RESEARCH ARTICLES
Care in the basic health network: study involving adolescent women in the city of Rio Grande/RS
Vera Lúcia de Oliveira GomesI; Camila Daiane SilvaII; Cristiane Lopes AmarijoIII; Gabriela Del Mestre MartinsIV; Adriana Dora da FonsecaV
INurse. PHD in Nursing. Titular Professor from the Nursing School at the Federal University of Rio Grande. Leader of the Group of Researches and Studies on Nursing, Gender and Society. Tutor from Program for Tutorial Education in Nursing. Rio Grande, Rio Grande do Sul, Brazil. E-mail: vlogomes@terra.com.br.
IIAcademic Student of the ninth period from the Nursing Undergraduate Course at the Federal University of Rio Grande. Scholarship Student from the Program for Tutorial Education in Nursing. Rio Grande, Rio Grande do Sul, Brazil. E-mail: camilad.silva@yahoo.com.br.
IIIAcademic Student of the seventh period from the Nursing Undergraduate Course at the Federal University of Rio Grande. Scholarship Student from the Institutional Program for Scientific Initiation Courses. Rio Grande, Rio Grande do Sul, Brazil. E-mail: cristianeamarijo@yahoo.com.br.
IVAcademic Student of the ninth period from the Nursing Undergraduate Course at the Federal University of Rio Grande. Scholarship Student from the Program for Tutorial Education in Nursing. Rio Grande, Rio Grande do Sul, Brazil. E-mail: gabrieladm@yahoo.com.br.
VNurse. PHD in Nursing. Head of the the Nursing School at the Federal University of Rio Grande. Leader of the Group of Researches and Studies on Nursing, Gender and Society. Rio Grande, Rio Grande do Sul, Brazil. E-mail: adriana@vetorial.net.
VIWe thank to the National Council for Scientific and Technological Development for its interest in financing this research.
ABSTRACT: This is a quantitative, descriptive and exploratory study, which aimed at describing the reasons that drive adolescent women to seek care in basic health care units (BHUs). The data were collected from forms of the Outpatient Information System of the Brazilian Unified Health System, and they were referring to the years 2007 and 2008. 6.888 attendances were totaled, being that 1.037 (15,05%) were for young females aged from 10 to 14 years. Of these, 562 (54,19%) were associated to sexual and reproductive health. Only 125 (22,24%) sought the promotion of sexual health; the others were related to pregnancy, childbirth, puerperium or gynecological problems. We have concluded that the frequency of adolescents in relation to visits to basic health units was poor. Changing such reality means that all opportunities must be seized. Regardless the reason for the consultation, one should focus on matter of the sexual health and on the explanation of rights to young people, which are ethically and legally assured, since that this issue is only seriously addressed by health professionals and families in the face of a pregnancy.
Keywords: Adolescent’s health; sexual and reproductive health; health education; women’s health.
INTRODUCTION
During adolescence, there is a series of psychological and social transformations that, in conjunction with the biological maturity and the sexual learning, characterizes a whole decade. Nonetheless, such learning must not be limited to the use of methods of contraception and prevention of Sexually Transmitted Infections (STIs), since this reductionist view might trigger disastrous consequences such as those that have been described in epidemiological bulletins and in outcomes of recent studies.
The National School Health Survey, held in 2009 in the Brazilian capitals and in the Federal District, highlights that 30,5% of 618.555 students, with an average age of 15 years, had already performed their first sexual intercourse. Of these, 24,1% reported not having used a condom at last sexual intercourse, despite 88,5% have received information about STIs, highlighting the Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS), 81,6% about pregnancy prevention and 68,4% about the distribution of free condoms in health units1, similar results were found in a survey conducted in South Africa2. The claim that condoms reduce sexual pleasure is one of the most verbalized reasons for teenagers to justify the non-use of condoms during sexual relationships3.
These data show that most students have access to information relating to the promotion of sexual and reproductive health, which is a fact that, certainly, contributed to a reduction of 22,4% in the number of childbirths involving teenagers in the period between 2005 and 20094. Nonetheless, among adolescents aged from 10 to 14 years, the Information System on Live Births (SINASC) has notified 27.610 births, only in 2006, and pointed out that, between 2000 and 2006, the percentage of live births among young people of this age group remained stable, representing 0,9% in each year5.
With regard to abortion, a study performed by the International Planned Parenthood Federation shows that rates are growing among adolescents in Brazil. The magnitude of such data might be inferred by finding that, only in 2005, 2.781 attendances were registered in relation to post-abortion complications in young people aged between 10 and 14 years6. Thus, it is evident that the epidemiological characteristics of the adolescent population point to the urgent need for enhancement of health promoting actions. With the hypothesis that there is low demand for adolescents in basic health units (BHUs) to foster sexual and reproductive health and disease prevention, we have performed this study with sights to know the reasons that lead adolescent women to seek care in BHUs in the city of Rio Grande/RS/Brazil.
LITERATURE REVIEW
The regulatory standards of the Unified Health System (SUS) define as priorities the actions for disease prevention and health promotion and, from 2005, the Child and Adolescent Statute (ECA) recommends to children and adolescents a comprehensive care through this system, guarantying them, with absolute priority, the universal and equal access to actions and services for health promotion, protection and recovery7.
In order to meet the specific needs of this population group and qualify health staff for care of them, the Brazilian Ministry of Health (MS) launched the Adolescent Health Handbook for being used in the Basic Health Network. This document contains information on disease prevention, bodily changes, oral health, nutrition, as well as sexual and reproductive health8. Furthermore, the Ministry of Health published a script of guidelines for the care of adolescent health for professionals, and it has principles that might ease the establishment of a bond of trust among the health team, the young users and their families9.
The aforementioned script also highlights the needs for the adoption of an attitude of respect and fairness, i.e., with no trials; for an environment that provides privacy, besides the confidentiality of the content of the consultations. Moreover, the script of guidelines explains the right of young people to be served in BHUs without the presence of mother, father or legal guardian and emphasizes the importance of being referred for gynecological examinations: “all adolescents who have already started sexual activities or present some kind of gynecological problem”9:1.
Although there is consensus on the need for public policies to assist adolescents10 and the efforts to implement such policies8, many services are still guided by the perspective of risk and vulnerability10.
Among the procedures that preserve this stigma, one should cite the Gynecological Consultation for adolescents. In order to raise interest and demand, gynecological consultation need to be seen as a procedure of the process of health education. In addition to sexual and reproductive aspects, others regarding self-esteem and shared responsibility for the choices must be addressed during gynecological consultations. For the MS, the care of adolescents needs to go beyond the traditional model of clinical history, since it should consider “aspects of social life, work, sexuality, psychosocial situation and violence, among others"9:1.
According to the guidelines of the National Program for Comprehensive Health Care of Women, gynecological consultation is a fundamental procedure for the maintenance of sexual and reproductive health of women. Through the consultation, it is possible to provide the young women an individualized care and with quality. Nonetheless, there are countless adolescents who, due to the lack of information, realize it only as an embarrassing procedure that is capable to detect pathologies. With this conception, they imagine the need to take off all clothes and expose themselves to a stranger. It is noteworthy to clarify that gynecological examination is not a routine procedure in consultations, given that it is only necessary in some occasions. Adolescents also worry that the reason for the consultation is unveiled to the aware of parents, and that their sexual activity are revealed to their family members11,12.
It should be emphasized that the health care of adolescents is legally governed by the principles of ethics, privacy and confidentiality. With regard to ethics, the interaction between the health professional and the adolescent must be grounded on respect, freedom of expression of feelings, problematization of doubts and on autonomy, i.e., adolescents have the right to make decisions about their health. Privacy refers to the assurance that the information provided during the attendance will not be transmitted to those responsible or to their peers, whether there is not an explicit agreement. Secrecy is legally broken only in situations involving risk of life, sexual abuse, suicide-related ideas and information on homicides, among others11,12.
Thus, it is essential that young females know their rights to be served unaccompanied, as well as the secrecy and confidentiality of the content of the consultations13. To that end, it is necessary to remove them from the place of mere listeners and spectators, thereby allowing them to lead their process of living, raising awareness that health does not depend on chances, but rather on the decisions that each person takes10.
METHODOLOGY
This is an exploratory and descriptive study, with a quantitative approach, performed in 17 family basic health units (FBHUs) and 10 BHUs, which are linked to the Municipal Health Secretariat of the city of Rio Grande, Rio Grande do Sul State. We have collected data from forms of the Outpatient Information System of the Brazilian Unified Health System (SIA-SUS). The sample was comprised of all documents relating to the care of adolescent females, aged between 10 and 19 years (non-completed), registered in 2007 and 2008. Because it deals with restricted documents, the project was submitted to the Ethics Committee of the Federal University of Rio Grande (FURG) and, subsequently, approved under the Opinion nº 81/2009.
For tabulation, the collected data were entered into Microsoft Excel® Program spreadsheets, thereby generating a database. The related independent variables were age and reason for treatment. The results were presented by means of absolute numbers and percentages, and they were analyzed through descriptive statistics.
RESULTS AND DISCUSSION
6.888 attendances involving adolescents aged 10 to 19 years (non-completed) were recorded, of these, 4.795 (69,6%) were related to sexual and reproductive health, with 2.762 (40,1%) for pre-natal, delivery or puerperium, 528 (7,7%) related to the diagnosis of cervical cancer or the diagnosis and treatment of STIs, 449 (6,5%) associated to other gynecological problems, being that only 1.056 (15,3%) attendances were related to the promotion of sexual health and prevention of pregnancy and STIs. The remaining ones were related to other types of care.
By considering that, from 2000, the Brazilian Institute of Geography and Statistics (IBGE) included the age group from 10 to 14 years among the indicators of fertility and that this age cutting, as a specific category of public policies, has remained in a forgotten field, especially when it comes to sexual and reproductive health6, we decided to present these people in a separate way. In the present study, 1.037 (15,05%) attendances to adolescents in this age group were recorded.
Of these 1.037 attendances, 562 (54,19%) were related to sexual and reproductive health, and 475 (45,81%) were for intended to other types of care, being that this category has included both cases motivated by clinical problems and those for completion of dressings, administration of medicinal drugs and vaccines. By considering that the majority of the surveyed attendances were destined to sexual and reproductive health, one could infer that these findings go against studies in which it was evident that Brazilian adolescents do not consider health facilities as a priority and relevant places for obtaining reliable information about issues of sexuality13,14.
Nevertheless, upon analyzing in depth the reasons for such attendances, it was noticed that 270 (48,04%) were for suspected pregnancy, actual pregnancy, childbirth and puerperal period. It should be emphasized that 22 (3,91%) were for adolescents with 11 and 12 years old and 2 (0,35%) for adolescents with 10 years old. These findings confirm that the shortage of data on the sexual health of young people in early adolescence does not represent a lack of sexual and reproductive activity in this age group, besides demonstrating the need to change the conservative perception that issues related to sexuality and health reproductive should not be present in the lives of too young people6.
For the HIV examination, diagnosis and treatment of STIs and preventive screening for cervical cancer, 55 (9,78%) attendances were recorded; the category related to other gynecological problems has totaled 110 (19,57%) attendances. It has included the consultations due to metrorrhagia, leucorrhoea; lumps; pain or abscess in breasts; galactorrhea; menstrual cramps; ovarian cysts; dyspareunia and pre-menstrual tension.
Moreover, there were two attendances for sexual abuse, and the victims were adolescents with ages of 10 and 12 years, respectively. This type of aggression is a form of gender-based violence in which the perpetrator is usually within the family scope14. By considering that, because of fear, embarrassment or even shame, many young females do not report such violence, nor seek care in health units14, it is assumed that the number of victims is higher than the realized by researches.
It should be emphasized that only 125 (22,24%) attendances were performed with preventive purposes or to promote sexual health, and the reasons that led users to BHUs and the FBHUs were the search for guidance or for obtaining condoms and contraceptive stuffs. In a recent study, the lack of information on sexual and reproductive health was identified as a triggering factor for unplanned pregnancy and unsafe abortion among teenagers from the Latin America15.
Similar results were obtained by researchers upon concluding that, except for the “specific condition of pregnancy, adolescents do not frequently use of health services and, when they do, seek only healing services, rather than preventative measures”16:887. Among the reasons pointed by young females for not searching for a gynecological consultation before the course of the pregnancy, it emerges the excessive manipulation of the body17, shame; fear; lack of courage to go to a consultation; unawareness of the need for care to avoid reproductive health problems; administrative barriers, among them, the requirement for company of a responsible, the lack of female gynecologists, the requirement for documents to schedule the consultation, besides the suspicion that the reasons [...] of the consultation and the information given to health professionals would not be kept in secrecy, especially in relation to parents16:892.
On the other hand, there are studies claiming that a comprehensive care to adolescents requires the active participation of nurses, which transcends the technical and assistential conception of care, and evoking educational and relational skills, as well as specific knowledge about the process of human development18,19.
Furthermore, it is considered that, to efficiently act, professionals need to know the health legislation and the programs targeted to this population group. It is known that the care of young people, who are in their early adolescence period, triggers an ethical dilemma in many health professionals. Nonetheless, the MS states that any requirement with regard to the presence of a responsible for monitoring adolescent in health services is a violation to the right to a healthy life13, despite recognizing that the family might represent a source of support.
Contraceptive methods also create apprehension among health professionals. Many of them avoid taking the responsibility to inform about their use and prescription20, which is configured in incoherence. Often, young people in their early adolescence period are advised about contraception, but do not have access to contraceptive methods offered by health programs, unless accompanied by an adult responsible. Despite this, numerous researches on sexuality in adolescence denounce that the knowledge acquired by young females is not used in practice1.
By considering that, before sexual initiation, health education with a focus on sexual and reproductive health might really resonate in the lives of teenagers, enabling them to make conscious choices and to hold self-care, it is necessary that the health team reflects on the care procedures that have been provided to this population group and confronts their own prejudices, because sexuality is not disassociated from reproduction at this stage of life4,6.
CONCLUSION
The frequency of adolescents in BHUs of the city of Rio Grande was low during the study period, and the consultations for health education were even rarer. Among the strategies to attract teenagers to the health services, one could include a discussion along with health professionals on the sexual and reproductive rights of adolescents, as well as the need for a differentiated welcoming and attendance.
It is also necessary to discuss, together with young people of both genders, the issues related to their rights, as well as demystify the gynecological consultation, presenting it as an alternative for the promotion of sexual and reproductive health, through which, besides accessing to contraceptive methods, a competent, safe and unprejudiced guidance takes place.
Another key aspect to the success of programs in health education is the synchrony between health and educational services. Schools and BHUs must act in a coordinated and complementary manner. This will allow the themes problematized in schools, about autonomy for the conduction of choices and youth participation, to be individually experienced. Winning the confidence of teenagers is not an easy task. Thus, every opportunity must be seized. Whatever the reason for consultation, the health professional must find a moment to highlight this issue and explain to adolescents about their rights with regard to confidentiality and privacy of such circumstance.
REFERENCES
1. Instituto Brasileiro de Geografia e Estatística - IBGE [site de Internet]. Pesquisa Nacional de Saúde do Escolar 2009. [citado em 10 mai 2013] Available at: http://www.ibge.gov.br/home/estatistica/populacao/pense/default.shtm.
2. Dietrich J, Khunwane M, Laher F, Bruyn G, SikkemaKJ, Gray G. “Group sex” parties and other risk patterns: a qualitative study about the perceptions of sexual behaviours and attitudes of adolescents in Soweto, South Africa. Vulnerable Children and Youth Studies: An International Interdisciplinary Journal for Research, Policy and Care. 2011; 6(3): 244–54.
3. Marston C, King E. Factors that shape young people’s sexual behaviour: a systematic
review. Lancet. 2006; 368 (9547): 1581-6.
4. Ministério da Saúde (Br). [site de Internet]. Portal da Saúde. [citado em 10 mai 2013] Available at: http://portal.saude.gov.br/portal/aplicacoes/noticias/default.cfm?pg=dspDetalheNoticia&id_area=124&CO_NOTICIA=11137.
5. Ministério do Planejamento, Orçamento e Gestão (Br). Indicadores Sociodemográficos e de Saúde no Brasil. Estudos e Pesquisas. 2009; 25: 9-16.
6. Gravidez de adolescentes entre 10 e 14 anos e vulnerabilidade social [site de Internet]. Estudo exploratório em cinco capitais brasileiras. 2004. [citado em 20 mai 2011] Available at: http://www.ecos.org.br/download/Pesquisa%20Gravidez%20na%20Adolescencia%20-%20Mar%C3%A7o2004.pdf.
7. Ishida VK. Estatuto da criança e do adolescente: doutrina e jurisprudência. 8a ed. São Paulo: Atlas; 2007.
8. Ministério da Saúde (Br) [site de Internet]. Caderneta de Saúde da adolescente. Brasília (DF): Ministério da Saúde; 2009. [citado em 12 ago 2012] Available at: http://portal.saude.gov.br/portal/saude/visualizar_texto.cfm?idtxt=29672&janela=1.
9. Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Orientações para o atendimento à saúde da adolescente. [citado em 07 abr 2012] Available at: http://bvsms.saude.gov.br/bvs/publicacoes/orientacoes_atendimento_adolescnte_menina.pdf.
10. Horta NC, Lage AMD, Sena RR. Produção científica sobre políticas públicas direcionadas para jovens. Rev enferm UERJ. 2009; 17: 538-43.
11. Ministério da Saúde (Br). Secretaria de Atenção à saúde. marco legal: saúde, um direito de adolescentes. Brasília (DF): Editora MS; 2007.
12. Taquette SR. Conduta ética no atendimento à saúde de adolescentes. Adolescência & saúde. 2010; 7(1): 6-11.
13. Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Marco teórico e referencial: saúde sexual e saúde reprodutiva de adolescentes e jovens. Brasília (DF): Ministério da Saúde; 2007.
14. Drezett J, Junqueira L, Antonio IP, Campos FS, Leal MCP, Iannetta R. Contribuição ao estudo do abuso sexual contra a adolescente: uma perspectiva de saúde sexual e reprodutiva e de violação de direitos humanos. Adolescência & saúde. 2004; 1(4): 31-9.
15. Decat P, Nelson E Meyer S Jaruseviciene L M; Segura Z Gorter A, et al.Community embedded reproductive helth interventions for adolescents in Latina America: developenment na avaluation of a complex multi-centre intervention. BMC Public Health 2013; 13:31. [citado em 13 abr 2013] Available at: http://www.biomedcentral.com/1471-2458/13/31.
16. Carvacho IE, Mello MB, Morais SS, Silva JLP. Fatores associados ao acesso anterior à gestação a serviços de saúde por adolescentes gestantes. Rev Saúde Pública. 2008; 42: 886-94.
17. Silva CM, Vargens OMC. Estratégias para a desmedicalização na consulta de enfermagem ginecológica. Rev enferm UERJ. 2013; 21: 127-30.
18. Higarashi IH, Baratieri T, Roecker S, Marcon SS. Atuação do enfermeiro junto aos adolescentes: identificando dificuldades e perspectivas de transformação. Rev enferm UERJ. 2011; 19: 375-80.
19. Costa RF, Queiroz MVO, Zeitoun RCG. Cuidado ao adolescente: Contribuições para a enfermagem. Rev enferm UERJ. 2012; 20: 197-202.
20. Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Saúde do adolescente: competências e habilidades. Brasília (DF): Editora MS; 2008.