Romania: facing the challenge of translating research into practice–policy and partnership to promote mental health among adolescents

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  The Romanian case study presents data on the mental health and well-being of Romanian youth from the 2006 HBSC survey, describes the socioeconomic context of public policies and intervention programmes, provides information on the “Health education
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  175 Romania: facing the challenge of translating research into practice – policy and partnerships to promote mental health among adolescents  Adriana Baban 1 , Catrinel Craciun 1 , Robert Balazsi 1 , Dan Ghenea 2 , Victor Olsavszky 3 . 1  Babes-Bolyai University, Cluj-Napoca; Romanian Health Psychology Association, Bucharest. 2  National Centre for Mental Health, National School for Public Health and Healthcare Management, Bucharest. 3  WHO Country Office, Romania, Bucharest. Executive summaryIntroduction The Romanian case study presents data on the mental health and well-being of Romanian youth from the 2006 HBSC survey, describes the socioeconomic context of public policies and intervention programmes, provides information on the “Health education in Romanian schools” programme and reveals lessons learned following its implementation. Having to negotiate a period of political and economic transition and to adapt to its new status as an EU country has left a mark on the social context of Romania. Economic instability has contributed to the development of health inequalities, marginalization of vulnerable groups and a decline in the mental health and well-being of the general population. This creates the need to intervene at an early age to prevent psychological problems and promote mental health. The 2006 HBSC survey showed that Romanian teenagers reported average mental health, with the majority being satisfied with their lives and considering themselves healthy. Social capital and socioeconomic differences emerged, however, reflecting the existence of mental health inequalities. Adolescents from a poorer socioeconomic background had the worst positive health as indicated by lower levels of mental health, self-perceived health and life satisfaction. Possessing high socialcapital, on the other hand, produced a protective factor, meaning that young people who had more social capital also enjoyed better mental health. Following WHO recommendations, the Ministry of Public Health decided to prioritize prevention interventions in the field of mental health. This included the adoption of laws and the planning of implementation strategies that targeted children and adolescents. In the case study, it is described the present policy aimed at improving adolescent health and mental well-being. “Health education in Romanian schools” represents a successful example of intersectoral collaboration involving: the Ministry of Education, Research and Youth; the Ministry of Public Health; local authorities; NGOs; and universities and schools. It reflects their joint effort to organize a programme designed to help children and young people to grow up healthy, prevent mental health problems and promote social inclusion. The partnership proved efficient in developing curricular, training and financing mechanisms, but effective process and outcome evaluation programmes need to be developed to measure the impact of this kind of educational intervention on the mental health of children and adolescents. Adequate financial and human resources need to be provided to help Romania face the challenge of translating research into practice.Drawing on data from the HBSC study regarding mental health and its determinants can contribute to effective policy and programme development. This issue can be addressed through the development of interventions that help build bonding, bridging and linking social capital to promote social inclusion and augment mental well-being among adolescents.During the last 16 years, Romania has been facing the challenge of changing from a communist regime to democracy and a market economy and is currently adapting to its new status as an EU country. Despite a rapidly growing economy, poverty remains a problem for many Romanians, with 14% of the population surviving on less than US$ 2.5 per day. The GDP per capita in 2007 was US$ 10 152, which represents an improvement from 2003 when it was US$ 7140 (1) . The World Bank estimated in 2002 that the Gini Index for Romania was 30.3, which placed it higher than other eastern European countries. Social disparities induce health inequalities reflected by the high incidence of tuberculosis, high number of children with low birth weight and the high rate of child and maternal anaemia found among low socioeconomic groups (2) .      R    o    m    a    n     i    a  176 Of the population of 21.7 million (2002 census), 17.95% is comprised of children aged 0–14 years (2 million males and 1.96 million females). In 2004, 24.4% of Romanian children lived in poverty, while 8.2% were living in very poor households (3) .Child poverty is most apparent in single-parent or extended households, in families where parents are unemployed, in rural areas and in Roma communities. The Roma ethnic group is particularly subjected to the consequences of health inequality. Romania is estimated to have one of the largest Roma populations in Europe, with around 2 million (representing 9.21% of the total country population) (4) . Among the factors that explain Roma people’s poor health are high poverty (in 2002 it was estimated that almost 50% of the Roma population live in poverty), lack of proper living conditions, low level of education, poor nutrition and poor communication with health professionals. Moreover, due to a lack of identity cards, the majority of the Roma are denied the right to benefits from the health insurance fund and access to health services. Consequently, Roma life expectancy is 10 years shorter than for the general population and infant mortality is 40% higher than that of Romanian children (5) . Levels of illiteracy and school drop-out rates are highest among this ethnic group. Romania has a legacy of more than 10 000 HIV-positive children, representing the largest child population living with HIV in Europe (6) . Most of these children were infected between 1986 and 1991 in health institutions and orphanages through contaminated needles and unscreened blood transfusions. Having survived with the help of antiretroviral therapy – Romania being the first eastern European country to provide general access to this treatment – they are considered “miracle children”. Unfortunately, this has not been accompanied by an effort to fight the stigma against them. In Romania, HIV-positive children and adolescents are facing social exclusion that takes the form of denied access to education (less than 60% attend any form of schooling) and lack of professional integration (7) .Other groups who are prone to social exclusion and health inequalities in Romania are children with mental and physical disabilities. In addition, children who are currently inside or exiting the social protection system are facing difficulties in the process of social and professional integration. Mental health and well-being status among Romanian adolescents In the following section, adolescent mental and physical health data collected from a national representative adolescent sample(n = 4654) are presented as part of the 2006 Romanian HBSC survey. Emerging social capital, gender and socioeconomic differences are discussed. Social cohesion Social cohesion was measured by using a social capital index calculated from computing the following: social networks and social support; local identity; power and control thorough engagement; and perception of local areas. The majority of Romanian adolescents enjoy strong social support networks. On average, communication within their peer group was perceived as being better than inside the family, with boys reporting slightly better peer communication than girls. In relation to social network structures (number of friends), more than two thirds of Romanian teenagers have three or more close friends. Gender differences concerning free time spent with friends appear only at age 15 and favour boys (p<0.05). Thesefindings are confirmed by data from interviews with adolescents. Girls report more frequently that parents restrict their ways of spending leisure time with friends. Social support   within the school setting was measured by computing scores from three items: the extent to which classmates like to spend time together; the amount of extra help students receive from teachers; and the degree of interest that teachers show for their pupils as individuals. Fifteen-year-old girls perceived a higher amount of social support within the school settingthan boys. This could be explained by the fact that girls were more often perceived as “good students” and consequently were rewarded with more social support from teachers. Most Romanian adolescents did not participate in any organizations, which can negatively influence their capacity to develop social networks and the amount of social support they receive (Fig. 1). Among the barriers to joining organizations, clubs or extracurricular activities that were most frequently mentioned in interviews were interference with school work and lack of  177      R    o    m    a    n     i    a attractive affiliation opportunities. Among those who got involved in organizations, girls chose voluntary activities, political organizations, church groups and youth clubs, while boys preferred sports clubs. Fig. 1 Involvement of Romanian adolescents in organizations 60.50No organizationVoluntary org.0.0020.0040.0060.0080.0023.60OtherChurch groupsPolitical org.21.10Youth clubCulture clubSport club14.5012.803.209.0024.10    T  y  p  e  o   f  o  r  g  a  n   i  z  a   t   i  o  n  s Percentage of adolescents involved in organizations  Local identity  was meant to reflect feelings of belonging and identification within the school setting. Two thirds of the sample felt integrated in the school setting, but gender differences emerged. More boys considered school a nice place to be, while more girls perceived school as a safe place. The percentage of adolescents who felt their classmates were nice or were involved in organizing school events dropped with age, reflecting a decline in feelings of belonging and received social support. Perception of local area  comprised feelings about safety, level of trust and leisure-time resources. Positive perception of one’s local area decreased with age, with only about half of the 15-year-olds reporting that they liked their neighbourhood, felt safe and trusted their neighbours. Significant gender differences (p<0.01) emerged, as boys tended to have a more flattering perception of their neighbourhood. Positive health Positive health was measured by using the following indicators: life satisfaction; self-perceived health; health complaints; mental health index; and level of self-esteem and self-efficacy. Life satisfaction was measured on a 1–10 scale, where “1” represents the worst possible life and “10” the best possible life. Romanian adolescents reported an above-average life satisfaction (Table 1). 11-year-olds (N = 1 625)13-year-olds (N = 1 429)15-year-olds (N = 1 600)BoysGirlsBoysGirlsBoysGirls Life satisfaction (>6) 80.3%75.5%86.2%79%83.2%71.4% Table 1 Young people with scores above the middle (>6) of the life satisfaction scale (%) There were significant gender differences (p<0.01), with girls reporting slightly lower satisfaction than boys (Fig. 2). Young people with a better financial situation (measured with the FAS) reported being more satisfied with their lives (p<0.01).  178 Fig. 2 Mean life satisfaction scores by FAS 1086420low FASmedium FAShigh FASboysgirls    L   i   f  e  s  a   t   i  s   f  a  c   t   i  o  n FAS group Self-perceived health  was measured on a four-range scale (“1” represents excellent health and “4” poor health). Most teenagers considered themselves healthy, with only a small number reporting fair and poor health, but “excellent” and “good” perceived health decreased with age. For each age group, girls reported poorer health than boys, as can be seen in Table 2. Table 2Table 3 Self-reported health by age and gender (%)Mean self-perceived health differences by social capital Self-reported health 11-year-olds13-year-olds15-year-oldsBoysGirlsBoysGirlsBoysGirlsFair and poor12.1%18.8%8.6%17.7%12.9%25.5% Adolescents who enjoyed higher economic status reported better health, with a slight advantage in the case of boys. Having social capital only made a significant difference (p<0.01) in the case of girls, those with more social capital considering themselves to be healthier (Table 3). Regression analysis results showed that having good communication within the family and peer group, possessing a local identity and perceiving one’s local area as being safe and nice to live in represented predictors of good self-perceived health (p<0.01). These social capital factors explained 7% of the variance in self-perceived health. Self-perceived healthBoys (M, SD)Girls (M, SD) Low social capital 1.75 (0.67)1.98 (0.64)* High social capital 1.84 (0.67)2.21 (0.71)* A standard symptom checklist was used to measure physical and psychological health complaints  experienced in the last six months, on a scale from 1 to 5 (“1” means having symptoms almost every day and “5” rarely or never). Frequently experienced symptoms (almost every day, more than once a week and almost every week) are shown in Table 4. Health complaints increased with age and there were significant gender differences, with girls reporting more symptoms than boys. In general, psychological health complaints were more frequent than physical ones, with “feeling low”  being the most commonly mentioned symptom. Among physical complaints, headache was the most recurrent.There were no significant differences in the number of reported health complaints as a function of perceived affluence (measured with FAS), but there were significant differences in the case of social capital (p<0.01), with girls with more social capital reporting fewer health complaints (m 25.54; SD 6.93) than those with low social capital (m 27.75; SD 7.81). * mean differences in self-perceived health as a function of social capital at p<0.01  179      R    o    m    a    n     i    a The mental health index  was measured by a ten-item scale, with scores ranging from 1 to 50. It included questions about the emotional state (such as “last week, did you feel sad?” ), cognitive state ( “last week, were you able to concentrate?” )and behaviours ( “last week, did you have fun with your friends?” ). The majority of adolescents had an average mental health (m 34; SD 6.61). Overall, girls had significantly (p<0.05) poorer mental health (m 32.98; SD 6.09) compared to boys (m 35.78; SD 7.08). High socioeconomic status and high social capital represented predictors (p<0.01) of superior mental health, perceived family affluence accounting for 8% of mental health variation while social capital explained 20% of mental health variance. Among teenagers, those who possessed a large network of friends, enjoyed good peer communication, were involved in organizations and in making decisions that affected their lives perceived themselves as having better mental health (p<0.01). Self-esteem represents the evaluative dimension that reflects how much you value yourself. It has been shown to be an important determinant of health (8) . Self-efficacy has been defined as the belief people have in being able to influence their environment by making use of their cognitive and motivational resources (9)  and is also recognized as an important determinant of healthy behaviours (8) . Most adolescents reported above-average self-esteem and self-efficacy. Significant gender differences (p<0.01) emerged for self-efficacy, with girls (m 32.77; SD 4.52) considering themselves less self-efficacious than boys (m 33; SD 5.55). Regression analysis showed social capital to be a predictor for both self-esteem and self-efficacy (p<0.01). Violence and bullying Violent behaviour among teenagers has been measured by using three items from the HBSC questionnaire: number of times one has been involved in a physical fight; number of times one has bullied others; and number of times one has been bullied. On average, boys (m 4.4; SD 2.23) were significantly (p<0.01) more aggressive than girls (m 3.37; SD 1.66), being involved frequently in  physicalfights or bullying  of others. Differences in relation to perceived family affluence emerged. Boys who had a better socioeconomic situation tended to be more aggressive towards others, while girls’ aggression decreased with perceived family affluence. On the other hand, both boys and girls who scored lower on FAS tended to be more bullied by others (p<0.01). On average, young people who possessed higher social capital were also significantly (p<0.01) less aggressive (Table 5). Risk behaviour Several risk behaviours were measured within the HBSC questionnaire: smoking frequency (1  5 scale, with “1” meaning smoking daily and “5” no smoking); number of times being drunk (1  5 scale) and condom use (yes/no answer scale). Scores Table 4 The frequency of experienced symptoms by age and gender (%) Symptoms 11-year-olds13-year-olds15-year-oldsGirlsBoysGirlsBoysGirlsBoysHeadache25.638.629.445.725.653.1Stomach ache19.428.42028.413.929.8Backache17.522.423.132.522.631.3Feeling low44.647.847.459.951.273.8Irritability30.529.940.547.851.767.8Feeling nervous27.631.136.645.744,866.1Sleep difficulties19.224.421.826.726.136.4Feeling dizzy1719.920.82515.926.9
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