Module 7 Sexual and Reproductive Health of Adolescents

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					                Integration of Adolescent Health and Development Domains into pre-service nursing curriculum



Prepared for integrating of Adolescent Health and Development Domains into
pre-service nursing curriculum at The Hong Kong Polytechnic University, World
Health Organization Collaborative Centre for Community Health Services.
Supported by WHO, Western Pacific Regional Office


                                      Module 7
                     Sexual and Reproductive Health of Adolescents

I.       Introduction

Unwanted and unprotected sexual relations among young people increase the risks associated
with too early and unwanted pregnancy and childbirth, reproductive tract infections, and
sexually transmitted diseases including HIV infection. In both sexes, these problems may be
devastating; in young women, they curtail education and employment prospects, and often
carry a social stigma (WHO 1997).

II.      Learning objectives

Upon completion of this module, learners will be able to:

1. Differentiate between sexual health and reproductive health
2. Develop appropriate attitudes and counselling skills to address adolescent sexual concerns
3. Work with adolescents to improve their knowledge, understanding, informed
   decision-making and sense of responsibility in relation to sexuality, the range of sexual
   expression, the risks and consequences of sexual activity, contraception, fertility and
   gender issues
4. Be familiar with sexual and reproductive health services in the local context, including
   antenatal, labour and postnatal programmes, to make provision for adolescent boys and
   girls




     Sources:
     1. World Health Organization. (2009). World Health Organization: Adolescent Job Aid. World
     Health Organization.
     2. World Health Organization. Orientation Program on Adolescent Health for Health-care
     Providers. Facilitator Guide - New Modules. World Health Organization.
     3. World Health Organization. Orientation Program on Adolescent Health for Health-care
     Providers. Handout - New Modules. World Health Organization.



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III.     Content

Upon completion of this module, learners will be able to:

•      Differentiate between sexual health and reproductive health
•      Develop appropriate attitudes and counselling skills to address adolescent sexual concerns
•      Work with adolescents to improve their knowledge, understanding, informed
       decision-making and sense of responsibility in relation to sexuality, the range of sexual
       expression, the risks and consequences of sexual activity, contraception, fertility and
       gender issues
•      Be familiar with sexual and reproductive health services in the local context, including
       antenatal, labour and postnatal programmes, to make provision for adolescent boys and
       girls




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             Integration of Adolescent Health and Development Domains into pre-service nursing curriculum


Objective 1: Differentiate between sexual health and reproductive health


Activities

 Activity 7.1: Group discussion

 Discuss the issues of adolescent sexuality raised in the video, and their implications.

Definitions of Sexual Health

According to the WHO (2003), sexual health is the integration of the physical, emotional,
intellectual and social aspects of the sexual being, in ways that are enriching and that enhance
personality, communication and love.

There are three elements that should inform discussions of sexuality and health:

•   the capacity to enjoy and express sexuality without guilt or shame in fulfilling, emotional
    relationships
•   the capacity to control fertility
•   freedom from disorders which compromise health and sexual or reproductive function

According to Camden & Islington National Health Service Trust, London, UK, sexual
health?/sexuality? is defined as “Enjoyment of affirmative sexual relationships, behaviours,
identities and lifestyles of one’s choice, avoiding unwanted sexual outcomes, including
physical or psychological harm” (cited in WHO, 2003).

Thus, sexual health is the right and option of an individual to express sexuality and enjoy
sexual practices, made with informed consent, within a non-judgmental and
non-culturally-biased environment, with access to good health care.

Definition of Reproductive Health

•   A state of complete physical, mental and physical well-being
•   Not merely the absence of disease or infirmity
•   All matters relating to the reproductive system, its function and processes
•   Safe sex practice
•   Safe pregnancy and childbirth




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Local data on sexual activity among adolescents in Hong Kong


                                                         World Health Organization




                                                                                     Orientation Programme on Adolescent Health for Health-care Providers




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Objective 2: Develop appropriate attitudes and counselling skills to address adolescent
sexual concerns


Attitudes of health care professionals

When health care providers discuss and work with adolescents who are victims of
gender-based violence or sexual abuse, they should:

•   Listen carefully to the need of adolescents
•   Create an atmosphere of respect and privacy and establish trust between each other
•   Help adolescents to express their feelings and clarify any problems
•   Treat any medical problems
•   Provide information on emergency contraception and a pregnancy test, as well as services
    for STD or HIV screening and treatment
•   Provide information and refer adolescents to specific organizations which can give more
    legal advice and mental health counselling




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Tips for helping a pregnant adolescent

Assessment

1. Assess the adolescent’s maturational experience as well as synergism among various
   developmental skills.
2. Explore whether the adolescent mother functions appropriately in interpersonal settings
   with her family and peers.
3. Ascertain whether conflict exists between the adolescent mother and her own parents,
   especially her mother, and whether her family provides her with adequate emotional
   support.
4. Assess the adolescent’s emotional capacities, i.e. try to ascertain whether she can regulate
   her emotions to avoid risk-taking behaviour.

Interventions

1. After the assessment, an appropriate treatment plan should be designed. To accomplish
   this, we should target the area of dysfunction. For example, if friction exists between
   the adolescent and her family, a protocol of family treatment would be recommended.
   Dysfunction emanating within peer relationships might lead to the recommendation of
   peer group participation.
2. Encourage the adolescent mother and her family members to explore their feelings and
   predict outcomes.

The goals of providing counselling for pregnant adolescent

1. Reduce anxiety so that the pregnant teenager can concentrate on the decisions she has to
   make.
2. Create a safe environment in which she can discuss her hopes and fears about her
   decision.
3. Impart knowledge and facts about the various options and their implications.
4. Identify the teenager’s strengths and support systems.
5. Clarify her choices and her feelings about her choices.
6. Help her accept responsibility for her decision.
7. Help her act on her decision, with referrals as needed.
8. Support her decision.




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Tips for counsellors of pregnant adolescents (appropriate attitudes and counselling
skills)

•   Counsellors must remain neutral and non-directive, letting the teenager reach a decision
    that is right for her.
•   Counsellors should provide information about each option so as to give the pregnant
    teenager a true sense of the options.

Remarks:

Pregnant adolescents need caring, compassion, and options, not judgments. If you do not
feel you can provide unbiased information to a teen in this situation, the fair thing to do is to
refer her to someone who can (RCAPP).

Tips for counsellors

•   Prepare in advance; make certain you know what to do in your setting when an abused or
    pregnant adolescent is identified; be aware of potential referrals, resources, etc.
•   Interview the adolescent in private.
•   Ask the adolescent whether she has been harmed or if she feels unsafe. This is also part
    of the regular prenatal care interview.
•   Make certain that a physical examination identifies any injuries; document all evidence of
    injury, as well as the client’s explanation of how the injury occurred.
•   Discuss a plan for the adolescent’s safety.
•   Provide appropriate education about violence and abuse.
•   As indicated, follow local guidelines for reporting physical/sexual abuse.

Tips for parents to help their teens prevent teen pregnancy

The counsellor can deliver these messages to the parents:

•   Be clear about your own sexual values and attitudes
•   Talk with your children early and often about sex, and be specific
•   Supervise and monitor your children and adolescents
•   Know your children's friends and their families
•   Help your teenagers to have options for the future that are more attractive than early
    pregnancy and parenthood
•   Know what your kids are watching, reading, and listening to (NCPTP)




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Objective 3: Work with adolescents to improve their knowledge, understanding,
informed decision-making and sense of responsibility in relation to sexuality, the range
of sexual expression, the risks and consequences of sexuality activity, contraception,
fertility and gender issues


Identify some risks and consequences of adolescent sexuality

Risks factors that are related to reproductive health

•    Curiosity
•    Self-image
•    Peer pressure
•    Gender difference
•    Stress
•    Socio-economic status
•    Sexual education

Be familiar with the relevant country’s statistics on the reproductive health of adolescents:

1.   population figures
2.   fertility rate
3.   contraceptive use
4.   birth rate
5.   fertility rate of adolescents

What does sex mean to adolescents?            (Gender difference)

•    Young men often believe that sexual initiation affirms their identity as men and gives
     them status in the male peer group
•    Girls’ and women’s prescribed roles in sexual relations are often passive

Gender affects the reproductive health of youth

Gender involves roles that are determined by society and culture.

Gender affects:
• Expectations of sexual activity of boys and girls
• Views regarding responsibility for contraception
• Social consequences of pregnancy
• Cultural acceptance of harmful behaviours and practices

Reproductive health risks --- gender-based violence and sexual abuse

•    Sexual violence -- an umbrella term for rape, sexual assault, sexual harassment, child
     sexual abuse and incest
•    Domestic violence -- an act of violence committed by a husband or wife against the other
     spouse or by any member of a family against another member of the same family.




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             Integration of Adolescent Health and Development Domains into pre-service nursing curriculum


Adolescent pregnancy

•   Any woman getting pregnant during adolescence
•   Great impact in terms of physical and psychological consequences for adolescent women
•   Appropriate attitudes and counselling skills are needed to address adolescent concerns

Common features of adolescent pregnancy and birth

•   Delayed management
•   Maternal complications
•   Infant complications
•   Impact on self-esteem

Identify the psychological consequences of adolescent parenthood

•   Psychological and developmental impact
•   Family life, adolescent mother and father, their child and the origin family
•   Educational impact, career problems
•   Economic impact
•   Early marriage and consequences
•   Child neglect




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              Integration of Adolescent Health and Development Domains into pre-service nursing curriculum


Objective 4: Be familiar with sexual and reproductive health services in the local
context, including antenatal, labour and postnatal programmes, to make provision for
adolescent boys and girls

A.     The physiology of pregnancy

Pregnancy

To provide care contributing to the good quality of life of both mother and baby. This
includes:

•    Supervision of the pregnancy
•    Education
•    Psychological and physical preparation
•    Support




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*Refer to the WHO Adolescent Job Aid Part 2 menstrual and pregnancy p.36-83




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Presumptive evidence

•    Amenorrhoea
•    Morning sickness
•    Bladder symptoms
•    Vaginal discharge
•    Breast changes
•    Skin pigmentation
•    Quickening


B.     Antenatal care services

Advice to pregnant women

It is very important to educate and prepare pregnant women for pregnancy, labour and child
rearing. Advice should include:

•    Nutrition
•    Exercise and rest
•    Personal hygiene
•    Dental care
•    Breast care
•    Clothing and footwear
•    Sexual activity
•    Avoidance of drugs, smoking and drinking
•    Travel
•    Attending subsequent visits
•    Seeking medical aid
•    Preparation and time for admission




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Onset of labour

•    Pains / Regular uterine contractions
•    Show
•    Leaking of amniotic fluid / Rupture of membranes
•    Shortening / Dilatation of cervix

C.     The postnatal care services

Normal puerperium

Psychological changes

•    Unstable mood, tearfulness, mild depression

Physical changes

•    Involution of the uterus
•    Lochia
•    Cervical change
•    Vulva and vagina
•    Perineum
•    Breasts
•    Urinary tract
•    Gastro-intestinal system
•    Cardiovascular system
•    Endocrine system

D.     Contraceptive methods

Contraceptive issues for young people

1. No medical reason currently exists to deny any method based on young age alone
2. Non-medical issues:
   • High-risk behaviour
   • Lack of accurate information
   • May not use methods consistently and correctly
   • Have unplanned and sporadic sexual activity
   • Lack of knowledge or access to emergency contraception

Limited contraceptive use: characteristics of youth

•    Tend not to plan ahead or anticipate consequences
•    Think they are not at risk
•    Feel invulnerable
•    Lack confidence or motivation for use
•    Embarrassed or not assertive
•    Lack power and skill to negotiate use
•    Social or cultural expectations or beliefs




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Natural & artificial contraceptive methods

1. Contraception
   • Natural methods of family planning
   • Abstinence
   • Hormonal methods
   • Intrauterine contraceptive device
   • Barrier methods
   • Permanent methods

 Discuss the effectiveness of different contraceptive methods

*Refer to the WHO Orientation Program on Adolescent Health for Health-care Providers.
Facilitator Guide - New Modules. World Health Organization. Module J Pregnancy
Prevention in Adolescents.

*Refer to the WHO Orientation Program on Adolescent Health for Health-care Providers.
Handout - New Modules. World Health Organization. Module J Pregnancy Prevention in
Adolescents.

2. Develop appropriate attitudes and counselling skills to address adolescent sexual concerns
   regarding contraception

What is contraceptive counselling?

It is a way to help the adolescent choose the most suitable method to prevent pregnancy and
protect against STDs and HIV/AIDS. The counselling should include:

•     Active listening
•     Providing correct information on contraception
•     Helping the adolescent to choose the most suitable contraceptive method

Important skills in contraceptive counselling:

1.    Build up a good relationship with the adolescent
2.    Use language that is easy for the adolescent to understand
3.    Give unbiased information and advice
4.    Reassure them that the conversation is confidential
5.    Understand their problems/difficulties
6.    Welcome them and help them to relax
7.    Help them to choose a suitable contraceptive method
8.    Ensure that they understand the information you have provided
9.    Use positive body language (e.g. nodding)
10.   Ask open-ended questions
11.   Arrange follow-up
12.   Use a sense of humour
13.   Don’t be judgmental
14.   Be patient
15.   Be friendly




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Options for adolescents with unintended pregnancy

1. Adolescents with unintended pregnancy

    •   According to the American Academy of Pediatrics, any adolescent who had been
        diagnosed as pregnant should be counselled about her three options, which include:
        1. continuing the pregnancy and parenting the child
        2. continuing the pregnancy and putting the child up for adoption
        3. obtaining a medical or surgical abortion

2. Risk factors or causes of unintended pregnancy

    •   Poor academic results in school
    •   Lack of educational goals
    •   Being from a poor / low income community
    •   Poor prospects for the future
    •   Recurrent pregnancies
    •   Experience of sexual abuse
    •   Early initiation into sexual activity
    •   Unprotected sexual activity
    •   Substance abuse

3. Applying for legal termination of pregnancy

•   In Hong Kong, in accordance with Section 47 of the Offences Against the Person
    Ordinance, two registered medical practitioners must concur with the following
    conditions and sign the consent form.

    1. Unconscious/Coma
    2. Minor
    3. Confused and unable to access family members

4. Unsafe abortion: statistics

According to the World Health Organization’s estimate in 2000:

•   13% of maternal deaths are related to unsafe abortion
•   70,000 women die from complications from unsafe abortions each year
•   Over half of the world’s unsafe abortion cases take place in Asia (about 10.5 million
    (Olukoya, 2000))

5. Complications of unsafe / illegal abortion

•   Bleeding heavily
•   Pelvic infection
•   Perforated uterus
•   Cervical injury
•   Septic shock




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6. Preventive measures for unsafe abortion

•   Education on effective contraceptive use so as to prevent unintended pregnancy
•   Giving adequate and accurate information to adolescents to enable them to identify safe
    abortion services
•   Providing post-abortion counselling to prevent further unintended pregnancy
•   To a certain extent, effective contraceptive use can help to prevent STDs; adolescents
    should be informed of this

7. Counsellor’s attitudes to abortion

•   Listen actively
•   Use both open and closed questions
•   Adopt non-judgmental beliefs and attitudes in order to establish a relationship of trust
•   Respect the adolescent’s decision
•   Give post-abortion counselling to prevent the recurrence of unintended pregnancy, which
    in turn may lead to abortion

8. Signs and symptoms of post-abortion complications

•   Fever and chills
•   Foul smelling discharge
•   Heavy bleeding
•   Severe abdominal pain

9. Family Planning Association Resources in Hong Kong

Youth Health Care Centre of FPAHK

•   Service provision
    − Sexual and reproductive health
    − Management of teenage pregnancy
    − Contraceptive counselling and supplies, including emergency contraception

•   Female service
    – Single
    – Under 26 years old

•   Young men’s sexual health service
    – 14-25 years old

•   Locations
    – Wan Chai
    – Mongkok
    – Tsuen Wan

•   Opening hours
    – 9:00 a.m. - 8:00 p.m.
    – Prefer booking by appointment



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V.    Summary

Establishing a sound information base on the health of adolescents and particularly their
sexual and reproductive health, through situation analyses in different settings, is now an
urgent priority. Using adolescents themselves as the primary source of information and
involving them in the research and the formulation of programmes will ensure relevance,
acceptability and long-term effectiveness. Creating a sense of ownership on the part of the
community and of adolescents themselves is the key to successful implementation of
programmes which will be enthusiastically and constructively received (WHO, 1997).




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VI.     References

•     Hockenberry, M., Wilson, D., Winkelstein, M., & Kline, N. (2007). Wong’s nursing care
      of infants and children. (8th ed.). St. Louis: Mosby.
•     Sexual and reproductive health of adolescents and youth in China: A review of literature
      and Projects 1995-2002. Amazon.Com Books.
•     World Health Organization. (1997). Coming of age: From facts to action for adolescent
      sexual and reproductive health. Geneva: World Health Organization.
•     World Health Organization. (1998). Adolescent Health & Development: The second
      decade. Western Pacific Region: World Health Organization.
•     World Health Organization. (1999). Status and trends of STIs, HIV/AIDS at the end of
      the Millennium (p.6). Western Pacific Region: WHO.
•     World Health Organization. (2001). Global prevalence and incidence of selected curable
      sexually transmitted infections: overview and estimate (p.9). Geneva: WHO. World
      Health Organization. (2003). STI/HIV Counselling in Pacific Island Countries. Western
      Pacific Region: WHO.




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