Discourses of professionals and adolescents about the access of adolescents to Health Services in Venezuela, 2017

Heredia, Henny; Artman, Elizabeth

doi:10.1590/S0104-12902019190195

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Articles • Saude soc. 28 (4) • Oct-Dec 2019 • https://doi.org/10.1590/S0104-12902019190195 copy

Discourses of professionals and adolescents about the access of adolescents to Health Services in Venezuela, 2017 ¹ 1 This work was developed with the Instituto de Altos Estudios “Dr. Arnoldo Gabaldon” del Ministerio del Poder Popular para la Salud de Venezuela, the support of the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (Faperj) and the Programa de Estudantes-Convênio de Pós-Graduação (PEC-PG) of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superiorl (Capes) in partnership with the Conselho Nacional para Desenvolvimento Científico e Tecnológico (CNPq) and the Ministério de Relações Exteriores (MRE) of Brazil. The authors also thank the Instituto Fernandes Figueira (IFF) and Escola Nacional de Saúde Pública (Ensp) of Fundação Oswaldo Cruz.

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Abstract

The aim was to analyze the discourses of professionals and adolescents about the factors that hinder and potentiate this population’s access to health services (HS) and the effects it generates in the scope of equity in a Venezuelan state. Twelve interviews were conducted with adolescents and 12 with professionals, based on the Critical Discourse Analysis (CDA) and the triangular structure of Thiede, Akweongo and McIntyre. The results were structured around three themes: the power of stereotypes and beliefs; the law outside the right to health; and building humanized practices. The judicial-legal framework admits unacceptable contradictions that amplify inequalities. Age predominates as a barrier to consultation for alone adolescents, although it is not perceived by professionals and is accepted as a mandatory requirement. Adolescents claim the right to be respected, listened and cared when they are alone. Some professionals defend the rigid application of norms that limit access, and others try to generate forms to guarantee rights. The discourses that confront the hegemonic must be valued because they show that it is possible to facilitate the access with strategies that focus the users. Trust appears as an important value in the formation of links between professionals/adolescents. The gap between professional/adolescent perspectives influenced by organizational culture are elements for (re)thinking new institutional positions in HS to facilitate the access. The CDA makes it possible to give a voice to minority groups (adolescents), identifying strategies to achieve equity in access to the HS.

Keywords:
Adolescent; Health Services; Equity in Access to Health Services; Stereotype

Topics	Adolescents’ excerpts	Professionals’ excerpts
The power of stereotypes and beliefs: “abortion and sexuality should not be discussed”	[1] It is good that they see us as an adult* , that we are already able to understand things and that they support us, that they guide us* (IA6).	[4] I feel that we have not given enough importance to the adolescence, it is a difficult age in which there are many unknowns , and problems […] Right now, we even continue to see the sexual orientation as a taboo , there are doctors who don’t like to touch on this subject because they don’t feel prepared for it. I feel that we need more training about it , […] instructing us about how to handle this complicated stage (IP6).
	[2] First of all take initiative, not with the adolescents, but with the parents , because those who instill in the adolescents the fear of going to the health services are often the parents (IA1).	[5] Who are always* afraid to ask, to approach, the sorrow of, to say, I don’t know, they never want to ask anything, they are always so ehhh as inhibited with, with us* [health personnel] (IP10).
	[3] the culture has made us see that abortion and sexuality should not be discussed […] that’s why I feel that they are not direct [professionals]. Do they want to explain something? Go straight to the point […] abortion is considered very bad and if a person aborts is wrong […] and it’s something that seems illogical to me, it should be legalized , because I think it’s unfair to say that a woman doesn’t have the right to decide about her body because the fetus is an individual body. But who carries this individual? (IA12).	[6] Well, the hardest thing* is that sometimes they lie. So you have to look, ehhh, as one says “ find a way around things ” to be able to face the situation* (IP12).
		[7] can be questions that are inside themselves some kind of question , because suddenly I’m 12 years old and I had my sexual relationship and I’m pregnant and I’m afraid that the social worker is a friend of my mother and she will tell her , or that I had an abortion […] or that I come for condoms and I don’t want to give this information to my mother (IP1).
The law outside the right to health: “Not to the blue shirts”	[8] that they do not attend me because I am not accompanied by a representative or because I am with somebody who is minor, they ignore me and all that, because there is not an elderly person [adult] (IA3).	[11] Ohhh in reality for none, only in special cases when they are minors who come without the a representative, it is explained to them , if they are 17, 16 years it is made an exception and they are attended […] but in general we are going to attend all of them, to all we attend them (IP9).
	[9] Well, mainly at the time the teenagers arrive, you don’t have to treat them different because you’re a minor, you have to give them the best attention, egalitarian, equal to that if you’ re an adult […] not because you’re a teenager they have to treat you worse than someone else […] if they should rather pay more attention* to you than to someone else, because you’re still a teenager who’s changing and all that* […] lately the attention for teenagers is pathetic […] (IA5).	[12] Look, we would not deny the consultation, at least we demand with regard* , that is, that “if you are an adolescent, you have to come obligatorily with a representative”* […] because most of the time we explain, but sometimes they arrive, the mother “noooo, I didn’t know how to explain this ” and there is always a wrong understanding and then what we are dealing with is that (IP11).
	[10] they treat you as if you were useless then, until you reach 18 years old, even if you reach 18, they still treat you like that . Because I am in full stage of growth, but I am not useless! Maybe I am not able to do much things by myself, but I can give my opinion which is what matters most (IA12).	[13] Well, sometimes the most difficult thing is that it is difficult for us to know at the moment of attending them, there are some barriers that hinder us from attending them, that make one feels safe , if I am going to attend them […] or I am not going to attend them, I become the representative and that this entails a responsibility that we should not have assumed and what the representatives may think (IP2).
		[14] I don’t know how legal it is [laughs], so that scares me a bit because I try to help and I don’t want to get into trouble for helping (IP13).
		[15] I don’t know if everybody [the health team] have the same perspective as I do, that if they come alone, “take care of them! ” this is the most common . The day when this 15 year old patient came, everyone said to me, “ Look, are you going to do the Pap smear? ”, nurses and everybody. And I: “my love, sign here , we are going to do the Pap smear”, because she needed it, that is, she was already living with her partner, she was practically, in theory, “adult”, in quotes , because she already had a family, in quotes , without children, but she is living with her partner apart, without her parents (IP13).
		[16] The one who attends them without the representative is an access facilitator* , yes, yes, because I was reluctant to attend adolescents in the consultation* […] but I have seen that, that is not good, because many of them have no parents, as simple as that, they are 16 or 14 years old but they live almost alone […] then wow it seems to me that it is not fair that they do not receive attention because of this (IP4).
		[17] When “the blue shirts” go to fourth grade, that’s my group, but I don’t give condoms to “the blue shirts” no, not to them, I don’t give it to them, because I say no, this, they’re just 12, 13 years old, they’re just starting, but it’s my responsibility to save […] even the “brown shirts” this “beige” say to me: “Hey is those third year boys more awake than we are ?”. And really the pregnancy rates are mostly achieved between the second and third year (IP1).
Building humanized practices: matches and mismatches	[18] That’s to say you arrive at a place and they treat you in a polite way, not with screams, not with a bad look, not with a lemon-sucking face , because to be a doctor, you have to be sociable with the person and talk to him and make him feel confident […] who can help the patient and doesn’t treat you in a way that is too much like ahhh “ I am a doctor, I am better than you and I have a postgraduate degree and you have nothing”, do you understand me? (IA10).	[22] It would be missing to inform adolescents about services we have for them . We give so much importance to the prevention of sexually transmitted diseases, to the prevention of pregnancy in adolescents avoiding the other part, we do not give importance to the issue of the services (IP5).
	[19] ehhhh to have a special attention* to teenagers then, that is not an ordinary and common treatment, because it is a different case ehhh different because* […] That they have a personal and private attention , because, that girl who comes pregnant had the courage to come, even if did what she did. Do you understand ? She had the courage and confidence to tell a doctor what she didn’t tell to her parents. And if she’s badly cared she will never come back again (IA4).	[23] mistreatment can also be when they doesn’t achieve anything , that most people come to achieve , but if they can’t […] then they don’t take it from the point of view that it’s not something we can’t do it, but something we don’t want to give to them, see? (IPF11).
	[20] are doctors, but sometimes they don’t see things from the other perspective […] I would tell them to put themselves in the adolescent’s place and to think like an adolescent . What would I do in their place? And seeing the pain they are suffering: How are they feel? And how to be able to help them (IA7).	[24] we as health professionals must give them the confidence to express themselves to us, because if we do not give them confidence , they will never speak to us, we must be charismatic , we must be affectionate, we must attract them and not isolate them (IP7).
	[21] I think they should inform us about the services they provide to us because it’s for ourselves and our health (IA1).	[25] For example, here comes one and says: “no, I want to talk to Dr. Maria”, doesn’t want another doctor if it’s not Dr. Maria, because of the trust, you see ? The same with nurses, they always tell you: No, I’m looking for this nurse. Ahh and why not me? “No, I looking for her because she treats me better than you [laughs] (IP3).

Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br

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[1] Correspondence Henny Heredia Av. Bermúdez Sur. Maracay, Aragua 2101, Venezuela. CP 2101.