1. Advancing Training in Adolescent Medicine for upgrading the quality of health care for Adolescents Christos Kattamis M.D. Emeritus Professor of Pediatrics Athens University, School of Medicine 4 th Joint Meeting on Adolescent Medicine Catanzaro 12-14 October 2010

2. Main Objective of Pediatrics The concern of the health of infants, children and youths, their growth and development and their opportunity to achieve full potential as adults. The concern of the health of infants, children and youths, their growth and development and their opportunity to achieve full potential as adults. Nelson’s Textbook of Pediatrics

3. Definition of Adolescence (Derives from the latin word adolescere meaning grow into maturity) «Adolescence refers to the stage of human development encompassing the transition from childhood to adulthood. Is broader than puberty, the period of biological changes and sexual maturation, including in addition the period of psychological and sociocultural dimensions of developmental maturation»

5. Factors influencing prolongation of transmission period Extreme changes in cultural and socioeconomic conditions of modern societies Extreme changes in cultural and socioeconomic conditions of modern societies Relevant favoring factors Relevant favoring factors  Increase affluence  Prolonged education period  Structure change in family, school, society  Socioeconomic-environmental conditions Comment: Prolonged adolescence created new health problems for adolescents (rise in psychosocial mental disorders, substance misuse, antisocial disorders and others)

6. WHO Terminology Adolescents: People aged 10-19 years Adolescents: People aged 10-19 years Youth: People aged 15-24 years Youth: People aged 15-24 years Young people: People aged 10-24 years Young people: People aged 10-24 years Adolescence subgroups Early: 8-11 years Early: 8-11 years Middle: 12-16 years Middle: 12-16 years Late: 17-20/24 years Late: 17-20/24 years Adolescence period in literature: 10-19; 12-19; 12-24; 15-24 yrs and other 10-19; 12-19; 12-24; 15-24 yrs and other

7. Adolescents Population (10-24ys) worldwide Total: 1.75 billions Total: 1.75 billions In developing countries: 1.5 billions In developing countries: 1.5 billions In least developed nations: more than one third of population In least developed nations: more than one third of population The poorer the country the younger its population, and the higher the mortality and morbidity rates The poorer the country the younger its population, and the higher the mortality and morbidity rates

8. Diseases with increasing morbidity rates in America’s Adolescents Sexually Transmitted Diseases Sexually Transmitted Diseases Mental Health Conditions Mental Health Conditions Obesity Obesity Substance abuse or substance depended disorders Substance abuse or substance depended disorders 26%21%16% 8% 8%

10. Fundamental Principles incorporated in Lancet’s papers for adolescent health care (8) Rapidly change of social context created new and unexpected priorities Rapidly change of social context created new and unexpected priorities Health and ill health are better understood as a result of complex interplay between biological, psychological and sociological factors Health and ill health are better understood as a result of complex interplay between biological, psychological and sociological factors Sociological factors have global reach in their effect on young people Sociological factors have global reach in their effect on young people

11. Topics for discussion The demography of adolescents health care in Europe and other countries The demography of adolescents health care in Europe and other countries The youth friendly health care services; their contribution to upgrade the quality of adolescents health The youth friendly health care services; their contribution to upgrade the quality of adolescents health The necessity of advanced training in adolescent medicine of the workforce of health care services The necessity of advanced training in adolescent medicine of the workforce of health care services

12. Systems of primary pediatric- adolescent health care services The pediatric system: More than 75% of children and adolescents are under the care of pediatricians The pediatric system: More than 75% of children and adolescents are under the care of pediatricians The general practitioner (GP) and/or family physician (FP) system: GP and FP follows > 75% of the population The general practitioner (GP) and/or family physician (FP) system: GP and FP follows > 75% of the population The combined system (Pediatric - GP/FP), offers care to almost equal number of pediatric population (50 ± 25%) The combined system (Pediatric - GP/FP), offers care to almost equal number of pediatric population (50 ± 25%)

13. Types and distribution of primary health care services in Europe (UNESPA, survey) SystemCountriesRemark Pediatric6/29 GP/FP9/29 UK, *Denmark, Norway, *Netherlands, *Portugal, Spain, Switzerland, *Estonia Combined14/29 Germany, France, Italy, Sweden and others * No pediatrician in primary health care for adolescents

14. Additional findings of UNEPSA survey Variations of the upper age limit of adolescents under pediatric care, for in and out patients Variations of the upper age limit of adolescents under pediatric care, for in and out patients Difficulties in hospitalization and lack of special wards for adolescent’s inpatient care Difficulties in hospitalization and lack of special wards for adolescent’s inpatient care Lack of proper training and confidence of the majority of physicians in adolescent’s health care services Lack of proper training and confidence of the majority of physicians in adolescent’s health care services

16. Important attributes of quality health care For all age groups: For all age groups:  Access,  Affordability  Clinical effectiveness  Empathy For children requires in addition: For children requires in addition:  Relation of pediatrician with families and institutions (schools, child care providers) For adolescents: For adolescents:  The pediatrician’s support to patients and families to develop: autonomy, responsibility and adult identity

17. Types for the provision of youth-friendly services (21) Centre specializing in adolescent health. It is set in a hospital and provides inpatient and drop in services to young people, serves as referral centre for nearby health facilities and provides training and research. Centre specializing in adolescent health. It is set in a hospital and provides inpatient and drop in services to young people, serves as referral centre for nearby health facilities and provides training and research. The community based health facility. The facility caters for young people in the context of health services to all segments of the population. It is a model of stand alone unit that is run by the government or non-governmental organizations. The community based health facility. The facility caters for young people in the context of health services to all segments of the population. It is a model of stand alone unit that is run by the government or non-governmental organizations. School or college based health services and centers linked with schools or colleges. School or college based health services and centers linked with schools or colleges. Community based centre that provides other services in addition to health. They provide health information, some health services and links with nearby health facilities for adolescents. Community based centre that provides other services in addition to health. They provide health information, some health services and links with nearby health facilities for adolescents. Pharmacies and shops selling health products (condoms etc) Pharmacies and shops selling health products (condoms etc) Outreach information and service provision. Efforts to distribute health information, health products and services to marginalized young people (bars, malls, factories, schools etc). Outreach information and service provision. Efforts to distribute health information, health products and services to marginalized young people (bars, malls, factories, schools etc).

18. WHO guide for development of youth friendly services (21) An equitable point of delivery (equitable provision and experience of care. In all patients. regardless of status) An equitable point of delivery (equitable provision and experience of care. In all patients. regardless of status) An accessible point of delivery (health services are free or affordable to all young people at convenient location and working time with community support) An accessible point of delivery (health services are free or affordable to all young people at convenient location and working time with community support) An acceptable point of delivery An acceptable point of delivery  Policies and procedures guarantee confidentiality for all  Health care providers are well educated, informed and motivated to work with youths  Point of delivery ensures privacy, has clean and safe environment, and  Young people are actively involved in the assessment and provision of health services Appropriateness of health services for young people Appropriateness of health services for young people  Health services are provided for all young people either at delivery or referral linkages Effective health services for young people Effective health services for young people  Health care providers are competent, have technical facilities and follow proper guidelines and sound protocols  Points of service delivery are fully equiped

19. Proposed options of training in Adolescent Medicine to improve quality of health services Enriching medical education programs in Adolescent Medicine topics Enriching medical education programs in Adolescent Medicine topics Formulation of efficient training programs in Adolescent Medicine (European and other countries) Formulation of efficient training programs in Adolescent Medicine (European and other countries) Implementation of advanced postgraduate programs for Adolescent Medicine subspecialty in Pediatrics, Family and Internal Medicine Implementation of advanced postgraduate programs for Adolescent Medicine subspecialty in Pediatrics, Family and Internal Medicine

20. Enriching medical education programs Adolescent Medicine topics should supplement: Adolescent Medicine topics should supplement:  Undergraduate and postgraduate (especially in pediatric residency curriculum)  UK favors delivering adolescent medicine training to all health professionals, rather than creating a separate workforce or specialty. The same option is shared by other countries

21. Formulation of efficient teaching and training programs in Adolescent Medicine in Europe The European training in Effective Adolescent Health Care (EUTEACH) The European training in Effective Adolescent Health Care (EUTEACH) The program developed by adolescent health professionals from 11 European countries and offers an effective and efficient training curriculum. It is managed by the “Multidisciplinary Unit of Adolescent health” in Lausanne and is freely available to all health professionals.The Unit also run an annual one week summer school The Israel’s “Alternative Effective Procedure of Training in adolescent Medicine where formal training program is not available” The Israel’s “Alternative Effective Procedure of Training in adolescent Medicine where formal training program is not available” The program includes a hospital and community based multidisciplinary adolescent health service and a diploma course (6 semesters of weekly 4 hours meeting). The course creates physicians who are able to operate adolescent clinics and teach adolescent medicine.

22. Fellowship programs in Adolescent Medicine Developed in USA since 1994 by the Boards of Pediatrics, Family Medicine and Internal Medicine and lead to Adolescent Medicine Certificate. The ABP issues the certificate to Pediatricians after a 3 years fellowship and successful examinations. 25 institutions in 15 states operate fellowship programs. Up to 2007 more than 500 pediatricians have been certified, distributed unevenly within the 50 states. The physician to child ratio ranges from 0 to 3.7 per 100.000 children. Only in 7 states the ratio is more than 1. Developed in USA since 1994 by the Boards of Pediatrics, Family Medicine and Internal Medicine and lead to Adolescent Medicine Certificate. The ABP issues the certificate to Pediatricians after a 3 years fellowship and successful examinations. 25 institutions in 15 states operate fellowship programs. Up to 2007 more than 500 pediatricians have been certified, distributed unevenly within the 50 states. The physician to child ratio ranges from 0 to 3.7 per 100.000 children. Only in 7 states the ratio is more than 1.

23. Efficacy of training in Adolescent Medicine during pediatric residency and Adolescent Medicine fellowship programs in USA Significant variations and gaps disclosed in both programs throughout the USA. Significant variations and gaps disclosed in both programs throughout the USA. The main gaps affect: The main gaps affect:  The coverage of topics important to adolescent health care (injury and violence, prevention, mental and behavioral health and others)  The availability of facility to teach adolescent medicine especially in pediatric residency  The ambulatory care training experience

24. Proposed Reform options to improve Education Training in Adolescent Medicine in USA Extending the one month Adolescent Medicine rotation in pediatrics Extending the one month Adolescent Medicine rotation in pediatrics Introducing more flexibility in residency programs Introducing more flexibility in residency programs Covering a combined pediatrics/adolescent medicine residency Covering a combined pediatrics/adolescent medicine residency Supplementation of pediatric residency with one year adolescent medicine clinical training program Supplementation of pediatric residency with one year adolescent medicine clinical training program

25. Commentary on: “Meeting the needs of Adolescents: Pediatric Medical Education and Workforces Development” in Pediatrics concludes: “Preparing future pediatricians to provide high quality adolescent health care is necessary, but not sufficient for improving adolescent health services and reducing existing disparities. Adolescent access to care and a coordinated primary care system linked to community programs are also essential”

26. Conclusions (1) The health of adolescents is an issue of: The health of adolescents is an issue of:  quality care  professional education  personal, family and society responsibility A priority for those responsible for adolescent health is to ensure support and provision of innovative well assessed youth friendly service. A priority for those responsible for adolescent health is to ensure support and provision of innovative well assessed youth friendly service.

27. Conclusions (2) Quality of health care for adolescents varies widely. Quality of health care for adolescents varies widely. USA, Canada and Australia are notable exceptions with dedicated multidisciplinary adolescent health care centers, active appropriately trained adolescent health physicians and active adolescent medicine societies. USA, Canada and Australia are notable exceptions with dedicated multidisciplinary adolescent health care centers, active appropriately trained adolescent health physicians and active adolescent medicine societies. In well developed countries Institutions, Societies and others are working on initiatives to improve the quality of health care for adolescents in their regions. In well developed countries Institutions, Societies and others are working on initiatives to improve the quality of health care for adolescents in their regions. Reforms for advanced training in Adol. med in all levels of medical education are of primary importance to improve the quality of health care services. Reforms for advanced training in Adol. med in all levels of medical education are of primary importance to improve the quality of health care services.

28. Conclusions (3) A major objective of MAGAM is to support member countries of Mediterranean and Middle East regions, to develop and implement programs of adolescent health care and improve education and training in adolescent medicine. A major objective of MAGAM is to support member countries of Mediterranean and Middle East regions, to develop and implement programs of adolescent health care and improve education and training in adolescent medicine. The recent predominating issue of MAGAM and Italian Society of Adolescent Medicine concerns the upgrade of collaboration of member countries in research and education in adolescent medicine. The recent predominating issue of MAGAM and Italian Society of Adolescent Medicine concerns the upgrade of collaboration of member countries in research and education in adolescent medicine. The establishment of a permanent School of Adolescent Medicine, by Prof Raiola, will facilitate the integration of the major objectives of the two Societies. The establishment of a permanent School of Adolescent Medicine, by Prof Raiola, will facilitate the integration of the major objectives of the two Societies.