WHO-F,M/WRH/OOti/Efl.
Distribution: Limited
Report on the
CONSULTATIVE MEETING ON BUILDING NATIONAL CAPACITY FOR THE PROTECTION AND PROMOTION OF ADOLESCENT HEALTH AND DEVELOPMENT IN THE EASTERN MEDITERRANEAN REGION Hammamat, Tunisia, 27-29 October 1999
World Health 01-ganization
Regional Office for the Eastern Mediterranean Alexandria, Egypt 2000
@ World Health Organization 2000
This document is not issued to the general public and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval syslem or transmitted in any form or by any means--electronic, mechanical or other-without the prior written permission of WHO. The views expressed in documents by named authors are solely the responsibility of those authors.
CONTENTS 1.
INTRODUCTION ............................................................................................................ 1
2.
TECHNICAL PRESENTATIONS ................................................................................... 3 2.1 Building national capacity in adolescent health and development: a regional overview .................................................................................................................. 3 2.2 Adolescence, health, and development: a giobaI overview ...................................
4
2.3 2.4 2.5
Adolescent sexual and reproductive health ............................................................. 5 The youth for youth project ..................................................................................... 6 Fillclil~gb flu111 the WHOEMRO s u ~ v c y tu Clctcl~i~i~lc 11ativ11a1 capacily in
2.6
responding to adolescent health needs in the Eastern Mediterranean countries ..... 7 Introduction to the regional manuals on health education for adolescents .............8
3.
COUNTRY REPORTS ON ADOLESCENT HEALTH AND DEVELOPMENT ...........9 3.1 Bahrain .................................................................................................................... 9 3.2 Egypt ...................................................................................................................... 10 3.3 Tunis ...................................................................................................................... 12 14
Islamic Republic of Iran .....................................................................................
13
4.
GROUP WORK ............................................................................................................. 13
5. 6.
CONCLUSIONS............................................................................................................. 14 RECOMMENDATIONS
................................................................................................ 15
Annexes
............................................................................................................................ 17 2 . PROGRAMME ................................................................................................................... 18 3 . LIST OF PARTICIPANTS.................................................................................................... 20 7
1. ACkNDA
.
4 . VJ'HOIEMRB SURVEY TO DETERMINE NATIONAL CAPACITY IN RESPONDING T 3 ADOLESCENT HEALTH NEEDS IN THE EASTERN MEDITERRANEAN COUNTRIES ....................................................................................................................... 26 5 . GROUP DISCllSSlON QUESTIONS ................................................................................ 28
1.
INTRODUCTION
A consultative meeting on building national capacity for the protection and promotion of adolescent health and development in the Eastern Mediterranean Region was held in Hammamat, Tunisia, from 27 to 29 October 1999. The meeting was hosted by the Government of Tunisia and was oganizcd by thc World IIcalth O ~ g i i l ~ i ~ a (WHO) liu~~ Regional Office for the Eastern Mediterranean (EMRO) with the financial support of the Department of Child and Adolescent Health and Development, WHO headquarters, Geneva. The objectives of the meeting were to: carefully examine the current status of the health and development of adolescents; assess progress made in building national capacity for promoting adolescent health and development in the Eastern Mediterranean countries, based on the findings of a regional survey conducted at country level; a
explore means of establishing a strategy for promoting the health and development of adolescents in the Eastern Mediterranean Region; develop a framework for a regional strategy for strengthening national capacity in adolescent health and development.
Eleven experts and twelve observers from nine Eastern Mediterranean countries, and four resource persons were invited by WHOlEMRO to participate in the meeting. The resource persons were from the United Arab Emirates, the Centers for Disease Control and Prevention, USA, the World Organization of the Scout Movement for the Arab Region, Switzerland, the International Planned Parenthood Federation (IPPF), the Islamic Educational, Scientific and Cultural Organization (ISESCO), the United Nations Population Fund (UNFPA), the United Nations Children's Fund (UNICEF), the United Nations Relief and Works Agency for Pulcstinc refugccs in the Near East (UNRWA), WHO/HQ and
WHOEMRO. The agenda, programme and list of participants are given in Annexes 1, 2 and 3 respectively.
The meeting was opened by Dr Ghada Hafez, Special Advisor, Gender Mainstreaming and Women's Development. Dr Hafez delivered a message on behalf of Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. In his message, Dr Gezairy stated that adolescents constituted one third of the Region's population. He pointed out that the proportion of adolescents in the Region would continue to increase over the roming years. Dr Gezairy noted that the Regional Office had been collaborating with Member States since 1989 to improve the accessibility of adolescents to health information and services. Several innovative programmes existed in the Region that provided important Icssons.
Dr Gezairy stated that many inter-related factors affected the health and development of adolesc~nts. T ~ I G faclor-s ~c: i~icludcdlevels of education, ~ C O ~ O income, ~ I ~ C nutrition, po1ltical
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Page 2 environment, peer pressure, media, and cultural expectations. Effective adolescent health programmes needed to provide appropriate information and services while attracting political and community support. In recognition of the information needs of adolescents, the Regional Committee for the Eastern Mediterranean adopted, at its Forty-third Session in 1996, a resolution on health education for adolescents. This resolution urged Member States to orient decision-makers to the needs of adolescents and raise public awareness of these needs through different government sectors. In order to assist Member States in this endeavour, the Regional Office commissioned a set of health education guidelines aimed at adolescents, parents, teachers, health workers and the media. These guidelines incorporated the appropriate beliefs and practices of the Region. Dr Gezairy pointed uut that investing in the health and development of the youth should
yield critical economic benefits to a country. He indicated that this consultative meeting would go a long way in advancing the agenda of adolescent health in the Region, enriching the understanding of the health and development needs 01 adolescents, and expanding the capabilities to meet those needs. In his address to the meeting, H.E. Dr El Hedi M'henni, the Minister of Public Health, Tunisia, welcomed the participants and members of the United Nations and international agencies. Dl* M'henni said that protection and promotion of adolescent health and development had always received great attention from the Government of Tunisia. This had been manifested through providing preventive, curative and rehabilitative health services uimed at healthy growth and development of the young people in the country. Closc
collaboration and coordination had been maintained through involving all concerned bodies including government sectors, private and nongovernmental organizations, the United Nations and international agencies. Health education and counselling services had been promoted through the school health clubs, which covered 75% of elementary and secondary school students in Tunisia. The school health clubs provided a unique opportunity for the promotion of a healthy lifestyle among adolescents and ensured their roles as agents of change in the community. Medical, mental and social services had also been provided to the youth through the school and university health programmes of the Ministry of Public Health, promoting responsible healthy behaviour among school and university students. Mr Abdul Muniem Abu Nuwar, UNFPA, Egypt, conveyed good wishes from Dr Nafis Sadek, UNFPA Executive Director, and Dr Thoraya Obaid, Director, Division of Arab States
and Europe. Mr Abu Nuwar stressed the importance of young people aged 10 to 24 years as tlxy rcprt;scntcd the largest proporti011 uf the world population. He stated rhdl since lhe 1994
International Conference on Population and Development, UNFPA has regarded adolescent health as a priority area of reproductive health. Collaboration between UNFPA, UNICEF and WHO had been ensured through a joint programme on adolescent health he said. Dr Mohamed Kamel, IPPF Regional Director for the Arab World, conveyed good wishes from Ms Ingar Brueggemann, P P F Director-Generai. Dr Kamel emphasized the importance of enhancing the role of adolescents in promoting reproductive health and reproductive rights in the community. He said the increased recognition of the importance of adolescent health had resuIted in closer collaboration among Member States, UN agencies and
WHO-EM/WRH/OOG/E/L Page 3 international organizations which would enable young people to achieve their potential and would magnify their future adult roles in the community. Dr Karnel stressed IPPF commitment toward a better future for youth in the Arab Region.
The objectives, mechanics, and expected outcomes of the meeting were explained by Dr Kunal Bagchi, Short-Term Professional, WHOEMRO. Dr Moncef Sidhoum, Tunisia, was clcctcd chairman and DLS u l i e ~ n a A1 ~ l Shchri, Saudi Alabia, cu-cl~air-ir~ar~. Dr Gilberto Chavez was the rapporteur. 2. 2 . 1
TECHNICAL PRESENTATIONS Building national capacity in ndolcsccnt hcaltb and development: a regional
overview Dr Rarnez Mahaini, Regional Adviser: WomenS ur~d Reproductive Heulth, WHO/EMRO Adolescence is a period of rapid change when intellectual abilities are stimulated while cognitive and emotional faculties are nurtured. During these formative years, adolescents are subject to influences from parents, teachers, peer groups, health care providers, the media, as well as the religious and cultural norms in the community. The current health behaviour of is crucial to the young people, such as eating habits and use of tohaccn and other ~~rh<tanres, health and disease patterns that will be observed in the future. Thc numbcr of adolcsccnts in thc Rcgion has grown rapidly over the lab1 clt;cadt: and is expected to be 177 million this year (2000). For years, this large segment of the population has been marginalized or simply forgotten by health and social organizations.
The programme on adolescent health and development of the Eastern Mediterranean Region is aimed at: increasing the awareness of adolescents towards healthy lifestyle issues with particular emphasis on reproductive health;
advocating the special health needs of adolescents to policy makers in ministries of Ilcaltl~ and curicet~iedgovc1-1l111enla1, nongovernmental and local institutes in the Region. In recent years, the Regional Office has extended increasing support for building-up national capabilities in adolescent health and development as an essential component of national programmes on health protection and promotion in Member States. Several countries, including Egypt, Jordan, Saudi Arabia, Syrian Arab Republic, Tunisia and United Arah Emirates have made remarkable advances in various facets of adolescent health. In recognition of the special importance of adolcsccnt hcalth and development as an
area of strategic priority for health protection and promotion, the Regional Committee for the Eastern Mediterranean adopted in its 43rd Session in 1996 resolution EMlRC43R.11. This resolution identifies several main strategies and recommends them for action. In response to
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Page 4 the resolution and to fill the gap in the health education of adolescents, in 1998 WHOtEMRO in collaboration with the Islamic Organization for Medical Sciences (IOMS) and ISESCO developed three regional manuals to guide the health education of adolescents. These manuals are aimed at priority target groups including parents, teachers, and adolescent girls and boys. The manuals address nutrition, dietary practices, personal health and hygiene, healthy lifestyles for health promotion and disease pre.vention, mental health, reproductive health and sexual maturation, and the institution of marriage and the family. Senior experts in health education technology, sociology and religious sciences reviewed these manuals. The Regional Office has maintained its collaborative activities with Member States, the Arab Regional Office for the World Organization of the Scout Movement, WHO headquarters, Geneva, and other concerned UN agencies and international and nongovernmental organizations to support adolescent health and development through multiple activities. Considerable efforts are still needed to build up the capabilities of the health sector and other concerned partners to recognize the special needs of adolescents and to develop appropriate national activities to meet with these needs. Lack of information on the health status and living conditions of adolescents in some countries is another area of constraint. Special attention should be focused on the following health-related areas: reproductive health and sexuality including pregnancy, sexually transmitted diseases (STD) including AIDS and the effect of reproductive health on infectious and parasitic diseases; personal health and hygiene; smoking; drug and alcohol use; accidents and unintentional injuries; mental health; nutrition and dietary practices.
2.2 Adolescence, health, and development: a global overview Dr Venkatraman Chandra-Mouli, Department o f Child and Adolescent Health and Development, WHO headquarters, Geneva Child and adolescent health programmes have evolved at WHO over the last two decades. The initial emphasis was on childhood nutrition and Mother and Child Health services. In the late 1980s, a separate adolescent health and development programme was established. Recently, child health and adolescent health activities have been combined into a single department of Child and Adolescent Health and Development (CAH). The objectives l~ealth pi-ogriunil~c are: of the child and adolcsccl~~ To develop and support countries to introduce technical policies, strategies, and plans for adolescent health in order to reduce nsk, morbidity and mortality, and improve growth and physical and psychosocial development; To undertake research and to develop evidence-based integrated interventions for child and adolescent health services; To strengthen the capability of countries to work with communities to devise, test, and implement health promotion, prevention and care interventions for children and adolesccnts in homcs and the community;
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Page 5 To advocate policies and strategies to protect the rights of children and adolescents in relation to health and health care. There are some significant differences between child and adolescent health and development. While most actions taken on a child require an intermediary, the adolescent is both a target and an agent for interventions. Many of the child health activities focus on mortality whereas adolescent health activities focus primarily on development. In children, disease prevention (and management) promotes development. Among adolescents, development promotes disease prevention. Tht: cl~ild'b~ i l ~ i l ~ l l l is l ~Ille ~ l lhome t whilc the adolescent's environment is less controllable. Lastly, child health is an established branch of medicine while adolescent health often fdis between paediatric and adult care. Just as there are significant differences between children's and adolescent health and development, there are also important similarities. For both, health, growth and development are inter-linked. Both require a safe and supportive environment and accessible functioning health services and actions in the family and community. The health and development of children and adolescents is closely linked with reproductive health. In addition. violence and accidents are growing concerns affecting children and adolescents. Promoting hcalthy growth and dcvelopment and preventing and managing illnesses are two inseparable aspects of improving child and adolescent health and development. As children and adolescents get older, their health and development needs change substantially. At birth and infancy, perinatal conditions and infections play a major role. During childhood, infections are a significant problem. In adolescence, early, unwanted and unprotected sex, WN/AIDS, sexually transmitted infections, alcohol and substance abuse, tobacco use, accidents, violence and certain diseases emerge as major problems. Changing interventions across age groups is necessary due to the changing nature of the problems affecting children and adolescents. At birth, infancy and childhood the interventions that work include safer pregnancies and childbirth, breastfeeding counselling and support, complement~yfeeding counselling, micronutrient supplementation, immunizations, deworming, integrated management of childhood illnesses, and early chiIdhood care for development. During adolescence, interventions need to include the building of competencies ir~cludirrgsexual and to prevent main health problems and yvulfl fricrrdly health be~vi~es, reproductive health.
2 . 3 Adolescent sexual and reproductive health Dr Heli Bathija, Department of Reproductive Health and Research, WHO headquarters, Geneva The Department of Reproductive Health and Research (RHR) is part of WHO'S family and community health programme RHR's area of work covers a wide range of issues
including: planning and programming for reproductive health, sexual development and maturation, fertility regulation, maternal and newborn health, unsafe abortion, reproductive tract infections, ccrvical cancer, female genital mutilation and othcr harmful practices.
WHO-EM/WRW006/E/L Page 6 Expanded adolescent sexual and reproductive health activities are a major planned activity for the department over the next two years. Currently, RHR works in three main areas:
Documenting the context of adolescent reproductive and sexual health including the magnitude, determinants, and consequences; Identification through intervention research in various national settings and ongoing interventions and programmes, the optimal provision of health and information servtces and best practices that respond effectively to the needs of adolescents; Development of a network of reproductive health researchers conducting work among adolescents with opportunities to exchange ideas and to get technical support from resource people. An operations research project was initiated in 1996 to assess reproductive health services for adolescents in seven French speaking sub-Saharan countries. RHR is facilitating
and coordinating the initiative. All funding is raised locally. The initiative includes a baseline survey to define the profile of adolescent users, quality of services offered, and channels through which adolescents get information and services. Each country will develop an intervention strategy depending on the results of the baseline survey. Intervention will address the need for increasing information to adolescents, training service providers and modifying services to make them more user friendly.
2.4
The youth for youth project Mr Fathi Farghali, Director of Special Projects Department, World Organization of the Scout Movement for the A rub Region, Cairo, Egypt
In accordance with its educational role, the World Organization of the Scout Movement for the Arab Region has paid special attention to determining the major health problems of the youth population in Mcmbcr States. In collaboration with WHO/EMRO, a survcy on thc health needs of adolescents was conducted in the Region. The survey revealed that adolescents' peer-groups were the prime source of information on health-related issues and the role ot the family in this respect was extremely limited. As a result, the Scout Movement for the Arab Region initiated a "Youth to Youth" project which is aimed at raising youth awareness with regard to three health education priorities namely: addiction, bio-sexual maturation, and violence and accidents. The scout leaders in Arab countries were trained on adolescent health education and counselling techniques. Appropriate and socioculturally sensitive audio-visual and printed material were produced to support the implementation of the project activities in communities.
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2.5
Findings from the WHO5MRO survey to determine national capacity in responding to adolescent health needs in the Eastern Mediterranean countries Dr Gilbert0 Chavez, ChieJ; Epidemiology and Evnllmtinn, Maternal and Child Health, California Department of Health Services and Supervisory Medical Officer; Division of Reproductive Health, US Centers for Disease Control and Prevention, Sacramento, USA
WHO/EMRO conducted a survey among Member States to determine the national capacity in responding to adolescent health needs in the Eastern Mediterranean countries (Annex 4). The specific purpose of the survey was to obtain an overview of the situation of adolescents in the countries of the Region, their health and nutrition status, and the quality and quantity of health services available to them from the individual governments. Responses were received from 12 out of the 21 countries included in the survey, which represented a response rate of 57%. The responding countries were: Bahrain, Cyprus, Djibouti, Islamic Republic of Iran, Jordan, Kuwait, Morocco, Oman, Saudi Arabia, Syrian Arab Republic, United Arab Emirates, and Republic of Yemen. There is a great deal of variability in the types and scope of services offered to adolescent boys and girls in the Region. Very few countries have formal processes in place to promote and protect the health of adolescents. Countries with policies or decrees on adolescent health appear to have increased coordination of services across governmental and non-governmental agencies.
The availability of information on the health and developmental status of adolescent boys and girls varied greatly across nations. The majority of nations had survey data available to them, however the depth and scope of information was limited. In many cases, countries did not have an adequate information-based understanding of the health and nutritional status of their adolescent population. Programme activities do not always incorporate the findings from the analysis of survey data or the asxsslllent of needs in the adolescent population. Thc scopc of services provided to adolescents varies greatly across countries. Most nations have a stable system to provide curative and preventive services. The scope of preventive and health education services for adolescents is not clear from the questionnaire data. It appears that non-traditional emerging public health programmes have not yet been fully incorporated into adolescent health programmes in most countries. These include injury prevention, tobacco control, nutrition and physical activity promotion, oral health and personal responsibility. Many nations have mechanisms in place to share health information with adolescents including: onc-on-one discussions, lectures, health magazines, health booklets, pamphlets, posters, leaflets, books, awareness programmes, and workshops. Mass media is rarely used as a means to provide information on health to adolescents.
WHO-EM/WRWOO6/E/L Page 8 Traditional maternal and child health services and primary health care centres are not always involved in the provision of services to adolescents. Services are provided to q the main w-rvirp adolescents via a variety of medical and non-medical staff P h y ~ i r i ~ nare providers. School-based health services are prominent in many nations but not always integrated and coordinated with the rest of the health care system. Most school-based health servi~cs ~ I I ;plovidrd in the context of screening, prcvcntivc carc, and food/cnvironmcntal safety. Health education is part of school-based care in only a few instances. School health servlces function largely outside the traditional health care system. In many instances, out-of-school adolescents have limited access to health services. When services are provided to these adolescents, they are largely curative in nature and primarily administered through community health centres. The monitoring of health activities takes place in a variety of ways in just over half the countries. The ocher half does not monitor these wrvices. Evaluation of adolescent health activities is rarely done.
2.6
Introduction to the regional manuals on health education for adolescents ,Or Clznda Hafez, Special Advise? Gender Mainstveaming und Women's Development,
WHO/EMRO During their formative years, adolescents are subject to many influences. These influences include parents, teachers, peers, health care providers, the media, and religious and cultural norms. Communicating health information to adolescents is a very sensitive subject. Parents often claim embarrassment or ignorance and shift the responsibility to the school system while teachers routinely neglect to talk to young students. The remaining alternatives for adolescents to obtain information on health and development issues are peers, the media, or the strect. In early 1998, the Regional Office developed a set of regional manuals for the health education of adolescents in response to resolution EMlRC43lR. 11 and to fill the gap in health education of adolescents. The health education material comprises three manuals addressed to priorily tal.gct g~oups: the parents, teachers, health workel-s and media; adolescent girls; and adolescent boys.
The manuals identify and elaborate major areas of concern for adolescent health programmes in the Region, including: nutrition and dietary practices personal health and hygiene healthy lifestyles for health promotion and disease prevention mental health reproductive health and sexual maturation thc institution of marriage and the fnmiiy.
o
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Page 9 The manuals provide information on adolescent health and development issues that concern the target groups. The following is a list of the topics covered by the manuals: nutritional problems and improving the nutrition of adolescents personal health and hygiene healthy lifestyle for health promotion and disease prevention clinical mental conditions, adolescent concerns about puberty gender discrimination, mitigating factors regarding mental health in the Region phases uf developrrienl in adolescence, wlial hippens inside lht: body during bio-sexual maturation marriage, homosexuality, contraception for married adolescents worrisome questions and events for adolescents sexually transmitted diseases teen marriage and parenthood, why do teens become pregnant before marriage? sources of influence on adolescence sharing the responsibility for educating adolescents about sexuality. The materials produced were reviewed by senior experts in health education technology, socioiogy and religious sciences in a consultation organized by the Regional Office in collaboration with thc Islamic Organization for Mcdical Scicnccs (IOMS) and thc Islan~ic Scientific, Educational and Cultural Organization (ISESCO) in Istanbul, Turkey, in September 1998.
3.
COUNTRY REPORTS ON ADOLESCENT HEALTH AND DEVELOPMENT
3.1. Bahrain Dr Ahdulla Ahmed Ali, Head, Public Health and Health Education Progrummes, College o f ~leulth Scierzces, hfurtur~~u, Duhl-uira
Adolescents comprise not less than 40% of the popuIation of Bahrain. While almost one-third of adolescent girls are married by 19 years of age, only 2.5% of boys get married during adolescence. Adolescents in Bahrain have many health and social problems. Teachers in intermediate and secondary schools believe that the problems of adolescents are not adequately targeted in health programmes and that parents are not sufficiently involved. Bahrain collected information on the health and development of adolescents through telephone surveys conducted among social workers. teachers. headteachers: literature searches and research analysis; and interviews with physicians and members of the Adolescent Committee. Iron deficiency is one of the most important health problems in Bahrain. In 1985, a high proportion of girls between the ages of 11 and 13 years (21.2%) had anaemia. Iron deficiency anaemia is a pervasive problem that affects all socioeconomic segments of the adolescent population of Bahrain. Obesity and low optimal weight are also significant problems. Smoking is another serious and increasing problem among male adolescents. In 1982, 8.1% of
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Page 10 male adolescents smoked. The smoking rate increased to 21.4% in 1989. Dental caries and periodontal disease are significant problems in Bahrain. In 1986, 46% and 25% of 12-year-olds had dental caries and periodontal disease respectively. Anecdotal information suggests that the rates of oral health problems may have decreased recently. Infectious diseases are aIso a regular source of morbidity among young people in Bahrain. Tuberculosis, hepatitis B and sexually transmitted diseases are among the most prevalent infections. Thalassaemia, G6PD and epilepsy are the most common chronic diseases among adolescents in thc country. Diabctcs is an increasing problem alnoag buy&and girls. Accidents, primarily traffic-related, are an emerging cause of morbidity and mortality for adolescents. Teachers reported that psychoIogicaI problems were very prevalent among adolescent boys and girls in school. Among the accomplishments in adolescent health is the establishment in 1996 of the Adolescent Committee. The committee comprises 13 members from various ministries. It has made significant contributions to the provision of health services to adolescents, the availability of health education activities, and increased the awareness among parents, teachers and community groups of health issues affecting adolescents. Research on nutrition, smoking, drug usage, psychosocial problems and hcalth cwc needs has been conducted. In addition, workshops, seminars, speeches, and health education campaigns have been recently undertaken. One of these activities included the development of a full strategy to int~glati; aclo1t;scl;nt health willin the primary health care system. Bahrain has identified some constraints and problems which interfere with the provision of services to adolescents. These include financial barriers, shortages of adequately trained personnel, legal system issues, difficulties with the discussion of sensitive issues, lack of awareness among rural families, and lack of cooperation and time among those providing services to adolescents. Efforts should be focused on increasing the awareness and providing health facilities for young people to develop physically, mentally and socially. Teenagers must have adequate knowledge of sexual health and fertility. They should be empowered to have better control over their sexuality and aggression. They should also be taught how to handle peer pressure adequately. Bahrain needs additional referral clinics and information centres to treat and to provide services and consultation. It also needs to target policy makers with awareness campaigns. Reducing the amount of time children are exposed to television, video games and movies while encouraging parents to get more involved in the lives of their adolescents should prove very useful.
3.2
Egypt Dr Moushira El Shafie. Under-Secretaryfor Family Planning and Pnp~~lation, Ministry of Health and Population, Cairo, Egypt
Over 13 million adolescents between the ages of 9 and 20 ycars livc in Egypt. Adolescents comprise 22% of the country's population. Iron deficiency anaemia occurs
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Page 11 among all segments of the adolescent population and is also a particular problem among adolescents living in poor households where there are varying degrees of malnutrition, anaemia, growth retardation and parasite infestation. While the majority of adolescents in Egypt have regular access to food, boys (84.3%) are more likely than girls (74.1%) to eat three meals a day. Girls are more likely than boys to eat snacks, 30.7% and 20.9% respective1y. The access to basic education has increased due primarily to increased enrolment of teenage girls of low sociocconomic status and Uppel Egyyl. Poor scholastic performance, bad
treatment by school staff, and the need to help with family chores are among the key reasons for dropping out of school. Despite recent changes in employment laws, many adolescents continue to work and to be exploited. There is a significant need for additional information on sexual maturation, STDs and reproductive tract infections that affect 49% of girls and 4.4% of boys. The average age of menarche is 13 years. Among university students, sexual activity is more common than might be expected. In a survey. 16% of students said that they had had sexual intercourse and onethird of them did not use a condom. Knowledge of AIDS is fairly widespread (70%) while knowledge of STDs is more limited (48%).
In urban areas the number of married adolescents is decreasing. Contraception is frequently not used until after the first pregnancy. The time lapse between marriage and pregnancy alllur-rg ado1esc;cnls is very short, and the majority (67%) of adolescents gives birth at home. Most parents (93%) plan to circumcise their daughters. The prevalence of circumcision among adolescent girls aged between 13 and 19 years is estimated at 84%. Among students, 64% of males and 42% of females support female circumcision. Among adolescents aged between 16 and 19 years. 28% classify themselves as .smokers and 78% report having peers who smoke. When asked about illicit drug use, 3.5% reported current use while 38% had at least one peer who used illicit drugs. The drugs of choice are bango, hashish and heroin. Poor psychosocial adaptation is a common problem among adolescents, particularly those from low socioeconomic households. Egypt provides services to adolescents through a network of primary health care services consisting of 3600 health units and 282 hospitals. Services are available to 98% of adolescents including those out-of-school and married. School health services are also avaitable to all students. Services provided include curative and preventive approaches. In addition, the Ministry of Public Health introduced a reproductive health module to expand services from family planning to all reproductive health services in its 4200 urbadrural clinics and 430 mobile clinics. Reproductive health services include premarital examination, prenatal care, natal care, post-natal care, contraception, and management of post-menopausal syndrome and osteoporosis. Strategies exist in the areas of nutrition, nutrition education, reproductive health, and psychosocial development.
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3.3
This Dr Aleya Mahjoub Zarrouk, Director; School Health Services, Ministry of Public Health. Tunis. Tunisia Adolescents aged between 10 and 19 years represent approximately 20% of the
population of Tunisia. More than 90% of 10 to 13-year-olds and 60% of 14 to 19-year-olds
attend schoo1:Since 1990, Tunisia has had a strategy that gives educational institutions the responsibility for the health of adolescents. This strategy is based on three main activities: health education, rrlental hcallh, mlcl rcproduclivt: hcaltll. The framework for this national adolescent health programme includes five major components: a service allowance for first and second line services; actions to promote health; diversity of sectors and association of diverse participants; research and evaluation; and training and recycling of the working teams. First line services include epidemic control, periodical medical exams, medical exams for stiidcnts failing a grade, pi~pil information cards, vaccinatinnq, discussion and advice
groups, advice and information groups on reproductive health, and social action groups at schools. All first line services are free of charge. Second line services are provided through the school and university national ccntrc, rcgional ccntrcs, rcgional rchabilitation units for the handicapped, family planning clinics, private offices, private dispensaries, intermediary care, and public and private paediatric services. These services are free of charge up to the d~agnosisstage. Treatment services are free for boys and girls in school and subject to an inconre-based fee for those not in school. Health promotion activities are a crucial component of the adolescent health strategy. They are carried out through the school programme, school manuals, sessions organized during the periodic medical team visits. and celebration of the national days. Two of the specific activities carried out include the establishment of health clubs and peer education. Tunisia has made a concerted effort to integrate services for adolescents. A high priority has been the sensitization of different public and private institutions that are in contact with adolescents. Another high priority has been to encourage and promote collaboration among these institutions. These institutions include government ministries, knowledgeable societies, and nongovernmental organizations.
Many surveys and investigations concerning the physical and mental health of adolescents have been carried out in Tunisia since 1990. These research activities have focused on addiction, sexual and reproductive health, family health, psychiatric hospital admissions, suicide attempts, lifestyles of students, smoking, nutrition, AIDS and mental health. A national survey concerning adolescent health is in the planning stage. Because of the need for supplementary training on the physlcal and mental health of adolescents for school health teams, an annual national course for medical staff was implemented in 1990. Other tlaining activities includc cvulses un riicntal hcaltll, x ~ ~ ~ i n i a ub, national congress of school health, visits to countries with adolescent health programmes, and
WHO-EM/WRW006/E/L Page 13 training within the social action programme in schools on pedagogic, somatic, psychological, and social issues. 3.4
Islamic Republic of Iran Dr Siarnak Alikani, Deputy, School Public Health Department, Ministry of Health and Medical Education, Teheran, Islamic Republic of Zran
There are approximately 16 million adolescents aged between 10 and 19 years of age in the Islamic Republic of Zran. They comprise about 27% of the Iranian population. Half of the adolescents are males and half are females. Approximately 60% reside in urban areas and only 4.5% are illiterate. Nearly three-quarters of adolescents attend school. Most are not married during adolescence (98.2% of males and 90.15% of females). Primary health care networks are available in 85% nf the cnl~ntryand have the main
responsibility for providing health services and health education to adolescents. These activities are provided through urban health centres and health houses in rural areas. Services provided by this system have been integrated. Othcr scrviccs offcrcd include school hcalth
activities, disease control and prevention, family health and oral health. Efforts are under way to design a model for integration of adolescent health as an independent programme in the primary health care networks. There is a pilot project under way in four provinces. There are also some attempts for collaboration with other institutions providing sewices to adolescents. There are some limitations in the provision of services to adolescents that need attention. These limitations include lack of interest on the part of policy makers, barriers due to religious and cultural norms and lack of a comprehensive health information system. In
addition, thcre is a lack of social mobilization, minimal amount of collaboration across
agencies responsible for adolescents, and barriers due to legal aspects of adolescent health activities. There is a great need for a national comprehensive plan for adolescent health. 4.
GROUPWORK
There were two sessions for group work. Participants were assigned to working groups according to areas of expertise. The first session focused on the obstacles and achievements for thc hcalth and development needs of adolescents, the elements of a successful adolescent health and development programme, and priority actions of a strategy framework for promoting the health and development of adolescents. The second session centred on the promotion and application at the national level of the adolescent health education manuals. A set of suggested questions for each session was provided to each group at the onset for consideration (Annex 5). Groups were advised that the questions had been given to stimulate discussion and they were encouraged to discuss any relevant additional questions.
WHO-EM/WRH/O06/E/L Page 14 The participants were divided into three groups. Each group nominated a chairman and a rapporteur who presented the conclusions and recommendations of the group which were then incorporated into thc ovcrall conclusions and rccommcndarions of thc workshop (sections 5 and 6). 5,
CONCLUSIONS Although most rnuntriec in the Region are RwarP nf the impnrtanre of adolescent health,
only a few are able to provide comprehensive medical, social and counselling services to this important population group. One of the main obstacles for the development of comprehensive adolescent health services is thc insufficicnt support of decision-makcrs in some countries
towards programmes targeting adolescent health. Political support is essential for adolescent health efforts to be sustainable, institutionalized and well integrated. In some instances, leglslat~on may be necessary. It was noted that adolescents are still not actively involved in the planning and development of adolescent health and development programmes. In several Member States, adolescent health care activities are not well integrated with the national primary health care programme. Adolescent health programmes. where they exist, are not adequately monitored or evaluated and a major segment of the health workers are inappropriately trained to provide quality care and counselling services to the adolescent recipients.
Most persons responsible for the education and counseiling of adolescents, including parents, teachers and religious leaders, lack information and communication skills. Available information or, aciolescenl health is often inadequately used. Governments, nongovernmental organizations, UN agencies and other donor agencies are active in the provision of services to adolescents across many conlmunities in the Region. However, the level of coordination between the government and the donors needs to be further strengthened. Exchange of information and expertise takes place between countries only on a limited basis. There are many adolescent health needs and issues that are common to the various countries and that would benefit from enhanced communication and sharing. There is insufficient research on adolescent lifestyles. Quantitative and qualitative dala,
when available, are inadequately utilized in some countries for programme development and advocacy. The participants noted with satisfaction the manuals on health education for adolescents developed by the Regional Office in collaboration with ISESCO and IOMS. The manuals were considered an excellent health education tool that could serve as a source material for promoting healthy lifestyles in adolescents in accordance with the sociocultural norms and values prevailing in countries of the Region.
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6.
RECOMMENDATIONS
To Member States 1.
The countries in the Region should conduct adolescent health strategic planning based nn clear goals and measllrahle nhjectives. The design of any adolescent health programme should always make use of existing available services. Adolescent health programmes and activities should be integrated with the existing national health care systems.
2.
Partnerships for advocacy with key internal and external stakeholders should be established. Involving partners in research needs assessment, and programme planning may increase cooperation and ownership of adolescent health activities. Use of all available channels in adolescent health education and counselling activities should be encouraged. These channels include school curricula, extracurricular activities, mass media (radio. television). community seminars and printed educational materials, youth for youth education, parent education, recreational activities and youth clubs. Services to adolescents should be provided in a culturally sensitive and nonjudgemental way and should address both females and males. The services provided should also mainlain quality and assure satisfaction to the adolescents, while conforming to the highest professional standards. Services conforming to similar high quality should also be ensured for adolescents in school and those out of school and in marginal groups. Health workers providing adolescent health care should also be adequately trained in aspects of adolescent health and development. Health programmes for adolescents should maintain collaboration with other non-health care sectors. The major needs and problems of adolescents should be identified based on local data and scientific information in a way that is sensitive to the religious and cultural norms of thc Rcgion. Collcction of new data for the purpose of assessing riccds is only recommended after an exhaustive review and analysis of existing data. Communication and sharing of information and research findings across countries in the Region should be further strengthened. The monitoring and programme evaluation mechanism for adolescent health activities should make use of quantitative and qualitative methods for which standardized outcome and performance indicators for monitoring progress should be developed. The Regional Office, ISESCO and IOMS are recommended to introduce the manuals to governments as welt as other local and regional concerned agencies at intercountry workshops.
3.
4.
5.
6.
7.
8.
WHO-EMIWRWOOGEL Page 16 9.
Member States should adapt the manuals in accordance with their local needs.
To WHO
10.
The Regional Office should develop guidelines to promote the use of the manuals at the couiltiy level. Such guidclincs should cnsurc covering out-of-school adolescents through collaboration with the concerned UN agencies and non-governmental organizations.
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Page 17 Annex 1
AGENDA I. Inaugural session 2. 3. 4. 5. 6. 7. Introduction of participants. election of chairman and rapporteur Adoption of agenda Building national capacity in adolescent health and development: a regional overview Objectives, mechanics and expected outcomes of the Meeting Adolescence, health and development - a global overview Developing national policies and strategies in adolescent health and development - the Tunisian experience 8. Country reports on adolescent health and development 9. Findings from the regional survey on adolescent health and development 10. Group session in three groups Group A: Health and development needs of adolescents - obstacles and achievements Group B: Elements of a successful adolescent health and development programme Group C: Priority actions of a strategy framework for promoting the health and development of adolescents 1 1 . Precentatinn o f grnllp reports and discussinn
12. Introduction to the Regional Manuals on Health Education for Adolescents 13. Group work on the Regional Manuals on Health Education for Adolescents: How to promotc and apply thc manuals at thc national lcvcl
14. Major conclusions, recommendations and future directions 15. General discussion 16. Closing session
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Annex 2
PROGRAMME Wednesday 27 October 1999 08:30 - 09:OQ Registration 09:OO - 1O:OO Inaugural session Message by the Regional Director Inaugural speech by the Minister of Public Health, Government of Tunisia Inaugural speech by representatives of other supporting agencies Introduction of participants 10:30 10:45 Selection of chairperson and rapporteur Adoption of the agenda Building national capacity in adolescent health and development: a 1045 - 11:05 Regional overview Dr Kurnez Muhaini, Regionul Adviser, Women's and Reproductive Health, WHO/EMRO Objectives, mechanics and expected outcomes of the Meeting 11 :05 - 11 :15 Dr Kunal Bagchi, Short-Term Professional, WHOIEMRO Adolescence, health and development: a global overview 11: I S -- 1 1 :35 Mr Venkatraman Chandm-Mouli, llzvssinn of Child and Adolescent Health, WHO/HQ Country Reports on adolescent health and development 11:35 - 12:05 Bahrain Egypt Developing national policies and strategies in adolescent health and 12:OS - 1230 development - the Tunisian experience Dr Aleya Mahgouh Ztrrrouk, Director, School Health Services, Mirzi,stry of Public Health, Tunisia Presentation of findings from the Regional survey on adolescent 14:0i9 -- 15:OU hc:~lthand development Dr Gilberto Chavez, Temporar~) Adviser; WHO/EMRO Discussion on survey findings 3 : 3 Introduction to the Regional Manuals on Health Education for 15:45 - 16:15 Adolescents Uu Ghada Nufez, Special Arlvisel; Gender h!lainstrearning and Women S Development, WH(I/EMRO -
'1hursday 28 October 1999 Briefing for Group Session 08:30 - 09:00 Group Session in three groups: 09:00 - I 2 :30 Group A: Health and development needs of adolescents obstacles and achievements Group B: Elements of a succe\sful adolescent health and Deveiopmenr programme Group C: Priority actions of a strategy framework for promoting the health and developrnent of adolescents 1 1 :30 - 12:3Q Presen~alion of group repulls and d i s c u s ~ i u ~ l
WHO-EM/WRWOOB/E/L
Page 19 13:30 - 15:30 15:45 - 1630 Group work on the Adolescent Health Education Manuals: How to promote and apply the manuals at the national level Presentation of group reports and discussion
Friday 29 October 1999 Plenary Session: Major concIusions, recommendations and future 08:30 - 10:30 directions
11:00 - 12:00
Closing Session
WHO-EM/WRW006/E/L Page 20 Annex 3 LIST OF PARTICIPANTS
BAHRAIN Dr Abdulla Ahrned Ali Head, Public Health and Health Education Programmes College of Health Sciences Manama
EGYPT Dr Moushira El Shafei Under-Secretary for Family Planning and Popujation Ministry of Health and Population Cairo ISLAMPC REPUBLSC OF IRAN Dr Siarnak Alikani Deputy, School Public Health Department Ministry of Health and Medical Education
Teheran
LIBYAN ARAB JAMAHIRIYA Dr Abdulbaset A1 Fituri Head of National Committee for Health Education Ccneral's People Committee for Health and Social Security 'rripoli
MOROCCO Dr Najia Hajji Cllicf, Nu11iliunlMakrna1 and Child Health
Ministry of Health Rabat
SAIJDI ARABIA Dr Sulieman A1 Shehri Director-General of School Health Presidency of Girls' Education Riyadh
SYRIAN GRAB REPUBLIC Mr Ychia Bouzo
Head, Healthy Lifestyles Programme Ministry of Health Damascus
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Page 2 1
Dr Mazen Khadra Director, Primary Health Care Ministry of Health Damascus TUNISIA Dr Moncef Sidhoum Director, Primary Health Care Ministry of Public Ilealth Bab Saadoun
lbnis Dr Aleya Mahjoub Zarrouk Director, School Health Services Ministry of Public Health Bab Saadoun lbnis
REPUBLIC OF YEMEN Dr Naguiba Abdel Ghani
Director, Reproductive Health Ministry of Public Health Sana'a
RESOURCE PERSONS Dr Reyed A1 Ali Ministry of Health Abu Dhabi UNITED ARAB EMIRATES Dr Gilberto Chavez Chief, Epidemiology and Evaluation Matcrnal and Child Ilcalth
California Department of Health Services and Supervisory Medical Officer Centers for Disease Control and Prevention Sacramento, California USA Mr Fathi Farghali Director of Special Projects Department World Organization of the Scout Movement for the Arab Region Caf ro EGYPT
WHO-EM/WRH/006/E/L, Page 22 Mrs Hind Moussa Freelance Counsellor C cncva SWITZER1,AND
OTHER ORGANIZATIONS
International Planned Parenthood Federation (IPPF) Dr Mohamed Kame1 Regional Director Arab World Regional Office International Planned Parenthood Fund Tunis TUNISIA Islamic Educational Scientific and Cultural Organization (ISESCO) Mrs Asmaa Abdalla
Specialist in Charge of Cooperation, International Organizations ISESCO Kabat MOROCCO
United Nations Population Fund (UNFPA) Mr Abdul Moneim Abu Nuwar UNFPA Representative to Egypt Cairo EGYPT
United Nations Children's Fund (UNICEF) Dr Kame1 Ben AbdaHah Programme Officer, UNICEF Tunisia Tunis TUNISIA United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Dr Haifa A. Madi Chief, Family Health Division UNRWA Headquarters Branch
Amman JORDAN
W HO-EMIW KH/UU6/EIL
Page 23
OBSERVERS Dr Mongia Ben Attia Mkdecin Major, Chef du Service Universitaire Direction de la MCdecine Scolaire et Universitaire Ministry of Public Health
Tunis TUNISIA M Hafedh Bouktif Psychologue et Directeur du Centre de Defense et d'Int6gration Sociale de Mellassine (Tunis) Ministry of Public Health Tunis TUNISIA Mrne le Pr. Souad Bousnina Chef de Service de PPdiatrie 5 I'HGpital d'Enfants Ministry of Public Health Tunis TUNISIA
Mme le Pr. Hella Chelly Chef de Service a la Maternite - la Rabta Centre National de MCdecine Scolaire et Universitaire Tunis TUNISIA
M Mokhtar Dhahri Sous-Direction de ]'Education Pour La SantC Direction des Soins de Santi de Base Ministry of Public Wealth
l'unis TUNISIA Dr Mounira Garbaouj Sous-Directeur de \'Education 3 la Santk Direction des Soins de Sant6 de Base Ministry of Public Health
Tunis TUNISIA
W HO-EM/WRW006/E/L Page 24 Mlle Atf Ghrissi Sage-Femme B I'unitk du programme SMI Direction des Soins de Santt de Base Ministry of Public Health Tunis TUNISIA
Dr Aida Ismail Medecin Principal Sous-Directeur B la Direction de la MCdecine Scolaire et Universitaire Ministry of Public Health
Tunis TUNISIA Dr Ahmed Maamouri Unit6 MST-SIDA Direction des Soins de S a t 6 dc Basc
Ministry of Public Health Tunis TUNISIA
Dr Mohamed El Motaz Bellah Mahmoud Population Sector Ministry of Wealth and Population Cairo EGYPT Dr Saloua Sassi
Mkdecin Major Responsible de la Santd Scolaire et Universitaire B Nabeul Dil-cction de la Mddccirit: Scolaire et Universitaire Ministry of Public Health Tunis 'I'UNISIA Dr Hossam A1 Din A. Shalaby Population Sector Ministry of Health and Population Cairo EGYPT
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Page 25
WHO SECRETARIAT Dr Ghada Hafez, Special Adviser, Gender Mainstreaming and Women's Development, World Health Organization, Regional Office for Eastern Mediterranean, Alexandria, Egypt .
Dr Ramez Mahaini. Regional Adviser. Women's and Reproductive Heaith, World Organization, Regional Office for the Eastern Mediterranean, Alexandria, Egypt
Health
Dr Mikhail Lichnevski, Regional Adviser, Child and Adolescent Health. World Health Organization, Regional Office for the Eastern Mediterranean, Alexandria, Egypt Dr V. Chandra-Mouli, Department of Child and Adofeccent Health and Development, World
Health Organization Headquarters, Geneva Dr Kunal Bagchi, Short-term Professional. Health of Special Gm~ips, Wnrld Health
Organization, Regional Office of the Eastern Mediterranean, Alexandria, Egypt
Dr Heli Bathija, Division of Reproductive Health and Research, World Health Organization Headquarters, Geneva Mrs Amal Elrouby, Sccrctary, World Hcalth Organization, Regional Office for the Eastern
Mediterranean, Alexandria, Egypt Mrs Sil~lor~t: Sil1e111, Sec~etaly, World Ilcalth Organization, Regional Office for the Eastern
Mediterranean, Alexandria, Egypt
WHO-EM/WRWOOB/E/L Page 26
Annex 4 WHO/EMRO SURVEY TO DETERMINE NATIONAL CAPACITY IN RESPONDING
TO ADOLESCENT HEALTH NEEDS IN THE EASTERN MEDITERRANEAN COUNTRIES The purpose of this questionnaire is to obtain an overview of the situation of adolescents in the countries of the Region, their health and nutrition status and the quality and quantity of health services available to them from the governments, in order to build capacity in adolescent health. The survey is not intended to be detailed. As such, we expect the responses to be brief and specific. However, if additional data were available from the concerned ministry, we would welcome such response. If reports and documents pertaining to the queries were available, we would be grateful to receive copies. Since some of the questions concern the pnlicy and planning, yniith and NGO affairs, ~ c i a l and economic affairs sectors of national governments, responses could also be sought from ministries/government institutions dealing with such sectors.
1.
Is there a national policy/commission/decree on the health of adolescent boys and girls (10 fa 19 years)? If yes, please ~ n d ~ c a t e : e the nature of the policy/commission/decree; 0 was there any consultation with young people during the development of the poiicy/commission/decree; e since when has the policylcommissionldecree been operational; what age groups are covered by the policylcommission/decree: r what benefits/services/opportunitiesare provided by the policy/commission/decree; e what administrative mechanisms are utilized to provide the benefits/services/opportunities identified in the policy/commission/decree;
what governmentallnon-governmental/private sectors are involved in providing care to the adolescents: 2.
Has any survey been conducted recently on the health and development status of adolescent boys andlor girls between 10 and 19 years of age? If yes, please indicate: what was the focus of the survey; what were the main findings from the survey; bnscd on thc survcy findings, has any action bccn planned. What information is available on the health and nutrition status of adolescent boys and girls between 10 and 19 years of age? a morbidity patterns among adolescent boys and girls (inciuding anaemia, STD/HIV, tuberculosis, schistosomiasis, malaria, accidents, alcoholism, substance abuse) 0 proportions of adolescent girls and boys who are marriedlever married; 0 what proportion of pregnancies in adolescent girls result in normal, full-term deliveries; p~vpvrtivll uf ~ d u l c b ~ cg~ i l~ ht alld boy?, allending primary, preparatory and secondary schools;
3.
WHO-EM/WRII/006E/L
Page 27 proportion of adolescent girls and boys worlung in the economic sector. 4.
What types of health services are provided to boys and girls between 10 and 19 years of age?
preventive services including measurement of nutritional status, vision and hearing ability; counselling and information on health issues including reproductive health; curative services including diagnosis, treatment and referrals for tuberculosis, malaria, STDIHIV, behavioural disorders; how and where are the services delivered; who provide these services; are the services similarldifferent for adolescent boys and girls; how is information on health available to the adolescents.
5.
Do the Maternal and Child Health ServiceIPrimary Health Care centres provide any specific I~eallh services iu girls and boys between 10 and 19 years of age? If yes, please indicate: what types of services; where and how are the services provided; what category(ies) of health staff provide(s) these services; have any modifications been made to the existing MCWPrimary Health Care Centres for providing health care to the adolescents. School Health Clinics: what heaIrh services are routinely provided as part of the school health programme; a who provide these services; + how frequently do the school health clinics function; do the school health clinics follow an established referral system; + do the school health clinics provide health education/training in advocacy to the adolescent students; is the school health service a part of the national MCH programmela separate programmelad hoc in nature (i.e., varies from school to school); Are there health services In the cornmunlty available to adolescent boys and girls who are out of school? if yes, please indicate: e who delivers these services; what is the nature of such services; where and how are the services delivered. How are adolescent health activities monitored? Has the adolescent health programme heen evalt~ated? If yes, please indicate: what have been the main findings of such an evaluation; + what actions have been talcen on the findings of thc evaluation.
6.
7.
8.
9.
WHO-EM/WRH/006/E/L Page 28
Annex 5 GROUP DISCUSSION QUESTIONS
GROUPA. Health and development needs of adolescents - obstacles and achievements 'l'he tollowing questions are given to encourage discussion. However, the participants are expected to raise other questions relevant to the topic in order to facilitate better discussion. 1. Do we have adequate information to describe reliably the health and development. needs
of adolescents from countries of this Region? Is this information gender-specific? Is this information age group-specific? How may the information-gathering process be improved?
2, Do the findings from the regional-level survey challengelalter the current state of knowledge regarding the health and development needs of adolescents?
3. What have been the major obstacles in promoting and maintaining the health and development of adolescents in the Region? 4. The cultural and religious values and practices prevalent in countries of this Region expect
adolescents to follow certain established norms. How may these traditions be utilized to promote the health and development of adolescents? Can these traditions also act as obstacles in addressing the health and development needs of adolescents?
5. What have been the major achievements in adolescent health and development in your country'? In the Region? Can these achievements be applied uniformly in other countries of the Region? If not, what are the constraints?
6. The influence of the family on adolescents is gradually declining in many situations in several countries of the Region How may the influence of the family be strengthened to provide adequate support to adolescents?
GROUP B. Elements of a successful adolescent health and development programme The following questions are given to encourage discussion. However, the participants are expected to raise other questions relevant to the topic in order to facilitate better discussion. 1. What, according to you, is a successful adolcsccnt hcalth and development programme?
What are the key components and measuring tools of such a programme?
2. it is generally agreed that adolescents should be involved in the planning, implementation and assessment of programmes dealing with them. How may this be achieved? To what extent should adolescents be actually involved in such exercises? 3. Do you think the conventional maternal and child health services provide adequate
healthcare to adolescents? If not, what could be done to ensure this? What findings from the EMRO survey may be used to improve health care of adolescents? 4. Can the conventional school health programme, either independently or as a component of the existing maternal and child health service, be an active provider of healthcare to adolescents? If no, what may be done to ensure this?
5. During adolescence, psychological, emotional, social and physical needs require particular attention? How may these be addressed in a programme to promote the health and development of adolescents?
W HO-EM/WRWOOG/E/L Page 29 6. What steps should be taken to prevent the adolescents from absorbing or practising 'risky behaviour' under the influence of the media? 7 . How rclcvant is what children are taught in health and development in relation to thc
environment in which they live and the changes that surround them?Are the convenf~onal health education, information and communication activities adequate to address adolescent needs?
GROUP C. Priority actions of a strategy framework for promoting the health and development of adolescents The following questions are given to encourage discussion. However, the participants are expccted to raise other questions relevant to the topic in order to facilitate better discussion. 1 . In any strategy, baseline information and analysis of the existing situation are two
important issues to be considered at the outset. Do you think similar components should be included in the strategy for promoting the health and development of adolescents?
2. The counlries in the Region may be divided into affluent, very poor and in-between, with regard to resources and infrastructure. Is it necessary to develop different strategies catering for each category of countries? Should such strategy(ies) have a phased (shortterm versus long-term) approach? Will such strategy(ies) focus on broad or specific issues in the heaIth and development of adolescents? 1. Ilow will high level support (financial, political and tcchnical) be incorporated in the
strategy for promoting the health and development of adolescents? How will such support be maintained and expanded? 4. What specific priority actions should be included in the strategy for promoting the health and development of adolescentsi? 5. Research in health and development of adolescents is considered an important aspect of
adolescent health. How may research be included in the strategy for adolescent health and developmenr? Is it possible to combine 'research' with evaluation while trying to ~rndcrstand the impact of the interventions?