Переход к основному содержанию
 Европа и Центральная Азия Европа и Центральная Азия
  • English
  • русский

Global Links

  • Назад к ЮНИСЕФ
  • Высокий контраст
 Европа и Центральная Азия Европа и Центральная Азия
    • Узнать о ЮНИСЕФ
      • О нас
      • Наш мандат
      • Региональный директор
      • Положение детей в регионе
      • Где мы работаем
      • Портал для родителей
      • Наши голоса: Молодёжь региона
      • Послы ЮНИСЕФ в Европе и Центральной Азии
      • Наши партнеры
  • Пресс-центр
Поддержать

Main navigation

  • Что мы делаем
  • Исследования и отчеты
  • Истории из региона
  • Действуйте
Search area has closed.
Search area has opened.
ПОИСКЗакрыть

Поиск ЮНИСЕФ

  • Доступно на:
  • English
  • русский
  • Українська
  • (-) Блог (2)
  • Заявление (3)
  • (-) Отчет (9)
  • Пресс-релиз (12)
  • Программа (3)
  • Статья (19)
  • Страница (1)
  • COVID-19 (7)
  • Disaster risk reduction - DRR (1)
  • Roma children (2)
  • Бедность (2)
  • Беженцы (1)
  • Бюджетное финансирование социальной сферы (1)
  • (-) ВИЧ/СПИД (1)
  • Вакцины (2)
  • Вода, санитария и гигиена (1)
  • Вооружённый конфликт (1)
  • Гендерное насилие (2)
  • Грудное вскармливание (1)
  • Гуманитарный кризис и реагирование (2)
  • Дети-беженцы и дети-мигранты (3)
  • Европейский Союз (1)
  • Защита детей (7)
  • (-) Здравоохранение (9)
  • Иммунизация (7)
  • Коммуникации в целях развития (1)
  • (-) Мигрант и кризис с беженцами (2)
  • Миграция и кризис с беженцами (1)
  • Образование (3)
  • Образование в чрезвычайных ситуациях (1)
  • Охрана здоровья новорожденных (1)
  • Питание (2)
  • Подростки (1)
  • Помощь при стихийных бедствиях (1)
  • Права детей (5)
  • Права детей (2)
  • Права человека (2)
  • Развитие детей раннего возраста (1)
  • Сексуальная эксплуатация (1)
  • Социальная интеграция (2)
  • Социальная политика (1)
  • Цели Устойчивого Развития (1)
  • Школы дружелюбного отношения к ребенку (1)
  • Болгария (1)
  • Европа и Центральная Азия (6)
  • Литва (1)
  • Региональный офис ЮНИСЕФ по странам Европы и Центральной Азии (3)
  • Региональный офис ЮНИСЕФ по странам Европы и Центральной Азии (2)
  • Республика Молдова (1)
Report
08 Январь 2020
Interpersonal Communication for Immunization
https://www.unicef.org/eca/reports/interpersonal-communication-immunization
Health providers have always been an important and trusted source of information for parents and caregivers in the Europe and Central Asia (ECA) region and beyond. The way they interact with families and the quality of their communication and engagement may have a positive or negative influence on caregivers’ decision to immunize their children. Research in ECA has shown that health workers do not always engage with caregivers in an open and supportive way, often using a patronizing and top-down approach in communication. As a result of time constraints and limited communication capacities, they often fail to understand the immunization-related concerns, fears and expectations of caregivers and fail to identify and address vaccine hesitancy. To help strengthen the communication and community engagement skills of front-line workers, the UNICEF Regional Office for Europe and Central Asia (ECARO) has developed this interactive and evidence-based training package to identify and address their own biases and misconceptions and to equip them with the essential knowledge, skills, and attitudes they need for positive and meaningful interpersonal communication. It consist of a Facilitator Guide, Participant Manual and a set of Presentations. Options Available options Facilitator guide Participant manual Presentation Download file (PDF, 5,62 MB) (PDF, 5,57 MB) (PDF, 11,88 MB) November 2019
Report
06 Ноябрь 2019
Interpersonal Communication for Immunization. Presentation
https://www.unicef.org/eca/reports/interpersonal-communication-immunization-presentation
Health providers have always been an important and trusted source of information for parents and caregivers in the Europe and Central Asia (ECA) region and beyond. The way they interact with families and the quality of their communication and engagement may have a positive or negative influence on caregivers’ decision to immunize their children. Download file (PDF, 11,88 MB) November 2018
Report
06 Ноябрь 2019
Interpersonal Communication for Immunization. Participant manual
https://www.unicef.org/eca/reports/interpersonal-communication-immunization-participant-manual
Good interpersonal communication can mean the difference between a child being fully immunized or not at all. This Interpersonal Communication for Immunization Participant manual seeks to help health workers value, acquire, and consistently use the knowledge, skills, and attitudes needed to communicate effectively with caregivers and communities about childhood immunization. Interpersonal communication for immunization capacity development is critical. Almost every study of health worker practices in the region finds that interpersonal communication for immunization overall is weak. Yet, at the same time, the vast majority of caregivers of young children cite health workers as their primary source of information about immunization. Health workers and health services must close this gap if nations and the world are to achieve universal immunization.  Download file (PDF, 5,57 MB) November 2019
Report
06 Ноябрь 2019
Interpersonal Communication for Immunization. Facilitator Guide
https://www.unicef.org/eca/reports/interpersonal-communication-immunization-facilitator-guide
Health providers have always been an important and trusted source of information for parents and caregivers in the Europe and Central Asia (ECA) region and beyond. The way they interact with families and the quality of their communication and engagement may have a positive or negative influence on caregivers’ decision to immunize their children. Research in ECA has shown that health workers do not always engage with caregivers in an open and supportive way, often using a patronizing and top-down approach in communication. As a result of time constraints and limited communication capacities, they often fail to understand the immuni-zation-related concerns, fears and expectations of caregivers and fail to identify and address vaccine hesitancy. To help strengthen the communication and community engagement skills of front-line workers, the UNICEF Regional Office for Europe and Central Asia (ECARO) has developed this interactive and evidence-based training package to identify and address their own biases and misconceptions and to equip them with the essential knowledge, skills, and attitudes they need for positive and meaningful interpersonal communication. Download file (PDF, 5,62 MB) November 2019
Report
28 Октябрь 2020
Protecting young children from vaccine-preventable diseases
https://www.unicef.org/eca/reports/protecting-young-children-vaccine-preventable-diseases
PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES MODULE 22 Disclaimer: The resource modules were authored by the individuals under the guidance of the UNICEF Regional Office for Europe and Central Asia. The text is presented in draft format and it is expected that it will be adapted and contextualized for use by interested countries. The material has not been edited to official publication standards. UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. Coordination and Editing: Aleksandra Jovic, UNICEF, Early Childhood Development Specialist Lead Author: Bettina Schwethelm, Young Child Health and Development Specialist, Director, MCH-ECD Co-authors: Svetlana Stefanet, UNICEF, Immunization Specialist Sergiu Tomsa, UNICEF, Communication for Development Specialist Contributors: Silvia Sanchez R., UNICEF, Knowledge Management Consultant Viviane Bianco, UNICEF, Communication for Development Consultant UNICEF/ Krepkih Andrey TABLE OF CONTENTS Key Messages Why is this Topic Important to you? ..................................................................................6 Learning Outcomes ....................................................................................................................................6 Pre-Test for this Module ...............................................................................................................................7 Glossary and Definitions ............................................................................................................................10 I. Introduction ..................................................................................................................................111. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing ................................112. Vaccination Trends Globally and in Europe ...........................................................................................................143. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary ..........................................................................................................................15 II. Immunization and Vaccine Preventable Diseases A Major Public Health Achievement ...................161. Childhood Immunization .......................................................................................................................................162. How Vaccines Work .............................................................................................................................................173. The Benefits of Vaccination to the Individual Child and Society ...........................................................................204. Vaccine Safety and Side Effects ...........................................................................................................................225. Family-Held Vaccination Records ..........................................................................................................................23 III. Understanding Barriers to Vaccination ...............................................................................................241. Caregivers Along the Continuum of Vaccine Acceptance, Hesitancy, and Rejection ...........................................242. Understanding how Individuals Make Behavioural Choices .................................................................................26 a. The Behaviour Change Journey ........................................................................................................................26b. Factors Influencing Caregiver Decisions ...........................................................................................................27c. Perception Biases, Beliefs, and Myths About Vaccines The Internet and Social Media ................................31d. The Role of Health Workers ..............................................................................................................................34 IV. Communication Skills and Tools to Support Vaccine Acceptance by Caregiver .................................371. Active Listening Skills ...........................................................................................................................................37 a. Verbal Communication ......................................................................................................................................37b. Non-Verbal Communication ..............................................................................................................................38c. Empathy ............................................................................................................................................................39 2. Working with Caregivers Along the Continuum of Vaccine Hesitancy .................................................................39a. Vaccine-Accepting Families ...............................................................................................................................40b. Vaccine-Hesitant Caregivers .............................................................................................................................41c. Vaccine Refusers and Anti-Vaccine Advocates .................................................................................................44 3. Helping Caregivers Overcome Barriers to Vaccination .........................................................................................46a. Preparing Caregivers for Vaccination and Helping Them Manage Mild Side-Effects ........................................46b. Helping Caregivers Problem-Solve ....................................................................................................................46c. Addressing Rumours in the Community ...........................................................................................................47 V. Summary of Key Points and Post-Test .................................................................................................481. Summary of Key Points ......................................................................................................................................482. Post-Test with Answers ......................................................................................................................................49 VI. Websites And Video Clips .....................................................................................................................531. Websites .............................................................................................................................................................532. Relevant Video Clips ...........................................................................................................................................53 Annexes: Information Cards ........................................................................................................................55Information Card 1 - Common Vaccine-Preventable Diseases ...........................................................................................55Information Card 2 - Frequently Asked Questions (FAQS) About Childhood Vaccinations .................................................58Information Card 3 - Simple Ways to Show Empathy ........................................................................................................62Information Card 4 - Responses that Encourage Communication ......................................................................................63Information Card 5 - Roadblocks to Communication ..........................................................................................................64Information Card 6 - Practical Communication Skills Case Study ....................................................................................65Information Card 7 - The CASE Approach ...........................................................................................................................66Information Card 8 - Steps to Address Negative Rumours in the Community ...................................................................67Information Card 9 - Reducing Pain ....................................................................................................................................68Information Card 10 - What is Community or Herd Immunity and Why is it Important? ....................................................70 Worksheets................ ..................................................................................................................................71 References................. ..................................................................................................................................73 6 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES KEY MESSAGES Why is this topic important to you? Vaccination is one of the worlds safest and most cost-effective public health interventions. Yet growing distrust in science, coupled with misinformation, means that vaccination coverage rates are declining in some countries and communities, resulting in an upsurge of vaccine-preventable diseases. The routine vaccination schedule brings families into frequent contact with the healthcare system, providing opportunities to reach children with life-saving vaccines and other crucial services for children and their families. Research shows that those caring for children tend to trust the advice of their health workers when it comes to vaccination, despite conflicting and often misleading information from other sources. That is why your role is so important: poor or disrespectful responses to caregivers and their concerns, coupled with a lack of uptake of vaccines (whether at a clinic or during a home visit), can have a strong and negative impact not only on their future demand for vaccination, but also for a whole range of other health services. As a professional who is trusted by the families you serve, you have a unique opportunity to identify vaccine-hesitant caregivers; understand their fears, dilemmas and choices; provide them with relevant information; help them overcome their vaccination hesitancy; strengthen their confidence in vaccines and immunization, and, in some instances, vaccinate their children. Using your communication skills and your knowledge about how individuals make behavioural choices, you can influence and guide parents to make decisions in the best interests of their children by listening to and understanding their concerns, providing answers to their questions, and helping them make the best choice for their child and their community. LEARNING OUTCOMES Once you have completed this module you will: Have a good understanding of vaccine-preventable diseases and the importance of immunization. Understand the role of health workers particularly home visitors in guiding families in their decisions to have their children protected against vaccine-preventable illnesses. Understand the importance of checking the immunization status of the child during each relevant visit and reminding caregivers about upcoming vaccination appointments. Understand that the views of caregivers range across a continuum from vaccine acceptance, to hesitancy and rejection, and that tailored approaches and actions are required from you to ensure that as many infants and children are protected against vaccine-preventable diseases as possible. Be able to apply evidence-based techniques and approaches to address hesitancy and influence caregivers decisions and behaviours. When checking a childs records, know how to give their caregivers the space to voice concerns and ask questions so that you can provide facts about vaccination benefits and address rumours and misinformation. Know how to identify caregivers who are hesitant about vaccines and respond to their questions and concerns with facts and empathy to help them make informed decisions and move towards vaccination. Communicate with caregivers who are rejecting vaccines in a respectful and empathetic way, reminding them that vaccines are safe, advising them of the dangers and symptoms of vaccine-preventable diseases, and reinforcing their responsibilities, as caregivers, to inform health workers if their child has not been vaccinated. Show your appreciation and validation of families that have accepted vaccination and that might be willing to become vaccine advocates in your community. Be able to advise parents on how to deal with the possible common side effects of vaccination. 7 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES PRE-TEST FOR THIS MODULE Some of these questions may refer to topics that are unfamiliar to you at this early stage, but do not worry. The module will cover all of these issues and features a post-test (with answers) at the end so that you can assess your own progress. 1. Costing studies have shown that childhood vaccinations constitute one of the most cost-effective public health interventions. True False 2. The number of parents refusing vaccinations for their infants and young children is increasing. This group should, therefore, be the main target for education by home visitors. True False 3. Increasing herd/community immunity is not a good argument for increased support for immunization programmes. True False 4. Several countries in Europe have had a high number of measles cases. Some of the reasons for this include (please mark all answers that apply): a. Shortages of measles vaccine in these countriesb. Caregivers who are complacent, because they do not know that measles is a dangerous and very infectious diseasec. Researchers who have been unable to dis-prove the myth that measles vaccine causes autismd. Measles brought in by travellers from poor, under-developed countriese. Falling immunization coverage. 5. The reason for vaccine hesitancy is simple: caregivers just lack the evidence about the benefits of vaccines. True False 6. Some of the strategies to overcome vaccine hesitancy among parents include (please mark all answers you consider correct):a. Improving the interpersonal and communication skills of health workersb. Listening to the concerns of caregivers and showing empathyc. Understanding how behaviour change takes place and using a solid behaviour-change approachd. Ensuring that health workers welcome caregivers who may feel socially excluded and stigmatizede. Telling caregivers that health professionals know best and that they should not question immunization, as they are not expertsf. Improving the quality of health services. 7. Some of the challenges to the achievement of high immunization coverage rates for measles and rubella coverage (please circle the answers you consider correct)a. The rejection of vaccines by some families in small communities and urban areas creates pools of unprotected children, increasing the risks of the rapid spread of epidemicsb. Measles vaccine is routinely provided to children when they are one year of age: a time when some caregivers may feel that their young children have already received enough vaccines to be protected MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 8 c. Lack of trust in vaccine safetyd. Shortage of vaccines in some countries as a result of recent epidemics. 8. Home visitors should be prepared to respond flexibly to the concerns of parents about vaccinations, with brief, tailored and fact-based elevator speeches (short enough to be presented during an elevator ride of just a few floors). True False 9. Polio has been eradicated and will soon be removed from all immunization schedules. True False 10. Arrange the following stages into the correct sequence for an expanded behaviour-change model: 11. List some non-verbal communication features you can use to make caregivers feel more comfortable: 12. Giving young infants multiple vaccines at the same time can overwhelm their immune system. True False 13. Naturally acquired immunity works better and is safer than vaccine-acquired immunity. True False 14. The following approaches need to be avoided when addressing the concerns of caregivers about vaccines (mark all that apply): a. Reflective listeningb. Solving any problems the caregiver has in getting to the clinicc. Empathy for their concerns about whether they are making the best decision for their childd. Praising them by telling them that they are your best parents and that you are so proud of theme. Rebuking caregivers for missing vaccination appointmentsf. Reminding caregivers that they are not experts and should not question immunization. Stages Step Decision Advocacy Pre-contemplation Maintenance Preparation Contemplation Trigger Fine-tuning Trial 9 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 9 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 15. Caregivers who refuse vaccines are likely to include individuals with some of the following characteristics (mark all that apply)a. They are from marginalized populationsb. They question science and are often highly educated c. They come from poor and uneducated families in urban areasd. They dont trust their health care system or health workers. 16. The three Cs are (mark all that apply) Complacency Concern Convenience Confidence. 17. Vaccination programmes are expensive because of the costs of vaccines, cold-chains and the salaries needed to deliver so many vaccines to so many children. It is an important public health intervention, but not very cost-effective. True False 18. 18. Measles is so dangerous because (mark all that apply)a. The disease kills most unvaccinated children because the vaccine only starts working when a child is around two years oldb. It is so infectious that herd community cannot be achievedc. It can wipe out much of the immune memory that a young child had acquired before contracting measlesd. Survivors of measles have an increased likelihood of death in the 2-3 years after contracting the diseasee. The infection spreads rapidly when a group of unvaccinated individuals is exposed to a case of measles. 19. There are no good sources of credible information about vaccines and vaccine safety. True False 20. Vaccine rejectors have a responsibility to inform health workers that their child has not been protected against vaccine-preventable diseases and should know about the signs and symptoms of these diseases. True False 21. While vaccination contributes primarily to Sustainable Development Goal 3 (SDG 3) on good health and wellbeing by reducing the number of vaccine-preventable deaths, it also contributes indirectly to many other SDGs. True False 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES GLOSSARY AND DEFINITIONS Caregiver. The parent or primary guardian of the child. This module uses the terms parent and caregiver interchangeably, recognizing that while most children are cared for by their parents, this is not always the case. For the purposes of this module, the terms parent or caregiver refer to the adults responsible for children and who make critical decisions on their behalf around immunization. Closed questions. Questions that are generally answered with a simple yes or no, in contrast to open-ended questions that encourage the other person to elaborate on their answer and encourage a genuine, two-way dialogue. Empathy. The capacity to understand or feel what another person is experiencing from their point of view, i.e. putting yourself in their shoes. This contrasts with sympathy, which often conveys pity for someone else, but not necessarily an understanding of their situation. European Centre for Disease Prevention and Control (ECDC). EU agency aimed at strengthening Europes defenses against infectious diseases. The core functions cover a wide spectrum of activities: surveillance, epidemic intelligence, response, scientific advice, microbiology, preparedness, public health training, international relations, health communication, and the scientific journal Eurosurveillance.1 Herd/community immunity. It is achieved when the vast majority of a population (at least 95% of children for childhood vaccination) is vaccinated, ensuring the protection of the whole community, including individuals who have not been vaccinated. Immunization. The process by which a person develops resistance to an infectious illness, usually through the application of a vaccine. Interpersonal communication. The exchange of information, thoughts, and feelings both verbal and non-verbal between two or more people that leads to dialogue, mutual understanding, respect for different perspectives and positions and immediate feedback. It can take place in a face-to-face setting or via video or audio settings by phone or Internet. MMR. Measles-mumps-rubella vaccine. Vaccination. Act of introducing a vaccine into the body to produce immunity to a disease. Vaccine hesitancy (WHO, 2019). The reluctance or refusal to vaccinate despite the availability of vaccines. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines, and is influenced by multiple factors, such as complacency, convenience and confidence. 1 European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/about-ecdc https://www.ecdc.europa.eu/en/about-ecdc 11 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IINTRODUCTION 1. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing Recent decades have seen a surge of research on neuroscience and child development that has identified what newborns and young children need to survive, thrive, and lead healthy and productive lives. In May 2018, this critical body of scientific knowledge was brought together and used to create the Nurturing Care Framework by the World Health Organization (WHO), UNICEF, the World Bank and other partners. Compelling and robust scientific evidence was translated into five easily understandable and mutually supporting components that are essential for children to thrive (also shown in Figure 1): Good health Adequate nutrition Opportunities for early learning Responsive caregiving, and Security and safety. G OOD HEAL TH ADEQUATE NUTRITION G O PP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y R ESPO NSIV E C AR EG IVIN G Components of nurturing care Figure 1. The Nurturing Care: five interconnected components UNICEF/Kudravtsev 12 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES To survive, thrive and reach their full developmental potential, infants and young children need all five components of the Nurturing Care wheel. The components are not stand-alone, nor do they work as additions to each other: they are indivisible and synergistic. Responsive caregiving, for example, creates an enabling environment that can safeguard the other components: that is, a caregiver who is responsive to a child will be able to detect early signs that the child is feeling ill, tired, overwhelmed, anxious or threatened and will be able to respond in a way that protects the childs wellbeing. Similarly, a responsive caregiver is sensitive to the signs that a child is feeling well, alert, and ready to play and explore, and will be able to respond with appropriate activities. While parenting is perhaps the most challenging task for any adult, measures and support to prepare people for parenthood and education in parenting are more often available in high-and middle-income countries. Where such support is available in low-income countries, it tends to be accessed most frequently by high- and middle-income families. Families in many countries in the Europe and Central Asia region are fortunate to benefit from universal health care and home-visiting services provided by the public sector during the critical times of pregnancy and the first few years of a childs life. While the number of visits provided to all families is often limited, home visiting can be an effective entry point and opportunity to provide reliable and valid information and advice on child development, child rearing and parenting. Universal home-visiting services can also be used to identify families that are vulnerable or that need additional and targeted services. Providing all families with trusted and evidence-based information and advice and identifying the families with additional needs require knowledge and special skills in working with families from all walks of life to build a genuine and supportive partnership. About the resource package for home visitors and its modules The resource package for home visitors Supporting Families for Nurturing Care is a growing set of training modules (see Figure 2). It aims to strengthen the knowledge of home visitors on the key components of Nurturing Care, and enhance their skills in working with families to enable and empower them to provide the best start to their children. While targeting home visitors, many of these modules are also suitable for other health and non-health professionals who interact with pregnant women and the families of young children. Each of the modules responds to one or more components of Nurturing Care and builds capacity and skills needed by the home visitor to provide supportive home visits. In addition, each module aims to help home visitors reflect on professional attitudes and strengthen practices to engage inclusively and respectfully families that are diverse and face different needs and challenges. The modules have been developed by well-known experts and can be translated and adapted to different country contexts. In some countries, the modules have already become a mainstay of lifelong learning and continuing professional development for health workers and social-service providers engaged in promoting the comprehensive wellbeing of young children and their families. You can find hard copies of all modules on the International Step by Step Association (ISSA) website at https://www.issa.nl/modules_home_visitors and on UNICEF Agora. UNICEF/Voronin https://www.issa.nl/modules_home_visitors 13 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Knowledge Module 1: The Early Childhood Years - A Time of Endless Opportunities Module 7: Parental Wellbeing Module 11: Working against Stigma and Discrimination - Promoting Equity, Inclusion and Respect for Diversity Module 12: Children Who Develop Differently - Children with Disabilities or Developmental Difficulties Module 18: Gender Socialisation and Gender Dynamics in Families - The New Role of the Home Visitor Skills Module 2: The New Role of the Home Visitor Module 10: Caring and Empowering - Enhancing Communication Skills for Home Visitors Module 13: Developmental Monitoring and Screening Module 15: Working with Other Services Module 17: Supervision - Supporting Professionals and Enhancing Service Quality Module 22: Protecting Young Children from Vaccine-Preventable Diseases Figure 2. The Supporting Families for Nurturing Care resource package and its modules (asterisks indicate complementary pre-existing training packages) Components of nurturing care Thinking Healthy*Care for Child Development*Module 4: Falling in Love - Promoting Parent-Child AttachmentModule 5: Engaging Fathers Module 8: Common Parenting Concerns Integrated Management of Childhood Illnesses (IMCI)*Module 20: Healthy Weight, Physical Activity, Sleep and Sedentary TimeModule 21: The Care of Small and Sick NewbornsModule 22: Protecting Young Children from Vaccine-Preventable Diseases Module 6: The Art of Parenting - Love, Talk, Play, ReadModule 19: Early Childhood Education Programmmes Module 9: Home Environment and SafetyModule 14: Keeping Young Children Free from Violence, Abuse and Neglect Infant and Young Child Feeding (IYCF)*Baby-friendly Hospital Initiative (BFHI)Module 16: Responsive Feeding G OOD HEALT H ADEQUATE NUTRITIO NG OPP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y RE SPO NS IVE C AR EG IVIN G 14 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. Vaccination Trends Globally and in EuropeSince the development of the first vaccination against smallpox more than a century ago, vaccine programmes for children have become an integral component of preventive primary health care in every country on earth. Vaccination programmes prevent between 2 and 3 million deaths globally each year (WHO, 6.12.2019). In 2019, about 86 per cent of infants worldwide (116.3 million infants) received 3 doses of diphtheria- tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness, disability or death. Individuals and governments benefit from vast cost-savings as a result of the prevention of illness (EU and WHO, 2019). Based on the costs of illnesses, including treatment costs and productivity losses, that have been averted, every dollar invested in vaccines during the Decade of Vaccines (2011-2020) is estimated to have yielded a net return of about $16 (Ozawa et al., 2020). Two of the three strains of wild polio virus strains have been eradicated. A growing number of countries have achieved disease-free certifications (i.e. the European region has sustained its polio free status since 2002). The growing number of combination vaccines (i.e. the child is vaccinated against several diseases with one injection) is reducing the number of injections needed. In recent years, however, vaccination programmes have become victims of their own hard-earned success: few caregivers remember epidemics of polio, measles, pertussis or chickenpox that took the lives of many children, left many more with disabilities, and undermined their health and development. They may be unaware that measles is one of the worlds most contagious diseases, and that its transmission can only be halted if at least 95 per cent of the population is protected by immunization. In addition, misinformation that links vaccines to autism is easy to find and continues to circulate through social media and on websites, despite being discredited repeatedly, including by large-scale population studies (Hviid et al., 2019). Misinformation is sometimes disseminated deliberately to contradict (and appear alongside) evidence-based information about the benefits of vaccination. As a result of such challenges, countries around the world, and particularly in the Europe and Central Asia Region, have seen a resurgence of measles as the number of unprotected children and adults has grown. Measles cases have reached their highest level in Europe in 20 years (The Guardian, 21.12.2018). In total, 49 of the 53 countries in WHO European Region reported more than 192,943 measles cases and more than 100 measles-related deaths between 1 January 2018 and 31 December 2019, with a regional coverage with 2 doses of measles vaccination of only 91 per cent for the two doses of measles vaccination, which is too low to ensure herd immunity. Large disparities at the local level persist: some communities report over 95% coverage, and others below 70%. Several countries in the region Albania, the Czech Republic, Greece and the UK have recently lost their measles free certification. In the absence of disease, fear of disease has been replaced by fear of vaccines for some people (WHO, 2017). UNICEF/Bershadskyy Yuriy Immunization is one of the most cost-effective ways to save lives and promote good health and well-being. Every year, vaccines save 2-3 million lives, and millions more are protected from disease and disability. It routinely reaches more households than any other health service and brings communities into regular contact with the health system. This provides an effective platform to deliver other primary health care services and upon which to build universal health coverage. (Gavi The Vaccine Alliance, 2019) 15 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary UNICEF/ Krepkih Andrey Because of the frequency of the contact required with families, especially during the early months of a childs life, the quality of immunization services can either enhance or endanger the trust families place in health care services and professionals. As a health visitor for families with young children, you are in a unique position to educate the families you meet on the importance of vaccines and the vaccination schedule and identify caregivers who have some concerns or who may even reject vaccines. In their own home, and when talking to someone the family trusts their home visitor caregivers may feel more comfortable asking questions and voicing fears that have not been addressed during crowded vaccination sessions or in a busy doctors office. Your knowledge of the benefits and safety of vaccines, your communication skills and empathy for families, and your understanding of their concerns are your major tools for the promotion of this crucial health intervention. Once you have completed this module, you will be able to answer questions and provide practical tips to caregivers on how to support their child while they are being vaccinated and help them deal with common side effects. You will also be able to provide evidence-based information to counter any misinformation that might be spreading through the caregivers network or social media. Because you have the information about the childs vaccination status, you can tailor your response and refer families to other experts and specialists where necessary. The quality of your support is vital. It may influence whether caregivers complete the vaccination schedule for their children, and the way in which they engage with health services in the future. You may never know for sure, but you may have saved a childs life, while protecting other young children who cannot be vaccinated because of counter-indications, as well as infants who have not yet received their first vaccines! MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 16 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IIIMMUNIZATION AND VACCINE PREVENTABLE DISEASES A MAJOR PUBLIC HEALTH ACHIEVEMENT 1. Childhood Immunization In its listing of 100 objects that have shaped public health, Global Health NOW of the Johns Hopkins Bloomberg School of Public Health called immunization one of the most important public health achievements in human history.2 The development of vaccines has accelerated since the first use of a smallpox vaccine in 1798, and particularly since the middle of the 20th century. Today more than 30 infectious diseases can be prevented with vaccines (see Information Card 1 in annexes for information about common vaccine-preventable childhood diseases). Even though the worlds population has grown by almost 70 per cent, Gavi The Vaccine Alliance reports that cases of common vaccine preventable diseases have fallen by around 90 per cent (Gavi, 29.01.2019). Smallpox has been eradicated, as well as two of the three wild polio strains (WHO, 24.10.2019), and a number of countries have achieved measles-free status. Today, WHO recommends 10 vaccines during infancy and the early childhood years, plus one (for HPV) during adolescence recommendations that apply to every country (WHO, April 2019). Bacillus Calmette Guerin (BCG) (1 dose protects against tuberculosis) DTP-containing vaccine (3 doses protects against Diphtheria, Tetanus, and Pertussis Td (Tetanus and Diphtheria) booster at 9-15 yrs Hepatitis B (34 doses - protects against hepatitis type B) Hib (3 doses - prevents Haemophilus influenzae type b) Pneumococcal (3 doses - protects against pneumococcal disease) Polio (OPV and/or IPV, 34 doses - protects against poliomyelites) Rotavirus (23 doses - protects against rotavirus disease) Measles (2 doses - protects against measles) Rubella (1 dose - protects against rubella) HPV (2 doses - protects against human papilloma virus that can cause cervical and other types of cancer) (adolescent girls) Most of the countries in the ECA region use the MMR vaccine, a combined vaccine against measles, mumps and rubella. WHO recommends vaccination against mumps in high performing immunization programmes with the capacity to maintain coverage over 80% and where mumps reduction is a public health priority. Unfortunately, there has been a 30 per cent increase in cases of measles globally, and many countries in Europe and Central Asia have reported falling immunization coverage: half of the countries in the Region have DTP3 and MCV1 coverage below the 95 per cent minimum needed to ensure herd immunity. In 2019 WHO declared vaccine hesitancy as one out of 10 threats to global health. As we will discuss in more detail below, the WHO Vaccines Advisory Group has attributed this to the three Cs: Complacency, in-Convenience, and lack of Confidence, which contribute to vaccine hesitancy among parents and caregivers. Health workers, especially home visitors who work closely with their communities, have a critical role to play, as their advice is trusted by parents and can influence decisions around vaccination. To fulfil this role, however, home visitors need clear, factual information on vaccines, as well as communication tools to tackle the global threat to health posed by vaccine hesitancy (WHO, 2019). 2 Global Health NOW. One hundred objects that shaped public health. Retrieved from https://www.globalhealthnow.org/object/vaccines https://www.globalhealthnow.org/object/vaccines 17 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 17 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. How Vaccines WorkAs a home visitor, you often have very little time to cover a large range of relevant topics with the families you visit. That is why you need to be able to explain, in concise and understandable terms, how vaccines work and why it is important to vaccinate all children. To be efficient, apply the Elevator speech approach (Karam et al., 2019a, b) to make your most important points in the time that it would take for a ride in an elevator. It is important to tailor your messages to each family, taking into account their existing level of knowledge, as well as their concerns and attitudes around vaccination. Visuals can often be very powerful, helping you to make a point quickly and convincingly. Reflection and discussion There are many reasons why children are not vaccinated or vaccinated incompletely, but the following four steps can help you prepare short, clear responses to families that have concerns. First write down some of the questions and concerns you and your colleagues have heard from the caregivers you visit. Then choose several questions related to how vaccines work and develop brief elevator speeches with your colleagues or on your own. For your responses, use simple language, avoid jargon and technical terms; use analogies or simple examples and comparisons. Then try out your elevator speeches on others (family, caregivers, etc.) Finally, compare your responses to those provided by experts from WHO and the European Centre for Disease Prevention and Control (ECDC) and modify your elevator speeches as needed. Here are your practice questions: the kind of questions you may well be asked by the families you visit. Look through them and prepare some answers. When you have finished, compare your answers to the information provided in Box 1 below: How do vaccines work? Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Can vaccines cause the infection they are supposed to prevent? What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? I have heard that vaccinating my child also protects other children. What is community/ herd immunity and why is it important? UNICEF/Krepkih Andrey MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 18 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES How do vaccines work? Vaccines contain either a much-weakened form of the virus or bacterium that causes a disease, or a small part of it. When the body detects the contents of the vaccine, its immune system will produce the antibodies required to fight off infection and eliminate the disease-causing virus or bacterium. When a person later comes into contact with the virus or bacterium, the immune system will recognize it and protect the person by producing the right antibodies before any disease can be caused. (ECDC, Questions and answers about childhood vaccinations) Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Infants and young children are vaccinated in controlled settings (doctors offices or clinics), and parents are informed about possible side effects, how to manage these, and when to seek additional advice. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective (WHO, 2017). The only way a child can acquire natural immunity is to become sick with the disease itself. Even when the impact on the child is mild, it may mean additional caregiving and expenses for some families. But the disease could also result in complications, long-term illness, disability and even death, and many other children may become exposed in the process. For measles, the Center for Disease Control and Prevention (CDC) has reported complications with 30 per cent of measles cases, most commonly diarrhoea, ear infections and pneumonia. For every 1,000 cases of measles, one child may also be affected by encephalitis and two may die. Whats more, the measles infection can destroy much of the wider immunity a child has built up, increasing their risk of contracting other diseases. Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Newborns commonly manage many challenges to their immune systems at the same time. The mothers womb is free from bacteria and viruses, so newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunological cells circulating in their bodies. Therefore, vaccines given in the first two years of life are a drop in the ocean of what an infants immune system successfully encounters and manages every day. (ECDC. Questions and answers about childhood vaccinations) Can vaccines cause the infection they are supposed to prevent? Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. (WHO, 2017) What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? The defences of children who have survived a vaccine preventable-disease are not necessarily stronger. On the contrary, the disease tends to make the child weaker and more vulnerable. Recent research on measles has shown that having suffered and survived this deadly disease may make it harder for a child to fight other infections for years to come. It has been known for some time that children who had measles were 2-3 times more likely to die from pneumonia, diarrhoea or other conditions in subsequent years. Now, we have learned that the measles virus infects and destroys memory B-cells. These are the cells where the immune system stores information about past Box 1. How vaccines work https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html https://www.ecdc.europa.eu/en/immunisation-vaccines/childhood-vaccination/faq?pdf=yes&preview=yes 19 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 19 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES infections that can help it in fighting new infections. In addition, the measles virus also reduces the ability of the immune system to respond to new and dangerous pathogens. It now seems possible that there could be actually five times more indirect deaths from immune amnesia (caused by the measles virus) than the initial infection caused. (Gallagher, 2019) I have heard that vaccinating my child also protects other children. What is community/herd immunity and why is it important? Vaccination protects you and your family, and it also helps protect others. It contributes to community immunity. This is achieved when enough people in a population are immune to an infectious disease (through vaccination and/or prior illness) so that it is unlikely to spread from person to person. Even those who cannot be vaccinated because they are too young, are allergic to vaccine components, or vaccination is contraindicated for them, are offered some protection because the disease cannot spread in the community and infect them. This is also known as herd or community immunity. When more than 95% of population is (blue dots) in a community they can protect those who are not yet vaccinated (yellow dots) from those who are infectious (red dots) When groups of unvaccinated people build up and are in close proximity, community immunity doesnt work and the disease spreads. For additional brief answers to common questions and concerns (developed by WHO and ECDC communication experts), check Information Card 2 Frequently Asked Questions (FAQs) about Childhood Vaccinations (in annexes), which also includes links to additional information. However, keep in mind that you will have to tailor your answers to the needs of individual families, their attitudes towards vaccination, and level of knowledge, so just learning some standardized answers by heart is not enough. 20 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 20 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. The Benefits of Vaccination to the Individual Child and Society NOPOVERTY AFFORDABLE ANDCLEAN ENERGY CLIMATEACTION LIFE BELOWWATER LIFE ON LAND PARTNERSHIPSFOR THE GOALS DECENT WORK ANDECONOMIC GROWTH SUSTAINABLE CITIESAND COMMUNITIES ZEROHUNGER EDUCATIONQUALITY EQUALITYGENDER AND SANITATIONCLEAN WATER PEACE, JUSTICEAnd STRONG INSTITUTIONS RESPONSIBLECONSUMPTIONAND PRODUCTION GOOD HEALTHAND WELL-BEING INDUSTRY, INNOVATIONAND INFRASTRUCTURE REDUCED INEQUALITIES GLO BA L S TRA TEGY FOR WOME NS, CHILDRENS AND ADO LESCEN TS HEA LTH SU RVIV E TH RIV E TRANSFORM Figure 3. Sustainable Development Goals (SDGs) Reflection and discussion Immunization for vaccine-preventable diseases provides one of the strongest financial returns of any public health intervention, but its benefits go far beyond the health sector alone. Take a look at Figure 3, which sets out all of the Sustainable Development Goals. Can you list ways in which the benefits of immunization can be felt across all of these goals? To help you, the potential links between immunization and the SDGs are set out in Table 1: perhaps you can think of others! When you see how vaccination supports the achievement of the SDGs, you can feel confident and proud in promoting such a cost-effective and safe service to your community and to the families you serve. Immunizing children is one of public healths best buys. Vaccines are relatively easy to deliver and, in most cases, provide lifelong protection. They boost development both through direct medical savings and indirect economic benefits such as cognitive development, educational attainment, labour productivity, income, savings and investment (Gavi The Vaccine Alliance, 2019) https://www.gavi.org/vaccineswork/value-vaccination https://www.gavi.org/vaccineswork/value-vaccination 21 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Sustainable Development Goal Vaccination programmes 1. No povertyPrevent expensive illnesses and associated health-care costs, reducing the number of people forced into poverty. 2. Zero hungerProtect childrens nutritional status, because illness impairs absorption of essential nutrients. Malnourished children are also at a higher risk of death from vaccine-preventable diseases. 3. Good health and wellbeing Reduce mortality and morbidity and provide the platform for the delivery of other health services. 4. Quality educationVaccinated children have better nutrition and health status, and have, therefore, better chances to learn and achieve. 5. Gender equalityGlobally, this is a gender-equal intervention, with similar rates of vaccination for girls and boys 6. Clean water and sanitation (WASH) Prevent diarrhoeal diseases, alongside WASH programming. 8. Decent work and economic growth Contribute to the growth of healthy children who attain education and become a productive workforce. Caregivers are more likely to be able to work when children are not affected by vaccine-preventable diseases. 10. Reduce inequalityProtect all communities and children, including the most marginalized, those living in rural areas and in conflict zones, which can be further devastated by epidemics of infectious disease. 11. Healthy citiesProtect children from increased risk of exposure to vaccine-preventable diseases in cities where infections are more able to spread quickly. 16. Peace, justice and strong institution Contribute to equity and strong health services. Table 1. Vaccination and the achievement of the Sustainable Development Goals (SDGs) Source: Gavi, 2019 UNICEF/ Krepkih Andrey 4. Vaccine Safety and Side Effects Before you respond to concerns about the safety of vaccines in general
Report
01 Апрель 2013
Tracking anti-vaccination sentiment in Eastern European social media networks
https://www.unicef.org/eca/reports/tracking-anti-vaccination-sentiment-eastern-european-social-media-networks
Page 1 Page 2 A lie can travel halfway around the world while the truth is putting on its shoes. Mark Twains quote is more relevant than ever in times of online communication, where information or misinformation, bundled in bits and bytes, streams around the earth within seconds. SUMMARY DISCLAIMERUNICEF working papers aim to facilitate greater exchange of knowledge and stimulate analytical discussion on an issue. This text has not been edited to official publications standards. Extracts from this paper may be freely reproduced with due acknowledgement. For the purposes of this research, no personal data has been extracted and stored for data collection and analysis. This UNICEF working paper aims to track and analyse online anti-vaccination sentiment in social media networks by examining conversations across social media in English, Russian, Romanian and Polish. The findings support the assumption that parents actively use social networks and blogs to inform their decisions on vaccinating their children. The paper proposes a research model that detects and clusters commonly-used keywords and intensity of user interaction. The end goal is the development of targeted and efficient engagement strategies for health and communication experts in the field as well as for partner organisations. Page 3 CONTENT1. Rationale 2. Introduction 2.1 Social Media: the conversation shift 2.2 Social Media: Fertile ground for anti- vaccination sentiment 2.3 Social Media Monitoring 2.4 Influencers 3. Research Objectives 4. Methodology 4.1 Descriptive and Explorative Research Design 4.2 Data Collection 4.3 Limitations 4.4 Ethical Considerations 5. Empirical Findings 5.1 Networks: Volume and Engagement 5.2 Common Arguments 5.2.1 Religious and Ethical Beliefs 5.2.2 Side Effects 5.2.3 Development Disabilities 5.2.4 Chemicals, Toxins and Unnecessary 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest 5.3 Influencers 6. Discussion and Recommendations 6.1 Discussion 6.2 Recommendation Acknowledgements Literature Appendix 4 555 78 9 1111121313 1414191920212222 23 252527 313134 Page 4 Over the past few years, the region of Central and Eastern Europe and the Commonwealth of Independent States has been troubled by the rise of a strong anti-vaccine sentiment, particularly via the internet. Wide ranging in origin, motive, source, and specific objectives, this online sentiment has succeeded in influencing the vaccination decisions of young parents, in many instances negatively. A number of factors are at play in this online anti-vaccine sentiment. First, vaccination coverage in this region is generally high. As a result, vaccine-preventable childhood diseases like polio and measles have been absent in most countries for the past few decades. This has led to complacency toward the diseases and has unfortunately made vaccines, rather than the diseases, the focus of debate and discussion. Meanwhile, poorly-managed immunization campaigns in some countries have caused widespread mistrust of vaccines and government vaccination programs. Most countries have run sluggish, high-handed public communication campaigns while avoiding transparent dialogue with the public on possible side effects, coincidental adverse events and other safety issues. Moreover, when new vaccines have been introduced, they have often just exacerbated the publics existing doubts, hesitations or outright resistance. Into this mix, rapid penetration of the internet in the region has provided a powerful, pervasive platform for anti-vaccine messages to be disseminated. Rooted in scientific and pseudo-scientific online sources of information, messages are often manipulated and misinterpreted, undermining the confidence of parents and causing them to question the need for, and efficiency of, vaccines. The result is hesitation towards vaccination, which in large numbers poses a serious threat to the health and rights of children.This paper aims to examine this rapidly growing phenomenon and its global lessons. Depending on the nature of the problem, special strategies need to be developed to tactically address and counter, diffuse or mitigate its impact on ordinary parents. The prevailing approach of most governments in largely ignoring these forces is unlikely to address this growing phenomenon. Governments, international agencies and other partners - in particular the medical community - need to combine forces to identify the source and arguments of these online influences, map the extent to which they control negative decisions, develop more effective communication strategies and ultimately reverse this counterproductive trend. RATIONALE Page 5 The first part of this paper describes how anti-vaccination groups communicate and how social networks connect concerned parents in new ways. The second part emphasizes the role of social media monitoring in strategic communication, based on understanding audience needs. 2.1 Social media: The conversation shifts The rise of social networks has changed both the way we communicate and the way we consume information. Even within the relatively recent internet era, a major evolution has occurred: In the initial phase known as Web 1.0, users by-and-large consumed online information passively. Now, in the age of social media and Web 2.0, the internet is increasingly used for participation, interaction, conversation and community building1. At the same time, conversations or social interactions that used to occur in community centres, streets, markets and households have partly shifted to social media2. Parents, for instance, suddenly have an array of collaborative social media tools with which to create, edit, upload and share opinions with their friends, peers and the wider community. These conversations are recorded, archived and publicly available. 2.2 Social media: Fertile ground for anti-vaccination sentiment In todays information age, anyone with access to the internet can publish their thoughts and opinions. On health matters in particular, the public increasingly searches online for information to support or counter specialised, expert knowledge in medicine3. Due to the open nature of user participation, health messages, concerns and misinformation can spread across the globe in a rapid, efficient manner4. In this way, social media may influence vaccination decisions by delivering both scientific and pseudo-scientific information that alters the perceived personal risk of both vaccine-preventable diseases and vaccination side effects. INTRODUCTION 1 Constantinides et al, 2007 2 Phillips et al, 2009; Brown, 2009 3 Kata, 2012 4 Betsch et al, 2012 Page 6 In addition to this accelerated flow of information (whether accurate or not), social media messages tend to resonate particularly well among users who read or post personal stories that contain high emotional appeal. This holds true for anti-vaccination messages too. In other words, both logistically and qualitatively, social media is intensifying the reach and power of anti-vaccination messages. Negative reactions to vaccines are increasingly being shared across online platforms. All of this leads to a frustrating predicament and critical challenge: Immunizations protect people from deadly, contagious diseases such as measles, whooping cough and polio. But parents influenced by anti-vaccination sentiment often believe vaccines cause autism, brain damage, HIV and other conditions, and have begun refusing them for their children. As a consequence, health workers face misinformed, angry parents, and countries face outbreaks of out-dated diseases and preventable childhood deaths5. Why do anti-vaccination messages resonate with so many parents in the first place? Parental hesitation regarding vaccinations is thought to stem from two key emotions: fear and distrust: Vaccination is a scary act for many children and parents. A biological agent is injected into the child. The way the biological agent works in the childs body is for most people unclear, which appeals to parents fears. The high level of distrust stems from the intersection of government, medicine and pharmaceutical industry. The nature of its act and the fact that vaccinations are mostly compulsory leads to worries among citizens. (Seth Mnookin, 2011) This distrust, along with the interactive nature of social media, suggests an urgent need for health workers to become attuned to arguments and concerns of parents in different locations and of various cultural backgrounds. To achieve more synergistic relationships with an audience, organisations need to shift their communications strategy from getting attention to giving attention6. Compounding this challenge is the fact that some anti-vaccination groups are not merely sceptics or devils advocates, but operate in an organized, deliberate and even ideological manner. These anti-vaccination groups often employ heavy-handed 5 Melnick, 20116 Chaffrey et al, 2008 Page 7 communication tactics when dealing with opponents: they delete critical comments on controlled media channels, such as blogs7 ; they mobilize to complain about scientists and writers critical of their cause; sometimes they go going as far as to take legal action to prohibit the publishing of pro-vaccine material. Governments and organisations aim to keep parents accurately informed about vaccinating their children. As more of the public conversation indeed battle takes place across social media, there is an urgent need to understand this online landscape. This, in turn, requires the use of effective monitoring tools. 2.3 Social media monitoring Social media analysis plays an important strategic role in understanding new forms of user-generated content8 . Indeed, this type of monitoring has become a leading trend in Marketing, PR, political campaigns, financial markets and other sectors. As demand for this kind of data increases, more monitoring tools are becoming available. These tools search social networks for relevant content, and archive the publicly available conversation in a database. Researchers conduct their internet analysis primarily by formulating combinations of keywords that can be placed in relation and weighted for importance. There are four different types of social media monitoring: Monitoring by volume looks at the amount of mentions, views and posts a topic, organization or user receives. Monitoring by channels maps and examines the various networks that users use to exchange content. Monitoring by engagement seeks deeper insight into how many users actually respond, like, share and participate with the content. Monitoring by sentiment analysis is a qualitative approach that uses word libraries to detect positive or negative attitudes by users towards an issue9. The first phase in social media monitoring is listening to what users say, because in order, for instance, to engage effectively with parents on social networks, it is important to know what they are talking about10. 7 Kata, 2012 8 Cooke et al, 2008 9 The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. 10 Kotler et al, 2007 Page 8 Social media monitoring is a young discipline that began just a few years ago, and in its initial phase the practice faced a number of challenges. Data was very complex, so first generation monitoring tools produced results that were unstructured and generally overwhelming11. Even when that data was sorted and structured, organizations struggled to generate actionable management recommendations from it12. Since that time, however, social media professionals and research communities have made steady progress in overcoming the early challenges. 2.4 Influencers Recent studies on social media networks emphasize the central role played by influential individuals in shaping attitudes and disseminating information13. Indeed, it is argued that a group of such influencers is responsible for driving trends, influencing public opinion and recommending products14. One study found that 78% of consumers trusted social peer recommendations, while just 14% trusted advertisements15. Intensive interaction and content sharing through social media means that an audience instinctively determines its own opinion leaders. What makes opinion leaders particularly interesting and important from our perspective is that they add their personal interpretation to the media content and pass it on to their audience. Depending on whether these influencers speak responsibly or not, this can have positive or negative impact on the goal of disseminating accurate information. In his book The Panic Virus, journalist Seth Mnookin offers some examples of controversial influencers: A British gastroenterologist, Andrew Wakefield, entered into the vaccine discourse and alleged that the measles-mumps-rubella vaccine might cause autism. The medical community eventually dispelled his arguments and he lost his medical license. For a decade Wakefield - though not a public health specialist - very successfully disseminated misleading information and garnered a significant social media following. Meanwhile, actress and model Jenny McCarthy has become another self-proclaimed expert on vaccine safety. Through frequent public appearances she has positioned herself as an 11 Wiesenfeld et al, 201012 Owyang et al, 201013 Tsang et al, 2005; Kiss et al, 2008; Bodendorf et al, 201014 Keller and Berry, 200315 Qualman, 2010 Page 9 educated, internet-savvy mother set on challenging the medical establishments information about vaccinations. This, too, has helped fuel the recent growth in anti-vaccination sentiments. The public following and authority gained by Wakefield and McCarthy demonstrate how with the proliferation of online channels and the user as the centre of attention, it becomes difficult for information seekers to differentiate between professional and amateur content16. By the time the record is set straight, trust in immunization is been partly destroyed. Fostering the positive opinion of influencers in communities can have a disproportionately large impact in terms of online reputation17. Though they may not know each other in the real world, and despite ever-expanding advertisement platforms and sources, consumers around the world still place their greatest trust in other consumers18. Audiences listen to opinion leaders because they are known to be independent, credible and loyal to their peers19. Identifying and influencing the influencers of the social media conversation in the region should therefore be part of any effective strategy to reinforce positive messages in the vaccination debate. Though the internet is increasingly used to search for health information, a number of questions about social media and vaccination decisions are still unanswered: Which channels are used by anti-vaccination groups? What are the key arguments and conversation themes? What makes anti-vaccination messages appealing to parents? Who are the opinion leaders in online discussions? What are the best strategies to respond to anti-vaccination arguments? This paper seeks to understand the internal dynamics of anti-vaccination sentiment in social media networks in Eastern RESEARCHOBJECTIVES 16 Cooke et al, 200817 Ryan et al, 200918 Nielsen, 200919 Weiman, 1994 Page 10 Europe20. These insights are expected to help health workers, partners and national governments to develop appropriate response strategies in order to convince the public of the value, effectiveness and safety of vaccinations. The objectives of this research are: 1. To monitor social media networks, consolidate existing data and information from partners. 2. To categorize and analyse conversation themes, based on volume of discussion, influence, engagement and audience demographic as appropriate. 3. To identify influencers in the different language groups and platforms. 4. To contribute to a set of recommended strategies to address specific anti-vaccine sentiment around the various conversation themes. This content analysis is expected to help us understand the motivations and mind sets behind the sentiment, and offer clues that can inform the development of a strategy to effectively address the phenomenon. The research is also expected to help drawing comparisons between the anti-vaccination sentiment phenomenon and similar sentiments expressed against interventions in nutrition, child protection and other areas of UNICEF practice. This paper is supported by UNICEF Department of Communication in New York and UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States. The region covers 22 countries and territories: Albania, Armenia, Azer-baijan, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kosovo (UN Administered region), Kyrgyzstan, TFYR Macedonia, Moldova, Montenegro, Roma-nia, The Russian Federation, Serbia, Tajikistan, Turkey, Turkmenistan, Ukraine, Uzbekistan. UNICEF does not have a country programme in the Russia Federation but is in discussions to develop a new mode of engagement. Page 11 In order to assess the dynamics of the anti-vaccination sentiments in the four languages, a systematic mapping and content analysis via social media monitoring is proposed. For the purpose of stakeholder monitoring in social media, a combination of descriptive and exploratory methods in form of quantitative and qualitative observation is proposed. According Wiesenfeld, Bush and Skidar (2010) it is reasonable to combine both methods because social media monitoring offers the richness of qualitative research, with the sample sizes of quantitative research. It may also give the opportunity to overcome problems associated with each research method in order to understand stakeholders dynamics in social media. 4.1 Descriptive and Explorative Research Design The descriptive methodology involves recording the activities of users and events in a systematic manner. Information is recorded as events occur and archived. Descriptive research in this case involves: Figure 1: Research Process for data gathering and analysis. METHODOLOGY 12 Aggregating text from public accessible social networks in in English, Russian, Polish and Romanian language. Cleaning and categorizing the data over time. The data is categorized and analysed into reoccurring conversation themes, based on volume of posts, engagement and audience demographic as appropriate. The exploratory methodology follows the descriptive research to allow for the interpretation of patterns and to provide background understanding of sentiment and attitudes of users. The results of the structured observation will be put into context by the human judgement of the researcher through the participant observation. In this research, the researcher will be a complete observer and will not interact with the users during the participant observation (Saunders et al, 2009). 4.2 Data Collection Traditional sampling techniques such as random, convenience or judgemental sampling are difficult to apply to a fluid social media environment. On top of the social media measurement process, the selected social media channels feed into the sample set. The posts are further categorized into different issue arenas that will be associated with relevant stakeholders. Figure 1 presents the data collection process for monitoring stakeholders in social media.The process contains the following six steps: 1. Channels: The first step of the data collection process involved the selection of relevant social media channels. Social media monitoring is instead generally considered to provide a complete set of all contributors, because tools like Radian6 or Sysomos are designed to capture a wide range of social media channels, such as blogs, forums, Twitter, Tumblr, Youtube and Facebook. 2. Demographics: The software gathered relevant posts that were posted in English, Russian, Polish and Romanian language3 during the period of 1 May and 30 July 2012. Posts could be submitted from all regions worldwide. 3. Context: The quality of data collection is determined by how well the collected data is gathered with regards to formulated searches. Keyword logic and search profiles were employed to filter the data. The full list of keyword combination can be found in Appendix A. 3The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. Page 13 4. Data Collection: Relevant social media mentions that contained an issue-related keyword in relation to a stakeholder-related keyword was archived in the database. The list of relevant mentions was stored chronologically and assigned an ID. The full list of exported information about each mention was stored in a separate EXCEL file. 5. Data Analysis: The empirical application and content analysis of the relevant posts can be found in Chapter 6. 4.3 Limitations There are limitations in terms of reliability and validity of the recorded data. The data collection covers a three-months period. There is a need for caution when generalizing the data because events and evolution of discussions may alter the findings in other time periods. Therefore, limitations in reliability refer to reproducibility of research results. Reliability in the extent to which measures are free from error and therefore provide consistent results, such as the consistency of data availability in social media monitoring, is the second limitations. Quantitative observation has relatively high reliability because it reduces the potential for observer bias and enhances the reliability of data (Malhorta et al, 2007). However, social media monitoring might carry the risk of monitoring bias, as the relevant posts are extracted through keyword logic that is developed by the researcher. The collected data cannot be regarded as complete. For example, the share of Russian-speaking discussions seems to be fairly low compared to the amount of users accessing social media. Governmental control and censorship might also be contributing for lower volumes.The external validity, which is defined as the extent to which the research results are applicable to other research settings (Malhotra et al, 2007), is relatively low. Because of the richness of data, the sampling needs to be based on the experience of the researcher. As a disadvantage, the lack of established sampling technique in social media limits the ability to generalize the findings to other relevant issue arenas or stakeholders in the population. However, the ability to generalize the results was enhanced by careful use of the theoretical terms and relationships in the stakeholder literature (especially Freeman, 1984; Mitchell et al, 1997; Luoma-aho et al, 2010; Owyang et al, 2010). 4.4 Ethical Considerations Monitoring social media conversations raises two important questions about a) the protection of privacy, and b) ethical concerns. The growth of interest in social media monitoring has Page 14 triggered a new debate about ethics, which centers on what is in the public domain and what is not (Poynter, 2010). Privacy is a big issue, and social networking sites are under public criticism for lax attitudes regarding the security and respect of users privacy (Wakefield, 2011). It is the responsibility of the market researcher to protect a respondents identity and not disclose it to external audiences (Malhotra et al, 2007). Social media monitoring offers a rich volume of data, however the Internet is largely unregulated. The data of users around the world is stored on servers in the US and completely available to the US authorities. What might seem legal to the researcher may not necessarily be deemed morally right by society. Public interactions in social media are available for anyone and can be assigned to a personal IP address, geographic location, language, date and even specific computer. For the purposes of this research, no personal data has been extracted. The IP addresses and geographic locations have not been stored in the excel exports as it is not necessary for the purpose of the research. A unique post ID identifies each post. The following findings start with an overview of the networks used by the anti-vaccination community. Trends in volume and engagement are outlined in 5.1. In 5.2, clusters of common belief of the anti-vaccination sentiment are categorized and explained. The importance of influence in the anti-vaccination discussion is illustrated 5.3 because it is critical to understand that communication needs require adjustment to each country or region, which itself can present a challenge. 5.1 Networks: Volume and Engagement During May to July 2012, the researchers recorded messages with anti-vaccination sentiment from 22,349 participants. The majority of participants spoke English, followed by Polish, Russian and Romanian. EMPIRICALFINDINGS Page 15 Figure 2: Participants of anti-vaccination discussions per language. Across all four researched languages, blogs are the most frequently used channel for posting anti-vaccination content in social media. Blog is short for weblog, which is a website normally maintained by an individual (or group of individuals) and updated with regular entries. Entries are typically displayed in chronological order and tagged with relevant keywords and phrases. Blog visitors usually have the opportunity comment and share the content on blogs. Blogs are by far the most important channel in terms of volume of posts in Romanian (86% of all posts) and Polish (85% of all posts). In Russian discussions, 65% of all posts are submitted on blogs and in English nearly half of the anti-vaccination content (47%) is posted on blogs. Facebook is the second largest channel in terms of volume of posts. The social network has a share of 25% in English speaking networks, 13% in Polish, 8% in Romanian, and 5% in Russian channels. Facebook allows users to build personal profiles accessible to other users for exchange of personal content and communication via the Facebook. Twitter, which allows users to send brief (<140 character-long) updates, is the second largest channel in Russian-speaking (24% of the total volume) and fourth with 5% in English-speaking anti-vaccination communities. Other channels to consider are News websites and Forums in which users post comments to engage in discussions about specific topics. Since 68% of all participants in the anti-vaccination discussions during the observed time-period speak English, the dataset is able to reveal more accurate insights into demographics compared to the other languages. Insights in all languages can be found in Appendix 4, while the following analysis focuses on the English Page 16 data set. The English dataset also reveals that blogs have generally the highest rates of mentions (61%), conversations (67%), posts (67%) and interactions (43%). Based on the volume of posts, it is a logical consequence that most engagement takes place on blogs. Engagement is defined as followed: Post: An initial message submitted to a social networking site, i.e. a blog post, Facebook status, tweet, video, etc. Interaction: Any activity created as a direct response to an initial post, i.e. comments, likes, retweets, @replies, etc. Conversation: The sum of a post and all its related interactions. Note: a post with at least one interaction is considered as conversation. Mention: An appearance of search terms in a public social media space. Figure 3: Distribution by channel for Romanian, Russian, English and Polish networks Page 17 Blogs, forums, and Facebook are the leading networks for anti-vaccination discussions in English during the observed time-period. In other words, the anti-vaccination sentiments are expressed on those platforms through posting user-generated content. However, while conversations on forums only makeup 2% of total conversations, they account for 25% of all interactions among users. This indicates a heavily engaged audience. It can Figure 4: Mentions, Conversations, Posts and Interactions per channel. Page 18 be argued that opinions are formed during interactions among users and therefore, it is vital to add pro-vaccination content to the discussions on forums. Similarly, Facebook only contains 9% of conversations, but 21% of interactions. Both channels are important to consider for interactions with the anti-vaccination sentiment even if more posts occur on blogs. Similar findings occur in Forums. Forums are designed to be interactive conversation, where topics are discussed in greater depth. The English dataset is a reflection of this distinguish feature 16% of all posts and 25% of all interaction occur on Forums. The figures show that while the volume of content on Forums is relatively low, the engagement is an important strength that shaped the opinion in the anti-vaccination community. Figure 5 indicates that the data skews towards female audiences when issues such as developmental disabilities (59%), chemicals and toxins (56%) and side effects (54%) are discussed within the anti-vaccination sentiment, whereas men focus on arguments around conspiracy theory (63%) and religious/ethical beliefs (58%). Anti-vaccination social media participants are approximately 56% female and 44% male. Figure 5: Gender comparison in English per argument. Page 19 5.2 Common Arguments The amount of argument-mentions in anti-vaccination sentiment changes significantly by language during the observed time-period. Figure 6 illustrates that conspiracy theory and religious/ethical beliefs are the main topic trends in English, while religious/ethical beliefs drive the majority of discussions in Russian speaking anti-vaccination discussions. Polish anti-vaccination discussions are driven by arguments about side effects and chemicals and toxins in vaccines. The issue of chemicals and toxins is the major driver in Romanian discussions during the observed time-period. The arguments are described in detail in the following sections. The categories are based on keyword strings that were narrowed down over time. Issues should not be regarded in a static way, they might overlap and are interconnected. 5.2.1 Religious and Ethical Beliefs Religious and ethical discussions are especially active in discussion in Russian, with 96% of all anti-vaccination discussions focused on that issue. In English discussions, 32% of all anti-vaccination discussion use religious and ethical arguments. The arguments are less relevant in Polish (5%) and Romanian (0%) speaking anti-vaccination discussions. The main train of thought derives from Figure 6: Allocation of arguments by language for the anti-vaccination sentiment. Page 20 the belief that humans are created just as they should be and external interference is not required. My body was designed by God to be self healing and self regulating and no man will be able to do better than God is a quote by a female blog commentator from the US. Another user states, anything that involves substances that should never belong in a humans body, should not be injected or consumed without that individuals consent. Anti-vaccination advocates believe in homeopathy and alternative medicine. My BodyMy Decision writes a community member from Australia. A broad sentiment that mandatory vaccination is a violation of human rights can also be detected. From an ethical standpoint, the anti-vaccination community claims that it is a basic human right to be free from unwanted medical interventions, like vaccine injections. The same kind of argumentation can be recorded in all four languages. On June 15th 2012, the Polish Parliament voted to change the existing laws on vaccinations. The Act on Preventing and Fighting Infections and Infectious Diseases in Humans and in The Act on National Sanitary Inspection has created controversy among social media users because of it makes vaccination mandatory. The anti-vaccination advocates were sending petitions to the Polish President demanding him to stop the act. The petition received support from some representatives of the Catholic Church, but not an official support from the church as whole. Radio Maryja, the most powerful independent catholic media in the country, also critiqued the act based upon: The argument that vaccines are made based on cell lines derived from the bodies of babies killed by abortion. The notion of unethical activities by campaigning teenagers and women to be vaccinated against HPV infection and it is promoting immoral, and disorderly behaviour in the area of sexuality. 5.2.2 Safety and efficacy Side effects are the most common anti-vaccination theme in Polish networks (28%), but they also play a role in English networks (9%) and Romanian (5%). The argument is mentioned in less than 1% of all anti-vaccination discussions in Russian language. Typically, parents who reach out to online communities because they are unsure about vaccines trigger the discussions about side effects. Individual stories from parents are powerful because they humanize the discussion. One user writes, My baby is 5 months old, not vaccinated and he is going through pertussis right now! Its very scary! I HATE it! I have 3 children, the other 2 were vaccinated but Im scared to vaccinate my baby! Any other mommys new at Page 21 this? This quote reflects a level of fear and uncertainty about the right thing to do, even though the mother has experienced both the effect of vaccines and vaccine-preventable diseases. Another parent writes: My brother, sister in law, and all three kids under the age 5 were vaccinated for whooping cough and they all got it! An argument in a Russian network claims that live vaccines can mutate in the organism and create deadly strains. The fear of side effects leads to discussion about vaccines causing diseases and death. A user from the UK argues, The only way you can get this virus is if it is injected into you. Besides individual stories, argumentation backed by figures without context or sources are equally powerful in fostering fear of vaccines. For example, a member in one English network posts: Vaccinated children have up to 500% more diseases than unvaccinated children. Community members in Russia postulate that vaccinated children get sick 2-5 times more often than non-vaccinated children. For example in Romania, school nurses perform the mandatory vaccination during class, which is seen as a human rights violation and a safety issue. Parents are sceptical about the skills of the school nurses and feel surpassed by authorities in its decision to have children vaccinated. A user in a Polish anti-vaccination community states: I am a mother of two disabled children. When my daughter was five months old, she had a negative reaction to the vaccine, now she has been diagnosed with autism and mental retardation. For 10 years, I did not vaccinate my children and I would not want the right to decide on this matter taken away from me. I am an educated person, and have researched the subject and do not believe in the efficacy or safety of vaccinations. 5.2.3 Developmental Disabilities Another reoccurring argument in the anti-vaccination sentiment claims that vaccines contain toxins and harmful ingredients. Injecting vaccines into the body of a child leads to brain injury and developmental disabilities. This theme is discussed in 15% of all English and Polish speaking anti-vaccination discussions. Development Disabilities was in less than 1% of anti-vaccination discussions mentioned in Russian or Romanian networks. The arguments evolve from sentiment surrounding vaccines posing challenges to the immune system and producing antibodies that may cause autoimmune diseases. Another notable argument is that vaccines are not able to fight off the mutant viruses that develop over time. Across communities, anti-vaccination advocates link vaccines to Page 22 epilepsy, autism and neurodegenerative diseases (Parkinson and Alzheimer). A member of the Polish community writes: Mercury causes developmental disorders in children (including epilepsy and autism), in adults, neurodegenerative diseases (Parkinsons and Alzheimers), and degenerative changes in the reproductive systems of men and women, impairing their ability to reproduce offspring. It is notable that figures are used based on estimates by the author without links to sources. A Russian speaking user notes that vaccinations against pandemic influenza H1N1, also known as swine, can lead to the development of Guillain-Barr syndrome, acute poliradikulita in adults, according to Canadian researchers, published in the journal JAMA. 5.2.4 Chemicals, Toxins and Unnecessary(administration of vaccines) Our doctor has advised us to avoid vaccines in absence of a direct disease risk, since the long-term side effects have not been studied writes a member of an English-speaking community. One common argument recorded in the anti-vaccination sentiment is that studies about risks and impact of vaccinations are insufficient. Vaccines have not been tested enough and have concerns regarding the lack of long-term side effects studies. Another user states that I would really want to know whether and how well vaccine manufacturers test their final vaccine products () and how much contamination they discover. A common belief is that children having a vaccine-preventable illness just need food, water, and sanitation. In Polish communities, members use the example of Scandinavian countries lobbying for a ban of questionable and potentially harmful ingredients in vaccines. The notion that Scandinavian countries banned Thimerosal a long time ago and they have a much lower percentage of children with autism was classified was an important argument for users. Drawing on that example, the most common belief in Polish communities is that mercury may cause autism. A Russian-speaking user concludes, a recent large study confirms the results of other independent observations, which compared vaccinated and unvaccinated children. They all show that vaccinated children suffer 2 to 5 times more often than non-vaccinated children. Sources or links to the recited studies are not provided. 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest In English-speaking anti-vaccination communities (24%), a strong distrust against governments and pharmaceutical industry is Page 23 recorded. The same applies for Polish (5%), Russian (1%) and Romanian (3%) at a smaller scale. However, the U.S. and western governments are viewed critically when discussing about governments and conflict of interest. In Polish networks excessive vaccinations are seen as promoted by pharmaceutical companies in order to gain profits. The role of the pharmaceutical industry is discussed mostly negatively. The sector is regarded as corrupt marketing machine. An English-speaking user states that: In the vaccine industry, scientific fraud and conflicts of interests are causing a similar cycle of deaths and injuries that is being concealed and denied by regulators and vaccine manufacturers. The industry is viewed as profit-driven and has moved from its original purpose to save lives and protect humans. Romanian discussions directly blame the U.S. for purposefully infecting people with HIV using polio vaccines. Users create a direct link between vaccines and widespread HIV in Romanian orphanages. In the same sense, users claim that vaccines are being used against the Romanian populations. According to members of the anti-vaccination sentiment, vaccines against polio and chickenpox are used in Romania, which are not used in the U.S. anymore. Polish anti-vaccination communities state the examples of swine flu and bird flu two years ago. According to the users, both cases are plots by giant pharmaceutical companies. Some countries desperately bought a huge quantity of vaccines, while Poland acted rationally and did not buy the vaccines, which saved the state budget a couple of billion. The activists are suspicious because the epidemic ended after the new vaccines were purchased by several governments. The distrust against governments is also reflected in conspiracy theories. Patterns in English-speaking communities suggest that immunization is used to control and reduce the world population. One strain of argumentation is that vaccines that are not allowed in developed countries are imported to developing countries in order to reduce population growth. 5.3 Influencers Opinion leaders in anti-vaccination sentiment show varying characteristics across countries. However, they often appear to be well educated in alternative medicine. Some have no college education; others are in the medical field (such as nurses). A high level of volume and interaction can be recorded for influencers. They often subscribe to social channels of homeopaths and Page 24 alternative medicine advocates but they can be found across platforms. The following section lists a range of influencers that are active in different channels or languages: Name Position Facebook Fans Twitter Followers Blog Language Dr. Tennpen-ny The Voice of Reason about Vaccines 36,282 1,475 Yes English The Truth About Vac-cines Answering questions from concerned parents 21,246 N/A Yes English International Medical Council on Vaccination Purpose is to counter the messages asserted by pharmaceutical com-panies, the government and medical agencies that vaccines are safe, effective and harmless 7,983 N/A Yes English The Refusers "Vaccination choice is a fundamental human right." 9,069 12,457 Yes English Mothering Magazine Mothering is the pre-mier community for naturally minded par-ents. 66,504 102,173 Yes English Oglnopo-lskie Sto-warzyszenie Wiedzy o Szczepieniach STOP NOP Protest against new laws for mandatory vaccinations in Poland and against disinforma-tion campaigns about the effectiveness and safety of vaccines. 3,203 N/A Yes Polish STOP Pr-zymusowi Szczepie Petition campaign against new new laws for mandatory vaccina-tions in Poland. 2,866 58 Yes Polish Table 1: Examples of influencers in the anti-vaccination sentiment in social media. Page 25 With respect to the above-mentioned arguments, opinion leaders in the anti-vaccination movement put an emphasis on highlighting negative stories that focus on individual cases. In some cases, they blame outbreaks on shedding vaccinated children who get unvaccinated children sick. The argumentation is based on the conviction that vaccines are unsafe and dont work. A list of common arguments by arguments by influencers per language can be obtained in Appendix B. In this section the research question will be discussed in light of the theoretical and empirical findings. It needs to be noted that the discussion only focuses on engagement with anti-vaccination advocates in the four researched languages. This does not include pro-vaccination movements, medical professionals, partners or others. The discussion will propose a model that illustrates the different drivers of anti-vaccination sentiment based on three elements. The recommendations section builds on the three elements of the model and provides practical advice for communication strategies. 6.1 Discussion In order to develop engagement and messaging strategies for anti-vaccination sentiment, it is vital to have an abstract understanding of what drives users to become suspicious about vaccinations. Based on the findings, the paper proposes a model of anti-vaccination sentiment identification and salience. We classify three main spheres that attribute to a negative sentiment towards vaccine, which help us in the identification of trends within the anti-vaccination sentiment. The classification is illustrated in the following figure: DISCUSSION &RECOMMENDATIONS Page 26 The first attribute is the individual sphere. The main motivations for users to get involved are highly personal matters driven by concern and fear. When it comes to vaccinations, some parents are not sure what the right decision is. Am I a good mother if I do not get my child vaccinated or is it my responsibility as a caring parent to ensure the best protection for my child? Personal testimonies of other parents, especially negative stories, have a huge impact on the parent and fuel the concern. The second element that characterizes the anti-vaccination sentiment is the contextual sphere. The main driver behind the contextual sphere is a distrust of governments, pharmaceutical industry, scientific bodies and international organizations. It seems to be overwhelming for parents to understand the role of the big players. An interesting observation is that users in the contextual sphere do not seem to have a general resentment against vaccines per se but most arguments focus on lack of transparency in the decision processes as well as the potential conflict of interests trigger distrust. The third attribute is labeled as transcendental sphere. Negative attitudes towards vaccinations are derived from idealistic, religious and ethical beliefs. Arguments are rooted in strong beliefs and appear dogmatic, such as God creates us in the most ideal way or a body has its natural balance. Figure 7: Model of anti-vaccination sentiment identification and salience. Page 27 Individual, contextual and transcendental sphere are the key attributes of a member of the anti-vaccination movement. We argue that the various combinations of these attributes are indicators of the salience of members. We can identify four groups that derive from Figure 3. In order to understand salience within anti-vaccination community members, we propose the following classification Core Members are users that apply to all three spheres. They are concerned about side effects, distrust the government and live according to strong religious or ethical beliefs. Intense Members are members that apply to two of the three spheres. For example, a user might have concerns about vaccinations based on an individual sphere and also carry distrust against the pharmaceutical industry. But they are not driven by any idealistic beliefs. Alert Members are users that apply only to one of the three spheres. The doubt about vaccines derives only from one sphere and has human characteristics. They seem to be less convinced of the harm of vaccinations than the other two member groups. There is a fourth group of users, the Non-Members. They simply do not apply to any of the classification. We argue that Alert Members are easier to convince of the necessity of vaccines than Intense Members. Core Members are the hardest to convince, because the arguments against vaccines are based on various foundations. The findings also show that the intensity of argumentation, the interaction and the volume varies between the spheres. Therefore, the next section outlines practical recommendation on how to draft engagement strategies for each sphere. 6.2 Recommendations The following graphic summarizes the framework for the engagement and messaging plan that enables communication officers and health workers to react to the anti-vaccination sentiments. The framework is designed to be customizable for local realities. However, it does provide an overarching guidance for communication and campaigning initiatives. Members of the individual sphere should be approached with an emotional appeal. Users in this sphere go online and search for information in order to make an informed decision. Content that encourages parents to get their children vaccinated needs to be easy to find. Hence, search engine optimization plays an important role in the outreach strategy. Search marketing is used to gain visibility on search engines when users search for terms that relate to immunization. In order to appear on top if the search Page 28 results two general approaches should be considers: Organic search (SEO): When you immunization or vaccines into a search engine like Google or Yahoo!, vthe organic results are displayed in the main space of the results-page. For example, when parents search for information about vaccinations, pro-vaccine information should rank on top of the search engine results. By optimizing websites and posts, organizations and governments can improve the ranking for important search terms and phrases (keywords). Engaging actively in discussion and providing links to pro-vaccination content also helps to increase the visibility in the ranking. Paid search (SEM) enables to buy space in the sponsored area of a search engine. There are a variety of paid search programs, but the most common is called pay-per-click (PPC), meaning the information provider only pays for a listing when a user clicks the ad. The emphasis of the content strategy is to empower parents to ask doctors the right question in order to build confidence for the decision making process. Rather than criticising parents choices not to vaccinate, the messaging should promote an individuals ability to make the world a safer place for children. The communication strategy should also highlight the individual right and responsibility to choose to vaccinate. Through emotional Figure 8: Engagement Matrix for core spheres of the anti-vaccination movement. Page 29 messaging, hesitating parents should receive key information and explain how their choices affect their own children and the ones of others. The communities in the contextual sphere source their scepticism from general distrust against the large players involved in the vaccination industry. The engagement strategy should be based on a rational appeal that focuses on the hard facts of vaccines. It is important to avoid obvious communication tactics. Transparency about vaccines, testing, ingredients, potential side effects, funding and preventable diseases is crucial to reduce distrust. The messaging should also take into account past errors in vaccine campaigns by governments and suppliers in the regions and most importantly focus on the lessons learnt and how processes have been improving since then. Transparency can be built through a multi-channel approach that features the development of vaccines with expert testimonies. Successful cases, such as the near eradication of polio as a global effort, help to reduce distrust as well. This can be backed by official statistics on how infant mortality rates have been reduced over the past 20 years. Countries that generally have a favourable public perception, such as Scandinavian countries,
Blog post
23 Март 2022
Inside the journey of Ukrainian refugee children and families
https://www.unicef.org/eca/stories/inside-journey-ukrainian-refugee-children-and-families
In the past three weeks Moldova’s southern border has seen crowds that one could hardly imagine here even several weeks ago. With thousands waiting to flee war-torn Ukraine, the life of both communities has changed irremediably. Armed violence has not spared civilians for weeks and millions of Ukrainian families were forced to leave their homes in a matter of days or, in some instances, hours. Now they are arriving in Moldova and neighbouring countries in pursuit of safety.  Since the first day of the war waged against Ukraine, UNICEF's teams have been on the ground, providing life-saving aid to the most vulnerable children both in Ukraine and outside of its borders. Together with a group of first-responders in Moldova, I arrived at the border crossing point of Palanca that has already seen thousands of Ukrainians seeking refuge in the past weeks. The first thing that catches your eye as you look at the people traveling through Palanca is that there are almost no men among them. The vast majority of those fleeing the hostilities in Ukraine are women and children as men between 18 to 60 are banned from leaving the country. According to UNICEF’s estimates, at least one child is crossing Ukraine’s border every single minute. The total number of children seeking asylum in Moldova and the European Union has already gone beyond 1.5 million. As for those children who have been displaced within Ukraine, a comprehensive count could not be done yet due to the rapidly changing situation. The second observation that you can hardly miss at Palanca is the profound exhaustion on the faces of those who walk across the border. Many women and children we meet started traveling days ago. Roads, trains, buses, queues, shelters – families lost the count of those on the way to Palanca. The journey’s logistical hardships are coupled with many dangers, ranging from gunfire to air strikes. Ukrainian refugees, some with children, arrive at the Palanca border crossing in Moldova Ukrainian refugees, some with children, arrive on March 08, 2022 at the Palanca border crossing in Moldova, on the Moldova-Ukraine border after they fled war in their country. Once they reach the crossing point, families have yet to face another challenge. In the bitter cold, children and their mothers form lines stretching many kilometres away from the border. There are two separate queues. The first one, for cars, is so long that some mistakenly confuse it for a traffic jam on the way. The second one, for pedestrians, is somewhat shorter, although probably more exhausting. Mothers are clutching their children and hurriedly packed suitcases – the only remnants of their safe, pre-war lives. Some are trundling pushchairs or prams; others have three or even four children to look after. After crossing the border, Ukrainian mothers and children receive, along with long-awaited safety, an immediate aid from the Moldovan government, working together with UNICEF. Welcomed at Blue Dots placed by UNICEF along the road, families get what some of them described as “a much-needed moment to breathe”. Designed to provide a safe space for children and their families, the Blue Dots offer mothers and children vital services, play, protection and counselling in a single location. As mothers crossed the border, I could hear them say: “Hold my hand, hold my hand. Whatever you do, do not let go of my hand!”. What would seem a generic comment in any other circumstances was truly essential in this context. In the past three weeks, UNICEF has received many reports about missing or unaccompanied children traveling through Ukraine and across its western borders. We now work with the Moldovan government to increase the capacity of their social protection systems to screen, track and account for unaccompanied children. They then attempt reuniting the children with their families or provide temporary protection to shield them from risks of trafficking and abuse. The Blue Dots serve as a platform to identify unaccompanied children, as trained workers activate a screening mechanism during the art programme held at these safe spaces. In less than three weeks, Moldova has welcomed 200,000 refugees. It is at least half the size of the population of the country’s capital, Chisinau.The others opt to continue traveling to Romania or further into the European Union. Regardless of their choice, asylum seekers can receive immediate support from the local authorities in Moldova, including food, lodging and transportation. A child therapist and social worker assists families at a UNICEF-UNHCR Blue Dot centre A child therapist and social worker (right) assists families on March 16, 2022 at a UNICEF-UNHCR Blue Dot centre at a refugee reception centre close to the Palanca border crossing in Moldova, near the Moldova-Ukraine border. The Moldovan government has built more than one effective partnership to house Ukrainian mothers and children: both local hotels and university dorms have opened their doors. Many others are hosted in temporary shelters: theatres, gyms, sports stadiums, basketball courts and many other premises have been rapidly turned into accommodation. MoldExpo Exhibition Center, a location for trade fairs, has also found a new purpose. Structured cubicles used for commercial events have become tiny homes with beds, mattresses and pillows for the centre’s new residents. As our team arrived at the MoldExpo Exhibition Center, we immediately noticed the difference between the atmosphere here and at Palanca. Most of the families seemed calm and rested. They now had access to hot meals, electricity and running water. With a variety of food available in the centre’s kitchen areas, one would also assume that nutrition is no longer a concern. However, for many mothers with small children, finding the right nutrients, continuing breastfeeding or preventing infants’ diarrhoea remains a challenge. Another invisible danger that looms in almost every collective centre these days is a high risk of an infectious disease outbreak. In the past five years, Ukraine has faced more than one outbreak of vaccine-preventable diseases. In fact, a polio outbreak continues in the country to this day, and the latest case of polio-induced paralysis was confirmed in February. As this crippling disease recognises no borders, it now threatens every unvaccinated child in the region. With many Ukrainian children missing their compulsory vaccination doses due the war-related disruption of the healthcare system, we must ensure they have access to immunization as soon as they arrive in the host countries. UNICEF is already working with the Moldovan government to roll-out immunization services for the youngest refugees and their families. Having spent some time at the MoldExpo Exhibition Center, we had a chance to observe how it is being transformed from empty premises with beds and pillows into a structured child-friendly space. Blue Dots have been set up and first children joined the art programme. Moldova has already opened their educational and day-care centres to Ukrainian asylum seekers, and, as of today, 191 children have enrolled. Access to quality pre-school and school education marks the start of a new beginning both for them and their parents. Meanwhile, there are thousands of children back in Ukraine who are robbed of the chance to learn, as their families are still trapped on the roads or bomb shelters. We are still far from understanding every layer of the unprecedented influence that the war in Ukraine has on our communities. Although, something has become clear to me after visiting Moldova last week. The war in Ukraine is not just any crisis. It is, first and foremost, a child protection crisis. A child protection crisis that will have an impact on the entire region. Afshan Khan is a UNICEF Regional Director Europe and Central Asia, UNICEF Representative to the UN in Geneva, Special Coordinator, Refugee and Migrant Response in Europe. She has spent 25 years in the United Nations, primarily with UNICEF, responding to some of the biggest humanitarian crises of our time, from the Indian Ocean earthquake and tsunami to war and conflict affected countries.
Blog post
19 Май 2021
Frontline social workers provide vital support to improve health
https://www.unicef.org/eca/stories/frontline-social-workers-provide-vital-support-improve-health
Yura has been a social worker for many years. “When I started working in social services, I was mainly interested in family therapy,” she says . “In time, I found out that supporting communities to become resilient and self-reliant is an extremely rewarding experience.” A year ago, she joined the Council of Refugee Women in Bulgaria (CRWB) – a civil society organization created in 2003 to support the integration of refugees and migrants. “Guiding through people from refugee and migrant backgrounds on health-related procedures in their host country is a way to empower them to find solutions to health issues,” explains Yura. And this is particularly vital for those fleeing from armed conflicts and humanitarian crises. As they search for safety and better life opportunities, both adults and children go through many traumatic experiences as a result of often prolonged stays in refugee camps, limited access to health care, and the dangers they face as they travel through volatile areas. By the time they finally reach a safe destination, they are often in very bad physical and psychological shape. “In Bulgaria, refugee children arrive with their parents or – in some cases – unaccompanied. Psychological problems, infectious diseases, medically unobserved pregnancies and, in particular, a lack of immunization, are common problems that have a negative impact on their health and wellbeing.” Radostina Belcheva, Project Coordinator and Deputy-Chair of CRWB The CRWB partners with UNICEF Bulgaria to provide general health checks and referrals, as well as life-saving vaccines in line with children’s immunization schedules, and equips parents with information on health risks, entitlements and how to access medical services. “As part of the ‘Strengthening Refugee and Migrant Children’s Health Status in Southern and South-Eastern Europe’ (RM Child-Health) project co-funded by the European Union’s Health Programme, we work with our partners to ensure that children can follow immunization plans and that their vaccination status is updated in their immunization documents. These are crucial steps in ensuring good health . ” Diana Yovcheva, Programme Officer with UNICEF Bulgaria Working directly with refugees, Yura consults families that want to access health services. “Some cases are easier than others”, she says, recalling a consultation with Ahmed*, a 45-year-old father of six children, who fled Syria in 2020 and received humanitarian status in Bulgaria. A chef by profession, Ahmed settled quite well in the host country, found a job in a restaurant and, after some time, managed to reunite with his wife, his four sons and two daughters. “Ahmed was referred to the CRWB by friends and he came in for a consultation on the immunization process with his youngest baby girl, Yasmina, only one year old” explains Yura. During their meeting, the social worker provided information about the health system in Bulgaria, the role of a general practitioner, and how people with refugee status can access medical services including vaccinations for their children. Although Ahmed’s baby girl had been vaccinated before her arrival in Bulgaria and had an immunization passport, the father urgently needed to update her vaccination status to synchronize her vaccinations with the recommendations of the national immunization calendar. “I contacted the Regional Health Inspectorate and helped Ahmed to provide the necessary documents and find a translator, as the documents were in Turkish”, says Yura. Subsequently, she helped Ahmed schedule an appointment with a medical doctor and Yasmina received her next vaccine. Parents often lack the necessary vaccination documents. According to Yura, “Sometimes children have not had any vaccinations, or they have been vaccinated in their country of origin, but their immunization cards have been lost or destroyed.”    Such cases require additional consultations, research and coordination, as well as testing for antibodies and immune responses when it is not clear whether the child has been vaccinated. “By empowering parents to familiarize themselves with the immunization plans and procedures we help them become proactive in following up on their children’s health." Yura, Social worker To address the COVID-19 restrictions and keep active communication with refugees and migrants, the CRWB and UNICEF developed leaflets in Bulgarian, Arabic and Farsi with details about the health system in Bulgaria and the importance of vaccinations, and regularly provide health-related information via social media. “The role of communication in immunization is essential.  Our frontline staff interact on a daily basis with beneficiaries, but we have also used other means [such as a Facebook group dedicated to health-related topics] to keep the information flow going, particularly during the COVID-19 pandemic . ” Radostina Belcheva, Project Coordinator and Deputy-Chair of CRWB Logo - Strengthening Refugee and Migrant Children’s Health Status in Southern and South Eastern Europe This story is part of the Project Strengthening Refugee and Migrant Children’s Health Status in Southern and South Eastern Europe, co-funded by the Health Programme of the European Union (the ‘RM Child-Health’ initiative). The content of this story represents the views of the author only and is her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the European Health and Digital Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains .
Report
03 Апрель 2019
In Focus: Working to close nutrition gaps in the Europe and Central Asia Region
https://www.unicef.org/eca/reports/focus-working-close-nutrition-gaps-europe-and-central-asia-region
Enhancing child nutrition Working to close nutrition gaps in the Europe and Central Asia RegionAt first glance, it would seem safe to assume that children living in the Europe and Central Asia Region enjoy good levels of nutrition. Yet this is a Region characterized by nutrition gaps, with some children in some countries missing out on the proper nutrition they need to grow and thrive. It is a Region with a double burden of malnutrition undernutrition found alongside obesity. Children from marginalized communities are at particular risk of undernutrition, including the stunting that leaves them too short for their age and the micronutrient deficiencies that threaten their health and hamper their full development. Many of the problems start with the poor nutrition of women, even before they conceive, with women who are already suffering from micronutrient deficiencies more likely to have premature births. The problems continue into the earliest years of a childs life, with poor rates of exclusive breastfeeding in the Region and often inadequate feeding practices that put children at risk of either stunting or obesity. These problems are compounded by the fact that child nutrition is simply not a development priority in many parts of the Region. UNICEF works with partners across the Europe and Central U NIC EF/A RMEN IA/2 018/ OSIP OVA IN FOCUS: ENHANCING CHILD NUTRITION Toward 2030SDG 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture Avet, age 4, knows that salt matters. I always help my mom with the cooking; I add the salt, he said. My mother always tells me that we only need a little salt just one pinch. Avet is fortunate. As a result of universal salt iodization, he has effective protection against one of the worlds main causes of learning disabilities. Even mild forms of iodine deficiency a condition that can be particularly threatening during pregnancy and in early childhood leads to damage. Two decades ago, in Armenias mountainous areas, 50 per cent of all pregnant women and 40 per cent of schoolchildren had thyroid-related conditions a sign of iodine deficiency. But the country has been free of iodine deficiency since 2006, thanks to a partnership between the Ministry of Health, UNICEF and the countrys main salt manufacturer to achieve universal salt iodization. The Iodine Global Network points to Armenias success as a model for others to follow. 1 Enhancing child nutrition 2 Fast facts Approximately 12 per cent of the children in Central Asia and the Caucasus are stunted, rising to as high as 17 per cent in some areas. Stunting has a direct impact on learning outcomes in a childs early years. It can cause severe irreversible physical and cognitive damage, which can last a lifetime and even affect the next generation. The Region is seeing the worlds biggest rise in obesity among young children. Central Asia has the second highest prevalence of over-weight children under the age of five worldwide (approximately 11 per cent). Every year, more than 4 million children in the Region do not receive exclusive breastfeeding for the first six months of their lives, even though breastfeeding will protect them against health hazards such as undernutrition, micronutrient deficiencies and obesity. The Region also has some of the lowest rates of early initiation of breastfeeding newborns who breastfeed within one hour of birth in the world. In Azerbaijan, for example, 20 per cent of newborns are breastfed during their first hour of life, falling to only 14 per cent of newborns in Montenegro. In parts of Central Asia, less than half of all children are eating the diverse diet they need for healthy development. Asia Region to make child nutrition a priority and to close the nutritional gaps that put children at risk of a life-time of poor health and stifled development. Tajikistan Albania Armenia Uzbekistan Turkmenistan Azerbaijan Kazakhstan Kyrgyzstan Romania Georgia Turkey Montenegro Bulgaria Moldova Serbia FYROM Belarus Ukraine Bosnia and Herzegovina Double burden of malnutrition in Europe and Central Asia Region 0 5 10 15 20 25 30 nOverweight (%)nWasting (%)nStunting (%) Source: UNICEF State of the Worlds Children Report, 2016. Enhancing child nutrition 3 Vast returns on investment in anemia preventionInvestments in preventing anemia produce high economic returns. It is estimated that an investment of $600 million USD is needed in the Europe and Central Asia Region to meet the Global Nutrition Target for anemia by 2025. It is estimated that each dollar invested in this package of prevention interventions yields approximately $12 in economic returns. ChallengesThere has been some progress on child nutrition across the Europe and Central Asia Region, but there are still significant disparities that must be addressed. Approximately 68 per cent of children in the Region are deprived of exclusive breastfeeding during their first six months, missing out on the best nutritional start in life. The widespread use of breastmilk substitutes and the commercialization of ready-to-use baby foods also poses an additional threat to their nutritional well-being, undermining breastfeeding in a region with the second lowest rates of exclusive breastfeeding worldwide. Children living in some parts of the Region face greater nutritional deprivation. This includes children living in Tajikistans Gorno-Badakhshan Autonomous Oblast where more than 6 per cent of children under five have acute malnutrition, which threatens their survival. Between 12 and 17 per cent of children in Central Asia, parts of the Caucasus and in Central and Eastern Europe are stunted. The effects of stunting are devastating for a childs development, and can include a lower IQ, a weakened immune system and greater risk of serious diseases later in life. Stunting is caused by the lack of a good quality and diverse diet. It is also connected to high rates of premature births, as well as frequent episodes of acute malnutrition during the first 1,000 days of life. There are serious disparities in childhood stunting within countries: in Bosnia and Herzegovina, Montenegro, Serbia and the North Macedonia, stunting rates in Roma settlements are far above the national average. And in every country across the Region, girls, children living in rural areas and the poorest children are more likely to be stunted than others. School-age children and adolescents also face nutrition challenges. Although nutrition resources and programmes have traditionally been directed towards young children and pregnant women, we do know that obesity among adolescents increased in 16 of the 27 European countries included in the Euro Region of WHO between 2002 and 2014. The number of obese adolescents is continuing to rise in many countries and regions. This is particularly the case in Eastern Europe where, until recently, obesity prevalence was lower than in other parts of Europe. Because of the lack of data on adolescent nutrition, there is often a lack of interest in the issue among policymakers. There is, therefore, limited expertise or resources for adolescent nutrition programmes in the Region, which is a lost opportunity to bolster health, development and economic progress. Child nutrition is not being prioritized across the Region and is, therefore, chronically under-resourced. While most countries in the Region have a national nutrition plan, less than half of these plans have a fully costed-out budget, making it less likely that they will receive funding. Only 12 per cent of countries have dedicated national nutrition managers, and the Regions nutrition workforce is not equipped with the relevant expertise and skills needed to address complex nutrition issues. In addition, nutrition science is not a defined discipline, nor does it have a presence at any level of preventive primary health care or in education and research institutions. In Central Asia and the Caucasus, for example, not one academic institution offers an undergraduate or post graduate degree on nutrition. U NIC EF/U N04 0553 /CYB ERM EDIA Mother Macadan Ana Maria with her daughters Florina, 7 months and Madalina and Ioana, both 10 years old. The family lives in Bacau County, Romania where they are supported through UNICEFs Community Services for Children. The programme provides vulnerable families with a minimum package of services. These services include helping to ensure healthy early childhood development through advice and support on good nutrition, adequate care and access to education. Enhancing child nutrition 4 Our aimUNICEF supports action to improve nutrition from a childs earliest years through adolescence and, in the case of women, motherhood. This approach places children, adolescents and women at the centre of our nutrition advocacy, programming and research. Our ambition is to safeguard the nutrition of children and prevent the double burden of undernutrition and obesity for both girls and boys in every context, aiming for a nutritious and balanced diet for every child. Our ActionsUNICEF supports action to improve nutrition for young children, adolescents and mothers in the Europe and Central Asia Region, aiming to ensure that every child has the best possible nutritional start in life. This requires a focus on the systems that are in place or that need to be created to safeguard the nutrition of each child. UNICEFs systems approach in the Region aims to strengthen the capacity of national and sub-national systems to deliver nutrition-specific interventions to children from birth to adulthood and build programmes that are sensitive to their nutritional needs at every stage of life. Our approach prioritizes four delivery systems that are crucial for the achievement of Sustainable Development Goal 2 End Hunger by 2030: The Primary Health Care system The Food system Early Childhood Development The Education system The Social Protection system The Primary Health Care system We support Infant and Young Child Feeding (IYCF), which includes exclusive breastfeeding and the timely introduction of diverse and healthy complementary feeding (the introduction of other foods and liquids in addition to breastmilk for children aged six months to two years). In addition, UNICEF is also promoting a healthy and diverse diet for the children during their early year before school. This strategy aims to prevent both stunting and obesity in the priority countries. We provide intensive support to Armenia, Azerbaijan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan that have the Regions highest levels of child undernutrition, including stunting. We also support nutrition counselling during critical periods of life such as pregnancy and the early years, to promote a healthy diet. In addition, in Armenia, Bosnia and Herzegovina, Georgia, Kazakhstan, Montenegro and Serbia, UNICEF supports the promotion of healthy and diverse diet during childrens early years to prevent obesity. The Food system UNICEF supports large-scale food fortification programmes, such as Universal Salt Iodization (USI) and Flour Fortification to control micronutrient deficiencies among children and women, aiming for safer pregnancies and healthier children. We push for the enforcement of USI as well as legislation and programmes to boost the quality and consumption of iodized salt. We also develop standards for countries on the prevention and management of other micronutrient deficiencies such as iron deficiencies and neural tube defects (NTD), such as spina bifida, caused by a lack of folate among children, adolescents and mothers. Tackling iodine deficiencyMany countries in the Europe and Central Asia Region have made considerable advancements in lowering the rates of Iodine Deficiency through Universal Salt Iodization. For example, across the Region, the percentage of households using Iodized salt has increased from 26 percent in 2000 to 55 percent in 2009 and 70 percent in 2017. This significant improvement has been made by legislating mandatory salt iodization while ensuring households have access to appropriately iodized salt. Public-private partnerships have also contributed significantly to this success. Enhancing child nutrition U NIC EF/U N01 4320 0/VA S Ivanka Djordjevic, a visiting nurse with at the Jovanovic family in Pirot, Serbia, meets with Tea, who experienced developmental delays from birth. Ivanka made regular visits to the Jovanovic family to help the parents learn about nutrition and creating a stimulating environment for Tea. Thanks to this intervention, Tea is now meeting her developmental milestones. UNICEF and Serbias Ministry of Health are ensuring visiting nurses like Ivanka can support parents with information on baby development, including nutrition. Child nutrition is about much more than the amount of food on the table. It is about making sure that mothers have the nutrition they need for a healthy pregnancy, that young children have the breastmilk that gives them the best start in life, and that growing children have the range of foods, including micronutrients, that they need for healthy growth and development and to prevent non-communicable diseases in later in life. It is also about prioritizing child nutrition at national level, backed by the necessary resources. Afshan Khan, Regional Director for UNICEF in Europe and Central Asia 5 Enhancing child nutrition 6 On the prevention of obesity, UNICEF advocates for the full implementation of the International Code of Marketing of Breastmilk Substitutes as well as legislation to control the marketing of foods and non-alcoholic beverages to children. We also advocate for increased taxes on sugary and sweet beverages and junk food, as well as subsidies for healthy foods. Early Childhood Development In order to survive, thrive and reach their full potential, all children need nurturing care during their early years. Nutrition, together with good health care, responsive caregiving, safety and security, and opportunities for learning, is a key component of the Nurturing Care Framework which takes a holistic view of the developing child. Developed by WHO, UNICEF, the World Bank and associated partners, the Framework recognizes that parents and families are the primary providers of nurturing care and that it is critical that policies, programmes and services are strengthened to support them in their caregiving role. Optimal nutrition in early childhood, which includes breastfeeding, is critical for healthy growth. At the same time, feeding young children in a responsive and interactive way can contribute to their cognitive, social and emotional development. Caregivers need support not only for what to feed young children but also for how to feed them. The Education system UNICEF works through schools to prevent obesity among school-age children and adolescent girls and boys, to promote physical activity and to create a healthy nutritional environment in schools. Our work includes the promotion of nutritional policies for education and building the capacity of school staff. In addition, the engagement of young people in the promotion of healthy nutrition not only benefits them, but they can also play a key role in sharing their knowledge about healthy diets with their families. The Social Protection system UNICEF advocates for and supports a focus on nutrition as part of wider social protection programmes, where synergies across approaches to tackle poverty and malnutrition can have a more sustainable impact on the well-being of children. For example, we help countries to define what should be included in a basic food basket that should be available for each child to secure optimum nutrition (and that, in turn, helps to determine levels of social benefits), and develop dietary-based guidelines that are sensitive to the nutritional needs of children and adolescents. In addition, capacity building support is provided to countries to enhance public financing for child nutrition. We also focus on the precarious nutrition of children caught in crises, such as conflicts and other emergencies, and those in families affected by HIV. One innovative sub-regional partnership is the Regional Nutrition Capacity Development and Partnership Platform in Central Asia and the Caucasus. This aims to raise the profile of nutrition in national strategies, policies and programmes. This partnership brings on board a wide range of national partners including Ministries of Health, Education, Agriculture and Finance, as well as UN agencies and academia. The platform will develop the building blocks of the food and nutrition sector in the region. It has six main aims Enhance the leadership and governance of the Regions food and nutrition sector. Strengthen region-wide policy advocacy for better financing for nutrition by making the case for investment. Strengthen the nutrition workforce by defining standard organizational structures at the levels of primary healthcare, specialized consultative healthcare, and professional training, as well as equipping workers with the U NIC EF/U N04 0446 /PAN JETA Children eating fruit and vegetables at a food workshop in Foca, Bosnia and Herzegovina. Working with relevant ministries across the country, UNICEF supports the development of nutrition strategies and guidelines for the promotion of healthy lifestyles. Key government commitments on nutrition adopted by every country in the Europe and Central Asia Region in addition to SDG 2The Convention on the Rights of the Child, 1989 Article 24.2(c): States Parties will combat disease and malnutrition, including through the provision of adequate nutritious foods. Article 24.2(e): States Parties will ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition and the advantages of breastfeeding. Enhancing child nutrition 7 An unfinished agenda Child nutrition remains unfinished business across the Europe and Central Asia region. As well as needing more resources, child nutrition urgently needs more attention from policy makers, development and donor partners and communities to push it further up the list of national priorities. UNICEF seeks to leverage increased resources for children across the region, through meaningful partnerships and advocacy. A key priority is strengthening work with all partners, based on a common agenda for children and adolescents. From maternal nutrition to breastfeeding, and from micronutrients to research on adolescent nutritional health, the Region has a lengthy to do list. UNICEF and its partners have already demonstrated the impact of programmes to safeguard and promote child nutrition. The task ahead is to take these programmes to scale across the Region. World Health Assembly (WHA) 2016 members have also committed themselves to six targets for 2025: 1. a 40 per cent reduction in the number of children under five who are stunted 2. a 50 per cent reduction of anaemia in women of reproductive age 3. a 30 per cent reduction in low birth weight 4. no increase in childhood overweight 5. an increase of at least 50 per cent in the rate of exclusive breastfeeding in the first 6 months 6. the reduction and maintenance of childhood wasting to below 5 per cent. The UN Decade of Action on Nutrition 2016 to 2025 UNICEF has committed to support the UN Decade of Action on Nutrition to: Prevent stunting, wasting and all forms of undernutrition in early childhood. Prevent anemia and all forms of undernutrition in school-age children and adolescents Prevent anemia and all forms of undernutrition in pregnant women and lactating mothers. Prevent overweight and obesity in children, adolescents and women. Provide care for children with severe acute malnutrition in early childhood, in all contexts. U NIC EF/U N03 8720 /PIR OZZI Children have a meal in the dining room of an inclusive kindergarten in Yerevan, Armenia. UNICEF has been supporting the national iodization programme in Armenia and in 2006, the country was declared free of iodine deficiency. knowledge, skills and competencies for effective nutrition and food policy and programming. Reinforce a multidisciplinary (i.e., health, agriculture, education, social protection and finance) approach to address the double burden of malnutrition as a major risk factor for non-communicable diseases. Reinforce region-wide collaboration to generate hard evidence and guidelines based on that evidence, and share lessons on what works to inform policymaking and scale up nutrition programmes Improve information and research on nutrition and exchange knowledge across the region and beyond. Enhancing child nutrition 8 UNICEF Europe and Central Asia Regional Office 5-7 avenue de la Paix CH-1211 Geneva 10 Switzerland Telephone: +41 22 909 5111 ecaro@unicef.org www.unicef.org/eca March 2019 U NIC EF/U N05 5280 /LIS TER Amir is in the arms of his mother, Sozul Eisheeva, in the Karakol hospital in Issyk-Kul province, Kyrgyzstan. Between 12 and 17 per cent of children in Central Asia, parts of the Caucasus and in Central and Eastern Europe are stunted. The effects of stunting can include a lower IQ, a weakened immune system and greater risk of serious diseases later in life. UNICEF raises awareness on the importance of breastfeeding for a healthy start in life as well as a diverse and healthy diet for mothers and children. mailto:ecaro%40unicef.org?subject= http://www.unicef.org/eca
Report
01 Январь 2016
Adolescents Living with HIV
https://www.unicef.org/eca/adolescents-living-hiv
unite for children Adolescents Living with HIV: Developing and Strengthening Care and Support Services Adolescents Living with HIV: Commissioned by the UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States (UNICEF RO CEECIS) The opinions expressed in this publication are those of the contributors, and do not necessarily reflect the policies or views of UNICEF. The designations employed in this publication and the presentation of the material do not imply on the part of UNICEF the expression of any opinion whatsoever concerning the legal status of any country or territory or of its authorities or the delimitations of its frontiers. The subjects in the photographs used throught this publication are models who have no relation to the content. Extracts from this publication may be freely reproduced with due acknowledgement using the following reference: UNICEF, 2016. Adolescents Living with HIV: Developing and Strengthening Care and Support Services, Geneva: UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States (CEECIS). For further information and to download this or any other publication, please visit the UNICEF CEECIS website at www.unicef.org/ceecis. All correspondence should be addressed to:UNICEF Regional Office for CEECISHIV Section Palais des NationsCH 1211 Geneva 10Switzerland Copyright: 2016 United Nations Childrens Fund (UNICEF) Adolescents Living with HIV: Commissioned by the UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States (UNICEF RO CEECIS) Developing and Strengthening Care and Support Services unite for children Acknowledgements This handbook was written by consultants Magda Conway and Amanda Ely from the UK Childrens HIV Association (CHIVA) working in consultation with a number of partners and collaborators. The authors would like to thank Nina Ferencic, Ruslan Malyuta, Marie-Christine Belgharbi in UNICEF CEE/CIS Regional office for their trust and support with this work. They would like to thank their colleagues from health and social care in the UK who have generously given their time and expertise to support the development of this resource. Special thanks to: Dr Caroline Foster, Paediatric Consultant (Imperial College Healthcare NHS Trust); Susan McDonald, HIV Clinical Nurse Specialist (Imperial College Healthcare NHS Trust); Dr Tomas Campbell, Clinical Psychologist; Jill Hellings, Children and Families Social Worker (Barnardos); Sarah Lennox, Children and Families Social Worker (Barnardos); Sheila Donaghy, Paediatric HIV Clinical Nurse Specialist (St. Georges University Hospital) and Michelle Overton, support worker (Faith in People). Many thanks to colleagues and contributors who reviewed and provided valuable comments to the online draft publication, especially Dr. Nadia L. Dowshen (The Childrens Hospital of Philadelphia), Sara Paparini (London School of Hygiene and Tropical Medicine), Nisso Kasymova and Victoria Lozyuk from the (UNICEF country offices in Tajikistan and Belarus). Thank you to the young adults from UK who shared their experiences of growing up with HIV on the videos, and those that attend the Barnardos support service in Manchester for participating in group scenes. Special thanks goes to the all the HIV positive children and adolescents we have met over the years, who have shared their views and experiences and had a profound effect on the way we approach our work. FOREWORD In 2015, an estimated two million adolescents (10-19 year olds) were living with HIV worldwide and every hour an estimated 26 adolescents were newly infected with HIV. Adolescents living with HIV have mostly the same dreams and hopes as all other adolescents. Although they often face a number of health challenges in their day-to-day lives, many of the issues faced by adolescents living with HIV are linked to broader psycho-social aspects of their lives. In many ways, their experience of living with HIV provides the best guidance on how to support them to realize their rights and their full potential. The continuing high rates of new HIV infections and growing AIDS mortality among adolescents suggests that a change in adolescent programming is required. The voices and concerns of adolescents and young people need to be heard by care providers. Youth-centred and youth-led approaches that engage young people in the planning, implementation and evaluation of programmes are needed. Policy makers should put more effort into understanding the distinctiveness of adolescence in the context of HIV and make longer term commitments to funding and programme support. There is an increased need for capacity building and trained staff. The All In initiative launched by UNICEF and partners to end adolescent AIDS provides a platform for dialogue with young people, policy makers, care providers, community leaders and other stakeholders for action supporting adolescents. This handbook, with inputs from leading experts who have trained hundreds of professionals, provides indispensable tools for strengthening the management and care of adolescents living with HIV. Clinicians and social workers are provided with step by step guidance on how to work with adolescents and parents and increase their skills-sets to help them engage with and retain adolescents living with HIV in support services. It describes the challenges of working with families and care givers, promotes holistic models of child-centered assessment and practice, communication with families and children, with a focus on naming HIV, promoting adherence to treatment and ongoing conversations and supportive dialogue involving HIV positive adolescents as partners and leaders in their own care. Designed for optimal learning, the handbook allows to choose written, oral, visual, individual, and group strategies that best suit different learning styles. This handbook is about adolescents and it is for professionals who work with them. It is meant to be a living document that adapts as new information and evidence emerges and it hopes to support professionals to build their confidence, skills and better connections with adolescents living with HIV. UNICEF HIV Team Definitions Adolescent Aged 10-19 years of age. Parent Biological parent, step-parent, or adoptive parent. Carer Person who is primary carer of the child, but not their parent. This can be someone who is a legal guardian, such as a family member or state provided carer, such as a foster carer. Young adult Aged 19-25 years of age. Acronyms ART Anti-retroviral therapy ALHIV Adolescents living with HIV CEE/CIS central and eastern Europe and Commonwealth of Independent States CHIVA Childrens HIV Association for the UK & Ireland C&ALHIV Children and adolescents living with HIV UNICEF United Nations Childrens Fund UNCRC United Nations Convention on the Rights of the Child WHO World Health Organization 7 Adolescents Living with HIV:Developing and Strengthening Care and Support Services CONTENTS INTRODUCTION..................................................................................................................................9 The global context ............................................................................................................................9 Adolescents and HIV ........................................................................................................................10 SECTION ONE: CLINICAL ISSUES FOR ALHIV ............................................................................13 1.1 The brain and neurocognitive function ...................................................................13 1.2 Adherence ..........................................................................................................................14 1.3 Relationships and sexual health education ............................................................15 1.4 Onward disclosure of HIV .............................................................................................16 1.5 Transition to adult care ..................................................................................................18 SECTION TWO: THE PSYCHOSOCIAL NEEDS OF C&ALHIV ..................................................19 2.1 Growing up with HIV .......................................................................................................20 2.2 Managing HIV during adolescence ...........................................................................25 2.3 HIV and the family context ...........................................................................................33 SECTION THREE: VULNERABLE ADOLESCENTS WITH BEHAVIOURALLY ACQUIRED HIV ..................................................................................................36 3.1 Insecurely housed or living on the streets ..............................................................37 3.2 Sexually exploited ALHIV and involved in transactional sex ............................38 3.3 ALHIV who misuse drug and/or alcohol ..................................................................39 3.4 Adolescent men who have sex with men (AMSM)...............................................42 3.5 Engaging with health and managing HIV ...............................................................42 3.6 Ensuring inclusion of hard-to-reach groups ..........................................................44 SECTION FOUR: APPROACHES TO PRACTICE AND POLICIES .............................................45 4.1 Communication ................................................................................................................46 4.2 Talking to children about their HIV diagnosis ........................................................47 4.3 Confidentiality ...................................................................................................................51 4.4 Safeguarding children and child protection ..........................................................52 4.5 Managing behaviour ......................................................................................................55 4.6 Ensuring equality and inclusion .................................................................................58 8 Adolescents Living with HIV:Developing and Strengthening Care and Support Services 4.7 One-to-one work ..............................................................................................................59 4.8 Group work .........................................................................................................................61 4.9 General practice points ..................................................................................................63 SECTION FIVE: EXAMPLES OF UK PRACTICE ............................................................................67 5.1 Peer support groups .......................................................................................................67 5.2 Residential interventions ..............................................................................................68 5.3 Occasional sessions attached to clinics....................................................................70 5.4 Therapeutic creative activities .....................................................................................70 5.5 Advocacy and influencing policy ...............................................................................71 5.6 On-line activities ...............................................................................................................72 5.7 Consultation with ALHIV ...............................................................................................73 REFERENCES ........................................................................................................................................ 75 APPENDIX ONE: Activity sheets to use when working with C&ALHIV ...........................77 APPENDIX TWO: Further reading.................................................................................................131 APPENDIX THREE: Maslows Hierarchy of Needs ....................................................................133 APPENDIX FOUR: Four principles of motivational interviewing ......................................135 APPENDIX FIVE: Policy documents and practice tools.........................................................136 9 Adolescents Living with HIV:Developing and Strengthening Care and Support Services INTRODUCTIONThe global context This handbook has been written for practitioners working directly with C&ALHIV and for policy makers and management to help develop services and protocols. To that end, it includes policy and practice guidance for the development of services, practice models and practical examples. The global experience of HIV offers many shared elements and this handbook reflects these, setting out practical guidance and tools that can be used in different settings. Commissioned by UNICEF Regional Office for CEE/CIS as part of a wider project to assist the development of support provision for C&ALHIV in that region, this handbook has been produced by experts from the UK who have worked with children, adolescents and families living with HIV for almost two decades. This resource aims to: Share knowledge and learning from practice developments in the UK that can be useful in a global context Ensure practitioners have a broad understanding of the psychological and social impacts of HIV on childhood and adolescence Promote the development of support that responds to the holistic needs of the child and adolescent Promote professional responses to reduce the impact of HIV stigma on children and adolescents. The handbook promotes multi-disciplinary working as the best approach to addressing the physical, psychological and social impacts of HIV. A robust partnership between health and social care services ensures a collaborative approach, where a flow of communication between practitioners exists and services are working together to meet the needs of the child, adolescent or family. It also acknowledges throughout that HIV disproportionately affects more vulnerable social groups and that this should be reflected in the practice that is developed. 10 Adolescents Living with HIV:Developing and Strengthening Care and Support Services Adolescents and HIV There are approximately 1.2 billion adolescents in the world, over 80% of whom live in the developing world and an estimated 2.1 million adolescents were living with HIV in 2012 (UNAIDS, 2013). [1] In 2014, the WHO produced Health for the worlds adolescents: A second chance in the second decade [2] which stated that over the last decade, HIV had become one of the biggest killers of the worlds adolescents, second only to road traffic accidents. As global HIV rates decline and the prevention of mother-to-child transmission is being heralded as a global triumph, these findings clearly showed that ALHIV had been overlooked. Adolescence is the transition from childhood to adulthood and a time when the child moves from dependence towards greater independence. At this time children begin to gain a sense of autonomy and a desire to establish their individual identity. Friendships and the peer group, and fitting in with peers, can become increasingly important. Adolescence is known as a time of risk taking and experimentation. It is typical for an HIV diagnosis to be surrounded with secrecy for many groups of people who become infected. For children and adolescents who have grown up with HIV, HIV is closely linked to their sense of who they are, as it has always been a part of them. As such, secrecy and HIV can become interlinked and for many C&ALHIV, this means they keep part of themselves a secret. HIV remains highly stigmatised and for many HIV positive people there is frequently a fear of other people finding out. This can build a negative experience of having HIV, as it becomes viewed as shameful, emphasising difference. These negative associations can be internalised, and for the adolescent who is struggling UNICEF/NYHQ/2006-1329/C. Versiani 11 Adolescents Living with HIV:Developing and Strengthening Care and Support Services to work out who they are, the negative social responses to HIV can lead to a profound experience of self-stigma. This can reinforce feelings of difference, isolation (particularly from peers) and being of less worth than others. Poor adherence and engagement in clinical care during adolescence is normal for all health conditions. The common perception of HIV being associated with an imminent death and limiting opportunities can lead to ALHIV becoming fatalistic and so their risk taking behaviour may be seen as more extreme than their HIV negative peers. ALHIV often experience low self-esteem and struggle to see a future for themselves. But adolescence is also a time of opportunity and creativity and it is important to remember that adolescence is a transition period that may be turbulent, but it will end. The UN Convention on the Rights of the Child (UNCRC) The UNCRC is referred to throughout this resource. It was produced in 1989 and to date has been ratified by 192 countries (although some countries have placed reservations on some articles). The UNCRC is the basis for child-centred and child rights approaches. This Convention sets out the basic rights of children under 18 years without exception or discrimination of any kind, stipulating that the best interests of the child must be the primary consideration in all matters affecting children (Article 3); that childrens survival and development must be ensured (Article 6); and that children have the right to participate in decisions that affect them (Article 12). Within the context of children with health conditions, the UNCRC offers certain articles that are particularly pertinent for C&ALHIV: Every child should have access to information and material from a diversity of national and international sources, especially those aimed at the promotion of his or her social, spiritual, and moral well being and physical and mental health (Article 17) States parties recognise the rights of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States parties shall strive to ensure that no child is deprived of his or her right of access to such healthcare services (Article 24). 12 Adolescents Living with HIV:Developing and Strengthening Care and Support Services WHO guidelines for C&ALHIV This handbook has been influenced by practice experience and research and is closely linked with some key WHO publications. WHO (2011) HIV disclosure counselling for children up to 12 years. This guideline presents research which concludes that childrens health and well-being is supported when they have access to open conversations about their health and where HIV is named to them. The guidelines recommendations state that, children of school age should be told their HIV positive status: younger children should be told incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure [3]. This handbook upholds this recommendation, promoting C&ALHIV having full knowledge about their HIV status, which then enables work to take place to support them living well and challenges wider stigma towards HIV. WHO (2013) HIV and Adolescents; Guidance for HIV testing and counselling and care for adolescents living with HIV. This guideline considers operational approaches and different options of response to the needs of adolescents with HIV. It provides a range of practice examples which illustrate different responses to the needs of adolescents with HIV, and offers practice guidance. This handbook sets out to provide support in meeting the key recommendations from this WHO (2013) guideline, that: Adolescents should be counselled about the potential benefits and risks of disclosure of their HIV status to others and empowered and supported to determine if, when, how and to whom to disclose Community-based approaches can improve treatment adherence and retention in care of adolescents living with HIV Training of health-care workers can contribute to treatment adherence and improvement in retention in care of adolescents living with HIV [4]. Section One has been written by Dr Caroline Foster and offers a medical perspective, setting out the health needs of ALHIV. Section Two explores in detail different psychosocial impacts on C&ALHIV, to support an in-depth understanding of the lives of these children. Section Three looks specifically at those adolescents who acquire HIV behaviourally. Section Four sets out child-centred HIV specific approaches to developing practice and politics. Finally, Section Four offers examples of peer support group work from the UK. The appendices include numerous examples of activities that have been run with C&ALHIV, to explore HIV specific issues in peer groups and one-to-one sessions with workers. 13 Adolescents Living with HIV:Developing and Strengthening Care and Support Services SECTION ONE: CLINICAL ISSUES FOR ALHIVDr Caroline Foster Consultant in Adolescent Infectious Diseases/HIV Watch video: The impact of psychosocial needs on health provision - http://vimeo.com/112460123 (password: chiva) In regions of the world where ART is available, perinatally acquired HIV-1 infection is now a chronic disease of childhood [5]. High uptake of antenatal testing, reduced mother-to-child transmission rates from diagnosed women, improved survival following ART and later age at presentation among those born abroad [6] mean that the average age of perinatally infected children in many European cohorts is now over 13 years. Increasing numbers of ALHIV are therefore transitioning from paediatric to adult services and join the large numbers of ALHIV infected through sexual transmission [7]. This means that children are surviving into adulthood, yet the process of growing up with HIV can present clinical and psychological complications, not all of which are directly HIV related. Some key clinical issues faced by this group are outlined below. 1.1 The brain and neurocognitive function Whilst the importance of brain growth in infancy is well established, there is increasing recognition of the enormous changes that occur in the adolescent brain. At 11-12 years, brain function slows in preparation for increased synaptic proliferation (frontal lobe) then pruning and strengthening of neural pathways that continues into our mid-twenties. During adolescence, the thalamic drive UNICEF 2014/S. Noorani 14 Adolescents Living with HIV:Developing and Strengthening Care and Support Services for reward may be mismatched with later development of executive functioning reasoning and may explain why risk taking behaviour is much more common in adolescents. Whilst ART has had a remarkable impact on long-term survival for children born with HIV, the long-term effects of living with HIV and prolonged exposure to antiretroviral therapy throughout post-natal growth and development are becoming apparent. Data is now emerging regarding neurocognitive development, mental health and cardiovascular and bone toxicity, the longer-term outcomes of which remain uncertain. Perinatally acquired HIV occurs in the context of an immature brain with human brain development typically continuing into the third decade of a persons life. Without antiretroviral therapy, around 10% of infected infants present with progressive severe HIV encephalopathy (damage to the brain), which although arrested by ART, leaves residual cognitive and motor deficits with significant impact on independent mobility and daily living. Increased rates of expressive language delay and behavioural difficulties are reported in preschool children and more subtle educational difficulties become more apparent in secondary school aged children. Whilst mental health issues are more common in adolescence when compared to earlier childhood in the general population, increased rates of psychological disorders and psychiatric diagnoses, most frequently anxiety and depressive disorders, are reported in ALHIV, impacting on quality of life and on adherence to ART [8]. 1.2 Adherence Adherence to antiretroviral therapy appears to be poorer during adolescence for all ALHIV, although a similar pattern is seen in other chronic diseases of childhood. ALHIV often face multiple barriers to adherence including structural barriers in fitting medication into complex patterns of daily life, low expectancy for outcome of antiretroviral therapy and mental health/substance abuse. The impact of HIV as a family disease means that some adolescents have suffered bereavement, losing parents and other family members to HIV, further impacting on health beliefs and adult support networks around adherence. Early patterns of adherence on initiating ART predict the long-term adherence of HIV positive children, which means that time spent by a multidisciplinary team in preparation and education prior to initiation of therapy, and switching regimens, including the use of peer mentors, counsellors and NGO support are extremely important. Adherence messages need to be frequently repeated as medication fatigue occurs and particular attention given during the period of transition from paediatric to adult services, a time often associated with poorer attendance and adherence to medication. 15 Adolescents Living with HIV:Developing and Strengthening Care and Support Services Despite recent advances in co-formulations, smaller tablet sizes and multidisciplinary approaches to adherence, a small proportion of adolescents continue to either adhere very poorly or decline antiretroviral therapy despite severe immune suppression with its risk of opportunistic infection and death. Keeping this group engaged as they grow towards adulthood is extremely important, as those who choose not to, or are unable to take treatment, require ongoing support and education, including access to sexual health services to prevent onwards transmission to sexual partners and their offspring. This area is expanded further in Section Two: Managing HIV during adolescence. 1.3 Relationships and sexual health education The earlier discussions begin, relating to sex and relationships, the easier this is for the child, practitioner and parent/carer. Begin with an explanation of the physical and emotional changes that occur in boys and girls during puberty, emphasising that these are normal changes. In many countries sexual health education is part of the school curriculum, often occurring around the age of 12 years. However, the quality and retention of such information is extremely variable and ALHIV need specific information that is relevant for their unique situation. Encouraging the younger adolescent to have a small part of the consultation alone with the doctor/nurse supports these discussions. When they are familiar with this pattern of care, it allows opportunity for discussion, education and questions that adolescents may not wish to ask in front of their parent/carers, either because of embarrassment or because they worry about asking difficult questions that may upset their parent/carers. UNICEF/NYHQ2008-0572/A. Dean 16 Adolescents Living with HIV:Developing and Strengthening Care and Support Services Adolescents need simple, basic, clear, age-appropriate facts, explained in language they understand, given in small volumes and repeated frequently. Information should be generic; try to avoid making assumptions based on whether you think a young person is or is not sexually active we often know very little about their lives. Do not presume relationships are heterosexual; up to 10% of young people experience same sex relationships at some time and using the word partners until a young person has clarified their current sexual orientation avoids confusion. Consistent condom use should always be encouraged, with additional contraceptive methods discussed with adolescents. Recent research has shown that the risk of sexual transmission of HIV is substantially reduced where the HIV positive person has an undetectable viral load [9]. Typically suppressive ART reduces HIV viral loads in semen and cervico-vaginal fluid as well as plasma. However, occasional individuals have been shown to have detectable levels of HIV in genital secretions despite virological suppression in plasma, because of compartmentalisation of HIV within the genital tract. For this reason, and because a viral load reflects only one time point and other Sexually Transmitted Infections could be present, health professionals continue to recommend condom use with ALHIV. 1.4 Onward disclosure of HIV Whilst much attention has been paid to the process of naming HIV to a CLHIV, processes of supporting onward disclosure to family, friends and sexual partners have received less attention. However, as the perinatal cohort ages and much larger numbers of children enter adolescence, there is a need for UNICEF NYHQ2006-1478/G. Pirozzi 17 Adolescents Living with HIV:Developing and Strengthening Care and Support Services similarly robust processes to support them through onward disclosure. Many ALHIV have not disclosed their status to anyone and separate their life into compartments: their HIV life and their daily life. There is some evidence that self- disclosure may improve psychological wellbeing for some adolescents, which subsequently enhances their physical health, but there are also examples where outcomes have been less positive. Some adolescents want to disclose their status to close friends, relatives and to sexual partners. It may be helpful to talk through this process: the advantages (becoming closer, sharing, not living a double life), but also the potential disadvantages (rejection, anger, and wider disclosure of their status and possibly other family members). This is expanded further in Section Two: Managing HIV during adolescence. In some countries, transmitting HIV to your partner, even unintentionally, is a criminal offence and people have been prosecuted and received lengthy jail terms. Professionals need to be aware of the law in their own country so they can give sensitive, accurate guidance to ALHIV. It is important that these discussions empower the ALHIV with facts rather than fear. Talk through the detail simply and ask them to reflect back what they understand. If an ALHIV is going to travel, they will need to consider the legal position regarding onward transmission of HIV in the countries they visit. UNICEF/2014/S. Noorani 18 Adolescents Living with HIV:Developing and Strengthening Care and Support Services 1.5 Transition to adult care Transition has been defined as: the planned purposeful process that addresses the medical, psychosocial and educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child-centred to adult-oriented health care systems. Increasing numbers of perinatally infected ALHIV are entering adult care and the age at which this occurs varies markedly across the globe, from 12 years in parts of sub-Saharan Africa to 24 years in regions such as the US where there is dedicated adolescent/young adult services. With other chronic diseases, transition programmes have been shown to improve attendance, disease control, self-management and patient and carer satisfaction. Conversely, direct transfer to adult services has been associated with poorer attendance and adherence, resulting in increased disease-related mortality and morbidity. Thought and planning must go into this process to ensure the best outcomes for the adolescent and to ensure they remain engaged in care. See Appendix Two: Further Reading for resources relating to this. Conclusion Caring for ALHIV can be complex. HIV or the social situation the adolescent lives in can present difficult psychosocial issues that can impact on their engagement with health and how well they are able to self-care. There are worldwide examples of excellent support that provides a safe place for ALHIV who know their HIV diagnosis, to meet others and to share concerns. As the ALHIV often presents multiple non-health issues, multi-disciplinary teamwork is essential in providing a coherent package of care. Adolescence is a time of enormous change, much of it exciting although some challenges have to be negotiated. A chronic disease adds to the complexity of this period of life, and one that is stigmatising and sexually transmissible even more so. However, the success of ART in the last 15 years means that increasing numbers of children born with HIV have an optimistic long term future and require careful, coordinated, adolescent-centred multidisciplinary support to fulfil their potential as adults within society. Watch video: Developing youth-friendly HIV services - http://vimeo.com/112460122 (password: chiva) 19 Adolescents Living with HIV:Developing and Strengthening Care and Support Services SECTION TWO: THE PSYCHOSOCIAL NEEDS OF C&ALHIVThis section explores specific issues that HIV can present for children, adolescents and families. It focuses on the psychosocial impacts and support needs of C&ALHIV, and does not include access to health care and medication, which may be an issue in different contexts. For many C&ALHIV and their families, HIV is one of a multitude of issues they face, and at times the other issues - such as having sufficient food, housing, substance misuse, mental health problems - may be more critical. Wider social issues are not included in this section, but need to be acknowledged, and where possible addressed. A holistic approach should always be taken when supporting C&ALHIV, and these wider issues taken into account, as they will impact on all aspects of the childs life including engagement, adherence and health outcomes. Group and one-to-one activities that can be used to address some of these issues can be found in Appendix One. This section covers the following areas: 2.1 Growing up with HIV Talking openly about HIV Children fully understanding HIV Parental bereavement Children growing up without their biological parents. UNICEF NYHQ2006-1327/C. Versiani 20 Adolescents Living with HIV:Developing and Strengthening Care and Support Services 2.2 Managing HIV during adolescence Isolation Stigma and self-stigma Taking medicine Sex and sexuality Talking to others about HIV Having no home. 2.3 HIV and the family context How HIV was acquired The family Caring responsibilities for parents and/or siblings Drug use in the family. 2.1 Growing up with HIV Talking openly about HIV This area is covered in some detail in Section Three, but it is important to examine the role of professionals in addressing this issue. At the start of the HIV epidemic, when children were not expected to survive into childhood, not telling them their diagnosis was seen to protect them. The advent of ART and HIV becoming a manageable chronic health condition means the prognosis for children born with HIV is hugely improved, with the expectation that with access to ART, children can live long into adulthood. There have also been developments in understanding childrens rights and having this approach embedded in professional responses to children in settings such as health and education. This has generally lead to child-centred approaches to caring for children with health conditions, involving them in decisions about their own health care, taking their views into account and seeing them as competent in doing this. Children who are given clear, simple information about their health are seen to have less fears, increased understanding and improved outcomes. With respect to the above, HIV is far behind other health conditions. It is not uncommon for C&ALHIV not to be told 21 Adolescents Living with HIV:Developing and Strengthening Care and Support Services HIV is the virus they live with, or that they are only given partial information. When HIV is eventually disclosed to them, it can remain an area of some anxiety and concern. It is critical to consider how children are engaged in conversations about their HIV as this will have a significant impact on how they understand and accept their diagnosis. Professionals have an important role to play in addressing the stigma that surrounds HIV through the active encouragement of, and engagement in, open conversations about HIV. Children fully understanding HIV Having a clear and accurate understanding of HIV is essential to empowering C&ALHIV to live well and develop a good relationship with their medical condition. This needs to include a clear understanding of HIV as a virus, how it replicates and how it compromises their immune system. This knowledge will also mean they understand how their medication works and how to keep themselves well. Equipping C&ALHIV with this knowledge will empower them, giving them control and responsibility over their own health. Although HIV may be explained to C&ALHIV in a clinical setting, it is important that there are ongoing opportunities for conversations in other settings. Exploring the information in different ways offers multiple opportunities to ask questions and express any confusion or uncertainty. Clinics can feel like formal spaces for C&ALHIV and some may find it more difficult to ask questions in this setting. Experience of work with this group has shown that C&ALHIV respond well to receiving this information in youth- UNICEF NYHQ2004-0707/G. Pirozzi 22 Adolescents Living with HIV:Developing and Strengthening Care and Support Services friendly, engaging ways. Repeating information is important as often a child will take away the part of the information that is relevant to them at that time, so revisiting information regularly in different ways will provoke further discussion and debate. Active and participatory approaches to learning (as opposed to presentations of information) are also known to be particularly effective with children. Peer support sessions are good places where C&ALHIV can safely explore issues and ask questions. Never presume knowledge and understanding, and always get the child or adolescent to reflect back what you have been talking about to ensure they have properly understood. Parental bereavement One of the most significant things that can happen to a child is the death of a parent during childhood. This loss has a serious impact on any child, but in relation to HIV, it presents additional complexities. If the parent has died from AIDS related illnesses, the C&ALHIV could believe they will experience the same outcome. If the parent has died before the child was told their HIV status, when HIV is finally named they will be learning the truth about their parents death and again potentially relate this to what they perceive to be their imminent death. This link between HIV and death can bring a sense of fear and anxiety, compounding feelings around being lied to and possibly having to keep this family secret from siblings and other family members. When supporting C&ALHIV, it is important to carry out holistic needs assessments (see Appendix Five). This will enable bereavement to be highlighted and will assist an understanding of the impact on the child at that time and in the future. Open and honest conversations can help, offering the space to talk and ask questions as and when the child needs to. Group work can support the ALHIV to find the language to express themselves and be able to say how the death of their parent has affected them. It also offers the opportunity to share these experiences with others who have had a parent die, acknowledging that they are not alone in this experience. Children growing up without biological parents It is not uncommon for C&ALHIV to grow up in environments away from their biological parents, such as institutions, foster homes, child-headed households or living with extended family members. This can be due to the bereavement of parents; abandonment; mental health or drug use making the parent feel unable to care for the child; abuse meaning the home is not safe; or the issue of poverty. All children become additionally vulnerable due to the loss of parental care. It is understood that a critical feature of a childs social and emotional development is the opportunity to form attachments with a significant caregiver who is warm, sensitive and responsive. There is much psychological research on the impact of severed or absent relationships of attachment for children (see Appendix Two: Further Reading). 23 Adolescents Living with HIV:Developing and Strengthening Care and Support Services An HIV diagnosis in childhood can have a negative impact on a childs sense of self-esteem and self-worth. It can challenge a childs sense of hope about their future, their life, and relationship opportunities. Work with C&ALHIV who are growing up away from their biological parents, and particularly those who are living in institutions for whom a significant attachment relationship is more problematic due to the group care environment, will require special attention. They may face the emotional vulnerability and psychological impact of growing up without a secure attachment relationship with a parent, and the impact of a stigmatised illness which they may have limited understanding of. It is important to understand the difficulties they could face in forming trusting and secure relationships with those caring for them, and acknowledge this in working practice. Approaches to one-to-one support and group work should consider activities to build self-esteem, help C&ALHIV to feel empowered and create a sense of hope for the future. Consideration also needs to be given to how to integrate C&ALHIV with their HIV positive peers who do live with their biological parents and consider ways to challenge any negative attitudes within the peer group (if this should occur), stressing the profound shared experience of growing up with HIV. UNICEF/2014/S. Noorani 25 Adolescents Living with HIV:Developing and Strengthening Care and Support Services 2.2 Managing HIV during adolescence Isolation Many ALHIV describe the impact of HIV making them feeling isolated and different. Even in high prevalence settings, the stigma that surrounds HIV and the lack of people living openly means that ALHIV can feel like they are the only one. This sense of isolation and feeling alone in managing HIV can impact profoundly on psychological and emotional well-being. This is why it is so important to have open conversations about HIV with CLHIV at a young age normalising HIV before societal views can influence the child - and to continue these conversations and link them with their HIV positive peers as soon as possible. In low prevalence contexts, some C&ALHIV will be geographically isolated, which can present challenges to accessing their HIV positive peers. Direct outreach work and using residential interventions has been shown to be successful in overcoming this (see Section Five: Residential Interventions). Linking adolescents through online communication and social media is an option, but face-to-face contact is by far the most successful model. There may be financial barriers such as travel or accommodation costs to overcome and preliminary work may need to be undertaken with parent/carers or children if there is initial resistance or fear, but the impact of peer contact on ALHIV can be life changing. The authors of this handbook have worked with many geographically isolated ALHIV and their feedback following contact with their peers demonstrates immense relief in feeling that they are not alone, building emotional resilience and reducing self-stigma. Stigma and self-stigmaWatch video: Self-stigma - http://vimeo.com/112427513 (password: chiva) Stigma devalues people and generates shame. It blames and punishes certain people or groups to detract from the fact that everyone is at risk. Stigma focuses on existing prejudices and further marginalises people. The stigma attached to HIV comes from it being associated with sex, disease and death, and with illegal or culturally taboos practices. The real and perceived stigma of having HIV can lead to feelings of isolation and difference and experiences of discrimination and abuse. Stigma is also harmful to individuals because it can lead to feelings of guilt or shame. In this way, stigma can become internalised and lead to what is referred to as self-stigma, where the individual has negative beliefs about HIV and therefore negative beliefs about themselves. Self-stigma can result in denial of HIV, non-adherence, and refusal to talk about HIV. Research carried out into self-stigma states: UNICEF/2014/S. Noorani UNICEF NYHQ2004-1159/R. LeMoyne 27 Adolescents Living with HIV:Developing and Strengthening Care and Support Services It leads to fear of disclosure, which leads to social isolation, a life of no sex or anonymous sex that avoids disclosure, negative body image, feelings of hopelessness [10]. Many factors can influence the development of self-stigma: the views of the community a person lives in; how and when they were told they have HIV; and their experiences of HIV (such as abandonment or bereavement). For practitioners to understand the self-stigma of ALHIV it is important to understand the holistic experiences of the child. Working to reduce self-stigma is ultimately going to require a person changing their self-beliefs. Activities and discussion that support ALHIV to explore their self-perception, future aspirations and how they define their identity in relation to HIV, will start to work towards this change. Professionals should take a questioning approach to those beliefs that are self-stigmatising, in an effort to challenge and change them. Taking medicinesWatch video: Adherence - http://vimeo.com/112425742 (password: chiva) The development and advancement of ART means that HIV is now defined as a chronic manageable health condition. However, ART must be taken regularly and if doses are missed, the virus can mutate and the medicines no longer work. Although there is a number of different ART available (and this will vary in different settings) there are a limited number of combinations and poor adherence can lead to multi-drug resistance, morbidity and mortality. Adherence can be a complex psychological issue and solutions can be challenging. Ensuring that C&ALHIV have a good understanding about HIV, how medications help to control it and a proper understanding of what side- UNICEF NYHQ2004-1159/R. LeMoyne UNICEF 2014/S. Noorani 28 Adolescents Living with HIV:Developing and Strengthening Care and Support Services effects are and how they might manifest on different regimes, will support adherence. For C&ALHIV, adherence is a family/home issue and where possible, adherence support should be given to the family when the child is young, developing good models of adherence from an early age. As Dr Caroline Foster sets out in Section One, poor adherence is not unique to HIV and adherence patterns are developed in childhood. To that end, it is important to work with a family around adherence as soon as possible in an attempt to set up good models when a child is young. In its simplest form, adherence support can be divided into two necessary approaches: Approach one: Practical support C&ALHIV and their parent/carers may need practical tools to support them in remembering to take their medicine. This can be simple charts, pillboxes, alarms, mobile phone apps, etc. These techniques help those who struggle to establish daily routines with medication. Approach two: Psychological and emotional support The more complex area involves ALHIV who still feel unable to take medicine despite knowing all the facts about how important this is. This is not uncommon and it is important to understand how and why this situation occurs, as well as seeking to develop ways to work with the adolescent to explore how they can manage this. There are multiple reasons why ALHIV do not take their medication, including: Feeling they have some control That the medication is a daily reminder that they have HIV They feel well and the side effects make them feel unwell They feel that they do not have a future, and see no point in taking medicine Wanting to feel normal and be the same as their HIV negative peers. HIV is highly stigmatised and understanding self-stigma is significant to an understanding of poor adherence. Reflecting on ALHIVs early childhood experiences of HIV, attitudes to medication in their home and their experiences in healthcare will support practitioners understanding and ALHIV to see these links. It may be that there are other significant events or experiences not connected with HIV that impact on adherence, such as experiences of abuse, abandonment, parental drug-use, adolescents using drugs, caring responsibilities, issues at school and within friendship circles. 29 Adolescents Living with HIV:Developing and Strengthening Care and Support Services One-to-one and group work will offer the opportunity to explore these wider experiences. It is important to approach the adolescent holistically, to show an interest in them as a person and not simply in their HIV. Studies in the UK have shown that Motivational Interviewing has had some success in addressing adolescents with extremely poor adherence. [11] If an ALHIV is not taking medication and no intervention at that time seems to be working, focus should be on positive risk management, which means accepting the ALHIV is not taking their medication and supporting them to prevent onward transmission through safer sex or injecting practices during this time. Above all else, it is important that the ALHIV is not judged for their decisions relating to medication, that their choices are accepted and they are kept engaged within healthcare. Appendix One
Report
25 Ноябрь 2021
Deep Dive into the European Child Guarantee – Lithuania
https://www.unicef.org/eca/reports/deep-dive-european-child-guarantee-lithuania
Basis for a European Child Guarantee Action Plan in Lithuania PH OTO : DA NIJ EL SO LDO iBasis for a European Child Guarantee Action Plan in Lithuania When citing this report, please use the following wording: UNICEF, Basis for a European Child Guarantee Action Plan in Lithuania, UNICEF Europe and Central Asia Regional Office (ECARO), 2022. Authors: This policy brief has been prepared by a team led by Alina Makareviien, Project Manager and Lead Expert at PPMI. Haroldas Broaitis, PPMI Research Director, contributed to the report as a scientific advisor. The following experts have provided content on their areas of expertise: Greta Skubiejt (early childhood education and care and education), Agn Zakaraviit (health and housing), Aist Vaitkeviit (nutrition, material child poverty and social exclusion), Loes van der Graaf (administrative coordinator). Project management: Daniel Molinuevo, together with Kristina Stepanova (European Child Guarantee National Coordinator in Lithuania) and the rest of the Steering Committee of the third preparatory phase of the European Child Guarantee in Lithuania. Acknowledgements: Thanks are also due to James Nixon, language editor at PPMI, and many other experts who have shared their knowledge. UNICEF, 2022 The information and views set out are those of the authors and do not necessarily reflect the official opinion of the European Commission and the Commission cannot be held responsible for any use which may be made of the information contained therein. More information on the European Union is available at www.europa.eu. The material in this policy brief was commissioned by UNICEF ECARO in collaboration with the Lithuanian National Committee for UNICEF. UNICEF accepts no responsibility for errors. The findings, interpretations, opinions and views expressed in this publication are those of the authors and do not necessarily reflect the policies or views of UNICEF. Contents 1. Introduction 01 2. Free and effective access to ECEC 03 3. Free and effective access to education 07 4. Free and effective access to health care 11 5. Effective access to healthy nutrition 15 6. Effective accesss to adequate housing 18 7. Social services and benefits in cash 21 iiBasis for a European Child Guarantee Action Plan in Lithuania PH OTO CR ED IT: U NIC EF, SA MIR KA RA HO DA 1. Introduction Child poverty has an immediate and long-term effects on both individuals and society. Due to particular needs of children, and the limited coping capabilities tied to their specific life stage, children are impacted more acutely by poverty, particularly at an early age. Poverty and deprivation during childhood impact an individuals health, educational attainment, employability and social connections, and increase the risk of future behavioural problems. Thus, poverty and social exclusion at a young age often extend into later stages of life, perpetuating intergenerational poverty and inequalities. Childrens experiences of poverty and social exclusion depend not only on the extent of income poverty and material deprivation, but are also highly influenced by their immediate caregiving environment (e.g., family composition, foster care) and the characteristics of the local community (e.g. the level of access to public services). This policy brief contributes to the drafting of the Lithuanian National Action Plan on reducing child poverty and identifies the key challenges to achieving the goals of the European Child Guarantee in Lithuania. It provides an overview of the policies currently in place and provides recommendations ranging from improving access to free early childhood education and care (ECEC), to education, health care, healthy nutrition, , and adequate housing. This policy brief is based on the findings and recommendations identified in the deep-dive analysis and consists of five parts, each covering a different policy area. Each part comprises three sections, dealing with the main access barriers to access, policy responses and recommendations for ECEC, education, health care, nutrition and housing services for children. 1 2Basis for a European Child Guarantee Action Plan in Lithuania Key messages Effective access to quality ECEC services is one of the most important factors in ensuring equality in childrens further development and academic achievements, as well as to ensuring childrens safety. Meanwhile, in Lithuania, access to ECEC remains one of the biggest challenges especially for the youngest children. Not enough places are available in public centres, and private for-profit services are very expensive. In addition, hidden costs (such as meals and transport) exist even in the public sector, thereby rendering access to ECEC especially problematic for the most vulnerable children, such as children from low-income families and families at social risk. Due to the large group sizes in public ECEC centres and a lack of learning support specialists, there is also a lack of inclusion with regard to children with SEN (Special Education Needs), disabilities, and children from minority groups. Effective access to education, first and foremost, requires equality among schools and regions within the country, which is currently lacking in Lithuania. Vulnerable children, such as children from low-income families, children from families at social risk, children in rural areas, and children from national minorities within Lithuania, receive a lower quality of education. The reason for this is that schools in rural areas and in certain parts of cities, as well as schools for national minorities, lack qualified teachers, necessary learning equipment, up-to-date books and methodologies. The issue of hidden costs also applies, particularly in relation to access to non-formal education. Meanwhile, children with SEN and disabilities do not receive quality education due to teachers lack of knowledge about working with such children, as well as a lack of adapted methodology, and a lack of learning support specialists. To reduce these barriers, all schools should be equipped with laboratories, IT equipment, highly qualified teachers, all necessary learning support specialists, up-to-date books, and adapted methodologies. Schools should also provide children with universal benefits and represent cultural diversity. Meanwhile, with regard to non-formal education, children must be provided with a wide range of activities that correspond to their individual needs and capacities, and transport should be provided for children with SEN and disabilities as well as children living in distant areas. Socio-economic disadvantages negatively influence childrens access to the healthcare system in Lithuania due to families inability to afford treatments, long waiting lists, long travel times or no means of transport, a lack of time due to parents working commitments, etc. Effective access to free healthcare requires improved access to healthcare services for the most disadvantaged groups such as children in low-income families and precarious family situations; a greater focus on children with disabilities and special needs, as well as Roma and migrant children; the development of mental health services and the improvement of after-school opportunities for childrens physical activity. A lack of effective access to healthy nutrition during infancy contributes to a range of poor health outcomes in future life, as well as impacting physical and mental well-being and cognitive functioning, and contributing to lower learning outcomes. The most vulnerable children in Lithuania are those from low-income families, families at social risk, and children living in remote rural areas. Parents with low incomes cannot afford healthy foods as these are often more expensive than less healthy alternatives. In addition, parents at social risk may lack knowledge regarding the importance of nutrition, and parents raising children in remote areas may face additional barriers of access due to a lack of transport or its cost. The most vulnerable period for children is during infancy, when they should be breastfed, and their nutrition relies on mothers awareness as well as their eating habits. Tackling barriers to access such as the affordability of healthy foods, as well as addressing unhealthy eating habits by promoting and enabling healthy eating and ensuring that all children have at least one full healthy, balanced meal per day, are therefore particularly important in tackling food insecurity for AROPE children. Housing deprivation is a much bigger issue for children living in low-income families compared with other income groups of children in Lithuania. Effective access must be ensured to adequate housing and access to housing support services needs to be improved for the most disadvantaged groups in Lithuania: children in low-income households, children of single parents, children from large families, children with disabilities, Roma and migrant children. A greater focus should be placed on improving the income situation of families in Lithuania. Social services and benefits in cash significantly improve access to ECEC, education, health care, nutrition and housing. In Lithuania, some of these benefits include universal child benefits, social benefits, the family card, and one-time COVID-19 benefit and benefits for pregnant women. Other important programmes to improve the overall situation of the most vulnerable children include the action plan for complex services for families, the child well-being programme, case management and the policy of deinstitutionalization. 3Basis for a European Child Guarantee Action Plan in LithuaniaP HO TO C RE DIT : UN ICE F 2. Free and effective access to ECEC Main challenges experienced by children regarding ECEC in LithuaniaAccess to ECEC services remains a challenge in Lithuania. As in most post-Soviet countries where policies have been shaped to support stay-at-home mothering and nuclear families, and where a clear division of gender roles exists between men and women, insufficient attention has been paid to expanding the ECEC system. Policy in Lithuania has traditionally focused on supporting the aforementioned gender roles, and inattention towards developing the ECEC system has led to a lack of available ECEC services and a lack of flexibility in those services that do exist (both in terms of working hours and the types of ECEC providers), particularly with regard to children aged 0 to 3 years old. In addition, there is insufficient inclusion and access to ECEC services for children with Special Educational Needs (SEN) and disabilities, children with migrant backgrounds and children living in families at social risk, especially when such children live in rural areas. Due to a lack of public services, parents have to rely on private for-profit services, which are very expensive. Most vulnerable families, such as single-parent families, cannot afford them. For single-parent families, the situation is extremely complicated: they may face long waiting lists for enrolment into ECEC, as most municipalities in Lithuania give priority in enrolment into ECEC to families in which both parents are registered in the same area. On top of this, even in public ECEC centres, hidden costs constitute a great burden for low-income families. Meanwhile, in many cases, families with children living in rural areas cannot afford transport to and from ECEC services. Inequality between children in the education system is therefore present from a very early age. 3 4Basis for a European Child Guarantee Action Plan in Lithuania Table 1 . Number of children requiring free and effective access to ecec Vulnerable group Estimated size of the group Data source and year Children in low-income families 21.6% (38, 000) of children up to 6 years old are at risk of poverty Eurostat, 2020 Children living in families at social risk 17,430 (children of all ages) Official Statistics Portal, 2018 Children living in rural areas 50,232 Education Management Information System, 2020-2021 Children with special needs and disabilities 24,962 Education Management Information System, 2020-2021 Children with migrant backgrounds Returnee children: 976Immigrant children: 1,007 Ministry of Education and Science, 2018Official Statistics Portal, 2020 The policy responses to improve access to ECEC To improve the availability of ECEC services, the Lithuanian government has established mandatory pre-primary education. Other tools include recognizing different forms of ECEC provision, providing children with transport, free meals and more. The National Education Development Programme 2021-2030 foresees that by 2030, 95% of children between ages of 3 and the age of compulsory primary education will attend ECEC services, while 75% of children from families at social risk will attend ECEC. It is also foreseen to improve the inclusion of children with SEN. The main tools to achieve these goals include the creation of new ECEC sites (including modular kindergartens and family kindergartens), and the improvement of teachers competences via various courses and peer learning. Modular system kindergartens are flexible spaces, generally made from light construction modules, which can be easily remodelled if necessary. Family kindergartens, meanwhile, are formed when a child-raising parent takes care of other children for a certain fee, using the facilities of his or her own home. Nevertheless, while the goals of current policies are promising, there is a lack of concrete steps that need to be taken, together with a lack of financial distribution. In the current situation, access to ECEC among the most vulnerable children remains a challenge, as priorities regarding enrolment into ECEC remain based on the strengths of families, rather than their vulnerabilities, such as raising children alone, and there is a lack of transport, learning support specialists and other resources. The Description of the Requirements for Teachers qualifications foresees that at least one teacher in the childrens group should have a BA qualification; all teachers should have attended courses of at least 40 hours on working with children with SEN, disabilities, and other vulnerable backgrounds, and at least 40 hours of courses on teaching the Lithuanian language. Nevertheless, there is still a shortage of workforce in ECEC due to the professions lack of attractiveness and the lack of financing in this area. Although salaries for pre-primary teachers have been raised, ECEC teachers and learning support specialists remain among the lowest-paid professionals. To help ensure the quality of services, all ECEC centres are also provided with methodological recommendations. These recommendations include topics such as identifying childrens individual needs and improving childrens academic, artistic and social skills. Moreover, they provide information on how to approach and work with children with SEN, disabilities, migrant backgrounds, as well as children from low-income families and other vulnerable backgrounds. Meanwhile, mandatory pre-primary education for all children, and mandatory ECEC education for children from families at social risk, as well as a minimum of 5 hours mandatory provision of Lithuanian language courses for migrant children of all ages while attending ECEC, seek 5Basis for a European Child Guarantee Action Plan in Lithuania to ensure childrens safety and equality. The aim of these measures is to provide children with an equal starting point when they attend primary school; however, such measures are not always carried out due to a shortage of workforce and the competences of teachers, as well as the large sizes of childrens groups. Other tools include the provision of transport, increasing the number of ECEC centres, and assessment tools for children. In addition, children from families at social risk are also provided with free meals, learning equipment, family monitoring by The Child Welfare Commission, and counselling parents regarding the benefits of ECEC. Recommendations for improving access to ECEC Make ECEC universal for children from 0 years old to the age of compulsory primary education, with priority being given to children from disadvantaged backgrounds. The current goal is to achieve universal ECEC for all children between the ages of 2 and primary education by 2025. Progressive universalism could help to reach these goals. Progressive universalism means that children from vulnerable backgrounds are given priority in terms of access to ECEC. Financial allocations could also be raised to help children from vulnerable backgrounds to access ECEC. More attention to parents and their needs. It is important to inform parents about the benefits of ECEC via families social workers and health care specialists. Outreach mechanisms could provide significant benefits in terms of involving children from vulnerable backgrounds. It is also crucial to help parents with bureaucratic processes, and to simplify these processes as much as possible. Improve the inclusion of children with SEN. Although quality ECEC has a dramatic impact on the development of children with SEN, currently only around 20% of such children attend general ECEC in Lithuania. Improving the inclusion of children with SEN requires extended training for the ECEC workforce, both during their initial studies and while working in ECEC. There is currently a lack of teacher training in this area, mainly due to a lack of financing. This should be improved. In addition, it is important to reduce the sizes of childrens groups, and to determine the number of children per teacher. Where teachers work with groups including children with SEN, those groups should contain a smaller number of children. Address issues of gender inequality and reconciliation of work and family life. ECEC services are important for removing obstacles to the employment of women, particularly single mothers, and for single parents in general. Access to ECEC contributes to gender equality by allowing greater flexibility to manage family and work-life balance for both mothers and fathers. It is important that more flexible ECEC services are made available, with different working hours, and that single parents are given priority with regard to enrolment in ECEC. Address geographical disparities. Lithuania is currently unable to ensure equal enrolment into ECEC across the country. First and foremost, increasing access to ECEC, means developing infrastructure and increasing the number of teachers. The level of provision is lower in rural areas than in urban areas, and in urban areas, fewer high-quality ECEC resources are available in poorer neighbourhoods. Clear guidelines regarding structural quality and financing must be set at national level, to avoid children suffering inequalities in conditions depending on where they are born. It is also necessary to ensure equality among ECEC providers regarding the quality of services provided to children with SEN and disabilities, and to ensure that these children receive high-quality services close to their homes. Support the ECEC workforce. As previously mentioned, more time and money should be invested into the continuous professional development of working teachers as well as teachers training. The strong connections with teacher training institutions for ECEC could be further expanded to include on-site training or mentoring for working teachers. Moreover, professional development should be embedded into the process of quality monitoring, creating a system that focuses on measuring quality, reflecting on the results, and supporting teachers in making improvements. Every teacher should receive continuous professional development training continuous training and supervision in class, as well as training on special education, psychology, and IT; teachers should be able to attend qualification courses abroad and to receive video 6Basis for a European Child Guarantee Action Plan in Lithuania feedback. More attention should be focused on improving teachers salaries and the status of the teaching profession, as well as increasing diversity among teachers in ECEC centres. Set clear requirements for curriculum. Curricula need to be planned within an open framework that acknowledges and addresses the diverse interests and needs of children holistically. This should include addressing differences between boys and girls; children with SEN; children from national minorities; and children from families at social risk. While planning curricula, it is important to take into account global challenges, technological advancement, topics relating to everyday life challenges, and the identities of various ethnic minorities. Children, especially those from families at social risk, should be provided with facilities to meet their hygiene requirements, and centres should pay extra attention to the nutrition and health of such children. With regard to children with SEN and disabilities, recommendations provided by doctors and other services should be followed carefully at all times. It is also important to involve children and their parents in the process of creating curricula. Ensure that policy goals are oriented towards improving access to and the quality of ECEC. Strong public policy commitment to ECEC is important, and must be backed by a bold vision, strong plans and adequate funds. Promoting ECEC as a central priority in national education strategies and plans including clear targets, indicators and ministerial leadership can make a significant difference in terms of the political and financial importance given to the sector. Robust governance and accountability mechanisms across decentralized levels are also important in ensuring the efficient allocation and use of ECEC resources. Develop comprehensive quality monitoring. To ensure success, the monitoring and assessment framework should cover structural aspects of quality (child-staff ratio, qualification levels of staff); process quality (e.g., interaction with children, the content of activities); and outcome quality (looking at the benefits for children, families, communities and society). Monitoring needs to include assessments of the accessibility of ECEC for children living in rural areas, children from low-income and single parent families, for families at social risk, and for children from ethnically non-Lithuanian families. Furthermore, the quality of staff, price of services, curricula, governance and funding should also be monitored. General quality criteria need to be set at the highest possible levels, but should also encompass regional and local levels, and should ideally align with the EU ECEC Quality Framework. The ECEC workforce, the children themselves and their parents should all be empowered and included into the quality monitoring process. Information from both self-assessment and external evaluations regarding the quality of the ECEC system should be used as the basis for improvement. Information about the quality of the ECEC system should also be made available to the public. PH OTO CR ED IT: U NIC EF 3. Free and effective access to education Main challenges experienced by children in Lithuania in relation to education Although education is free and universal for all children in Lithuania, many barriers to access and other challenges still remain. First and foremost, great inequality exists between schools in terms of the quality of services, with the greatest disadvantage evident in schools in rural areas, certain areas of cities and in minority language schools. Such inequality exposes children living in rural areas and less well-off urban areas, as well as the children of non-Lithuanian ethnic groups, to low-quality education. Many of the schools attended by these children suffer a lack of laboratories, IT equipment, learning support specialists, up-to-date books and methodologies and highly qualified teachers, and a lack of transport to and from non-formal education activities as well as a lack of choice in such activities. The lack of learning support specialists and lack of choice in free-of-charge non-formal education activities, especially among children with SEN and disabilities, is major and prevent problem in all schools. Moreover, although education is considered free of charge for all children, hidden costs remain a great issue. Despite school tuition being free, the families of school students have to pay for certain school materials, activity books, transport, food and various extra courses and activities that contribute to their learning. This can be extremely problematic for low-income families, especially those living in remote areas, where hidden costs limit access to both formal and non-formal education. Immigrant children, returnee children and children of migrant origin are also insufficiently included in the educational system. There is a lack of teachers from different cultural backgrounds in schools, Lithuanian language is not sufficiently well taught to non-native-speaking children, and teachers lack the skills to work with children with different languages and cultures. A lack of learning support specialists is also a major problem in this context. 7 8Basis for a European Child Guarantee Action Plan in Lithuania Table 2. Number of children in need of free and effective access to education Vulnerable group Estimated size of the group Data source and year Children in low-income families 24.8% (100, 000) of children between ages of 6 and 19 are at risk of poverty Eurostat, 2020 Roma children 1,036 (children of all ages) Overview of Roma situation in Lithuania, 2016 Migrant and returnee children Returnee-children: 412 Immigrant children: 3,303 Ministry of Education and Science, 2018OSP, 2020 Children from non-Lithuanian ethnic backgrounds 31,502 Education management information system, 2020-2021 Children living in rural areas 53,510 Education management information system, 2020-2021 Children with special needs and disabilities 4,873 Education management information system, 2020-2021 Policy responses to improve access to educationThe Lithuanian government recognizes the issue of low academic achievements among Lithuanian children and its link to the lack of quality of education in Lithuanian. The government recognizes issues such as inequalities between schools and the lack of inclusion of the most vulnerable children such as children with SEN and disabilities and children of migrant origin. To reduce these inequalities, it proposes to equip all schools equally with highly qualified teachers, learning support specialists, laboratories, IT equipment and the necessary methodologies. The National Education Development Programme 2021-2030 foresees that by 2030, 97% of children with SEN and 75% of children with disabilities will attend general education schools; 75% of all children will attend non-formal education; 50% of children with SEN will attend non-formal education; 65% of teachers will be employed in schools after graduation; and 40% of teachers will have MA degree. In addition, it is expected to improve pupils PISA results to reach 16th place among all participating countries by the year 2025. To achieve these goals, the government has allocated a budget of EUR 550 million. The Strategic Action Plan of the Ministry of Education, Science and Sport for the year 2021-2023 seeks to improve teachers qualifications; implement the monitoring and assessment of students, schools and education as a whole; develop infrastructure for inclusive education; and to integrate formal and non-formal education. Tools to achieve these goals include courses to improve teachers competencies; increases in teachers salaries; online self-assessment programmes for schools; monitoring indicators for education; purchasing additional school buses and laboratory equipment; modernizing school infrastructure; modernizing non-formal education facilities; increasing support to Lithuanian schools abroad; providing coordinated support to immigrated and returnee children and their families; expanding the number of all-day schools; and increasing funding for student benefits. Nevertheless, teaching remains among the lowest-paid professions, and teachers do not receive any of the financial and educational support necessary to motivate them when working with children with SEN and disabilities, or with children from minority backgrounds. The Political Programme of the XVIII Government of Lithuania also sets similar goals. In addition, it foresees the establishment of national education quality standards and improvements in the quality of education in minority schools. Although most of these goals are similar to those set in previously mentioned documents, the Political Programme of the XVIII Government of Lithuania foresees the use of different tools to achieve these goals. These include modernizing the curricula (including a multilingual reading and maths programme, as well as updated history programmes that recognize the importance of minorities in Lithuanian culture), reduced class 9Basis for a European Child Guarantee Action Plan in Lithuania sizes, additional financing for learning support specialists, more up-to-date books in minority languages, and the digitalization of minority schools. According to data from interviews, the issue of schools lack of autonomy still remains, as they are not given the power to make their own decisions regarding financial allocations and various aspects of curricula, despite the schools themselves being best placed to know what is missing, and what is necessary for their children. Educational tools of the largest scale will include mobile school staff teams and millennial schools. Mobile school staff teams will consist of teams of teachers and other learning specialists that will go to schools facing issues and work there temporarily to improve the situation. Millennial schools will be located in different regions in Lithuania and will benefit from better teachers and STE(A)M laboratories, and modern curricula for formal and non-formal education. All children from the surrounding region will be able to use the facilities and courses provided at these schools. These schools are intended to reduce inequalities between regions, and to provide equal opportunities for all children irrespective of their living place, as well as to improve overall academic achievements. Nevertheless, some of the experts interviewed as part of this research expressed concern that these schools might even worsen equality among regions and children, as millennial schools would absorb all of the best resources in the area and become elite institutions. Children learning in other schools in the area would thereby receive an even lower quality education, as not all of them would have access to these elite schools. The inequalities between schools and regions with regard to quality therefore remains an issue. More detailed, focused tools and more integrated solutions are required to break the cycle of poverty by providing every child with the highest-quality education at all educational levels. Meanwhile, the Law Amending the Law on Education of the Republic of Lithuania and The Description of the Procedures for Organizing the Education for Pupils with SEN, seek to improve the inclusion of children with SEN, those with disabilities and those from other vulnerable backgrounds (migrants, at social risk, from low-income families etc.), as well as to reduce the number of school dropouts. The tools provided include continuously working with childrens parents, pupil self-care plans (provided for children who have various health issues), and individual learning plans. Other tools include the provision of special classes, transport, school meals, school supplies, and improved inter-institutional cooperation. Municipal administrations are encouraged to work more effectively to ensure the well-being of the child, to remove interdepartmental barriers between educational assistance, municipalities, state institutions and establishments, organizations and non-governmental actors, to ensure inter-institutional co-operation. Improved inter-institutional attention to vulnerable children and their parents should reduce social exclusion, dropouts from schools, as well as improve parents skills and involvement in their childrens education, in addition to improving childrens psycho-emotional well-being while attending educational institutions. Inter-institutional co-operation means that all of a childs needs must be identified and dealt with through cooperation between all of the necessary services and support providers. Nevertheless, the inclusion of children with SEN and disabilities, in general, remains a great challenge due to the aforementioned lack of competencies and motivation among teachers, as well as a lack of learning support specialists and the physical appropriateness of schools buildings. Other smaller-scale programmes also exist, such as quality baskets, all-day schools, day care centres and financial baskets for non-formal education. Quality baskets seek to improve pupils academic achievements. EUR 30,324,2001 were allocated to this programme across 270 schools. The programme includes the evaluation of schools, provision of improvement plans to the schools and the monitoring of their success. Meanwhile, financial baskets for non-formal education seek to improve childrens attendance in non-formal education by providing every child with a monthly allowance to purchase non-formal education activities. All-day schools are settings in which children are provided with educational activities after official school hours. The main goals of these schools are to improve the inclusion of children from vulnerable backgrounds and to reduce conflicts between parents family life and work commitments. Day care centres are social care settings in which children from the most vulnerable backgrounds (such as families at social risk) gather after school and receive help with their homework, participate in various educational and cultural activities, and receive free meals. These centres also seek to work with childrens parents to improve their parenting skills and to ensure that children receive all the support they need. Despite improved financial allocations and more attention being given to the parents, the hidden costs of education remain, and there is a lack of universal provision of school supplies and other necessary materials. 10Basis for a European Child Guarantee Action Plan in Lithuania Recommendations for improving access to education There should be universal and inclusive education for all children: geographical and socio-economic disparities should be addressed, as well as differences in levels of inclusion and quality among schools. Universality and equality in the education system would reduce inequality between children from families of different socio-economic status. It would also improve academic achievement and decrease school dropouts. It is necessary to provide all children with school supplies, transport and meals to reduce hidden costs and bullying in schools. It is also important to address such differences as the unequal distribution of learning support specialists, laboratories, IT infrastructure and high-quality teaching staff among schools, and to reduce differences between elite and rural as well as minority schools. Reducing inequalities between schools would also improve the inclusion of children with SEN and children with migrant backgrounds. Targeted interventions should also take place to improve boys academic achievements. Update curricula and provide greater flexibility in the selection and design of programmes. It is crucial to enrich learning experiences while supporting the effective use of digital technologies and encouraging activities that link learning with real-life experience. It is also necessary to improve the curricula in vocational schools so that they effectively combine strong basic and job-related skills. Regions, cities and schools should be allowed to choose from a list of validated activities and programmes that best meet the needs of their children. Greater investment in measures that reduce early school leaving. Interdisciplinary communication is crucial to ensure that children who are not well included in schools are identified and worked with, to reduce the risk of dropouts. It is also necessary to improve communication with childrens parents, to ensure that they receive all the necessary information and that their individual needs and those of their children are met. Preventive and tailored interventions that involve multiple actors (such as families, schools, and so on) are identified as being more likely to succeed. Developing early warning systems for pupils at risk could help to ensure effective measures are taken before problems become manifest. The availability of various routes back into mainstream education and training is also important. Expand all-day schools and non-formal education opportunities across Lithuania. The lack of teachers and other staff, as well as additional transport costs, learning supplies, additional school meals and the necessity to adapt methodologies, are all concerns that must be addressed in order to ensure the expansion and quality of all-day schools and non-formal education across Lithuania. It is also important to address the issue of access to non-formal education for children living in rural areas, as well as for children with SEN and disabilities. Also important is the need to ensure that a variety of after school activities options are available for these children. Strengthen the teaching workforce. It is important to attract teachers with different backgrounds, genders and ages. All teachers should have a BA degree and at least some should have a Masters degree. Initial teacher education also needs to be improved, and greater flexibility should be provided in terms of the ways in which people can acquire a teaching degree. It is important to ensure that new teachers can work in a well-supported environment and receive frequent feedback and mentoring during the early years of their careers. In addition, all teachers should be provided with qualification courses, and teachers opportunities to network and exchange knowledge and experiences at school should be strengthened and improved. There should be a more coherent career pathway for teachers that rewards teaching excellence. The methods used to recruit teachers should be improved, and salaries should be raised. Set national quality standards and implement monitoring. It is important to prioritize education at policy level as part of the overall solution to social exclusion and poverty throughout the integration process. Any strategy should therefore provide clear timelines, targets, baselines and indicators to monitor progress, as well as adequate financial, material and human resources. External evaluation must be carried out, as well as the provision of methodology and tools for internal evaluation by schools. General quality criteria need to be set as high as possible, while minimum quality thresholds are also required to avoid a lack of balance between regions and avoid a situation in which the quality of a childs education depends on the region in which they are born. Funding on a larger scale should also ensure consistency between richer and poorer regions, to avoid a situation in which municipalities with a higher prevalence of low-income families lack the means to serve the needs of those families. The possibility should be considered of assigning higher weights in the funding formula to socio-economically disadvantaged students. More attention should be devoted to improving efficiency in the allocation and use of school maintenance budgets. PH OTO CR ED IT: U NIC EF - VA KH TAN G K HET AG UR I 4. Free and effective access to healthcare Main challenges experienced by children in Lithuania in relation to healthcare Socio-economic disadvantages negatively influence childrens access to the healthcare system in Lithuania. Childrens medical and dental needs may remain unmet due to various reasons, such as families inability to afford treatment, long waiting lists, long travel times, or no means of transport, as well as a lack of time due to parents work or their responsibility to care for other family members. Children in low-income or single-parent families, Roma families and children living in precarious family situations are at a high risk of not receiving necessary health treatments due to travel costs, lack of time to take children to the doctor, and also due to some necessary and continuous treatments not being entirely free of charge and, in the case of and Roma families families in precarious situations, due to a lack of education and interest in childrens health on the part of parents. One of the most obvious issues is the insufficient level of vaccinations. Vaccination rate among children in Lithuania are lower than the 95 per cent recommended by the WHO, and the issue of non-vaccination is particularly common among Roma children. Another important issue relating to healthcare is a lack of physical activity by children, often determined by the absence of interest by parents and financial reasons. The children who experience the highest risk of low physical activity are those from low-income families, families at social risk, single-parent families and Roma families, as the main reasons for low levels of physical activity include the inability to afford after-school sports activities and/or transportation, lack of time to take children to these activities or to supervise childrens activities on a daily basis, as well as the previously mentioned lack of parents education and interest in their childrens health in the cases of families at social risk and Roma families. These same groups of children do not always have access to mental health services when needed, due to long waiting lists and parents lack of time or transport to take children to consultations, especially when they live in remote rural areas, far away from clinics. The lack of availability of psychological counselling is especially problematic for children from low-income and single-parent families, as their parents often cannot afford private consultations and are even more time-poor than wealthier families. Families raising children with disabilities or special needs report having limited access to certain treatments their children need, as well as a lack of specialists, long waiting periods, and so on. Migrant and refugee children may experience limited access to free healthcare. 11 12Basis for a European Child Guarantee Action Plan in Lithuania Table 3. Number of children in need of free and effective access to healthcare Vulnerable group Estimated size of the group Data source and year Children in low-income families 24% (138,000) of children between birth and the age of 19 are at risk of poverty Eurostat, 2021 Roma children 1,036 Overview of the Roma situation in Lithuania, 2016 Children living in precarious family situations 17,430 Official Statistics Portal, 2018 Migrant and returnee children 4,310 Ministry of Education and Science, 2018OSP, 2020 Children with disabilities 14,289 NGO Confederation for Children, 2017 Children with mental illness 701.05 per 10,000 children The Institute of Hygiene, 2018 Children in single-parent families 26% of all families150,000 children Eurostat, 2017Lithuanian Population and Housing Census, 2011 Policy responses to improve access to healthcareEnsuring childrens health and social well-being is an important part of the national health system in Lithuania. Access to, and the quality of, healthcare services, health literacy, mental and physical health and sex education are at the heart of the National Progress Programme 2021-2030, the Programme of the XVIII Government of the Republic of Lithuania, and the Public Healthcare Development Programme for 2016-2023. Physical activities and mental health services are not currently accessible for all children and their families in Lithuania; thus, the national focus is on spreading awareness of the importance of mental and physical health, increasing access to sporting activities, and improving childrens health monitoring. The National Progress Programme 2021-2030 strategically aims to increase social well-being inclusion within Lithuanias population, and strengthen its health. To achieve this goal, the following measures are planned: improved adaptation of the environment for people with disabilities, including children (e.g. transport, infrastructure, services, information); increased attention to childrens psychological state and access to mental health services; improved access to physical activities for children; high-quality health care services; improved health literacy; an efficient health system with focus on stronger primary care; and improved access to outpatient care. Moreover, issues such as long waiting lists to receive treatment, the high cost of drugs and high levels of corruption are also addressed. However, some healthcare programmes such as continuous rehabilitation services and treatments for certain developmental disorders, as well as transport services, remain among the biggest barriers to accessing healthcare provision for the most vulnerable children in Lithuania. The Programme of the XVIII Government of the Republic of Lithuania plans to improve access to sporting activities and mental health services. The main tools to achieve this include promoting more equal distribution of qualified sports specialists across the country; introducing up to three physical education lessons per week in all general education schools; updating the physical education curriculum; providing swimming lessons to all children in primary schools; improving sex education; and improving access to mental health services. The National Public Healthcare Development Programme for 2016-2023 also seeks to promote physical and mental health, as well as encouraging a healthy lifestyle and culture, by promoting health literacy and ensuring the sustainability of the public health care system. To achieve these goals, awareness will be raised with regard to physical and mental health, with an emphasis on the prevention of illnesses in schools; updating sports 13Basis for a European Child Guarantee Action Plan in Lithuania equipment and facilities in schools; monitoring physical activity and childrens mental state; increasing the availability of high-quality public health care services and improving the management of the public health care system overall. The key mechanism currently used ensure childrens health needs are met is preventive annual health inspections and the National Immunization Programme 2019-2023. The latter provides that all recommended vaccinations included in the national immunization scheme are free of charge. The Programme aims to ensure at least 90 per cent of children are vaccinated (in the case of measles and rubella, not less than 95 per cent) across the country and in each municipality. Meanwhile, preventive annual health examinations at health care institutions include consultations with family doctors and dentists, and are compulsory for all children attending pre-primary and general education. However, a lack of attention is paid to the health of children who fall outside formal care and education systems. Attending to the medical needs of these children depends solely on their parents who, as previously mentioned, may lack interest or knowledge about their childrens health. A grey area also exists with regard to refugee children, who have different rights to the nationals in terms of access to healthcare. Meanwhile, children with disabilities receive financial assistance and various free services. These include a social assistance pension; targeted compensation for assistance costs for children with disabilities; and universal and free early rehabilitation for children with developmental disorders. The mechanism for integrated family services includes the provision of positive parenting training, psychological counselling, ECEC services, transport and more. Nevertheless, many issues still remain for children with SEN and disabilities, who face additional challenges in addressing everyday medical needs such as dental treatment. They also lack access to special, targeted treatments and integrated assistance that could help to meet all of their needs and reduce the burden on their families. Recommendations for improving access to healthcare Consistent coordination between central and local institutions is necessary in order to ensure

Footer

Главная
  • Что мы делаем
  • Положение детей в регионе Европы и Центральной Азии
  • Где мы работаем
Исследования и отчеты
  • Публикации
  • Наши партнеры
  • Послы ЮНИСЕФ в Европе и Центральной Азии
Поддержать

Social - ru

Footer Secondary

  • Наши контакты
  • Условия пользования