Transcript Marketing Strategy

Hur arbetar Finland preventivt
med sexuell hälsa?
Hur lyckas man så bra??
Sexual Health Clinic
Dan Apter
[email protected]
Kliniken för sexuell hälsa
Väestöliitto
Lyckas man bra ?
Varför lyckas man inte bättre ?
Dan Apter
• Överläkare vid Klinken för sexuall hälsa, Väestöliitto
• Specialist i gynekologi och obstetrik, docent
• Grundare och ordförande för Barn- och
ungdomsgynekologiska föreningen i Finland, 19942009
• Ordförande för Sexologiska föreningen i Finland
2003-05
• Ordförande, International Federation of Pediatric
and Adolescent Gynecology, 2001-2007
• European Society of Contraception and
Reproductive Health, viceordförande 2008-
Sweden has the highest abortion
rate in Europe,
with the exception of some Eastern
European countries,
why?
Do we have information?
Background for differences??
• Available data about sexual and reproductive health
(SRH) of adolescents and children in the various
Nordic countries: abortion and delivery rates, STI,
contraceptive use, sexual behavior, sexual abuse,
other health aspects, gender equality, happiness and
quality of life? ?
• Present ways SRH services of adolescents are
provided
• Education of professionals in relation to SRH of
adolescents and children
SEXUAL HEALTH FOR
ADOLESCENTS
1. Recognizing sexual rights
2. Sexuality education and
counselling
3. Confidential high quality
services
• There was poor country, suffering
the consequences of war
• STIs were common
• Contraception hardly existing,
• Women dying of illegal abortion
Finland 60 years ago
Changing attitudes
• During the 1960s a new culture revolved, with
freedom for teenagers including sexual
behavior
• Adolescent childbirths peaked in the late 1960s
in northern and western Europe
• With liberalization of legislation, increasing
numbers opted for abortion in the 70s
• In some countries, adolescent premarital sex
was mainly approached from a moral point of
view; the Scandinavian countries were primarily
concerned with health consequences
Changing attitudes
• The Scandinavian approach was to create
preconditions for safer sex: increase
sexuality education, availability of
contraceptive methods, and accessibility to
sexual health services
• Balance between prevention of pregnancies,
prevention of STIs, allowing for sexuality as
a positive resource rather than a threat
Background for changes
The Nordic experience shows, that
with persistent and committed
actions many problems can be
prevented and solved.
Requires political commitment
Sexual/reproductive health
• Today sexual health is relatively good in the
Nordic countries according to available
indicators:
• Maternal and perinatal mortality is very low
• Incidence of abortions rather low
• Incidence of HIV very low
• Teenage pregnancy rare
• Gender equality good
Legislation in Finland
• The abortion law 1970, contraceptive
counseling obligatory
• The Public Health Law (1972) guarantied
free primary health care including
contraceptive services for the whole
population
• Sexuality education was integrated into
school programs in 1970 to ensure practice
of safer sex.
Responsibility of municipalities
in Finland
• Contraceptive counseling units were
founded throughout the country.
• Public health nurses & midwifes well
trained
• School health developed, school health
nurses participated in sexuality
education
• Close connection between education
and services
Legal abortion per 1000 15-49 yr
in the Nordic countries
Sweden
Finland
Deliveries in 15-19 yr olds in the
Nordic countries
Abortions in 15-19 yr olds in the
Nordic countries
Induced abortions in nordic
countries per thousand women
aged 15-49 in 2007
Antalet aborter och förlossningar
per 1000 flickor 15-19 år
Danmark
Finland
Island
Norge
Sverige
Aborter Födslar
Aborter Födslar
Aborter Födslar
Aborter Födslar
Aborter Födslar
2000 14,3
7,8
14,8 10,2
25,4
22,8
20,1
11,6
21,1
7,1
2001 14,0
7,6
15,4 10,6
21,7
19,7
18,8
11,0
22,5
6,6
2002 13,8
6,5
16,3 11,2
20,2
18,2
16,9
10,1
25,1
6,6
2003 14,8
6,0
15,3 10,4
19,1
16,4
16,3
9,1
24,4
6,0
2004 15,8
5,7
15,7 10,6
20,3
13,0
15,7
8,2
24,4
5,8
2005 15,8
5,6
15,0 10,3
15,5
15,1
15,4
8,0
24,3
5,8
2006 16,7
6,0
14,2 9,4
15,7
14,4
16,3
8,7
25,4
5,8
2007 16,3
5,8
13,5 9,0
17,7
14,2
17,0
9,1
24,8
5,8
2008 17?
6,9
12,7 8,8
24,4
5,8
18,0
17 juli 2015
L Marions
19
Attityder till abort i Sverige och Finland
Aborten berättigad
Land
Sverige (%)Finland (%)
Aldrig berättigad 1
2,3
13,6
2
1,2
6,2
3
3,9
6,1
4
1,7
6,2
5
9,2
18,9
6
7
9,5
7
9,8
10,9
8
15,9
12,7
9
12,3
8,7
alltid berättigad 10
36,6
7,1
http://www.worldvaluessurvey.org/
1995:
”The Evolution of Sexual Health in Finland:
How we did it”
2000:
”The Evolution of Sexual Health in Finland:
How we spoiled it”
2010:
How we did it again?
Abortions and deliveries
per 1000 girls 15-19 year old
in Finland 1975 to 1995
30
27,5
25 21,2
20
15
10
Abortions
Deliveries
15,3
12,4
10,7
9,9
5
0
75 80 85 90 91 92 93 94 95
Factors affecting sexual health in
mid 90th in Finland
• Economical depression, services cut
• School health services cut
• Sexuality education in schools became an
optional subject in 1994, now obligatory
again
• Population responsibility led to the close
down of contraceptive counseling centers
• The local municipalities implement health
care policy independently, even without
necessary qualifications
Abortions and deliveries (per
1000) in 15-19 yr old girls in
Finland 1975 - 2008
8,8
Preventivmetod vid senaste samlag,
och % andel flickor som haft samlag
STAKES, 2008
Grundskola
Gymnasium
Yrkesskola
9.
1.
2.
1.
2.
8. årskurs årskurs årskurs årskurs årskurs årskurs
Ingenting
Kondom
P-piller
20
61
11
15
53
23
7
53
31
7
44
39
15
36
40
13
30
47
Kondom och
p-piller
6
8
8
9
7
8
Haft samlag,
% av alla
14
30
36
52
69
79
% girls who have had intercourse,
Finland 1996-2007
STAKES school health survey
40
35
30
25
20
15
10
8 grade
9 grade
5
0
96/97
99
1
3
5
7
%-girls who did not use contraception at
last intercourse
25
20
15
8 grade
9 grade
10
5
0
1998
2000
2002
2004
2006
2007
Sexually transmitted infections
• STIs were common when our parents/
grandparents were young, gc 24 000/yr in
the mid 40th
• Were common when we/our parents were
young, gc 15 000/yr in mid 70th
• And they are common again, chlamydia
14 000/yr
Chlamydia,
Number of reported cases in Norway
6,0 % of tests + in 2000
7,7 % of tests + in 2006
Clamydia in the Nordic countries 2002-2008
Number of reported chlamydia cases
Reporting system changed in 1995
KTL
Reported number of STI:s in Finland
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Chlamydia Gc
Syfilis HIV
12567
2326
32
89
11245
1426
37
57
11462
993
33
93
9883
781
48
62
8289
493
63
69
9317*
331
122
72
9438
182
148
69
10175
218
172
71
10654
269
187
81
10660
243
116
143
11731
287
212
144
12142
247
159
127
13661
235
128
131
12862
189
132
131
13365
252
109
130
12697
240
144
140
13850
236
129
193
13973
194
188
187
13873
200
216
148
13246
237
191
179
Chlamydia
reprting
system
changed
in 1995
KTL
Reported number of chlamydia
cases by age in 2005
3500
3000
2500
2000
Women
Men
1500
1000
500
0
10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 6014 19 24 29 34 39 44 49 54 59 64
Reported numbers of chlamydia among
15-19 year old girls and boys in Finland
1988-2009
Chlamydia testing patterns
• Bakken et al, Sexually Transmitted
Diseases 33:26-30, 2006
• Chlamydia testing patterns, prevalence,
in central Norway 1990-2003
• 4% of men and 44% of women had
undergone chlamydia testing at least
once by the age 20;
44% respectively 84% by age 25.
Regler om könssjukdomar,
Finland
• Undersökning och behandling av
könssjukdomar är i princip kostnadsfria för
patienten inom den offentliga sektorn
• Smittospårning fungerar varierande
• Klamydia rapportering enbart från laboratorier
• Gc, syfilis och HIV rapporteras också av läkare
• Papa screening har fungerat bra, cx ca
insidensen lägst
Vad görs i Finland
• Alla inklusive ungdomar betalar fullt pris för
kondomer
• De senaste 10 åren minimal kampanjaktivitet
• Rekommendation 2007: Klamydiaprov tas av
alla nya preventivmedelsklienter under 25 år
vid första besök eller 3 månaders uppföljning,
samt vid ett års uppföljning. (men få känner till
denna rekommendation, och ännu färre följer den)
Karakteristiska för klamydiasmitta,
23 487 klamydiapatienter som behandlats vid
poliklinikerna för könssjukdomar 1995-2006
Men %
Kvinnor %
Smittad i Finland
92,7
95,3
Besmittad av tillfällig sexpartner
49
35
Möjligt att klamydia förts vidare
35
34
Haft klamydia inom det senaste året
13
16
Tid från smitta till diagnos
30 (16-58)
40 (20-81)
Klamydia prevalens
• Vid HPV vaccinering fas III studier
togs klamydiaprov av 5000 flickor,
16-17 år gamla 2004-2005,
• 2,5% klamydia +.
HPV Infection Occurs Shortly after
Sexual Debut
70 %
60 %
Cervical HPV Detection
50 %
40 %
30 %
20 %
10 %
0%
0
6
12
18
24
30
36
42
Time since first intercourse (months)
Collins et al: Br J Obstet Gynecol 2002;109: 96
48
Sex and HIV Education
Programs: Their Impact on
Sexual Behaviors
of Young People Throughout
the World
Douglas B. Kirby, B.A. Laris, Lori A. Rolleri
Journal of Adolescent Health 2007, 40: 206–217
reviewed 83 studies that measured the impact of curriculumbased sexuality education programs on sexual behavior
and mediating factors < 25 years anywhere in the world.
Sexuality education works !
• Two thirds of the programs significantly improved one
or more sexual behaviors.
• The evidence is strong that programs do not hasten
or increase sexual behavior but, instead, some
programs delay or decrease sexual behaviors or
increase condom or contraceptive use.
• Programs were effective across a wide variety of
countries, cultures, and groups of youth.
• Replications of studies also indicate that programs
remain effective when implemented by others in
different communities, provided all the activities are
implemented as intended in similar settings.
Impact on contraceptive use
Condom use
• Of the 54 studies measuring program
impact on condom use, almost half (48%)
showed increased condom use; none
found decreased condom use.
Sexual abstinence only programmes
to prevent HIV infection in high
income countries: systemic review
Underhill et al BMJ 2007
• 13 trials enrolling 16 000 US youths
identified, all outcomes were self reported
• No program affected incidence of unprotected
sex, number of partners, condom use, or
sexual initiation
How good is the evidence for effect of
sex education on different outcomes?
 Improved knowledge
Strong
 Improved skills
Good
 Less risk behaviour
Good
 Contraceptive use
Mixed
 Pregnancy reduction
Weak
 STI prevention
Weak
Judith Stephenson
Margaret Pyke Professor of Sexual & Reproductive Health, UK
Sexuality education as part of health
teaching
• Sexual health: human relations, sexuality,
behavior, values and norms
• The student should learn basics of sexual health,
the importance of contraception and methods for
it, and be able to consider and justify responsible
sexual behavior
• The student should be able to name, recognize
and reveal different feelings, and describe their
development and reasons, and provide examples
how behavior and interactions can be regulated
according to the situation
Ministry of education, guidelines for teaching 2004, but my translation
Aim and structure of the sexual
health knowledge study
• Produce a representative picture of sexuality
education of school grade 7-9 in 2006, and the
changes from 1996, particularly related to the
introduction of a new subject, health, as
described by teachers
• Evaluate the sexual health knowledge of 8 grade
students by a national quiz, and changes
between 2000 and 2006
• Combine the information provided by the teachers
with knowledge of the students in the same
schools, to evaluate the impact of sexuality
education
Väestöliitto 2007
A study of students’ sexual health
knowledge
• Carried out in 2000 and 2006 in the
form of a quiz at grade 8.
• In 2000 number of participating students
was 30241 from 401 schools
• In 2006 number of participating students
was 33819 from 462 schools
Lärarna
• Varierande bakgrund, men fått
specialutbildning
• Mer varierande metoder används
• Endast 4% tyckte att det var svårt att
tala om sexualitet, 80% tyckte att det
var lätt
• En lärare i skolan ansvarig för planering
och koordinering, enligt curriculum
Mean hours of sexuality education per
grade in 1996 and 2006 in Finland
Grade 7
Grade 8
Grade 9
1996
2,5
4,3
7,9
2006
5,9
8,7
6,2
Väestöliitto 2007
A study of students’ sexual health
knowledge
• 75 questions in common in 2000 and
2006
• In 2000, mean number of correct
answers was 49,6 and 51,5 in 2006
• The number of correct answers
increased for girls from 53,9 to 55,1,
and for boys from 45,4 to 48,3
Q41. Emerency contraception should be used:
80
80
64
60
Gir ls
40
20
3
8
14
B o ys
10
2 6
0
1
2
3
4
1. in a week from unprotected intercource
2. in two weeks from the absence of periods
3. as soon as possible, but at the latest 72 hours from
unprotected intercource
4. at the latest six hours from unprotected intercource
Effect of sexuality education and school
performance on sexual health knowledge
sexuality educ in health
school
performance
several one
lessons lesson
no
no
lessons health
educ.
Together
8,5-10
54,8
49,1
50,3
39,9
52,9
7,5-8,4
51,9
47,1
47,6
42,9
50,3
6,5-7,4
48,3
43,2
45,5
39,7
46,8
<6,5
45,0
40,3
39,8
37,3
42,8
Together
51,1
45,6
47,2
40,4
49,3
Väestöliitto 2007
Sexual health services
• Services for adolescents can be provided in
various settings.
• The clinic should have a youth-friendly
atmosphere, where young people can feel
welcome and comfortable.
• Unquestionable confidentiality is important.
The providers must not moralize and judge
the adolescents, but treat adolescents with
respect indicating that young people are
important.
Services for adolescents
• contraception, STI treatment, counseling and
testing for HIV
• pregnancy care and post abortion management;
• management of sexual violence;
• mental health services, including services to
address the use of tobacco, alcohol and drugs;
• information and counseling on development
during adolescence, including nutrition, hygiene,
sexuality
• The appropriate range of essential services must
be decided based on local needs assessments.
Median age of first intercourse,
Finland
• Girls 16,8 yr
• Boys 17,4 yr
• Based on 200 000 answers of
13-19 yr olds to a questionnaire
in 2008-09
Simopekka Vänskä, THL
Kådiskollen 2010, RFSU
– YouGovs Internetpanel bestående av 46 000
förrekryterade kvinnor och män i åldrarna 1574 år som vill delta i undersökningar.
– Dessa utgör ett representativt urval av
befolkningen vad gäller kön, ålder och region.
Målgruppen är personer som minst någon gång
haft sex.
– Målgrupp Sverige: 1129, Danmark: 1122,
Norge:1222, Finland:1699
– Undersökningen är genomförd under
perioden 4 -10 januari 2010
• YouGov källa.
Sexfrekvens
Seksfrekvens 15-20 år
YouGov Kådiskollen 2010, RFSU
YouGov Kådiskollen 2010, RFSU
Oskyddad sex 15-20 år
YouGov Kådiskollen 2010, RFSU
Accept parallell sexual relations
among married people, women
Osmo Kontula, Väestöliitto 2008
Conclusions
• When adolescent sexuality is not condemned but
sexuality education and sexual health services are
provided, it is possible to profoundly improve
adolescent sexual health with comparatively small
costs.
• But each year new groups of young people
mature, requiring new efforts. Education,
counseling and services are all needed. If the
resources are cut too much or not given, negative
effects are soon evident.
Political
commitment and resources
provided are reflected in results obtained
Sammandrag, Finland
• Sedan 1970-talet satsning på användande av
preventivmedel, inklusive kondom, som viktigt
• Hälsovårdspersonal skolad för detta
• Sedan 1960-talet nationell välfungerande
papa screening
• Sedan 2004 bra sexualundervisning i skolorna
• Attityder mer konservativa?
• Mindre sex??
Sexual Health Clinic