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• training material was published for the leaders of the clinics, which was based on the results of analysis and a summary of the practical experience of the Russian organizations that help teenagers and young people;
• in cooperation with WHO the methods of estimating the quality of the clinics' work in the sphere of reproductive health was approved;
• a textbook for doctors and public health organizations ("Clinics friendly to teenagers") was published. This book contains criteria and standards of the medico-social services for teenagers, as well as methods for estimating the quality of help based on the clinics' standards;
Municipal Consultative
The particular importance of the teenagers' reproductive health protection is explained by the crisis in the demographic situation in the country, which does not only have social causes but is also a result of the low reproductive abilities of the young generation.
Of the girls, 75 - 86 % have chronic somatic diseases, 10 - 15 % have gynecological disorders that limit their fertility [1, 2, 3]. The rate of gynecological disorders has trebled during the last five years. The prevalence of gynecological diseases increases with age by more than 2.5 times — from 116.2 at the age of 14 to 297.0 at the age of 17 per 1 000 examined girls.
The reproductive health among young males does not offer a better picture. The rate of andrological diseases in St. Petersburg varies between 13 - 56 0%, and 2.2 o% of the youths need andrological operative treatment. The necessity of surgical treatment is at its highest at the age of 14 - 16 years. About 60 %% of the diseases in boys and youths in the ages between 14 and 17 may become a real threat to their future fertility [4].
The early sexual activity of teenagers has become one of the most important social problems in Russia. Often they are not prepared for sexual life, physiologically or psychologically, they do not have sufficient knowledge about sexually transmitted infections, the possible negative consequences of an early sexual debut or pregnancy interruption.
A questionnaire aimed at schoolgirls from classes 9 - 11 (more than ten thousand) in St. Petersburg revealed that 52 o% of the 16 year old respondents had sexual experience; 68 % of the girls had their first sexual
• the experience of the Russian Federation in the development of services for teenagers has been recognized by WHO experts. Further, the full-scale introduction of the clinic's model for teenagers into everyday practice of the medico-social institutes that work with teenagers and young people has been useful in several ways (e.g., in developing the expansion of methodical and normative documentation regarding the organization of the clinics, increased the number of working persons and has helped them adapt to the conditions, important in health expert development and has introduced the mechanism of service quality monitoring.
contact either under the influence of alcohol or narcotic drugs, or had actually been raped.
Extramarital births make up 60.7 - 68.7 %%. During a period of so-called postponed parenthood, which according to our data is 8 years, every fifth woman has one or more abortions in her anamneses, every third woman uses urgent contraception, and every sixth of their sexual partners has had an STI in the past.
The number of abortions in Russia is about 40 per 1000 adolescents at the age of 15 - 19 years, which is one of the highest rates in the world [5].
Among numerous factors forming reproductive potential, one of the most important is information about a healthy life-style and safe sexual connections. Unfortunately, the main information source for adolescents is either an incompetent person of the same age, a sexual partner, or their own unfavorable experiences. Popular literature and advertisements are on second place; third and fourth place is shared by the information received in the family and from friends. Only in 16 %%, the information source was given by physicians. Specialists from whom schoolchildren expect to get knowledge are physicians and specially trained teachers. Only an insignificant number of adolescents answered that they would like to get this knowledge from their parents.
There is a shortage of physicians, teachers, and social worker specialists who are prepared and able to provide sexual education to adolescents — in 60 % of the cases they are trained by non-specialists.
The existing system of children health care does not appear to be ready to solve the newly arisen specific
MEDICAL AND SOCIAL AID IN THE REPRODUCTIVE HEALTH PROTECTION OF ADOLESCENTS
P. N. Krotin ([email protected])
and Diagnostic Center for Children — "Juventa" (reproductive health), St. Petersburg, Russia.
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problems of the adolescents. Today the consequences of risky behavior and the problems of reproductive health cannot be successfully solved within the framework of the present medical aid system for teenagers. Pediatricians begin to realize the necessity of such physicians, and, even within the pediatric health services, there is a search for specialists who will be able to work with youths only.
The mere presence of such services does not mean that adolescents make use of it. Formally these services exist, but adolescents do not wish to visit them. For example, juvenile gynecologists in the women's consultation and juvenile narcologists in the narcological dispensary are not popular with adolescents in Russia; young girls do not attend juvenile gynecologist in the women's consultation clinics, only a tenth of those who need help visit these specialists [4].
At present, the importance of a complex approach to the problems ofjuvenile reproductive health protection, sexual education, and the formation of a conscious contraceptive behavior is quite evident. A necessary condition for the efficiency of this work is the joint activity of medical workers, social pedagogical workers and psychologists who are appropriately trained in the psychology of communication and consultation methods.
The organized medical and social units or centers of juvenile reproductive health care that work according to the principle of "youth friendly clinics" are not an alternative and cannot replace the existing services, for example, the pediatric polyclinics. These services will supplement each other in reaching the single goal of ensuring a healthy young generation; youth friendly clinics may form part of the children's therapeutic and prophylactic institutions, forming a department of medical and social care for teenagers.
A youth friendly clinic is an institution that, based on principles of Voluntariness, Accessibility, Benevolence and Confidence, renders complex medical and psychological services on the problems of health care conditioned by a specific character of school age. The ideology of youth friendly clinics is to provide help to
teenagers by understanding their problems and by together searching for ways of behavioral change aiming to preserve their health (Table 1).
The motivation to organize youth friendly clinics (YFC) is driven by the following interrelated factors that characterize the current young generation:
• social value of teenagers health;
• deterioration of health and social protection;
• insufficiency of basic medical services, great needs in medical and social aid;
• mental and social immaturity, absence of insight into their own health condition, no practice in searching for aid by themselves combined with the absence of a self-monitoring ability and to adequately express their feelings and thoughts;
• changes in the structure of young people's diseases with an increased specific gravity of "diseases of risky behavior". Epidemics of HIV infection, STIs and drug usage demand a forced formation of services intended for solving problems of young people's health;
• little influence of the family, early pubescence and late matrimony create significant problems in reproductive health care;
• insufficient extent of knowledge of reproductive health problems;
• the necessity of a complex approach and interdepartmental interaction in youth health care; the necessity of a new model according to which the medical staff will work with teenagers.
This is why young people need services different from those rendered to adults and children. Experiences in Russia allow us to state that these services can be realized most efficiently in medical and social centers that meet the requirements similar to those of Youth Friendly Clinics (Table 2).
The following may be considered to be the first positive results of the medical and social services making use of the principles of Youth Friendly Clinics:
• adoption of new methods impossible to use in ordinary polyclinics; complexity of aid; change in
Table 1
Differences between the activities of therapeutic and prophylactic institutions and those of youth friendly clinics
Traditional therapeutic and prophylactic health institution for teenagers Youth Friendly Clinics
Aid mostly intended to diseased patients The aid is intended for healthy and diseased patients
Treatment Dealing with problem, prevention and treatment
Quality criteria — assessment by the fact of the aid Quality criteria — repeated visits
Particular specialization of the aid (medical) Complex aid (medical, psychological, social, legal)
Traditional problems, first of all treatment of somatic diseases Untraditional problems typical for a period of becoming adult with which they do not go to an ordinary clinic
Directional model: • a decision is taken by the specialist Cooperation model: • a decision is taken jointly with the person who needs advice
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Table 2
The activity indices of district specialists of the adolescent reproduction health care service in St. Petersburg
Indices District child and juvenile gynecologists (26 specialists) Consultations for teenagers (28 specialists) Total
Number of consultations on contraception 5407 27438 32845
Number of contraceptive users 2766 12337 15103
Combined oral contraceptives included (COC) 1709 8415 10124
Number of COC refusals 104 157 261
Consultations for young pregnant girls 55 1691 1746
Consultations after medical abortion 53 899 952
Consultations for boys — 1070 1070
Table 3
Number of pregnant girls under 18 according to the data presented by the Juventa clinic between 2001 and 2005
Indices 2001 2002 2003 2004 2005
The total number of pregnant young girls 1481 1521 1533 1527 1549
Among these:
• repeated pregnancies 192 195 154 148 149
• combined with infection 566 539 576 568 582
• threatening abortion 21 28 33 31 29
• more than 12-week pregnancy 146 138 176 153 168
• wish to keep pregnancy 105 98 101 106 104
psychology of medical staff; high value and independence in the work of paramedical personnel, especially when performing prophylactic examinations, when informing about the habits of a healthy life-style, and when consulting on contraception; team work; complex training of personnel;
active participation of young people (volunteers) in the work of the service, which is often headed by paramedical personnel from a Youth Friendly Clinic
• teenagers become more informed and the attitude towards their own health improves as well. Such services also improve their attitudes towards children's polyclinics.
Recently in St. Petersburg there has been a decrease in the number of abortions performed on young girls in spite of a marked increase in sexual activity (Table 3 and Fig.1).
Particular attention should be paid to the percentage who wanted to keep their pregnancy (less
Fig.1. Dynamics of the number of abortions performed on young girls according to the data of Juventa, St. Petersburg
Fig. 2. Number of patients who have completed a rehabilitation course after the interruption of a pregnancy
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Table 4
Post abortion complications in patients under 18
Complication Patients who had rehabilitation (%) Patients with no rehabilitation (%)
Acute hematometra 0,1 0,2
Subinvolution of uterus 3,7 1,1
Menstrual cycle disorders 1,2 4,3
PID 1,1 4,9
Fetal debris 0,4 2,2
Total: 6,5 12,7
than 10% in comparison with 30% and more in the RF and less than 10% of the repeatedly pregnant compared with 30% in the RF) as well as to the high rate of vaginal infectious diseases, a fact that leads to the abortion requiring thorough preopera-tive preparations.
The introduction of rehabilitation measures in the day time hospital of Juventa led to a significant decrease in the number of complications, especially remote such, following an artificial abortion (Table 4, Fig. 2).
Fig. 3. Percentage of repeated abortions in young women of St. Petersburg according to data from Juventa
Fig. 4. The availability of reproductive health care services decreases the risk of STDs in teenagers
Beginning in 1996, the use of combined oral contraceptive drugs in young patients increased by 24.3%, which reduced the number of abortions in under-age patients in St. Petersburg by more than a factor of two.
In comparison with data for 1996, the number of repeated abortions in young girls decreased by a factor of 4 (Fig. 3).
Teenagers consulting the family planning center express that for them the most acceptable and popular means of contraception are condoms and combined oral drugs. At present, considering the peculiarities of juvenile sexual behavior, these two methods are more often practiced simultaneously, which has resulted in a decrease of STI cases in adolescents and an increase in their appealability to medical and social centers.
The availability of medical and social services (YFC) makes pediatric polyclinics more attractive to adolescents, which increases the level of their prophylactic work and medical examination, decreases the risk of pregnancy and sexually transmitted infections in teenagers and contributes to the preservation of the reproductive potential of the country.
References
1. Gurkin Yu. A. Gynecology of teenagers / Gurkin Yu. A. — St. Petersburg, 2000. — 573 p. [in Russian]
2. Gurkin Yu. A. The grounds of juvenile obstetrics / Gurkin Yu. A., Susloparov L. A., Ostrovskaya E. A. — St. Petersburg, 2001. — 352 p. [in Russian]
3. Baklayenko N. G. The present state of the youth's reproductive health care / Baklayenko N. G., Gavrilova L. V. // Public Health Service of the RF. — 2000. — N 7. — P. 26 - 33.
4. GavrilovaL. V. Reproductive behavior of the Russian Federation population nowadays / Gavrilova L.V. — M., 2000. — 160 p. [in Russian]
5. Reproductive potential of the youths — future fathers / Yuriev V K. [et al.] — St. Petersburg, 2000. — 170 p. [in Russian]
6. Clinics friendly to youths (a manual for organizers). — Novosibirsk, UNISEF, 2002. — 235 p. [in Russian]
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