A. Explore powerlessness as a factor affecting adolescents’ use of the health care system.

• economic power inequalities
• legal and political powerlessness
• powerlessness and empowerment as themes in adolescent developmental process

B. Describe the health of adolescents in different socio-economic strata

• terms, trends, and theories
• research evidence of social gradient

Minilecture with class discussion

Refs 1, 2, 3

Module C1

C. Describe the mechanisms by which SES inequalities affect adolescent health, opportunities, and risks

• lack of education
• crowded living
• accumulation of unhealthy life styles
• efforts to improve health inequalities

Class discuss examples of the areas (related to health care, school, free time activities, adult support) where the discrepancies of resources and opportunities among teenagers are most apparent. How do these discrepancies operate to the disadvantage of youth in terms of well-being, disease (incl. psychosomatic illness, chronic conditions, and mental health), deviant behaviour, social opportunities and skills, etc?

Are participants familiar with any efforts to ameliorate health disadvantages for the lower SES strata?  What has worked and what has not, and why.

Activity option 1:
Hold a focus group with young people from an impoverished area, and listen to their suggestions for improvement on their health care. Can participants see how the suggestions could apply to their own work?

Activity option 2:
Discuss with the primary care team what socio-economic barriers may be operating to the disadvantage of some adolescents and propose remedies.

Participants are encouraged to implement one of the activity options upon returning to their home countries

Reading

Minilecture

Worldwide and country-specific prevalence data

Lecture, reading, or handout terms.

Lecturer briefly describes ethnic differences in such areas as disease prevalence, health-seeking behaviour, and use of prescription medicine. What examples or experiences do participants have with youth from ethnic communities in their areas?

Class discussion with invited community and religious leaders

(Discuss objectives B and C together)

Discuss mechanisms leading to poor outcomes among minorities, such as the interaction of poverty and ethnicity, discrimination, as well as negative ethnic practices such as female genital mutilation.

Also give examples where ethnicity may be a protective factor for a teenager.

C. Describe the stages of acculturation and understand the possible interaction between acculturation and the developmental process during adolescence, and the effect on health

• integration versus segregation
• research evidence on correlation of stages of integration and ill health

Refs 15, 21

Module A1

Participants share in small groups their experiences with ethnic groups different from their own, and whether they were aware of personal reactions that came into play.  Role play case studies to raise awareness of attitudes.

Case study 1:
a 14  year-old Romany gypsy male with haemophilia is accused of having stolen the coffee money in your medical Unit.

Case study 2:
A teacher sends two 16 year-old girls to the school nurse for a talk. The girls have decided to wear the burka in school to keep boys from looking at them, although it angers the teachers who complain they cannot teach without seeing the eyes and facial expressions of the students.

E. Integrate considerations of ethnicity into the intake interview with an adolescent from an ethnic minority.

• topic areas and assessment “criteria”
• interview techniques

Small group work

Case studiesTeenage volunteers

Small groups design a short tool that could be helpful in assessing the dimensions of “ethnicity” and “acculturation” for an adolescent patient. Formulate questions that would elicit sensitive information on: stage of integration, ability to meet developmental tasks, existence of value conflicts between patient’s family and host culture, of discrimination experiences, as well as evidence of positive influences from the ethnic group (group may add other considerations).

Participants practice using their created assessment tool (or a checklist suggested by trainer) in role play, case studies or with teenage volunteers.

Case study
A 17 year-old Somalian girl who migrated recently comes to a physician’s office with her parents because she requires a medical certificate. The parents don’t want her to leave with her class for an educational trip to Paris. What is an ethical way to handle this request? Explore how the local exposure to appropriate experiences might affect her psychosocial development.

G. Address the barriers to health care access that an adolescent of ethnic background might encounter.

• language barriers
• family values and beliefs

Group session with professional interpreter

Role play

Class discussion

Demonstrate and discuss the proper use of interpreter or cultural mediator. Discuss what to do if clinical setting cannot provide translators. If some participants are multilingual, devise a role play that helps class experience the problems inherent in translations. Class devise practical solutions.

Case study
A school nurse alerts clinic to the case of a 13 year-old Arabian girl with apparent onset of type 1 diabetes whose parents are negligent about diabetic care because they feel that the girl with such a disease will never marry and is worth nothing.

A. Understand theories of gender formation

• biological theories
• socialization theories
• effects of power and control

Describe how traditional child raising practices socialise girls to be pleasant and accommodating, while allowing boys to express themselves and take what they need.

Discuss the likely effects of this socialization upon illness patterns, e.g. internalising health problems (depression) and externalising behaviour (fighting).

C. Understand how gender differences influence health seeking behaviour

• gender-specific care: need vs. availability
• research data: patterns of care utilization
• gender-specific beliefs and attitudes affecting health behaviour
• puberty issues and interactions with health care professionals

Class discussion

Short data presentation

Focus group

Discuss the indications of the need for gender-specific services. What gender differences in health-seeking behaviour have participants observed in their adolescent patients? What kinds of problems are typical of each gender, and would gender-specific services ameliorate/solve the problems?

(Example of a gender-related problem for above discussion: Research shows males more likely than females to adopt a variety of attitudes and beliefs that undermine their health and well being, including beliefs related to perceived invulnerability to risk and to personal control over their health and masculinity.)

Utilize focus groups to explore how male and female adolescents experience the health care they get, what problems do they identify, and how would they like it to change.

Discuss how the unique pubertal period of development may emphasize gender issues in health care interactions
(e.g. body image, gender identity, sexual feelings issues).

Discuss in small, mixed-gender groups what unconscious biases and prejudices due to gender may operate in the health care setting.

How does the male or the female practitioner feel about :

• a powerful and assertive adolescent girl ?
• a shy and feminine boy?
• 15 year-old boy presenting with suspected STD who admits to having had five partners in three months ?
• 15 year-old girl with suspected STD who admits to having had five partners in three months ?
• 17 year-old boy who comes to clinic with a partner who is 25 years older ?
• 17 year-old girl who comes to clinic with a partner who is 25 years older ?

How can a practitioner put a patient at ease in a mixed-gender situation ? Participants share examples of situations they have experienced, and what has worked to improve the situation.

Participants discuss how to arrange adolescent boy-friendly services, and adolescent girl-friendly services. Analyse the following strategies, deciding why or why not the strategies could be implemented in the participants’ different settings. Suggest solutions to the problem of not enough finances.

• Combine different type of services in one location;
• Train peers to act as facilitators;
• Have low-threshold professionals (street workers) contact young people in their favourite locales;
• Implement a special « girl-free » boys-only initiative (such as special hours or services);
• Hire professionals who provide gender-specific counselling and care (i.e. andrologist)

What additional training do participants feel they would need?

Class discussion

Focus group

Class discuss experiences with trying to involve families of differing backgrounds in a meeting about health care. What community organization tactics seem to work best?

Hold focus groups with young people from an impoverished area to help participants practice organizing such groups, and using such a group to assess needs and make suggestions for improvement.

Discuss obstacles and identify strategies that can be used to influence policy-makers and decision-makers at various levels.

Prepare a speech/write a letter for decision makers describing how the needs of adolescents in an impoverished area could be better met.