuring supportive environments for optimal physical, mental, social, and spiritual wellbeing of adolescents. The guiding principles include human rights, gender equity, culture and adolescent participation. The operational approaches described under the strategic directions include, evidence based approach, life course approach, ecological model approach and building partnerships. As for the priority
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actions, they include placing adolescent health and development high on the political agenda; creating supportive policy and legislative environment; integrated response, which is synergy in delivery encompassing schools, media, health services, and community‐based programmes; and empowering adolescents. The document ends with an annex that describes the resolution on health education of adolescents issued by the Forty‐third Session of the Regional Committee in 1996.
3.2
Promoting adolescent health and development Dr Krishna Bose WHO defines adolescents as the age group between 10 and 19 years. This group is distinct from yet overlaps with the group known as youth whose age ranges between 15 and 24 years. The combination of both groups is usually referred to as young people, with ages ranging form 10 to 24 years. Adolescent health has been incorporated into global goals and targets both directly and indirectly. For example, the UN General Assembly Special Session on Children emphasized the need to develop and implement national health policies and programmes for adolescents, including goals and indicators, to promote their physical and mental health. The UN General Assembly Special Session on HIV/AIDS has highlighted two important targets: 1) by 2005, ensure that at least 90% (and by 2010 95%) of young people have access to the information, skills and services they need to reduce their vulnerability to HIV; and 2) by 2005, reduce HIV prevalence among youth (15–24 years) by 25% in the most affected countries and by 2010, reduce prevalence by 25% globally. In fact, there are over 10 million young people (15–24 years) living with HIV/AIDS today. In contrast, the Millennium Development Goals on maternal health calls for the reduction of maternal mortality rate by
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three quarters between 1990 and 2015. In 2000, 15 million adolescents gave birth at an age when the risks are particularly high. When compared with women in their 20s, girls under aged 15 are 5 times as likely to die in childbirth; girls aged 15–19 are twice as likely to die. Adolescent health is determined not only by adolescent themselves but also by key players that shape their social, economic, political, cultural and physical environment. Moving from the figures with the most direct influence to the ones with less direct influence, these players include: • • • • parents and siblings relatives, friends, family friends, teachers, sports coaches, health workers and religious leaders musicians, film stars, sports figures politicians, journalists and bureaucrats.
Therefore, a framework for programming for young peopleʹs health and development has been developed. This framework is made of a matrix that includes a vertical column of adolescents’ needs (information and life skills, health and counselling services, safe and supportive environment and opportunities to contribute and participate) and a horizontal row of influential sectors and individuals (health sector, education sector, media and parents, peers, etc). The health sector has the following three main focuses, known as the 3S strategy: 1. Strategic information: collect, analyse and disseminate the data that are required for advocacy, policies and programmes Health Services: provide services that include a focus on prevention, treatment and rehabilitation Support the development of evidence‐informed policies and strategies that provide vision and guidance
2. 3.
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4. Country presentations
4.1
Bahrain Bahrain regards its adolescents as the future of the country. The vision of the Ministry of Health is “to be working in partnership with stakeholders, to improve the health of the population of Bahrain and ensure that everyone has access to a high quality responsive health service throughout their lifetime”. The vision of the National Adolescent Health Committee is “to improve the quality of the health of adolescents and ensure that every one of them has reasonable availability and accessibility to high quality of health services”. Risk behaviour, such as smoking, is common, with 21%–25% of secondary schools male students being smokers. Other risky behaviour includes substance abuse and problems related to sexual behaviours. 45 cases of AIDS among people aged 10–29 years were recently reported in Bahrain. In addition, there are high levels of death and morbidity due road traffic accident reaching 5.14% and 18.4%, respectively. The strategic goal of the Ministry of Health regarding adolescent health is ensuring that today’s adolescents grow up in an environment that fosters physical health and intellectual, emotional, social and spiritual development that will enable them to become tomorrow’s capable parents, caregivers, workers and citizens. This can be achieved through increasing and improving the availability and accessibility of health services; providing a supportive environment for adolescents; involving young people in health management; coordinating all government and community interests in concerted efforts toward health gain; and increasing the knowledge and information based on adolescent health and well‐being needs.
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Promoting adolescent health and development in the Eastern Mediterranean Region
The achievements reached so far have been establishing the National Adolescent Health Committee and School Health Committee; developing premarital counselling system; and implementing adolescent health programmes since 1996. In 2005, a promising programme was formulated by the General Organization for Youth and Sports. Working to improve adolescent health and development in Bahrain, however, continues to face some constraints. There is insufficient information about adolescents’ needs and attitudes. There is a deficiency in information and training among various stakeholders (parents, health service providers, school teachers). Health care services are not designed for young people and can impede effective communication with adolescents and compromise the overall success of service provision to this group. Other constraints include the lack of financial resources, unavailability of an independent programme for adolescent health, and the absence of a national body that holistically addresses the issue of adolescent health and development. The future steps towards promoting adolescent health and development in Bahrain would require multisectoral and multidisciplinary collaboration, commitment of the policy makers and the community, allocating more funds for relevant programmes and activities, generating reliable and useful data, developing information, education and communication strategies, networking and ensuring community participation.
4.2
Egypt Egypt is still facing a serious population problem that has three dimensions: a high population growth rate, imbalanced geographical distribution, and low population indicators. These three dimensions also interact with all the economic and social development aspects. They influence the stability and progress of the Egyptian Society and reduce the effectiveness of efforts aiming at improving the quality of life of the
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Promoting adolescent health and development in the Eastern Mediterranean Region
Egyptian citizen. Facing the population problem requires collaboration with the governmental sector on one hand, and with efforts exerted by nongovernmental organizations and the private sector on the other hand. The ultimate goal of the national adolescent and youth care strategy is improving and upgrading the status of teenagers and youth in different aspects: social, political, economic, physical, mental and religious. This is to be achieved through: achievement of social development and loyalty to the community; economic development; and care for groups with special needs (the disabled, street children, orphans, etc). There are several challenges facing the promotion of adolescent health and development in Egypt. One out of four people in Egypt is a young person and a vast majority of them are underserved. At the same time, there are high rates of early marriage, unplanned pregnancy, illiteracy, school drop‐ out, harmful practices and sexual abuse among young people. Young people are not a homogeneous group but have different needs due to the diverse sociocultural and political circumstances within which they live. Young women in particular face many sociocultural, economic and political barriers which affect their sexual and reproductive health. Add to this the fact that there is a reluctance to accept young people as active citizens and as sexual beings who have rights. Therefore the sexual and reproductive health rights and concerns of young people are not integrated into the wider development agenda. Cross‐cutting programme interventions include building strong alliances for working with young people and fostering partnerships with parents, teachers, religious and community leaders, nongovernmental organizations and other institutions; strengthening a gender sensitive and rights‐based approach; and taking account of the diversity of young people in all interventions. The objectives of these programme interventions are to advocate for sexual and reproductive health and rights; strengthen meaningful participation; increase access to
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information and education; increase access to youth friendly services; and reduce gender related barriers. Two important programmatic aspects need to be considered to ensure the success of strategies aimed at promoting adolescent health and development. The first is capacity‐ building, in order to develop a cadre of competent staff that can deal with sexual and reproductive health and rights issues, as well as other adolescent health needs. The second is knowledge management, in order to build up a common understanding within the Ministry of Health and Population on young people’s sexuality and different health and social needs.
4.3
Lebanon The current programmes focusing on youth health in Lebanon can be categorized into either programmes that build skills of the youth or programmes focusing on a particular youth health issue. The programmes that build skills of youth include those emphasizing leadership skills and leadership development, communication skills, vocational programs, youth development, youth empowerment, life skills, youth advocacy (policy), electoral rights of youth and democratic principles, rights and responsibilities of young people, health education, human rights education, child labour, economic development, conflict resolution, capacity building, and information technology. Meanwhile, the programmes focusing on a particular youth health issue include those in the area of sexual and reproductive health, violence against women, disability, tobacco prevention, nutrition, mental health, social health and HIV/AIDS. These programmes are managed by different bodies, including WHO and other UN agencies; governmental bodies, such as concerned ministries and national AIDS programmes; academic institutions, such as universities; and nongovernmental organizations, such as the Lebanese Medical Students International Committee (LeMSIC), Scouts, the
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Promoting adolescent health and development in the Eastern Mediterranean Region
Lebanese Council on Women, the League of Women’s Rights, Dar El Amal, Higher Council on Childhood, Save the Children and the Lebanese Family Planning Association. The current opportunities for promoting adolescent health and development in Lebanon include the international focus on youth and the fact that many organizations are already working on issues of youth and are focusing on more social determinants. One other advantage is the traditional family and religious structures that provide protection for youth. However, there remain several constraints in promoting adolescent health and development in Lebanon. There are variable levels of awareness among programme managers, families, and communities of health and development needs of adolescents. Furthermore, there is lack of a complete situation analysis of the status of adolescent health and development in Lebanon. Some topics of relevance to youth are still considered ‘taboo’ and thus are difficult to discuss. In addition, there are the misconceptions that youth is a healthy period with no need to intervene and that if not engaging in risky behaviour, youth will be fine. Other constraints include the programmatic focus on raising awareness – which is necessary but not sufficient – and the scarcity of impact evaluation of programmes. Lastly, there is no national strategy for promoting adolescent health and development in the country. Future steps should entail the development, implementation, and evaluation of evidence‐based interventions to promote adolescent health and development that integrate theory for a better understanding of the pathways of change. While doing so, it is important to consider the ‘whole child’ and assets as well as ‘risks’. Multiple interventions targeting multiple layers of influence based on the ecological model should be developed. Building strong partnerships remain an integral component of the efforts for promoting adolescent health and development.
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4.4
Saudi Arabia In Saudi Arabia, adolescents make up around 20% of the total population. According to the Saudi Family Health Survey (2000), the prevalence of health conditions among adolescents aged 15–19 years were as follows: hypertension (1/1000), diabetes (3/1000), asthma (117/1000), teen age marriage among girls (4.7%), smoking (5.5% among boys and 0.2% among girls). The prevalence of obesity among those 9–12 years old was 12.2%, while 6.8% of this age group were underweight. In addition, the prevalence of anaemia among girls 10–18 years old was 35.3 (Alshri et al %). The policies for promoting adolescent health and development in Saudi Arabia divide areas of work among the different governmental and nongovernmental bodies. Although the Ministry of Health plays a great role in dealing with adolescent health issues, school health services and programmes are mainly under the responsibility of the Ministry of Education. Close coordination between the two ministries takes place at the level of the national committee on school health. Other partners do participate in promoting adolescent health and development. These include the Ministries of Information, Social Welfare, Interior, and Islamic Affairs. The role of nongovernmental organizations in this field is still insignificant. Many activities are conducted, but these remain scanty and not part of a clear‐cut strategy or plan of action. The major activities designed and implemented for promoting adolescent health and development are still limited to the work of the School Health Department at the Ministry of Education.
4.5
Syrian Arab Republic The National Population Conference was held in Damascus on 10–12 November 2001. The Conference recommended that the National Population Strategy should include wide participation of men, women, and youth; that youth in the Syrian Arab Republic should have adequate support by the
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government, nongovernmental and civil society organizations concerned with adolescence and youth issues to increase national commitment and social practice outside educational institutions; and that the execution of the strategy requires gender equality. Some of the challenges facing the promotion of adolescent health and development include the lack of adolescent participation in decision making, defining their priorities and needs, planning and implementing their own activities; scarcity of necessary modern educational facilities that parallel the current and future developments; the absence of sexual and reproductive health education in both educational courses and media; the lack of youth friendly service centres; and the need to attract out‐of‐school adolescent to get benefit of the educational and health services. An example of a pioneer project is that of the Syrian Family Planning Association (SFPA). The SFPA goal on adolescents is so that “All young people are aware of their rights and are able to make informed decisions and choices with regard to their sexual and reproductive health”. The objectives of SFPA are to: • Strengthen commitment to and support for the sexual and •
•
• •
reproductive health and rights and needs of young people; Promote young people’s participation in governance and in the identification, development and management of programmes that affect them; Increase access to comprehensive, youth friendly and gender sensitive sex education and reproductive health information, and according to social values; Increase youth access to reproductive health services, in accordance with social values; Reduce gender related barriers and practices which affect health and the sexual and reproductive health and rights of young people;
As part of this programme, the youth have been able to better participate in formulating their own strategy. In addition,
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there has been a significant exchange of experience with other Arabic‐speaking countries. Cooperation with concerned parties took place in order to conduct a youth festival and to arrange for participation in the Move for Health Day. In addition, SFPA has established 9 youth centres in 9 governorates to increase youth awareness on reproductive health and family planning issues. Their services and activities include a hotline for social and psychological counselling, legal counselling, health counselling, seminars, video, internet café, musical events, and theatre. The Association has also opened a youth counselling centre on STD and HIV. SFPA has also concentrated on: providing training courses for social advisors at schools and training courses for Damascus schools’ biology teachers; conducting seminars at universities and youth camps; and printing brochures on youth social and psychological problems.
4.6
Tunisia Around 20% of the population of Tunisia is made up of adolescents. Due to the high rates of schooling among this age group, the national programme of adolescent health has focused its efforts within the educational milieu. This programme works on three main aspects: physical health, reproductive health and mental health. The national programme contains elements of surveillance, case management, health promotion, training and retraining, research, and partnership building. Surveillance includes regular epidemiological surveillance in schools, routine medical testing within schools, and medical follow up of special cases. Other settings where surveillance takes place include counselling centres, health education centres, social work centres, primary health care clinics, hospitals, women’s health clinics and mental health clinics. Case management involves the provision of primary care,
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usually within the school‐based care system, and referral to secondary and tertiary care as needed. Places sought by adolescents for services include adolescent health clinics, family planning associations, pharmacies and hospitals. Health promotion activities have taken place within three areas: including health promotion in the school curriculum, allocating time for health promotion classes, and celebrating national, regional and international health promotion days. Training and retraining of school health groups takes place through training workshops, national assemblies, school health conferences and field visits to countries with national adolescent health programmes. Several research projects have been implemented on a national scale. These have included research in different areas of adolescent health, including dental and oral health, lifestyles, reproductive health, and family health. Building strong partnerships has been essential in addressing the needs of adolescents. Strong partnerships help to better evaluate needs, increase the effectiveness of health education campaigns, and strengthen field work.
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5. Group work
The group work was divided into three separate sessions, which would culminate in highlighting strategies for promoting adolescent health and development in the Region. The three distinct tasks included: Group A: Discuss and specify the role of political commitment and policy development in the area of adolescent health and development in the Eastern Mediterranean Region, as well as the challenges facing the achievement of political commitment and adequate policy development. Group B: Identify ways through which effective partnerships can be developed and resources can be mobilized. Discuss the role that effective partnerships and resource mobilization can play in promoting adolescent health in the Region. Group C: Identify the required information, education and communication (IEC) strategies for increasing community awareness and changing behaviour to improve adolescent health in the Region. The groups identified various critical issues to be considered in devising strategies for making pregnancy safer. Group A: political commitment and policy development The group identified the following challenges that hinder political commitment and policy development in promoting adolescent health and development: • Lack of political concerns and recognition resulting in poor commitment of decision makers to the adolescent health issues • Lack of information on adolescence and poor of awareness of adolescent needs
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Promoting adolescent health and development in the Eastern Mediterranean Region
• The fact that sexual and reproductive health, rights, and concerns of young people are not integrated into the wider development agenda at the government level • Certain socio‐cultural, economic and political barriers relating to adolescent issues • Lack of involvement of adolescents within the wider development agenda. As for the opportunities present for the promotion of adolescent health and development, the groups identified the current support of the UN agencies as a major strength. The social and religious values and traditions that characterize the Region are also important when someone is to consider moving forward. Each country should find its own opportunity to get all the different sectors involved. Therefore, the first step should be to prepare the needed environment to facilitate the process. This can be achieved by preparing the population to be informed, aware and open to deal with the concepts and principles of adolescence, its challenges and potentials. This, in turn, would ideally pave the way for political commitment and policy development. The group recommended the following actions in order to improve levels of political commitment and enhance the development of appropriate adolescent health related policies: • Conduct research and surveys that provide evidence‐based facts, highlight common problems of young people, and explain the long‐term effects of risky behaviour and the required interventions. • Involve youth in policy development and implementation • Organize meetings with parliamentarians and decision makers to present the developed strategic directions for promoting adolescent health and development in the Eastern Mediterranean Region. • Identify creative ways for engaging boys and men in addressing gender equity. • Establish a central administrative body to coordinate the goals and activities related to promoting adolescent health and development
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• •
•
•
• • •
Benefit from success stories from other countries Fight stigmas associated with adolescence issues by giving equal importance to all 5 components of adolescent health as recognized by WHO/EMRO, namely lifestyle, nutrition and eating habits, mental health, reproductive and sexual health, and personal hygiene, and by not focusing merely on reproductive and sexual health. Integrate adolescent health education and parenting education into school curricula, in order to prepare citizens that are informed, aware, and open to deal with all issues related to adolescence Train teachers and educators to be able to deal with adolescents and with changes that are faced in this stage of life Incorporate adolescence issues in the curricula of health care providers Establish peer education programmes that are centrally coordinated Establish adolescent‐friendly clinics/health services with well trained staff
The group stressed that political commitment should involve key players at all levels (national, districts and care delivery points) and within different sectors (ministries of finance, health and higher education; the private sector, nongovernmental organizations). Then the group discussed approaches to initiating and maximizing political commitment through availing information, sharing experiences, and using these for advocacy. Effective approaches in advocacy should be undertaken including writing effective proposals, depicting economic impacts and gains; and involving United Nations’ officials and nongovernmental organization officials, high level decision‐makers and religious leaders for supporting and initiating commitment. The group also highlighted the importance of close follow‐up and monitoring for making commitment sustainable and translating it into action, including the need to sensitizing the media, raising awareness among key political players and
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establishing a regional taskforce aims at monitoring the progress of the countries of the Region. Group B: partnership and resource mobilization The group identified different key partners. These included: • Ministries of health, education, higher education, labour, communication, social affairs, interior, youth, Islamic Affairs, planning, and research, as well as child care and child rights committees Intergovernmental bodies: League of Arab States, Executive Board of the Health Ministers’ Council for the Cooperation Council States Academic institutions and universities International agencies such as Arab Gulf Programme for United Nations Development Organizations (AGFUND), family planning associations, International Federation of Medical Students’ Associations (IFMSA), Islamic Educational, Scientific and Cultural Organization (ISESCO), child care and child rights committees Private sector: private schools, educational institutes, private hospitals, private companies, private media, leisure clubs, sport clubs United Nations organizations: WHO, UNICEF, UNDP, UNFPA, ESCWA, UNESCO, ISESCO, UNRWA and World Bank Commercial chambers, associations and unions of commerce Family practitioners unions, paediatricians Youth parliaments, youth bodies, scouts, girl guides.
•
• •
•
•
• • •
According to the group, all these partners are working with and for adolescents but with minimal coordination. It was, therefore, suggested to establish national committee for promoting adolescent health and development, hosted by the ministry of health, involving all key partners, and placed as part of primary health care. These partners would be involved in the process from adapting the strategic directions for
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promoting adolescent health and development through developing the plans of action through implementation and raising funds for implementation. The role of the national committee would be to adopt the strategic directions for promoting adolescent health and development and to develop a plan of action for implementation, including the mobilization of resources and including steps for evaluation. Adolescent participation within the committee would be crucial to be part of the process throughout. In addition, the group also found that there was an overlap among the international agencies in the area of adolescent health and development. It was, consequently, suggested that coordination and work through the adolescent health committee be developed in each country. The group stressed that partnership and resource mobilization are interrelated and mutually supportive, and that evidence‐ based knowledge is important for advocacy for both building partnerships and mobilizing resources. Countries of the Region can benefit from the experience of other countries that have made considerable progress in adolescent health. One example is partnership between the media and health. Building partnerships with the media would take place through: • • • Involving media representatives in national committees on adolescent health Buying air time (may in the long run lead to the development of partnership) Involving representatives of ministry of communication and those working the media in workshops and activities on adolescent health and providing them with active roles Presenting media shows under sponsorship of one or more of the partners involved in national committees.
•
Furthermore, the private sector can financially contribute to adolescent health and development by adopting certain programmes that cover the areas related to adolescent health. For example, companies manufacturing sanitary pads can
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undertake the promotion of certain aspects of reproductive health. Group C: Information, education and communication strategies The group highlighted that information, education and communication (IEC) should deal not only with behaviour change but also with determinants of behaviour change. The focus of programme and policy development should address both risk factors and protective factors explicitly. The focus on protective factors should target all youth, not just those who have problems. Youth involvement is critical in all phases of IEC development, implementation and evaluation. IEC materials will create demand; therefore, the services need to be available, accessible and acceptable to both health workers and ʹclientsʹ. The working definition that the group used for the terms awareness and awareness‐raising included change in knowledge, perceptions, beliefs, norms, attitudes and skills. Behavioural outcomes to be reduced include inappropriate eating habits, inactivity, tobacco smoking (sheesha, cigarettes), violence, risky sexual activity, drug use, unsafe pedestrian and driving practices, and others as defined by countries. Important partners to consider in the design, implementation, and evaluation of IEC campaigns are the youth, their nuclear and extended families, peers, policy makers, and the different concerned sectors including religious institutions, media, nongovernmental organizations, youth organizations, and both governmental and private health and education sectors. IEC material targeting youth should be tailored to the level of preparedness of the youth, and must emphasize youth involvement, peer‐to‐peer education and skill building (negotiation skills). Material targeting parents should emphasize listening and communication skills, role modelling, youth development training, and parents’ role in supporting their children (affection and regulation‐discipline). Results of research, such as that showing that young people care what their parents think, can be incorporated into school curricula.
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Promoting adolescent health and development in the Eastern Mediterranean Region
Furthermore, the importance of supportive relationship with teachers should be emphasized. It is important to build the capacities of teachers to deliver health messages using an appropriate approach. Approaches religious leaders can adopt should include open communication with adolescents in order to exchange ideas and build trust. Protective factors, such as good relationships with parents, should be emphasized. It may be beneficial to start discussing a behaviour that is “non‐threatening” from which other specific messages can be delivered. Health workers should receive training on youth development, communication and leadership, which is important for role modelling. In fact, such training is important in changing the perceived role of the health worker from an expert to a facilitator. Health messages should be delivered by all health professionals, not only the health educators; therefore, it is important to motivate health workers to changes attitudes, perceptions and behaviour. This can only be achieved by addressing different types of health provider, including both medical and paramedical, using different approaches. The mass media should be made more proactive; this may be partially achieved through training media professionals on logic models, behaviour change approaches, and youth development. When attempting to mobilize communities, it is important to assess community resources; consider key stakeholders, including community leaders; and to foster coalitions between young people and these stakeholders, which is a process involving negotiation and compromise and requiring real commitment. Regional, national and local specificities must be taken into account. Therefore, IEC materials should be developed from secondary review of data available, local research, or from understanding of gaps. It is also important to adapt rather than adopt and replicate IEC materials, and to pilot test and evaluate them with the involvement of young people.
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Promoting adolescent health and development in the Eastern Mediterranean Region
6. Conclusions
•
Adolescent health and development is still inadequately recognized as a priority issue in most countries of the Eastern Mediterranean Region. Policy makers in these countries still perceive adolescents as being healthy and not requiring further attention. The Region is facing several challenges, including rapidly changing socioeconomic environment, intergenerational educational gap, and military conflicts; however, the socio‐ cultural and religious values prevailing in countries of the Region continue to have a major protective influence on adolescents. Many countries need to collect or compile additional data on adolescent health and development. However, even in countries where adequate data are available, the utilization of such data in developing strategies and implementing programmes remains remarkably insufficient. Most of the existing national adolescent health programmes are still focused on increasing knowledge, overlooking the other essential components of awareness‐raising, which include perceptions, beliefs, norms, values, attitudes and skills. Mass media is increasingly important in adolescents’ lives, influencing their opinions, preferences, values and lifestyles, especially with the advent of satellite channels. In addition, it has become increasingly important to develop media literacy among adolescents, in order to equip them with the means to decrypt underlying commercial media messages and concepts, so as to handle such messages critically in
•
•
•
•
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Promoting adolescent health and development in the Eastern Mediterranean Region
order to avoid potential hazards, and ameliorate their harmful impact. • Providing youth‐friendly services is still in its primary stages in most countries of the Region. Further developing these services is critical for responding to the urgent needs of adolescents. There are great potentials for mobilizing civil societies in countries of the Region, that can be used for developing appropriate mechanisms and supporting their implementation for promoting adolescent health and development in the community. Available resources for adolescent health related programmes are still inadequate in most countries of the Region. Advocacy and partnership remain the key strategic approaches towards ensuring sufficient resources for the implementation of necessary programmes. Adolescents are a rich resource that has not yet been well tapped in the Region. One good example of an inexpensive method to develop human resources for the promotion of adolescent health in the Region would be training of adolescent trainers, particularly peer educators. Monitoring and evaluation are critical to have effective programmes, thus enhancing resource allocation.
•
•
•
•
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Promoting adolescent health and development in the Eastern Mediterranean Region
7. Recommendations
For Member States 1. Adolescents should be involved in all phases of strategy development and programme planning, implementation and evaluation to ensure optimal results in the activities implemented. Adolescence needs to be regarded as a gateway for health promotion and development rather than a stage of risky behaviour and other negative connotations. Ministries of health should aim to shift the focus of policies and activities from merely restricting risk behaviour to promoting healthy lifestyles and reinforcing protective factors, as well. Interventions focusing on protective factors should target all adolescents, rather than be restricted only to those at high risk. Adolescent health and development should be addressed through a comprehensive approach that considers all five main components of adolescent health and development identified by the Regional Office, namely: lifestyles; nutrition and eating habits; sexual and reproductive health; mental health; and personal hygiene. Adolescent health should be addressed through an ecological approach. Intervention programmes, services and policies should be developed for the adolescents themselves, their families, peers, teachers and health workers. In addition, supportive policies and laws should be strengthened whenever possible. National committees involving all concerned stakeholders should be established for adopting and/or adapting the
2.
3.
4.
5.
6.
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Promoting adolescent health and development in the Eastern Mediterranean Region
“Strategic Directions for promoting Adolescent Health and Development in the Eastern Mediterranean Region” and for developing plans of action, as well as for implementation, evaluation and resource mobilization and for ensuring sustainability of adolescent programmes. Adolescents must be involved in these national committees. 7. The formulated plans of action should be approved by the national authorities in order to ensure their commitment and active participation during implementation. Cultural diversities must be taken into account at the national and local community levels, and issues of adolescent health and development addressed in accordance with these specificities. Mass media professionals should be empowered in order to play a positive role in shaping adolescent health. The media should be wisely and effectively utilized to promote adolescent health and development through responsible programming, such as panel programmes, question and answer shows, live radio programmes, dramas created and performed by young people, and through involvement of popular entertainers and sports figures, chat rooms, and informative websites and internet links. Partnership should be strengthened at both the national and international levels in order to secure the required resources, and strengthen effective policies for the promotion of adolescent health and development. Investment in capacity building for concerned governmental and private sectors should be a priority issue to enable different partners to participate effectively in responding to the health, social and educational needs of adolescents. Appropriate information, education and communication materials that are culturally sensitive should be developed and disseminated to concerned partners. The rapid technological changes taking place within the environments in which
8.
9.
10.
11.
12.
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adolescents live should be taken into consideration in the development of these materials. 13. Efforts should be made to ensure that adolescent services are user‐friendly: available, accessible, and affordable for adolescents. These services must also be trusted by and acceptable to adolescents, their families and communities. All programmes and services should be monitored and evaluated. The development of logic models explaining hypothesized effect is important. Evaluation will ensure that programmes are effective and efficient. The outcome of these activities should be seriously considered in order to ensure the sustainability of these programmes.
14.
For WHO/EMRO and key regional partners 15. The Regional Office should finalize, translate into local languages and widely disseminate the document “Strategic Directions for Promoting Adolescent Health and Development in the Eastern Mediterranean Region” in order to facilitate efforts aiming at strengthening national strategies in Member States. The Regional Office should organize an intercountry meeting for policy‐makers in order to emphasize and advocate for adolescent health and development as a major priority that needs to be effectively addressed, and to outline appropriate interventions for strengthening national strategies using the “Strategic Directions for Promoting Adolescent Health and Development in the Eastern Mediterranean Region”. Networking among concerned partners, including UN agencies and international and nongovernmental organizations is greatly needed in order to amalgamate efforts and avoid overlap. The Regional Office, along with Member States, needs to further enhance the sharing of lessons learned from experiences in promoting adolescent health and development in the Region.
16.
17.
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Promoting adolescent health and development in the Eastern Mediterranean Region
Annex 1 Agenda 1. 2. 3. Inaugural session Welcome and opening remarks Introduction of participants, election of Chairperson and Rapporteur Adoption of the agenda Objectives, mechanics and expected outcomes Overview of the draft document on strategic directions for promoting adolescent health and development in the Region Promoting adolescent health and devlopment Country presentations of existing national strategies: achievements, constraints and future for promoting adolescent health and development: Bahrain, Egypt, Lebanon, Saudi Arabia, Syrian Arab Republic and Tunisia Working sessions in three groups to: • • •
4. 5. 6.
7. 8.
9.
Political commitment and policy development Partnership and resource mobilization Information, education and communication strategies for increasing community awareness
10. 11. 12.
Group presentations and plenary discussion Major conclusions and recommendations. Closing session
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Annex 2 Programme Monday, 26 December 2005 8:30–9:00 9:00–11:00 11:00–11:30 Registration Inaugural session Introduction of participants Election of the Chairperson and Rapporteur Adoption of the agenda Objectives, mechanisms and expected outcomes of the meeting Dr Ramez Mahaini Overview of the draft document on strategic directions for accelerating the reduction of maternal mortality in the Region Dr Abdelhalim Joukhadar and Dr Hossam Mahmoud Promoting adolescent health and development Dr Krishna Bose Plenary discussion Country presentations of existing national programmes and strategies for promoting maternal and neonatal health: Bahrain, Egypt, Lebanon, Saudi Arabia, Syrian Arab Republic and Tunisia Plenary discussion
11:30–12:00
12:00–12:30
12:30–13:00 13:00–14:00 14:00–15:30
15:30–17:00
Tuesday, 27 December 2005 9:00–9:30 Briefing for group work sessions 9:30–14:00 Working sessions in three groups A: Political commitment and policy development B: Partnership and resource mobilization C: Information, education and communication strategies for increasing community awareness 14:00–15:30 Group presentations 15:30–16:30 Plenary discussion Wednesday, 28 December 2005 9:00–10:30 10:30–12:00 Plenary discussion Major conclusions and recommendations
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Annex 3 List of participants BAHRAIN Dr Salah Abdul Rahman Member of Parliament Family Physician and Public Health Consultant Manama Dr Ali Al Baqara Chairperson Adolescent Health Committee Ministry of Health Manama Dr Amal Al Jowder Head of Health Education Department Public Health Directorate Ministry of Health Manama EGYPT Dr Yahia El‐Hadidi First Undersecretary Head of Reproductive Health and Population Sector Ministry of Health and Population Cairo JORDAN Mr Nazmi Madani Media Expert Amman
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LEBANON Dr Rima Afifi Associate Professor and Chairperson Department of Health Behaviour and Education Faulty of Health Sciences American University of Beirut Beirut SAUDI ARABIA Dr Sulieman Al‐Shehri Director General School Health Services–Girls Education Ministry of Education Riyadh SYRIAN ARAB REPUBLIC Mr Yahia Bouzo Director Health Protection Programme National Focal Point, Healthy Life Styles Ministry of Health Damascus TUNISIA Dr Alya Mahjoub Zarrouk Director General Sanitary and Environmental Control of Products Ministry of Public Health Tunis
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Other organizations International Federation of Medical Students’ Associations (IFMSA) Dr Lara Zahabi President Lebanese Medical Students’ International Committee Vice‐President for Internal Affairs of IFMSA Beirut Dr Hazar Kobayaa Internal Affairs Beirut Dr Zainab Al Awadhi Eastern Mediterranean Regional Assistant Standing Committee on Public Health Manama Dr Nayla Bushager President Manama International Planned Parenthood Federation Dr Lama Mouaque Executive Director Syrian Family Planning Association Damascus Girl Guides Movement Ms Faika Amin Girl Guides Movement Manama
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Promoting adolescent health and development in the Eastern Mediterranean Region
WHO Secretariat Dr Ramez Mahaini, Coordinator, Family and Community Health, WHO Regional Office for the Eastern Mediterranean Dr Hossam Mahmoud, Medical Officer, Making Pregnancy Safer, WHO Regional Office for the Eastern Mediterranean Dr Krishna Bose, Child and Adolescent Health, WHO headquarters Mrs Maha Wanis, Secretary, WHO Regional Office for the Eastern Mediterranean
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