7.7 Making health facilities more youth friendly
In Italy, Law no. 405 of July 29, 1975 has established family counseling in order to intervene in the support and protection of the family or the individual. The counseling centre is a territorial social and health service managed by the Regions through the Local Health Authorities: it is a public service that falls within the services of the SSN (the National Health Service).
The clinic’s main purpose is to provide:
• Psychological and social assistance for the preparation and support to parenting.
• Psychological support to the individual, the couple or the family unit.
• Women's health protection and support services.
• Prevention of maltreatment and abuse of minors and women.
• Gynecological and pediatric medical examinations.
• Birth preparation classes.
• Professional advice and information on responsible procreation.
• Contraception and fertility; counseling on voluntary termination of pregnancy (IVG).
• Psychological listening space specifically aimed at young adults and adolescents.
Among the initiatives aimed at making health facilities more suitable for young people, there is the establishment of a “youth space”, an environment reserved and dedicated to young people aged 14 to 20 for assistance and advice on problems related to sexuality, emotional and relational life, gynecology and andrology.
The activities promoted by the Youth Counseling Centre are diverse and have different professional figures:
- the gynecologist, who advises on the health of the female genital system, carries out medical examinations, offers advice on contraception, sexuality, STD (sexually transmitted diseases), infertility problems, follows up on pregnancies and also carries out interviews for those who decide to voluntarily terminate the pregnancy.
- the obstetrician, who welcomes new users and guides them in the service, carries out education in personal hygiene and pregnancy; follows physiological pregnancies and also carries out prevention activities for cervical and breast cancers, through the execution of pap tests and through the teaching of breast self-examination;
- the psychologist, who carries out a series of consultation activities concerning inherent psychological-relational problems, the individual, the peer group, the bond with adults, the couple, and with respect to problems related to situations of bullying and cyberbullying. When facing clinically relevant cases, also personally follows the transition to the services responsible for treatment.
The youth space can be accessed free of charge, without a prescription, in addition to moments of external consultancy with a social worker and a dietician.
1.Monitoring and evaluation
There is no mere strategy for monitoring and evaluating consultants, however, 35 years after their establishment, the Istituto Superiore di Sanità as part of the project carried out by the National Centre for Disease Prevention and Control “Analysis of the activities of the network of family clinics for a reassessment of their role with reference also to problems relating to endometriosis", carried a survey on the 1800 family consultants present on the Italian territory, coordinated by the Women’s Health and Developmental Department of the ISS. All the Regions and Autonomous Provinces joined the project. The data collection began at the regional level in November 2018 and ended with the collection in the individual counseling offices in July 2019.
It emerged that in 5 regions the counseling centres are based in the Maternal and Child Department, in 2 regions in the Department of primary care, in 7 regions they report to different Departments and in 5 they are not part of a Department but of a District. Private counseling centres are present in 6 regions and an autonomous province and are more numerous in the northern regions. Almost all the regions have set up corporate Birth Pathways Committees dedicated to monitoring and improving care in pregnancy, childbirth and the puerperium in collaboration with the regional level.
Assistance with the birth path, the voluntary interruption of pregnancy path and access to the youth space are free services guaranteed in all the regions. Five regions provide for the payment of a ticket for some services: tests for sexually transmitted infections/diseases, visits for menopause, psychological and sexological counseling, psychotherapy and contraception.
Almost all the consultants participating in the survey (1535 out of 1800; 622 in the North, 382 in the Center and 531 in the South) operate in the field of women's health. More than 75% of the consultants deal with sexuality, contraception, IVG pathway, pre-conceptional health, birth path, sexually transmitted diseases, oncological screening and menopause and post-menopause.
As part of the birth path, the clinic takes care of pregnancies with low obstetric risk and actively offers Courses of Accompaniment to Birth (CAN) and support for breastfeeding.
Regarding the couple, family and youth area, there are 1,226 (North 504, Center 224, South 498) counseling centres that carry out activities in this area. The areas covered are contraception, sexuality and reproductive health, sexually transmitted infections/diseases and relationship distress. Among the counseling centres that have carried out activities in schools, the most frequent theme is emotional and sexual education (94%), followed by lifestyles, bullying and cyberbullying; programs to prevent the use of substances are less frequent, but they are also in charge of other services. The professional figures most represented in the counseling centres are the gynecologist, the obstetrician, the psychologist and the social worker, with great suffering and variability in terms of staff between regions. Taking as an indicator the average number of weekly working hours per 20 thousand inhabitants foreseen for the various professional figures to respond to the institutional mandate, only 5 Northern regions reach the expected standard for the figure of the midwife, 2 for the gynecologist, 6 for psychologist and none for the social worker who in the South records an average number of hours per week (14) which is almost double compared to the Centre (8 hours) and the North (9 hours).
This first photograph of the Istituto Superiore di Sanità shows that in our country there are still few family clinics with respect to the needs of the population (1 clinic for every 35,000 inhabitants although they are recommended in the number of 1 every 20,000).
Another high-level initiative to make health facilities more suitable for young people is the Valore project (Local and Regional Assessment of HPV vaccination campaigns), launched in 2010 and concluded in 2013, funded by the National Centre for Disease Control (CCM) of the Ministry of Health, coordinated by the National Center for Epidemiology, Surveillance and Health Promotion (Cnesps) of the Higher Institute of Health and conducted in collaboration with the ASL and the Regions
The project aims to improve adherence to vaccination against HPV and to provide local health authorities and regions with some operational tools, with the ultimate aim of increasing vaccination coverage throughout the country. To achieve these objectives, as part of the project, an attempt was made to explore, with various activities, the points of view of the various actors involved in vaccination against HPV. In order to raise awareness among young women of the importance of vaccination against HPV and to bring them closer to the health facilities in charge, the project has tried to shed light on the points of view, considerations and needs of this particular user group, through a series of focus groups in which girls from the second grade of middle school were involved. In addition, an integrated offer of vaccinations for adolescents was proposed that includes all vaccinations provided for this age group (Hpv, dTP, MPR, chicken pox, meningococcus). With a view to making vaccination facilities closer and better known to young people, the project has encouraged collaborations with schools, through information/educational meetings with parents and children and vaccination days and has promoted an “activist” attitude of the Institutions on the internet, providing clear, complete and transparent information, monitoring the sites of the anti-vaccination movements and intervening on the contents considered misleading.
2.Funding of the Valore project
The project was funded with € 228,000 by the National Centre for Disease Prevention and Control (CCM) of the Ministry of Health.
At the end of the Valore project, an operational document “Areas of action and proposals to improve adherence to the HPV immunization program” was prepared which, in addition to providing a brief summary of the project results, describes the critical issues identified in the offer of vaccination against HPV, the areas of intervention identified and proposes some practical actions to promote adherence to HPV vaccination and improve vaccination coverage. To achieve these objectives, we tried to explore, with various activities, the points of view of the various actors involved in vaccination against HPV, namely:
- the contact persons of the Asl and Regions for vaccination against HPV, with a survey on the vaccination campaigns carried out in the Regions and Asl, aimed at evaluating the organizational, logistical and communicative aspects and collection of information material used in vaccination campaigns (letters, brochures, posters, invitation letters, etc.)
- families, with a study on the reasons for non-vaccination, aimed at furthering the point of view of the families of a sample of girls who, invited to be vaccinated, did not join the vaccination program
- pre-adolescent girls, with focus groups in which girls from the second grade of middle school were involved
- health professionals, with focus groups, in which various health professionals (pediatricians, general practitioners, gynecologists and vaccination services operators) were involved and with an online survey addressed to all health professionals to understand their opinions and attitudes towards vaccination against HPV.
The integration of the results obtained from the different activities of the project has made it possible to identify the critical issues encountered during the promotion and offer of vaccination against HPV and the “areas of action” to work on to improve adherence to the vaccination program for HPV and, more generally, compliance with vaccinations. Among the main areas identified:
- increasing the knowledge of health workers on the subject of HPV and vaccination, including aspects related to counseling
- study of the risks and benefits of vaccination through clear, transparent, exhaustive and documented communication
- strengthening the role of vaccination services as a reference point for vaccinations, both for the population and for local health workers
- reorganization of operating procedures to ensure an active offer of vaccinations with appropriate methods of vaccination counseling
- development of a network between vaccination services and local health workers for the promotion of vaccinations, which provides for a sharing of the message and communication objectives
- encouraging the active role of local health workers, including pediatricians and general practitioners, whose activity is crucial in communicating directly with families and girls, to implement an informed decision-making process
- integrated offer of vaccinations for adolescents through the proposal of a vaccination package that includes all vaccinations provided for this age group (Hpv, dTP, MPR, chickenpox, meningococcus)
- enhancement and integration of the institutional role at central, regional and local level
- adoption of good vaccination practices to improve vaccination compliance (for example: indicate in the vaccination invitation letter the date of the vaccination session at the vaccination service and a telephone line to obtain information, attach information material to the invitation letter, introduce the reminder active of defaulting girls on first call)
- encouraging collaboration with schools, through information / educational meetings with parents and children and vaccination days
- promotion of an "activist" attitude of the Institutions on the internet, providing clear, complete and transparent information, monitoring the sites of the anti-vaccination movements and intervening on the contents considered misleading
- improving the access of non-Italian families to information on vaccinations.
From the various activities, the crucial role of the health worker in the decision-making process of families emerged. For this reason, a package has been created that makes available, for the Regions and the Local Health Authorities, educational materials to be used for training courses aimed at healthcare professionals involved at different levels in vaccination against HPV: vaccination service operators, clinic operators, cervical screening service operators, general practitioners, pediatricians, gynecologists and other professionals involved in the HPv problem. The teaching material consists of 4 modules that can be used, even separately, for the organization of seminars and training meetings:
- Epidemiology of HPV and cervical cancer
- Vaccination against HPv
- Vaccination strategies and monitoring of vaccination against HPv
- Communication strategy planning: methods and tools for effective communication.
Each module consists of a set of slides, accompanied by an explanatory text and bibliographic references for further study of the issues. The goal is to give maximum dissemination to the products made, so that they can be of practical support at the regional and local levels in the organization of the next vaccination campaigns for HPV.