The (in)visibility of adolescents in primary care in the perception of health professionals: a descriptive study
Taynara Takuno da Silva1, Bianca Machado Cruz Shibukawa1, Marcela de Oliveira Demitto1, Juliane Ayres Baena1, Ieda Harumi Higarashi1, Maria de Fátima Garcia Lopes Merino1
1 State University of Maringá
ABSTRACT
Objective: To identify the perception of Primary Care nurses about their role in the development of health actions for adolescents. Method: A qualitative and descriptive research study, carried out in 30 Basic Health Units in a municipality of southern Brazil, with nurses, who responded to the interview. Thematic analysis was carried out, resulting in three categories. Results: The nurses' knowledge about the national guidelines for comprehensive adolescent health care is limited. In general, actions aimed at the promotion of adolescent health are overlooked by the nurses. Conclusion: The difficulty of approximation between nurses and adolescents in Primary Care opposes the need for bonds between them. The development of more effective health promotion strategies raises the need for professional training and structural conditions, which allow the professional to look back at this notoriously vulnerable population.
Keywords: Adolescent health; Family Health Strategy; Health promotion; Nursing.
INTRODUCTION
Adolescence is considered a phase of changes in the individual's growth and maturation, in addition to being a period of great vulnerability, due to the difficulty in identifying situations that can lead them to feeling fragile or exposed to some risk(1-2).
Since the beginning of this period of life, adolescents need support and guidance from parents and nurses in order to deal with their transformations and achieve a healthier lifestyle, reducing risk behaviors(3).
Considering the instability of this phase of life, adolescent health should be valued and monitored by the nurses, who are the planners and executors of harm prevention and health promotion actions. Nurses should take advantage of all the situations where the adolescent is in the primary health care (PHC) unit, in order to offer consultations, guidelines and links to relevant groups and workshops, providing them with healthier and safer living conditions(4).
Thus, taking into account this particularity, the Union, the states, and the municipalities acted together to develop public policies specific to the health of adolescents, which seek to guarantee comprehensive care. These policies aim to reduce the main diseases and conditions that affect adolescents, improve surveillance and protection of their health, and promote quality of life, also taking into account the determination of the Child and Adolescent Statute (Estatuto da Criança e do Adolescente,ECA), which guarantees the right to the protection of life and health(2,5).
However, despite the efforts, the search for the health services among adolescents is still limited. Absence of illness is the main reason for not seeking primary care, followed by difficulties in finding quality care or disliking its quality, as well as the absence of the desired service(6). An assessment conducted in 30 European countries showed that the inability to offer emergency consultations and the lack of confidentiality of the consultation are the reasons that most distance adolescents from PHC(7).
Strategies that effectively support the needs of this population, that go beyond purely technical actions and act in an integrative and humanized way, must be developed by the professional who works in care management. Therefore, the nurse needs to spread the importance of promoting the health of adolescents, considering the socio-cultural context, since this is an access barrier both to information and to the service itself(4).
However, to perform such actions, the nurse needs to understand the adolescent universe and to know its role; for this, the formation of a bond of trust between the nurse and the adolescents is encouraged, since they are facilitators of comprehensive health care(1,5-6).
The search for valuing life and building citizenship should also be encouraged in PHC, guaranteeing social rights to the young individuals, strengthening their individual capacities, helping them to understand and face adverse situations, and in the search for autonomy to make healthy attitude choices(8). Therefore, the aim of the study was to identify the perception of primary care nurses about their role in developing health actions for adolescents.
METHOD
The theoretical basis, which conducted the study, was based on the concepts suggested in the National Guidelines for Comprehensive Health Care for Adolescents and Youth in Health Promotion, Protection and Recovery. It aims at the incorporation of health actions and the implementation of new elements, targeted at the recognition of children and adolescents as full subjects of rights, providing them with the physical, mental, moral, spiritual and social development recommended by the ECA(2,9).
Youth participation, sexual and reproductive rights, life project, culture of peace, ethics and citizenship, racial and ethnic equality and gender equity are the concepts recommended by the guidelines. Thus, the role of the nurse must be based on the involvement of young people in their own health care and collaborate in the construction of autonomy, by solving real problems, whether at school, in the community or in social life(9).
Developed by the Ministry of Health in 2010, these guidelines recognize the vulnerability of the young collective with regard to the repercussions on the health-disease process, arising from the socioeconomic and political determinations in which this population is inserted, with the objective of guiding actions, in the face of the challenges evidenced by the present health situation of young people. By means of this strategy, it is sought to sensitize managers and professionals to a holistic view and a systemic approach to the needs of the adolescents, pointing to the importance of building inter-federative and inter-sectoral strategies that contribute to the modification of the national situation of vulnerability of adolescents and young people, influencing healthy development(9).
A qualitative research study of exploratory-descriptive nature, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) guideline was used as a guide for its production(10).
Data collection was carried out between June and July 2019. The sample components were nurses, and the choice was due to the fact that the care provided to adolescents, performed by a qualified professional, physician or nurse, constitutes a privileged space for health promotion actions, as well as for the prevention, diagnosis and treatment of diseases, with an approach that respects the specific needs of this age group(9).
The participants worked in the Family Health Teams (FHTs), allocated in the 34 Basic Health Units (BHUs) of a municipality in southern Brazil. Each BHU had a mean of two FHTs, and a total of 68 nurses.
The inclusion criteria were as follows: being an FHT nurse and having at least one year of activity in the function, considered important for the study, due to the professional's involvement in the work environment, which favors the construction of a bond with the team and with the community. The exclusion criterion included BHUs that were not part of the municipality's urban territory. Thus, two units, located in two districts, were excluded. Of the 32 professionals approached, two did not accept to participate in the study and, therefore, the final sample consisted in 30 nurses.
Data was collected through semi-structured interviews, containing questions related to the role of nurses in health promotion actions for adolescents and young people, which encompass the three fundamental axes: monitoring growth and development; comprehensive care for sexual and reproductive health; and comprehensive care in the abusive use of alcohol and other drugs by young people(9).
Data was collected by means of support questions, related to the topic of the interview: Do you know any program proposed by the Ministry of Health that addresses adolescent health? In case of affirmative answer, the following question was asked: Which of the axes do you consider that, as a priority, provide comprehensive care to adolescent health and are addressed by the professionals of your FHT? And, in case of a negative answer: What do you think are the national guidelines for comprehensive adolescent health care? The following were used as support questions, for example: In your perception, is Nursing working with the adolescents with an emphasis on health promotion in the context of primary care? Do you carry out educational actions in your care practice aimed at the adolescents in the area covered by your FHT?
The interviews were conducted during the participants' work period, at moments previously defined by them, in the institution itself and in a private room, with a mean duration of 25 minutes, and took place until new information was not reported.
The reports were recorded, transcribed and submitted to content analysis, thematic modality, following the stages prescribed by the reference including: pre-analysis, in which the material is explored and the data is processed. This stage was initiated by the organization, transcription, and separation of data. Subsequently, a floating reading of the empirical material was carried out, seeking to highlight the relevant aspects in view of the objective of the study(11).
In the material exploration stage, data was classified and aggregated from a thorough reading, identifying them by means of colors, common and more specific terms, originating the previous categories. Subsequently, in the treatment of the data, the categories were deepened, articulating the empirical findings with the theoretical material, always considering the objective of the research and the emerging themes of the analysis process.
The identification of the participants was carried out by means of the letter “E” and by the Arabic number corresponding to the order of the interview, in order to guarantee the confidentiality of their identity. The study was developed in accordance with the guidelines set forth in Resolution 466/12 of the National Health Council, and approved by the Research Ethics Committee of the State University of Maringá, under opinion No. 3402228 and CAAE 14287819.3.0000.0104.
RESULTS
The study participants were mostly female (93.3%) with a mean age of 37.5 years old. The time of professional training varied between two and 25 years, and the time acting in the same BHU, between 2 and 15 years.
The analysis of the speeches made it possible to identify fundamental aspects of the nurse's position in adolescent health care, allowing for the categorization into three themes: Public Policies for comprehensive health care for adolescents: nurses' knowledge; Challenges in implementing health actions for a systemic approach to the needs of the adolescents; and Health needs and strategies for transforming the vulnerability situation of the adolescent: nurses' action.
Public Policies for comprehensive health care for adolescents: nurses' knowledge
The survey showed that almost half of the nurses (46.7%) had limited knowledge about health programs aimed at adolescent care. Although among the participants some (30%) specifically mentioned a government health program aimed at this population, 10% did not know how to name it when requested.
[...] yes, I know it exists (adolescent care programs), but I can't tell you the name now. (E2)
[...] in fact we even have some letters from the ministry (MoH) about interventions proposed for adolescent health, but they are stored. (E21)
Among the existing programs in Brazil to protect the life and health of children and adolescents, the Health at School Program (Programa Saúde na Escola, PSE) was mentioned by 9 (30%) participants, while the National Immunization Policy (Política Nacional de Imunização, PNI) and the Child and Adolescent Statute (Estatuto da Criança e do Adolescente, ECA), were cited by two (14%) and one (7%) interviewees, respectively. These programs were mentioned when they discussed their knowledge and actions with young people in the area covered by the FHT they belonged to
[...] Yes I know! The groups with adolescents with Health at School. (E13)
[...] I know “vaccination” (Immunization Policy), Health at School and the campaigns we have in the ministry. (E26)
[...] I know that the Statute of Children and Adolescents already determines that we act as a side of the adolescents in the issue of health education, STIs, talking about diseases and other problems they may have. (E11)
Challenges in implementing health actions for a systemic approach to the needs of adolescents
The present study demonstrated that there are adverse conditions that interfere in the development, planning and execution of actions that meet the needs of adolescents, thus justifying the low performance of activities aimed at young people in most of the BHUs of the city.
Among the obstacles, the following were highlighted: the great demand for work attributed to nurses in PHC, which distances them from their care functions; the low adherence of young people to the activities proposed by the professionals, contributing to their distancing from the health service and, consequently, not allowing for the formation of bonds with the team; and the precariousness of financial and physical resources, hampering the execution of the actions.
Thus, the deviation in the attribution of the role of the FHT nurse was cited by most of the professionals (93%) as a factor that hinders carrying out activities to promote the actions with the adolescents.
[...] The nurse performs practically all actions within the BHU and we hardly have time for promotion. We always put out the fire, not to mention the stress that causes work overload in the professional. (E20)
[...] Nursing does a lot of bureaucratic and administrative things, and the issues of health education, Nursing consultation, end up being left out... I could be doing other things. There is a very large deviation from the real role of the nurse, as the one who only solves problems and not what is really his assignment. And with that, I can't bring the adolescents to the unit, so I can't say that this is a difficulty, if I didn't go after them myself. (E11)
The low adherence of young people to health interventions was presented as a demotivating factor for the professionals (60%).
[...] The young population seeks very little health care, so we have to go after them. (E18)
[...] Those who seek help the most are girls, like 14 years old, with an active sex life, but not many. (E5)
[...] Although we have a group of handicrafts and the active search for vaccination, in the group there are few people, they are not very interested. In this group of crafts, we have more girls. (E4)
The precariousness of financial and physical resources, which could enable the development of health actions, as well as stimulating and attracting adolescents to the service, were issues addressed by the participants and, among the reports, 30% of the nurses reported that, although some activities are carried out, they occur irregularly.
[...] It is a population that does not use the BHU, something should be done that would attract their attention... And we don't have all this technological resource to use with them. (E7)
[...] Despite the few resources that we have available, we still try to work with them addressing topics on drugs, sexuality, through continuing education in the form of lectures. (E19)
[...] With the use of cell phones, video games, they will not leave the house during school hours to attend a lecture. And we don't have all this technological resource to use with them. (E6)
The curative culture of today's society was also identified as responsible for the difficulty in implementing and adhering to the actions for adolescents.
[...] they (adolescents) think that it will never happen to them (diseases). Society has a curative culture that they only leaves the unit (BHU) if they have a prescription in their hand... if they leave only with some guidance, they are not satisfied and look for another doctor. (E6)
[...] We should have more time, more professionals, more training, a better place, everything should change to encourage us to work on prevention... (E3)
In view of the questions that addressed more purposeful ways of acting with the adolescents, at times, the nurses recognized the needs of this population and exposed issues that afflicted them, in their daily practice; at others, they disregarded this group, attributing the responsibility for the inexistence of activities targeted at them and, at other times, they attributed this responsibility to other professionals, suggesting a more effective multi-professional performance.
[...] We do nothing [...]. The adolescent does not come to the BHU. He forgets! [...] No activity is proposed for them (adolescents) because we have other groups of hiperdia, walking, mental health. But it's no use, because if we do something, there will be no adherence, they don't even care. (E1)
[...] We lack time because of the existence of other programs as well. And the NASF should expand its promotion activity schedule, they should be more active in the workload. They are all trained for this with a multidisciplinary team to develop activities and accompany them (adolescents). (E20)
Health needs and strategies for transforming the vulnerability situation of the adolescent: nurses' action
The third thematic category, emerging from the interviewees' reports, referred to the actions developed by the nurses in PHC, highlighting the priority needs of the adolescents in the area covered by the FHTs. Among the main needs in approaching the adolescents, although each professional has pointed out more than one, the following were mentioned: sexual and reproductive health (53%), with emphasis on sexually transmitted diseases (33%); the abusive use of alcohol and other illicit drugs (46%); adolescent violence (13%); and eating disorders, especially obesity (20%), among others.
[...] nowadays they have a lot of wrong information about searching the internet, pornography and don't know much about sex education [...] there is a very early search for sexual intercourse without information, without maturity, without knowing the own body. (E11)
[...] the school adolescents jump over the wall to smoke marijuana there on the court. Here near the BHU there is a lot of traffic! (E17)
[...] And obesity should also be addressed because it is not just a problem for the adolescent, it is a problem for the family because it is the parents who bring the food into the house, so the action must involve everyone. (E13)
Understanding the needs for health promotion and disease prevention, the development of some initiatives was reported by the nurses (50%) as: the active search of adolescents for vaccination and the conduction of lectures in schools.
[...] Yes, we held lectures and activities together with the health NASF in the school. The nurses provide guidance regarding the STDs and also have guidelines from nutritionists and physiotherapists. (E6)
[...] In our team, group meetings are held, together with the Community Health Agent (CHA) and medical interns, linked to activities such as outings, gymkhanas. (E9)
The link between the BHU professionals and the educational institutions was highlighted by most of the nurses (90%) as a way to positively contribute to the development of actions aimed at the health of young people, minimizing risks to their health and helping in the prevention of age-related harms.
[...] here, in this area, we don't have schools for the older ones and this makes it difficult for them to attend and to attract them, which makes our approach with adolescent a little difficult. (E1)
[...] If we go to the school, we can, because they are already there and are obliged to participate in the activities. (E10)
[...] We don't know how to talk to them, we don't know how to deal with their reactions... it's hard to establish a bond and have their trust. It is at this time that the school helps us a lot. (E2)
DISCUSSION
The PSE as a public policy aimed at adolescents was the most cited by the study participants, in addition to the PNI. These programs took a look at adolescence since childhood, representing an advance in child and adolescent health care(2).
In addition to knowing the strategies recommended by the Ministry of Health, nurses need to have skills and good practices in the care process, with an expanded look at the different social determinants involved in the health-disease process and in their work in PHC, from the perspective of inter-sectoriality and comprehensive care for adolescents so that they can obtain good results in the health actions(10).
However, the precariousness in terms of training programs for nurses, the reduced number of professionals, and the restricted and inadequate physical spaces to serve young people, are presented as obstacles in the application of public policies to adolescents(12).
The professionals perceive the need for training to deal with the adolescents and their families, but there is still resistance in addressing some issues like sexuality, which ends up hampering health promotion activities(4,13).
In addition to the difficulties encountered by the nurses due to lack of knowledge or coexistence with the health practices aimed at the adolescents, nurses also face other barriers to their performance. The bureaucratic activities of the BHU, to the detriment of actions aimed at the adolescent population, are at various times prioritized by nurses. Issues of work overload divert them from their functions, interfering, for example, in decision-making in favor of educational actions(12-15).
The adolescents need a support network, especially during this unstable stage of their lives, which goes beyond the families. In this context, PHC is of fundamental importance in protecting adolescents because, in situations of conflict in the family, school and community environments, it is almost always the first gateway to the search for specific guidance(16-18).
Thus, the relationship of the professionals with this population should extend to their support network considering that, in most cases, it is not the young person who seeks the service, but their family members and, in other situations, it is the schools and the child and adolescent protection agencies, or even health agents, that refer the demand to the health service(5).
It is also considered to increase the support network, that there is effectiveness and resoluteness of actions in units that perform activities linked to institutions outside the BHU environment, in schools, community and sports centers and, therefore, this type of strategy favors the participation and interest of the young population(18). Thus, these places of coexistence have been used to welcome the adolescents, in order to fill the deficiency that exists, in large part, in the physical structures of the institutions to develop health education actions(1).
In turn, the schools were highlighted as the most appropriate places for health education actions and also as facilitating institutions for the adolescent-professional approach. However, the development of health prevention and promotion actions comes up against the need for extra-wall partnerships and links with the education department and the other departments, for the development of inter-sectoriality as an intervention strategy(19-20).
When adolescents do not understand the importance of self-care, their health is neglected. This perception of lack of interest in the participation of young people with the professionals' proposals was also reported in other realities previously researched(8,15,17).
It was evidenced by the nurses' reports that the curative culture of today's society is an impediment to getting young people to adhere to the scheduled activities. This perception is anchored in the fact that adolescents, especially males, seek services only when a pathological condition is established(19).
Even though the adolescents have a positive perception of their health status, the awareness of the importance of PHC for them can be stimulated by welcoming, in the field of the FHT17,20).
The approach of young people allows for the development of mutual trust, enabling exchanges that lead to credibility in the professionals. Thus, establishing a bond is essential to promote care management(13).
It is also up to the services to present themselves as resolute and encouraging people to attract young people to decision-making about their own health, with an approach that respects their culture and individual values, using accessible, understandable and facilitating language(1,6,13,16). The use of active methodologies, with multi-professional participation in meetings with young people, can make the experience of health education richer and more stimulating, reflecting on mutual benefits between professionals and adolescents(1).
The active listening of nurses can provide systematic, reserved and safe assistance, meeting needs and clarifying doubts when expressing their real needs. Thus, nurses will apply their knowledge, recognizing and acting on the health problems, and on the gender differences and inequalities, since the genders differ in terms of sexual behavior(1,7,11,15).
In addressing issues related to adolescent sexuality, there is an increased difficulty, due to the lack of training in this area, unpreparedness and misinformation about public policies for the protection of children and adolescents(15-17). Thus, to develop activities with this approach, the nurse must be able to deal with the demands brought by the adolescents, based on knowledge of the biological, psychosocial, historical, cultural, and political aspects, as well as on the values and behaviors of the adolescents(14).
Although there are situations that make it difficult for nurses to work in PHC, different contexts must be considered in order to favor the promotion of adolescent health. Recognizing that only the use of booklets, lectures and leaflets is insufficient to attract the attention of this population, the promotion actions must be guided by the needs of the life period of each group of adolescents, so that the activities included are dynamics, playful and creative(14). Actions of this nature attract young people's attention and guarantee their frequency, placing them as protagonists in the growth process(11,14).
It also appears that, for the adolescent, the school remains the ideal environment for the development of educational activities in health, as they are training environments for the development of skills, in addition to being conducive spaces for exchanging information(19).
Therefore, the multi-professional approach with adolescents must be carried out through partnerships with other institutional and extramural sectors, promoting the convergence of knowledge that serves as a complement to Primary Care assistance actions(13).
CONCLUSION
Public policies aimed at adolescents are neglected due to the other activities performed by the nurses, triggering a precarious application of already existing protocols and exposing the professionals' disconnection between care theory and practice. The planning and development of multi-professional activities with this population is under construction by some nurses, although they are also affected by institutional issues.
The performance of the professionals in caring for adolescents and the difficulties reported by them in organizing the service, for this purpose, reflect in the low adherence of young people to the actions developed. Through education, screening, guidance and early intervention, preventive care can help establish healthy habits that last a lifetime and reduce harm.
Making adolescent health a priority is especially important, considering their specific care needs, while exploring the extent to which public health programs are addressing these needs.
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Received: 07/17/2020
Revised:09/10/2020
Approved: 09/22/2020