Rev. Enferm. UFSM - REUFSM
Santa Maria, RS, v. 10, e57, p. 1-15, 2020
DOI: 10.5902/2179769240345
ISSN 2179-7692
Submission: 03/12/2019 Acceptance: 07/05/2020 Publication: 13/07/2020
Original Article
The perception of community health workers about reproductive life planning with adolescents
A percepção de agentes comunitárias de saúde sobre o planejamento reprodutivo com adolescentes
La percepción de las trabajadoras comunitarias de la salud sobre la planificación reproductiva con adolescentes
Carolina Coutinho CostaI
Camila Daiane SilvaII
Daniele Ferreira AcostaIII
Victoria Leslyê Rocha GutmannIV
I Nurse. Specialist in Family Health. Universidade Federal do Rio Grande. Rio Grande, Rio Grande do Sul, Brasil. coutinhocarolc@hotmail.com https://orcid.org/0000-0002-1093-5366
II Nurse. PhD in Nursing. Universidade Federal do Rio Grande. Rio Grande, Rio Grande do Sul, Brasil. camilad.silva@yahoo.com.br https://orcid.org/0000-0002-0739-4984
III Nurse. PhD in Nursing. Universidade Federal do Rio Grande. Rio Grande, Rio Grande do Sul, Brasil. nieleacosta@gmail.com. https://orcid.org/0000-0001-5690-1076
IV Nurse. Graduated in Nursing. Universidade Federal do Rio Grande. Rio Grande, Rio Grande do Sul, Brasil. victorialeslye@gmail.com https://orcid.org/0000-0002-3457-7620
Abstract: Objective: to know the community health workers’ perception of reproductive life planning carried out with adolescents. Method: a qualitative study with ten agents from a Family Health Basic Unit. The Focal Group was used for data collection. Content Analysis was used. Results: the agents believed in the importance of reproductive life planning with adolescents, considering the little intra-family dialogue and the difficulty in approaching the subject during home visits. They recognized the need to approach reproductive planning in a broader way, meeting self-knowledge, respecting others, and preventing violence. Conclusion: the agents’ perception can be favored or impaired by a close relationship with health professionals. The theme should be discussed with adolescents, as many have no communication with their parents, representing a taboo in many homes, either for cultural reasons or because they believe it is an incentive to sexual practice.
Descriptors: Community health workers; Adolescent; Family planning; Primary health care; Family Health
Resumo: Objetivo: conhecer a percepção de agentes comunitárias de saúde sobre o planejamento reprodutivo realizado com os adolescentes. Método: estudo qualitativo com dez agentes de uma unidade básica de saúde da família. Para a coleta de dados foi utilizado Grupo Focal. Utilizou-se a Análise de Conteúdo. Resultados: as agentes acreditavam na importância do planejamento reprodutivo com adolescentes, considerando o pouco diálogo intrafamiliar e a dificuldade em abordar o assunto nas visitas domiciliares. Reconheciam a necessidade de abordar o planejamento de modo ampliado, ao encontro do autoconhecimento, do respeito com o próximo e da prevenção das violências. Conclusão: a percepção das agentes pode ser favorecida ou prejudicada pela relação de proximidade com os profissionais de saúde. A temática deve ser discutida com os adolescentes, pois muitos não possuem comunicação com os pais, representando um tabu em muitos lares, seja por questões culturais ou por acreditarem ser um incentivo à prática sexual.
Descritores: Agentes comunitários de saúde; Adolescente; Planejamento familiar; Atenção primária à saúde; Saúde da família
Resumen: Objetivo: conocer la percepción de las trabajadoras comunitarias de la salud sobre la planificación reproductiva realizada con adolescentes. Método: estudio cualitativo con diez trabajadoras de una unidad básica de salud familiar. El grupo focal se utilizó para la recopilación de datos. Se utilizó el análisis de contenido. Resultados: las trabajadoras creían en la importancia de la planificación reproductiva con los adolescentes, considerando la poca cantidad de diálogo intrafamiliar y la dificultad de abordar el tema durante las visitas domiciliarias. Reconocieron la necesidad de abordar la planificación de un modo más amplio, en búsqueda del autoconocimiento, del respeto por los demás y evitando la violencia. Conclusión: la estrecha relación con los profesionales de la salud puede favorecer o perjudicar la percepción de las trabajadoras. El tema debe discutirse con los adolescentes, ya que muchos no tienen comunicación con sus padres, lo que representa un tabú en muchos hogares, ya sea por razones culturales o porque creen que es un incentivo para la práctica sexual.
Descriptores: Agentes comunitarios de la salud; Adolescente; Planificación Familiar; Atención Primaria de Salud; Salud de la Familia
Introduction
Adolescence, between childhood and adulthood, is marked by the complexity of growth, biopsychosocial development, and maturity. The World Health Organization (WHO) defines adolescence as the age group between 10 and 19 years old, young people between 15 and 24 years old and young adults between 20 and 24 years old.¹ The Statute of Children and Adolescents (SCA) considers adolescents every person between 12 and 18 years of age and, expressed in law, the Statute also applies to those between 18 and 21 years of age.² In this phase of life, people are more susceptible to different situations of greater or lesser social, individual or collective vulnerability . 1
In this sense, the ambivalence of feelings, insecurity, the outbreak of doubts, shame are frequent, added to the fear of rejection by the group. Such aspects cause the adolescent to have difficulties, or suffer negative influence, in decision-making regarding his own health. For example, the difficulty in negotiating condom use in relationships stands out, increasing the risk of Sexually Transmitted Infections (STIs) and unplanned pregnancies.3 To address such situations, the Family Health Strategy (FHS) assistance model stands out, considered the gateway to other services in the network. Multidisciplinary teams work with education, promotion, and prevention measures for diseases and injuries, seeking to meet the population needs. One of the actions carried out by professionals, including Community Health Workers (CHW), is leading specific groups, such as hypertensive, pregnant women or adolescents.4 These meetings allow different approaches to promoting the co-responsibility of the subject by its own care.
With regard to the adolescent public, it is important to address issues that, most of the time, are not discussed at home or studied at school, for example, sexuality, the use of contraceptive methods¹ and the life project. Epidemiological data reveal this need, especially regarding reproductive life planning among adolescents. In 2018, 15.5% of pregnancies registered in Brazil were adolescents aged 10 to 19 years. In a municipality in the south of Brazil, it was identified that 13% of pregnant women were between 10 and 19 years old and 24.1%, between 20 and 24 years old.5
In this sense, the CHW role stands out, as it is the link between the community and the health team.6 These professionals know the difficulties and dilemmas of everyday life, as they live in the coverage area, which contributes to improving health care. Their familiarity in the neighborhood, in schools, in the unit favors the construction and maintenance of the bond with adolescents.
Thus, it is fundamental to problematize the CHW's perceptions about reproductive life planning (RLP) for adolescents, considering their doubts, beliefs, opinions, in order to strengthen an effective and responsible performance when meeting the demands of this specific group. The literature reveals that the lack of continuing education activities and the fragility in the interaction with the team are problems that affect their solid work, as they are often not able to address certain topics.7
Faced with problems such as violence, poverty, mistreatment, situations that are difficult to approach between parents and children, between school and students, the CHW has a primary role. They are the ones who often conduct the dialogue, the interchange between the actors because without building a trust relationship with the community, there is no way to access families and homes.6
Thus, it is unique to question with the CHW what they think about reproductive life planning for adolescents. It is believed that knowing their perceptions on the topic will make it possible to strengthen knowledge to find a praxis that is pleasant for the workers and attractive for adolescents. In this sense, this study aims to understand the community health workers’ perception of reproductive life planning carried out with adolescents.
Method
This is a descriptive, exploratory study with a qualitative approach. It was carried out using the Focus Group (FG) technique, from September to November 2017. All twelve CHW who worked in the Family Health Basic Unit (FHBU) in a municipality in the extreme south of Brazil were invited to participate in the study. The research was carried out in the unit where the Multi-professional Residence in Family Health was located.
Ten community health agents participated in the FG, as one of them was on sick leave and another on vacation at the time of data collection. It is noteworthy that the number of participants in the FG is variable in the literature, recommending three to twelve people, in order to obtain better results, not having the risk of deviating the focus from the theme and allowing everyone to participate.8
For the performance of the FG, the figure of the moderator, who in this case was a nursing resident, was counted and presented the motivations and reasons for investigating the theme. After an introductory conversation, the moderator instigated the speeches of the participants through a guided script of questions on the theme, facilitating exchanges, and maintaining the objectives of the group's work. The guiding questions were: What is the group's understanding of reproductive life planning? How do you see the reproductive life planning in the work of the CHW? Are there difficulties and easiness to approach the topic? What is the target audience for reproductive life planning? What is the importance of addressing reproductive life planning among adolescents? What strategies are needed to qualify reproductive life planning among adolescents?
Three meetings were held with the presence of all ten CHWs, with an average duration of 90 minutes each, in the FHBU’s meeting room, on Wednesdays, the day when the unit's internal working hours occurred. The first meeting was for the presentation of the study, explanation of the Free and Informed Consent Term, as well as the correctness for the date of future meetings, while the other two addressed the theme. It was decided to end the research at the third meeting, considering the repetition of information and data saturation. After the end of each meeting, the moderator made notes about the participants' impressions, reactions, and contradictory manifestations. During the collection, only the participants and the researcher were present in the room. At each meeting, a digital recorder was used for the subsequent transcription of the audios.
As a data analysis technique, Content Analysis, proposed by Bardin, was carried out, which proposes three stages - material exploration, treatment of results, and interpretation. The first relied on the material organization, in which the results were carefully read, seeking the particularities of each informant for the elaboration of the ideas and possible categories. After this search, the author performed the themes’ coding, so that they could be grouped in similar nuclei that, finally, gave rise to the categories.9
To maintain the anonymity of the participants, they were identified by the initials CHW followed by the successive numbering (CHW1, CHW2 ...). The project was approved in April 2017, by the Research Ethics Committee under CAAE nº 66563217.4.0000.5324.
Results
The ten participating women have worked at the unit for a different amount of time, ranging from five to sixteen years. The minimum age was 29 years and the maximum was 52. Regarding the marital situation, they were half married and half single, and all had children. Only one CHW had incomplete high school and the rest, complete high school. Most of them mentioned having participated in some training in reproductive life planning.
The CHW's speeches addressed as main themes the overview of adolescents, the perspective of an expanded RLP, the need to address sexuality at this stage of life due to the lack of communication with parents, as well as the doubts and taboos that permeate this phase. In addition, there were facilities and difficulties in discussing the topic at hand with the adolescents, with the bond and proximity to the families being the catalyst for both.
Regarding the age group, the CHW saw adolescents as vulnerable, uninterested in their health, and irresponsible.
Adolescence for me is the worst part of life because it's transformation, they don't listen to dad, friends, they listen to what they want to hear. ‘I will do what I want’. Teenagers need help from many sides. (CHW10)
I think there is a lot of lack of interest and lack of care because lack of information is not [...], but I think that lack of information is not at all, it is lack of interest even from the person [...], and that thing: 'nothing will happen' and it ends up happening. (CHW7)
I see that they want freedom, but they don't want commitment. (CHW1)
On the other hand, they recognized the importance of addressing reproductive planning with adolescents, highlighting the need to problematize aspects that go beyond sexuality, to meet the care of the body and with others.
Sexual orientation goes beyond diseases, it is a matter of orienting respect as a whole, knowing your body, respecting the other [...]. So, I think that you don't have to work only with diseases, you have to work carefully with yourself. (CHW8)
Even because they fight, they beat each other, violence is also exposed, not only sexuality, you see boys attacking girls and they also attack boys. So, the subject is very complex, reproductive planning covers a lot. (CHW4)
The conversation with them is different, we don't just think about the contraceptive method, these things like that with them, we talk about care. The most important thing for me, more than taking a contraceptive, is using condoms. (CHW5)
The participants also highlighted that at this age there is a lack of dialogue between adolescents and their parents, a fact that compromises their health care. In the present study, it was evident that the failure in communication was also related to cultural issues.
Sexuality in adolescence is very cultural, because, even if they have an orientation from us, if they don't have a good family base, with examples, an open conversation, I believe that it doesn't help much, they don't respond to that. They do what they want, depending on the family base they have. (CHW8)
In this sense, they reinforced the need to accompany this specific group, whether in the health unit, with other professionals, either through message or WhatsApp. They believed that issues related to sexuality and reproduction need to be problematized, considering it is a phase permeated by doubts and taboos.
One thing that helps a lot is the Internet, I received a message from a girl: “I'm sorry to bother you, but I think I'm pregnant, but don't tell anyone, help me ...” [...] But everything was by text message, if she saw me, she was ashamed. (CHW4)
They are not at liberty to sit down and talk to their parents and ask questions, so sometimes it is easier to come to a nursing appointment and clear up any doubts. (CHW7)
Or the mother leaves that taboo: ‘I can’t keep talking about sex, otherwise I’ll be encouraging her to think about it.’. (CHW 4)
Given the obstacles that permeate reproductive life planning in adolescence, the CHW believed that they could contribute with care actions. Besides, knowing the parents and the adolescents' life context makes a difference in health care.
Within the work it is already automatic to ask about it [reproductive life planning]. We see a mother we know, and we also know the teenager, we know how she is on the street, at school, so we know how to approach anyone in the family that we have a relationship with. So, this orientation is the look, our look inside the family home that makes the difference. (CHW10)
However, at the same time that the link between CHWs and families is something positive, it also makes it difficult for adolescents to dialogue with these professionals. This is because they believe the information will be revealed to their parents.
Many do not even ask us, for fear that we will say something to the family, to the mother. (CHW5)
At first it is that complicated thing, we didn't even know each other. But like this: ‘What you need can talk to me, we won’t talk to the father, we won’t talk to the mother, we are here to help you’. (CHW10)
In the same sense, the agents mentioned that their work with the adolescents could be impaired by the fact that home visits were carried out within the individuals' own homes, often in the presence of parents, siblings and family members who lived together, preventing further confidential conversation.
Talking to teenagers at home is complicated, because we sit there, look, we want to talk about it, but they cut you off, or in front of their mother or father they are more inhibited. So, I say that ‘saint at home does not work miracles’, because we are already from the area. (CHW10)
Can we access that teenager? Yes, but hardly that teenager who is suddenly starting his or her sex life, or thinking about starting his or her sex life, will ask us any questions during the family visit. (CHW5)
Thus, it is clear that, while the bond with the families facilitates orienting the adolescent, it also makes it difficult for the young person to spontaneously approach the professional.
Discussion
The CHW reported that adolescence is a phase in which young people deny the guidance of their parents, are irresponsible, do not plan their actions, are inconsequential and only pay attention to the opinion of the group itself. The literature shows us that adolescents have a distance from their families and insertion in groups of people of the same age, with technology being a factor of great influence in this process.10
Given the unpreparedness of this group for reproductive life planning, it is necessary to approach an expanded view with a simultaneous approach to other themes. Because of this, the CHW understood other facets of LRP, focused on self-knowledge, respect for others, the violence prevention and the culture of peace. It is necessary to take advantage of every opportunity to meet with teenagers to work on the life project, making them rethink the responsibility of being a father and mother. Symbolic violence, currently, has permeated the lives of young couples11 and, therefore, is pertinent and part of the approach to the theme.
On the part of the adolescents, the literature12 shows that they are not able to clarify doubts with the parents, either because the family does not problematize the subject or because they are not available for conversation at a satisfactory moment.12 Therefore, the nursing consultation was referred to as an additional resource in this sexual education process, considering that teenagers are in a phase in which they need special attention. In this sense, the reproductive life planning offered by the health service is fundamental, and the CHW is the professional who actively participates in this scenario.
The CHW also reported that adolescents have little dialogue with their families on the sexuality subject. In this sense, some authors claim that families have the intention of protecting adolescents, making it difficult to talk about sex education, as they believe that problematizing the subject influences an earlier sexual practice, 13 as evidenced.
At other times, there is shame on the part of the parents, who cut the subject off without attaching importance to the opinions of the adolescent.12 This may be due to the children phase change, who were children before and are now full of doubts and, like they are changing and do not know how to deal with the problems that arise, parents are also in this changing phase in the way they raise their children.
Something that facilitates communication and would allow a closer relationship between CHW and adolescents is the use of text message chats, so that they do not need to encounter another person, feeling more motivated to express their feelings and resolve doubts. The media are available at any time, facilitating the search for immediate answers to your needs.12
It is observed that the proximity to the families facilitates the view on the life context, providing a holistic approach. They establish dialogues, develop affection relationship, problematize situations and build, in a shared way, knowledge, allowing free expression and appreciation of the subjects in their reality.14
Knowing the families was relevant for the CHW, as it is known that family beliefs are often passed from generation to generation, favoring the approach by the health professional. At the same time, it is often difficult to demystify certain behaviors, as evidenced in a study that observed teenage mothers reproducing, in the baby care routine, various practices that were part of the local and family culture, such as not offering cheese, believing that it can impair the development of speech, use of teas for certain illnesses, without due scientific basis.15 The CHW, because they live in the same neighborhood, often know such beliefs, facilitating the problematization about the benefits and harms.
The strengthening of the bond allows the agent to be the reference in the health unit, as well as in the community surrounds, being viewed positively by the adolescents. Communication between CHW and adolescents may be impaired due to the fear that they will tell those responsible about what has been discussed, and sometimes this is an obstacle in obtaining the link with the CHW and in adhering to actions aimed at reproductive life planning. As much as this fear exists among adolescents, it is necessary that CHWs are information multipliers, guaranteeing professional secrecy regardless of age, as long as there is no risk of life or relevant risk to third parties.¹
On the other hand, even if this right is guaranteed, there is a failure in the training of professionals to serve this audience.16 Therefore, they are often limited to seeking help in basic health units because they do not feel understood by professionals. Also, the fact that CHWs make their home visits to the home where the adolescents live seems to become an impediment to more efficient conversation.
Although this fact does not appear in the literature as an aggravating factor, it was perceived in this study as an aspect that impairs the promotion of productive actions with these adolescents. The work of the CHW is fundamental within the community, as they live in the same neighborhood in which they operate, making them experience the same difficulties as the users, identifying the priorities that need to be resolved.6 Therefore, it is necessary to problematize the facilities and difficulties in the CHW's work process, in order to qualify health actions, minimizing barriers that prevent an effective approach to meeting the adolescents needs.
Conclusion
The CHW's perception of reproductive life planning carried out with adolescents is that it is a relevant activity, which can be favored or impaired by the close relationship between health professionals and the families of adolescents. On the one hand, adolescents may feel comfortable knowing the health professionals, on the other, they may suspect that they will expose doubts to parents. Thus, they realized that home visits become an inappropriate time to talk to these young people, considering that the presence of family members inhibits them.
The CHW had the perception that reproductive planning with adolescents is necessary, as many do not have communication with their parents about the theme, which represents a taboo in many homes, either for cultural reasons or because they believe that the dialogue on the theme will become an encourager of sexual practice. On the other hand, community health workers realized that adolescents are not very interested in their health, requiring attractive and captivating methods, such as messages by software applications.
Concerning study limitations, the reduced number of participants is pointed out, which makes generalizations from the data difficult, indicating the need to expand to other health units, including from different municipalities. The results of this study can contribute to the health and nursing areas, evidencing the perception of community health workers, as members of the team, acting in the adolescents’ reproductive life planning, seeking to minimize the difficulties in the CHW’s performance and strengthen successful practices with the group.
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Corresponding author
Carolina Coutinho Costa
E-mail: coutinhocarolc@hotmail.com
Address: General Osório, s/n, Bairro Centro, Rio Grande/RS
CEP: 96200-400
Authorship contributions
1 – Carolina Coutinho Costa
Participated in the design, planning of the research project, obtaining, analyzing and interpreting the data, writing and critical review. Author of the Conclusion of Residency Work of the Multiprofessional Residency in Family Health program entitled: Family Planning for adolescents: the perception of the community health agent, who originated this article.
2 – Camila Daiane Silva
Participated in data interpretation, writing and critical review.
3 – Daniele Ferreira Acosta
Participated in the design, planning of the research project, obtaining, analyzing and interpreting the data, writing and critical review.
4 – Victoria Leslyê Rocha Gutmann
Participated in writing and critical review.
How to cite this article
Costa CC, Silva CD, Acosta DF, Gutmann VLR. The perception of community health workers about reproductive life planning with adolescents. Rev. Enferm. UFSM. 2020 [Acesso em: Anos Mês Dia]; vol.10 e57: 1-15. DOI:https://doi.org/10.5902/2179769240345