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

Introduction

Cultural representations are beliefs, ideas and meanings that society uses to organize reality and are constructed, transmitted and transformed, among others, through discourse. Gender is a cultural representation, which contains values, prejudices, ideas, norms, responsibilities, prohibitions and differentiated roles, constructed and seen as natural due to social constructions, which determine what “is to be a man and be a woman”, as well as their reciprocal relations (Caricote, 2006CARICOTE, E. Estereotipos de género ponen en peligro la salud sexual en la adolescencia. Salus, Bárbula, v. 10, n. 3, p. 19-24, 2006.). Cultural representations of gender are manifested through stereotypes, or “preconceived generalizations about attributes/characteristics of people in different social groups” (Colás Bravo; Villaciervos Moreno, 2007, p. 38COLÁS BRAVO, P.; VILLACIERVOS MORENO, P. La interiorización de los estereotipos de género en jóvenes y adolescentes. Revista de Investigación Educativa, Salamanca, v. 25, n. 1, p. 35-58, 2007.). Gender stereotypes are learned since childhood and are the basis for the construction of the gender identity of adolescents (Colás Bravo; Villaciervos Moreno, 2007COLÁS BRAVO, P.; VILLACIERVOS MORENO, P. La interiorización de los estereotipos de género en jóvenes y adolescentes. Revista de Investigación Educativa, Salamanca, v. 25, n. 1, p. 35-58, 2007.), by leading them “to internalize expected patterns of behavior, which determine the existing expectations for men and women” (Henriques-Mueller; Yunes, 1993, p. 47HENRIQUES-MUELLER, M. E.; YUNES, J. Adolescencia: equivocaciones y esperanzas. In: GÓMEZ, E. (Ed.). Género, mujer y salud en las Américas. Washington, DC: OPS, 1993. p. 46-67.).

Adolescence as a social construction is associated with the stereotyped image of a conflictive period and with risk of adolescent pregnancy, sexually transmitted diseases, sexual libertinism, drug/alcohol consumption, violence, rebelliousness, suicide, among others. However, several studies conclude that this is not a more complicated stage than the others (Alonso; Luján; Machargo, 1998ALONSO, E.; LUJÁN, I.; MACHARGO, J. Actualidad de los estereotipos sobre la adolescencia. Anuario de Filosofía, Psicología y Sociología, Las Palmas, n. 1, p. 27-49, 1998.). There are hegemonic beliefs/myths and discourses in Latin America that stigmatize and make adolescents invisible, based on conceptions that characterize them as incomplete beings, immature, without reasoning capacity, unsure about themselves, dangerous; others reinforce ideas that adolescents do not get sick, during adolescence problems are only sexual or, on the contrary, adolescents are asexual (Chaves, 2005CHAVES, M. Juventud negada y negativizada: representaciones y formaciones discursivas vigentes en la Argentina contemporánea. Ultima Década, Valparaíso, v. 13, n. 23, p. 9-32, 2005.; Checa; Tapia, 2016CHECA, S.; TAPIA, S. (Coord.). Derechos sexuales y reproductivos de los y las adolescentes: diálogos posibles entre los jóvenes y los servicios de salud. Buenos Aires: Sociedad Argentina de Pediatría, 2016. Disponível em: <Disponível em: http://bit.ly/2zuc7xt >. Acesso em: 29 ago. 2019.
http://bit.ly/2zuc7xt... ; Correa; Cubillán, 2009CORREA, C.; CUBILLÁN, F. Manual de capacitación salud sexual y reproductiva: desde una mirada de género. Maracay: IAESP Dr. Arnoldo Gabaldon, 2009.).

Gender stereotypes affect adolescents unequally. In the hegemonic masculinity model, boys are prepared to perform better sexually, use physical force and repress their emotions. In contrast, girls are trained for motherhood, caring for others and be predisposed to love (Caricote, 2006CARICOTE, E. Estereotipos de género ponen en peligro la salud sexual en la adolescencia. Salus, Bárbula, v. 10, n. 3, p. 19-24, 2006.). For the World Health Organization (WHO, 2014), inequality in gender norms and stereotypes produce biases in policies, institutions and programming, negatively impacting the effectiveness and access to health services (HS). In health institutions, this system of beliefs and values shared by workers/users, using discourse (among other mechanisms), operates invisibly, playing a preponderant role in the definition of organizational culture and this exerts a strong influence on the practices of HS providers (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.).

In low and middle income countries, adolescents are the group that receive the worst attention and that uses HS most rarely (Kruk et al., 2018KRUK, M. E. et al. High-quality health systems in the sustainable development goals era: time for a revolution. The Lancet Global Health, Londres, v. 6, n. 11, p. e1196-e1252, 2018.). Provision is generally restricted to adolescent pregnancy and HIV, ignoring other health needs of this population (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ; WHO, 2014). Data about access and quality of care for adolescents are scarce, limiting the generation of measures about “user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes” (Kruk et al., 2018, p. e1197KRUK, M. E. et al. High-quality health systems in the sustainable development goals era: time for a revolution. The Lancet Global Health, Londres, v. 6, n. 11, p. e1196-e1252, 2018.).

According to Thiede, Akweongo and McIntyre (2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.), access to HS is not restricted to the use, and refers more to the “freedom” to use services. The authors propose to analyze the access using three interrelated dimensions: availability (physical access); affordability (financial access) and acceptability (perception of users and providers). The concept is based on the interaction and adjustment of the health system to individual and community factors (Thiede; Akweongo; McIntyre, 2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.).

Acceptability understood as “the social and cultural distance between health systems and their users” (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190., p. 163) covers three components: adequacy between users’ and professionals’ beliefs about health; commitment and dialogue between provider/user; and the influence of organizational adjustments on users’ reactions to HS. This considers the interaction between users’ expectations about professionals and health care facilities, as well as providers’ expectations about users (Thiede; Akweongo; McIntyre, 2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.).

In this way, improvements in access depend on the communicative interaction between the actors involved (Aitken; Thomas, 2004AITKEN, J.-M.; THOMAS, D. Synthesis of final evaluation findings from the Nepal safer motherhood project. Kathmandu: Ministry of Health, Department for International Development, 2004.; Thiede; Akweongo; McIntyre, 2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.). This dynamic process represents the potential to relate and make adjustments that will allow the health system to function better, as well as being the northern axis for promoting equitable access. Therefore, political action to address the dimensions of access must be based on solid qualitative information, in addition to the quantitative information traditionally used (Thiede; Akweongo; McIntyre, 2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.).

The perspective of the agents who build lives in the HS - managers, providers, professionals and users - is fundamental to understanding the problems related to access and the possible strategies to confront it (Esposti et al., 2015ESPOSTI, C. D. D. et al. Representações sociais sobre o acesso e o cuidado pré-natal no Sistema Único de Saúde da Região Metropolitana da Grande Vitória, Espírito Santo. Saúde e Sociedade, São Paulo, v. 24, n. 3, p. 765-779, 2015.), especially in the case of the adolescent population that makes little use of these services. In this study, this perspective will be explored through discourse, since it contributes to the construction of social identities and positions of subjects; social relations among people; and knowledge and belief systems (Fairclough, 2001FAIRCLOUGH, N. Teoria social do discurso. In: FAIRCLOUGH, N. Discurso e mudança social. Brasília, DF: Editora UnB, 2001. p. 89-132.). In addition, discourse has a fundamental role as an act in the interaction (constitutive of organizations or social relations between groups); as well as in the expression and (re)production of knowledge, ideologies, norms and values that we share as members of groups, and that regulate and control acts and interactions (Van Dijk, 2013VAN DIJK, T. A. Discurso y poder. Barcelona: Gedisa, 2013.). The dialectic between communicative action and discourse allows the construction of understanding between the participants of the interaction and the questioning of traditional cultural patterns (Habermas, 2012HABERMAS, J. Teoria do agir comunicativo. São Paulo: WMF Martins Fontes, 2012. v. 1.).

The Agenda 2030 aims to guarantee access to universal, equitable and integral provision of HS, prioritizing sexual and reproductive health (SRH) interventions related to improvements in maternal, child and adolescent health (WHO, 2018; UN, 2019). Universal access is defined as “the absence of geographical/economic/socio-cultural, organizational, or gender barriers […] achieved by the progressive elimination of barriers that prevent all people from using integrated health services, determined at the national level, in an equitable manner” (OPS; OMS, 2014, p. 4OMS - ORGANIZACIÓN MUNDIAL DE LA SALUD. Salud para los adolescentes del mundo: una segunda oportunidad en la segunda década. Ginebra, 2014.).

In Venezuela, despite efforts to expand coverage of the first level of health care (70% for 2016) (Venezuela, 2016VENEZUELA. Ministerio del Poder Popular para la Salud. Plan nacional barrio adentro 100%. Caracas, 2016.), barriers to access to HS persist, excluding, among other groups, adolescents. The coverage of this group is among the lowest, even in federal entities that have sufficient health services; the birth rate among adolescents is one of the highest in Latin America; data about adolescent health and access to HS are scarce; as well as studies regarding this subject (Venezuela, 2012VENEZUELA. Ministerio del Poder Popular para la Salud. Fundamentos de las normas de los programas de salud. Caracas, 2012.).

This article analyzes the discourses of professionals and adolescents about the factors that hinder and potentiate the access of adolescents to health services and the effects it generates in the achievement of equity, in a Venezuelan state, prioritizing the dimension of acceptability.

Methodology

This is a study of discourse analysis, carried out in the Venezuelan state of Nueva Esparta, aiming to understand the articulation of the discursive production on the factors that hinder and potentiate the access of adolescents in their historical-social context, under the perspective of the Social Theory of Discourse, using Fairclough’s (2001FAIRCLOUGH, N. Teoria social do discurso. In: FAIRCLOUGH, N. Discurso e mudança social. Brasília, DF: Editora UnB, 2001. p. 89-132.) Critical Discourse Analysis (CDA) and the acceptability dimension of access according to the conceptual framework of Thiede, Akweongo and McIntyre (2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.) and Gilson (2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). This state was selected because the areas of responsibility of health care facilities were delimited and had basic health equipment, although not complete (Heredia-Martinez; Artmann, 2018HEREDIA-MARTÍNEZ, H.; ARTMANN, E. Criterios para la (re)distribución equitativa de los equipos básicos de salud en el nivel local en Venezuela. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 10, e00171117, 2018.). Between September and October 2017, semi-structured interviews were conducted with 12 adolescents (of both sexes, between 10 and 19 years old, users and non-users of health services) and 12 professionals (4 doctors, 4 nurses/nursing assistants and 4 health promoters/social workers) from 12 health care facilities, 6 from the first level of care, 3 from the second and 3 from the third.

The CDA emphasizes the understanding of the relationships between social inequalities and the ways the texts are used to denote power/domination and ideology (Iñiguez, 2005IÑIGUEZ, L. A análise de discurso nas ciências sociais: variedades, tradições e práticas. In: IÑIGUEZ, L. Manual de análise do discurso em ciências sociais. 2. ed. Petrópolis: Vozes, 2005. p. 105-160.). It has a special interest in uncovering how discourse (re)produces the social inequalities that mainly affect minority groups, as well as the possibilities of social change by it. The proposed model of three-dimensional discourse analysis was followed. The first dimension includes the categories of textual analysis. The second concerns discursive practice, in which the cognitive activities of production, distribution, consumption of the text are analyzed, as well as coherence, intertextuality and the relationship between discourses. The third refers to social practice, related to ideology and hegemony in the analyzed discursive instance (Fairclough, 2001FAIRCLOUGH, N. Teoria social do discurso. In: FAIRCLOUGH, N. Discurso e mudança social. Brasília, DF: Editora UnB, 2001. p. 89-132.).

The results were structured by themes, with the acceptability category and its components as the guiding axes of the analysis (Thiede; Akweongo; McIntyre, 2014THIEDE, M.; AKWEONGO, P.; MCINTYRE, D. Explorando as dimensões do acesso. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 137-161.). Coherence and cohesion analyses were carried out on the basis of the textual elements. The structure of the argumentation of the sentences, the form of relation of the phrases and its coherence were identified.

Additional analytical devices were identified: metaphor, interdiscursiveness, irony, modality and polish, to approximate the discursive object of the social process where it is produced and to pass from the discursive object to the discursive process.

The recorded interviews were transcribed, maintaining the faithful expression of spoken Spanish in order to preserve all discursive particles and maintain the senses produced in the enunciation. References to the interviews were coded: Interviews with Professionals (IP), Interviews with Adolescents (IA).

The study followed the ethical principles of human research. It was approved by the Ethics Committee of the Research Directorate of the High Studies Institute “Dr. Arnoldo Gabaldon” of the Ministerio del Poder Popular para la Salud (MPPS - Ministry of People’s Power for Health) of Venezuela, on 04/03/17 under number 003/2017, as well as by the State Health Directorate of the state of Nueva Esparta on 04/12/17. Informed consent form was obtained from each adolescent, with prior authorization from parents or guardians, as well as from health professionals who agreed to participate in the research.

Declarative context

The Mission Barrio Adentro, alongside the others HS institutions, expanded the coverage of these services to the excluded population (Briggs; Mantini-Briggs, 2007; PAHO, 2006BRIGGS, C. L.; MANTINI-BRIGGS, C. “Misión barrio adentro”: medicina social, movimientos sociales de los pobres y nuevas coaliciones en Venezuela. Salud Colectiva, Buenos Aires, v. 3, n. 2, p. 159-176, 2007.). Priority was given to strengthening the primary health care network, from 4,605 health care facilities in 2003 to 12,515 in 2016 (OPAS, 2007; Venezuela, 2016VENEZUELA. Ministerio del Poder Popular para la Salud. Plan nacional barrio adentro 100%. Caracas, 2016.), an increase of 172%. Nevertheless, the following persist: the operational fragmentation of HS provision and financing; the institutional segmentation of the health system (Bonvecchio et al., 2011BONVECCHIO, A. et al. Sistema de salud de Venezuela. Salud Pública de México, Cuernavaca, v. 53, p. s275-s286, 2011. Suplemento 2.; Madies; Chiarvetti; Chorny, 2000MADIES, C.; CHIARVETTI, S.; CHORNY, M. Aseguramiento y cobertura: dos temas críticos en las reformas del sector de la salud. Revista Panamericana de Salud Pública, Washington, DC, v. 8, n. 1-2, p. 33-42, 2000.; PAHO, 2007); the scarcity of human resources and its unequal distribution; the existence of geographic points that concentrate supply; difficulties in working in integrated networks; and high private spending (out-of-pocket), for which the right to health depends on the ability of Venezuelans to pay (Roa, 2018ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, e00058517, 2018.). The country’s economic crisis exacerbated the problems of access to medicines and contraceptive methods, such as HS, due to the shortage of supplies and equipment (Roa, 2018ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, e00058517, 2018.).

In 2017, 5,558,445 of the 31,431,164 inhabitants were adolescents aged 10 to 19 (18%)²2VENEZUELA. Ministerio del Poder Popular de Planificación. Instituto Nacional de Estadística. Proyecciones de población. c2011. Disponível em: <https://bit.ly/2nXa6XX>. Acesso em: 30 set. 2019.. In the MPPS, attention differentiated according to the needs of adolescents is regulated by the Norma Oficial para la Atención Integral en Salud Sexual y Reproductiva en la Adolescencia (NOAISSR - Official Standard for Integral Sexual and Reproductive Health Care in Adolescence), in the subproject “Sexual and Reproductive Health in Adolescence” with six areas of intervention, where access to HS is transversal for the fulfillment of objectives (Venezuela, 2013VENEZUELA. Ministerio del Poder Popular para la Salud. Norma oficial para la atención integral en salud sexual y reproductiva. Caracas: UNFPA, 2013.). The Programa de Salud del Adolescente (PSA/MPPS - Adolescent Health Program) operates with limited presence at the state level: of the 24 federal entities, only 14 had at least one differentiated consultation for adolescents in 2017. Coverage percentages are low in states that report to PSA.

The main legal conditions for adolescents in Venezuela include: majority from 18 years old; criminal responsibility from 12 years old; age for HS care without parents/representatives from 15 years old; age to consent for heterosexual/homosexual relations, 16 years; and marriage/civil union with the consent of parents/guardians/judges, 16 years old for boys and 14 years old for girls (Venezuela, 2015VENEZUELA. Ley Orgánica para la Protección del Niño y el Adolescente (LOPNA). Gaceta Oficial de la República de Venezuela, Caracas, n. 6185, 8 jun.2015.). Article 435 of the Criminal Code prohibits abortion in its various forms, except when the woman’s life is at risk (Venezuela, 2000VENEZUELA. Extraordinario no 5.494, de 20 de octubre de 2000. Gaceta Oficial de la República de Venezuela, Caracas, 20 out.2000.).

Results and discussion

All discursive enunciations, organized by themes and numbered excerpts, are presented in Chart 1.

The power of stereotypes and beliefs: “abortion and sexuality should not be discussed”

Structural and power relationships influence professional practice and organizational culture, such as user/professional behavior and their interactions (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). Culture can be both a resource and an obstacle in the process of institutional change and it is not possible to interfere directly in it. Nevertheless, the positive traits of culture can be valued and approached it as a resource (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.; Habermas, 2012HABERMAS, J. Teoria do agir comunicativo. São Paulo: WMF Martins Fontes, 2012. v. 1.). Discursive enunciations stand out as the stereotyped image of adolescents sets the tone in the expectations of professionals and users (Excerpt 1-8).

The belief that adolescence is a complicated stage permeates the HS (Excerpt 4); this image is used to generalize “adolescents” as problematic and incomprehensible, although several studies have already shown the opposite (Alonso; Luján; Machargo, 1998ALONSO, E.; LUJÁN, I.; MACHARGO, J. Actualidad de los estereotipos sobre la adolescencia. Anuario de Filosofía, Psicología y Sociología, Las Palmas, n. 1, p. 27-49, 1998.). The low priority that adolescents have in health services is also recognized in the speech. The difficulty of professionals to deal with issues related to sexual orientation continues to be “a taboo” in the HS, there is a tendency to stigmatize the different expressions of sexuality and sexual identities that do not conform to social rules, a situation that directly affects adolescents with orientations different than hegemonic (Colás Bravo; Villaciervos Moreno, 2007COLÁS BRAVO, P.; VILLACIERVOS MORENO, P. La interiorización de los estereotipos de género en jóvenes y adolescentes. Revista de Investigación Educativa, Salamanca, v. 25, n. 1, p. 35-58, 2007.), such as those who are seeking counseling to address these issues. The training of professionals appears as a strategy to improve the care of the adolescent population.

The argument that access is limited by the adolescent’s problems is referred in several professional statements (Excerpts 5-7). These beliefs constitute a veiled barrier that limits access. The first is that adolescents are “fearful, painful”, so fear is mentioned as a matter proper of the user and not seeking to understand why they act that way (Excerpt 4). Sometimes this attitude can be related to the discomfort/shame of talking about their sexuality or the lack of confidentiality/privacy (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ; Henriques-Mueller; Yunes, 1993HENRIQUES-MUELLER, M. E.; YUNES, J. Adolescencia: equivocaciones y esperanzas. In: GÓMEZ, E. (Ed.). Género, mujer y salud en las Américas. Washington, DC: OPS, 1993. p. 46-67.).

Another stereotype is that teenagers are “liars” (Correa; Cubillán, 2009CORREA, C.; CUBILLÁN, F. Manual de capacitación salud sexual y reproductiva: desde una mirada de género. Maracay: IAESP Dr. Arnoldo Gabaldon, 2009.), the metaphorical resource used, “find a way around things”, has the connotation of an interrogatory where by any fault or neglect of the interlocutor, we try to discover the truth (Excerpt 5). Professional/user trust, understood as “a relational idea, is based on the user’s conviction that the professional will act in his interest” (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190., p. 166). This is not always cultivated, on the contrary, stereotypes undermine the possibilities of establishing a dialogue and links with the adolescent, who demands communicative actions, in the Habermasian sense (Habermas, 2012HABERMAS, J. Teoria do agir comunicativo. São Paulo: WMF Martins Fontes, 2012. v. 1.) in the search for consensus and not with strategic actions to impose the criterion from the HS.

In other cases, the issue of confidentiality is identified, however, it is not recognized as a barrier to HS but as an issue/problem of the adolescents (Excerpt 6). The use of “questions”, “question” shows the impossibility of defining the barrier (Excerpt 7). The professional then is placed in the adolescent’s place, citing examples of why HS are not used, all referring to confidentiality, but without recognizing that these services must guarantee it (UNFPA, 2015UNFPA - FONDO DE POBLACIÓN DE LAS NACIONES UNIDAS. Análisis sobre legislaciones y políticas que afectan el acceso de adolescentes y jóvenes a los servicios de SSR y VIH en América Latina. Nova York, 2015.). On the contrary, the phrase “inside themselves” makes the adolescent responsible.

The preservation or not of confidentiality is one of the elements used by professionals to exercise power (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). A fundamental characteristic of HS adapted for adolescents is that they can guarantee confidentiality and privacy, as is required for the rest of the population (Ford; English; Sigman, 2004FORD, C.; ENGLISH, A.; SIGMAN, G. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, Nova York, v. 35, n. 2, p. 160-167, 2004.; Venezuela, 2013VENEZUELA. Ministerio del Poder Popular para la Salud. Norma oficial para la atención integral en salud sexual y reproductiva. Caracas: UNFPA, 2013.). Some studies show how adolescent users prefer to be attended in places outside their community, for fear that their parents would know their situation (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ; OMS, 2018OMS - ORGANIZACIÓN MUNDIAL DE LA SALUD. Estrategia mundial para la salud de la mujer, el niño y el adolescente (2016-2030): salud sexual y reproductiva, violencia interpersonal y desarrollo en la primera infancia. Washington, DC, 26 mar.2018. Disponível em: <Disponível em: https://bit.ly/2oBJqwl >. Acesso em: 30 set. 2019.
https://bit.ly/2oBJqwl... ).

In contrast to the beliefs of professionals, adolescent discursive enunciations attempt to de-construct these stereotypes. One expectation of adolescents is to be “seen as an adult” and treated as such (Excerpt 1). It refers to enjoying some privileges and being able to assume responsibilities (Chaves, 2005CHAVES, M. Juventud negada y negativizada: representaciones y formaciones discursivas vigentes en la Argentina contemporánea. Ultima Década, Valparaíso, v. 13, n. 23, p. 9-32, 2005.; Correa; Cubillán, 2009CORREA, C.; CUBILLÁN, F. Manual de capacitación salud sexual y reproductiva: desde una mirada de género. Maracay: IAESP Dr. Arnoldo Gabaldon, 2009.), this implies, on the one hand, the demand to be attended in the same conditions, because they are also subjects of rights (with respect, confidentiality, autonomy, among others) (Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.; UNFPA, 2015UNFPA - FONDO DE POBLACIÓN DE LAS NACIONES UNIDAS. Análisis sobre legislaciones y políticas que afectan el acceso de adolescentes y jóvenes a los servicios de SSR y VIH en América Latina. Nova York, 2015.) and, on the other hand, to demonstrate that they have sufficient cognitive capacity to understand what will be said in the consultation and to take care of themselves (Checa; Tapia, 2016CHECA, S.; TAPIA, S. (Coord.). Derechos sexuales y reproductivos de los y las adolescentes: diálogos posibles entre los jóvenes y los servicios de salud. Buenos Aires: Sociedad Argentina de Pediatría, 2016. Disponível em: <Disponível em: http://bit.ly/2zuc7xt >. Acesso em: 29 ago. 2019.
http://bit.ly/2zuc7xt... ).

In the Excerpt 2 with the use of “but” two ideas are opposed to reinforce the need to work first with the parents, who appear as an authority figure to instill fear of the HS. Adolescents in the different spaces where they live are subjected to asymmetrical power relations (family/parents, school/teachers, HS/professionals). Thus their capacity to access the HS, independently of their parents, is limited (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ), even more so when the health system itself imposes it as an income requirement. This statement reveals the importance of parents/representatives as key agents in improving access to HS, since they can be the main barrier, and devising strategies to involve them in the care process is fundamental, not creating an obstacle to adolescents’ access when they demand care without the presence of parents. In spite of the asymmetries implicit in care, a relational dynamic that results in trust, whose central ethical nucleus is mutual respect, is possible if the HS are open to listening to the users, in the case of this study, adolescents and their parents (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.).

Access to information on issues such as abortion and sexuality is limited, as they continue to be taboo in Venezuelan society. Despite being included in the package of services to be provided, it is difficult for professionals to deal with, even more so with adolescents. The statement in Excerpt 3 is categorical in affirming that these issues are not discussed, at the same time that it manifests the difficulties of the professionals in dealing with them. The expression “go straight to the point” is used to denote a clear explanation. For adults (including professionals), “talking about sexuality or controversial issues such as abortion can produce fears and confront them with their own difficulties and uncertainties” (Correa; Cubillán, 2009CORREA, C.; CUBILLÁN, F. Manual de capacitación salud sexual y reproductiva: desde una mirada de género. Maracay: IAESP Dr. Arnoldo Gabaldon, 2009., p. 9).

It is argued that there is disagreement with the non-legalization of abortion, for attempting against a woman’s autonomy to decide about her body. The adjectives “illogical, unfair” underline the absurdity/arbitrary nature of the situation. Venezuelan law prohibits abortion and it is only admitted when a woman’s life is in danger (Venezuela, 2000VENEZUELA. Extraordinario no 5.494, de 20 de octubre de 2000. Gaceta Oficial de la República de Venezuela, Caracas, 20 out.2000.). It is a speech that questions the hegemonic discourse.

In several countries of Latin America and the Caribbean, the stereotypes analyzed prevail and limit adolescents’ access to HS, their deconstruction involves recognizing them and devising strategies/actions that combine changes in management practices and organizational culture (Caricote, 2006CARICOTE, E. Estereotipos de género ponen en peligro la salud sexual en la adolescencia. Salus, Bárbula, v. 10, n. 3, p. 19-24, 2006.; Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.; UNFPA, 2015UNFPA - FONDO DE POBLACIÓN DE LAS NACIONES UNIDAS. Análisis sobre legislaciones y políticas que afectan el acceso de adolescentes y jóvenes a los servicios de SSR y VIH en América Latina. Nova York, 2015.). Some cultural traditions can be criticized from the discourse and allow the construction of new consensuses and new institutional positions (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.; Habermas, 2012HABERMAS, J. Teoria do agir comunicativo. São Paulo: WMF Martins Fontes, 2012. v. 1.).

The law outside the right to health: “No to the blue shirts”

The age of care without parents/representatives is pointed out by adolescents as an obstacle (Excerpts 8-9). The figure of the adult is mentioned twice as a requirement for attention (Excerpt 8); the statement emphasizes in the first person the restrictions faced as an adolescent (“ignore me”), because they are not recognized as a subject of rights in the HS (Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.). Discriminatory care for adolescents in health services is highlighted by the phrases “treat them different”; “treat you worse”. For some authors (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ) children and adults are generally better served and these groups have historically been within the priorities of health systems with greater emphasis on structured programs and allocated resources, in contrast to adolescents.

In Excerpt 9, what is recommended in the HS policies for adolescents (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ; Venezuela, 2012VENEZUELA. Ministerio del Poder Popular para la Salud. Fundamentos de las normas de los programas de salud. Caracas, 2012.) is highlighted with the adjectives “egalitarian” and “equal”, as the importance that this population “should” have for the HS. The adjective “pathetic” indicates the dissatisfaction and the particularly evident abandonment that adolescents suffer for health services (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ). The statement emphasizes that because they are “minors”, they should have differentiated considerations.

The Excerpt 10 reveals the scarce autonomy that society grants to adolescents (Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.) and, at the same time, shows how, to the extent that the analytical capacity and critical sense of adolescents increases, adolescents question the rules/standards imposed in society. Thus, in spite of their limitations, adolescents communicate their capacity to express their opinions, which is often ignored by adults (health team/parents/representatives). The adjective “useless” used two times, highlights, on the one hand, the presence of the stereotype that adolescents are incapacitated (Chaves, 2005CHAVES, M. Juventud negada y negativizada: representaciones y formaciones discursivas vigentes en la Argentina contemporánea. Ultima Década, Valparaíso, v. 13, n. 23, p. 9-32, 2005.) and, on the other, the sensation of repudiation/anger/frustration of the adolescent about the received treatment.

In the speeches of the professionals (Excerpts 11-12), the apparent strategy of conceding access to minors (Van Dijk, 2013VAN DIJK, T. A. Discurso y poder. Barcelona: Gedisa, 2013.) is used and then the resource of modality and expressions of courtesy are used too, to say in a pleasant way that adolescents will only be attended with the presence of an adult (“special cases”; “at least we demand with regard”). The age is not seen as a barrier; on the contrary, it is naturalized as a mandatory requirement that affects exceptional cases. This is emphasized in Excerpt 11 with the phrase “but in general” and is justified by the stereotype that adolescents do not have the capacity for understanding, nor the level of maturity to make decisions about their health (Checa; Tapia, 2016CHECA, S.; TAPIA, S. (Coord.). Derechos sexuales y reproductivos de los y las adolescentes: diálogos posibles entre los jóvenes y los servicios de salud. Buenos Aires: Sociedad Argentina de Pediatría, 2016. Disponível em: <Disponível em: http://bit.ly/2zuc7xt >. Acesso em: 29 ago. 2019.
http://bit.ly/2zuc7xt... ), referred in Excerpt 12, by the use of direct intertextuality about what mothers claim, with the phrase “I did not know how to explain this”.

In legislation, age generally appears with a restrictive tendency when referring to adolescents (Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.). In Venezuela (2015), the Ley Orgánica para la Protección del Niño y del Adolescente (LOPNA - Organic Law for the Protection of Children and Adolescents) establishes that from the age of 15 adolescents can be attended without consent by Servicios de Salud Sexual y Reproductiva (SSSR - Sexual and Reproductive Health Programs and Services). No mention is made about other kinds of care, which could be interpreted as cases when the adolescent alone can be attended. The first contradiction of this law is that adolescents must be 15 years old in order to be treated alone in SSSR, but at the age of 12 they can be held criminally responsible (Venezuela, 2015VENEZUELA. Ley Orgánica para la Protección del Niño y el Adolescente (LOPNA). Gaceta Oficial de la República de Venezuela, Caracas, n. 6185, 8 jun.2015.). The second is that in the law there is a marked concern about the sexual and reproductive health of adolescents, more than about their integral health. And the third is that the predominant discourse in the HS is to not attend minors (under 18) alone, regardless of what they require.

Professionals’ fear of not knowing when an adolescent should be attended or not appears in Excerpts 13-14 and is recognized as a barrier (Excerpt 13). The verbs are conjugated in the first and third person, to express the personal and health team’s concern for the responsibility they must assume, especially regarding parents/representatives. In Excerpt 14, the sentences are constructed in the first person, to indicate the insecurity because they do not know the current legal norms. This impossibility of discerning what should or should not be done, within the “legal” framework, manifests the deficiencies of the health system as an organization, incapable of establishing mechanisms to make agreements with professionals and guarantee the care of adolescents.

For the professional speech in Excerpt 15, the adolescents alone have to be attended, because often they do not go with the representative. However, since the accepted/institutional organizational practices are against it, tensions are generated (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.), hence the fear manifested in Excerpt 14. With the resource of direct interdiscursiveness it exemplifies the pressures of other health team professionals, mentioning “the nurses”, a power group/hierarchy within the HS, as well as the measure implemented to “protect themselves” (informed consent).

The professional ironizes with the expression “in quotes” to speak figuratively and metaphorically of the condition of being adult, condition demanded by the health team to be able to provide the attention. The family constituted by the adolescent is also seen by the health team as “in quotes”, even more so because it is a girl who assisted alone (without a partner). Gender marking is evident in patriarchal Venezuelan society. An adolescent at the age of 15 who lives with a partner is badly considered, and in the HS this gender stereotype is present, so much so that in some HS they require the girl to go with her partner in order to receive care, a situation that does not happen with boys. Thus, age masks the real reasons for denying attention, often linked to the system of beliefs and values that prevails and influences the culture of health care organizations and it shapes the behavior of workers (Rivera, 2006RIVERA, F. J. U. Análisis estratégico en salud y gestión a través de la escucha. Rio de Janeiro: Editoral Fiocruz, 2006.).

The predominant discourse in the HS is that an adolescent without a representative cannot be attended to. However, there are speeches showing a discourse different than the naturalized one (Excerpts 16-17). Its concretion, by the implementation of strategies focused on adolescents, may be hindered by organizational culture (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.; Rivera, 2006RIVERA, F. J. U. Análisis estratégico en salud y gestión a través de la escucha. Rio de Janeiro: Editoral Fiocruz, 2006.). The professional speech in Excerpt 16 recognizes attention without parents/representatives as an access facilitator. It justifies that this action is necessary in the absence of the parents during the hours in which the health center is open. The “wow” denotes astonishment at the inequity generated by the lack of attention for this reason.

Age is not only a barrier to access to care, it restricts access to inputs such as condoms. Its application in practice is contradictory and determined by the attitudes of HS providers. The speech in first person is exhaustive in indicating that to students in grades seventh to ninth (“the blue shirts”) do not receive condoms (Excerpt 17). The criterion for determining age is the color of the shirt, which excludes the 12-15 age group, despite knowing that this is the group concentrating the highest number of pregnancies. With the direct interdiscursiveness, the professional brings the opinion of the adolescents of fourth and fifth years old (“the beige shirts”), who use an expression “are more awake than we are” to denote that the younger adolescents are already sexually initiated and therefore need to receive condoms. Beyond his concern for the “responsibility” he must assume when handing out condoms, the professional does not approve that adolescents between 12 and 15 years of age start their sexual activity, and this is the impediment to giving them condoms, despite the fact that the Sexual and Reproductive Health Program establishes that educational activities should be offered to all adolescents (Venezuela, 2013VENEZUELA. Ministerio del Poder Popular para la Salud. Norma oficial para la atención integral en salud sexual y reproductiva. Caracas: UNFPA, 2013.).

Building humanized practices: matches and mismatches

Quality care and the humanization of care are valued in the speeches of adolescents (Excerpts 18-20). Attitudes and behaviors respectful of the provider towards users, such as good communication practices, are referred in the Excerpt 18 and contribute to create links of trust (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.; Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). The “no with” is used three times to characterize inappropriate treatments. The expression “lemon-sucking face” is a metaphorical resource that indicates the opposite of a dignified treatment, as one of the aspects of the ethical practices of health systems (Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ). Technical competence is also demanded, as humanized practices, in a quality care, light technologies (relationship) must be used, such as the hard and light-hard ones that are required. Direct interdiscursiveness at the end of the Excerpt demands greater horizontality in the relationship between professionals and non-hierarchical and respectful adolescents (Ferreira; Artmann, 2018FERREIRA, L. R.; ARTMANN, E. Discursos sobre humanização: profissionais e usuários em uma instituição complexa de saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 5, p. 1437-1450, 2018.). Although the relationship between professionals and adolescents is asymmetric, configured according to the guidelines learned in training and hegemonic medical practice (with emphasis on the case of doctors), it is possible to implement communicative actions that privilege the encounter of the convictions of adolescents with those of professionals in the construction of a humanized culture (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.).

Excerpt 19 characterizes differentiated attention as a facilitator of access, where personalized consultation, privacy and trust are privileged. In primary care, when working from the health system with “user-centered” approaches, personalized encounters with more time between provider/user, such as continuity of contact, are key strategies for improving access (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.; Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ). Another point raised in this Excerpt is how negative experiences with HS can cause non-return of adolescents.

A notable barrier (Excerpt 20) is the difficulty that (medical) professionals have in understanding the expectations of adolescents. The recognition of their specific circumstances and the way the professional demonstrates consideration for them in moments of vulnerability is valued (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). Thus, the expectation is that the doctor tries to understand what happens to the other (the user).

The promotion of services offered to adolescents is a rare practice in HS, identified as a possible facilitator in Excerpts 21 and 22. Information about the offer of services available to adolescents allows them to feel that they are included in it and can be a facilitator of access; in addition, a component that contributes to strengthening trust is the set of services offered (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.; Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ).

If the HS organization is not able to respond to needs, trust will be affected. The speech of one professional (Excerpt 23) refers to this situation as “mistreatment”, because the HS cannot offer the adolescent what is demanded. Hence, in addition to the technical competence (perceived) mentioned above, the availability of medicines, supplies and equipment are required, because these items influence the attitudes of the users. The policy implemented to expand coverage in the country at the first level of care, in some cases, omitted this aspect and, in the absence of the basic factors of infrastructure, equipment, inputs/medicines, among others, access is restricted and distrust of users is reinforced (Heredia-Martínez; Artmann, 2018HEREDIA-MARTÍNEZ, H.; ARTMANN, E. Criterios para la (re)distribución equitativa de los equipos básicos de salud en el nivel local en Venezuela. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 10, e00171117, 2018.).

The co-responsibility of the HS and their professionals in creating bonds of trust is emphasized (Excerpts 24-25). The option of the adolescent being able to select the professional with whom they want to have the consultation is referred as an access facilitator (Excerpt 25), a strategy already suggested in similar studies (Checa; Tapia, 2016CHECA, S.; TAPIA, S. (Coord.). Derechos sexuales y reproductivos de los y las adolescentes: diálogos posibles entre los jóvenes y los servicios de salud. Buenos Aires: Sociedad Argentina de Pediatría, 2016. Disponível em: <Disponível em: http://bit.ly/2zuc7xt >. Acesso em: 29 ago. 2019.
http://bit.ly/2zuc7xt... ). With direct interdiscursiveness, the professional explains how trust is a determining factor in the selection of a specific professional by the adolescent (Excerpt 25). In these discursive enunciations, professionals try to (re)invent the way of providing HS to adolescents, valuing humanized practices of this population’s attention, such as quality, reception and their recognition as subjects of rights (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.; Rivera, 2006).

Final Considerations

In Venezuela, adolescents continue to be one of the most neglected and stigmatized groups in the health system, a reality common to several Latin American and Caribbean countries (Morlachetti, 2007MORLACHETTI, A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas de Población, Santiago, v. 34, n. 85, p. 63-96, 2007.; Rodríguez, 2009RODRÍGUEZ, J. Reproducción adolescente y desigualdades en América Latina y el Caribe: un llamado a la reflexión y a la acción. Madrid: OIJ, 2009.; UNFPA, 2015UNFPA - FONDO DE POBLACIÓN DE LAS NACIONES UNIDAS. Análisis sobre legislaciones y políticas que afectan el acceso de adolescentes y jóvenes a los servicios de SSR y VIH en América Latina. Nova York, 2015.). At the macro level, the legal framework admits unacceptable contradictions that amplify inequalities: (1) adolescents must be 15 years old to be treated alone in programs and SSSR, but at the age of 12 they can already be held criminally responsible. On the one hand, the adolescent’s health seems to be only restricted to sexuality and reproduction, and on the other hand, the idea of relating adolescents to the violation of norms is reinforced; (2) girls can legally enter into marriage/civil union with the consent of parents/guardians/judges at age 14, but boys only from the age of 16 (Venezuela, 2015VENEZUELA. Ley Orgánica para la Protección del Niño y el Adolescente (LOPNA). Gaceta Oficial de la República de Venezuela, Caracas, n. 6185, 8 jun.2015.); and (3) a girl (like the other groups of the country’s female population) is prohibited from having an abortion, except when her life is at risk (Venezuela, 2000VENEZUELA. Extraordinario no 5.494, de 20 de octubre de 2000. Gaceta Oficial de la República de Venezuela, Caracas, 20 out.2000.).

In this sense, the discursive production of professionals and adolescents is strongly marked by the stereotypes (including those of gender) and beliefs present in Venezuelan society. Polarization (Van Dijk, 2013VAN DIJK, T. A. Discurso y poder. Barcelona: Gedisa, 2013.), a key characteristic in hegemonic discourses, highlights the negative characteristics of this minority group as “difficult, liars, poor communicators, without cognitive capacity, among others”, which justifies the different forms implemented to argue “non-attention”, to the point that it is not a concern the low attendance by adolescents to the HS.

Age appears as a naturalized and instituted barrier in the HS and in the juridical-legal framework, in some cases it is used to overlap the real reasons for the lack of care related to: the non-acceptance of adolescents exercising their right to be sexually initiated; the fears of professionals to assume responsibilities before parents/representatives/society; the lack of knowledge and limitations to offer counseling on controversial topics such as homosexuality, abortion, among others. Age represents different types of barriers to access (to care, to condoms, to information), but no mention is made of the legal framework, that is, what is established in the LOPNA - which is also limitative - is ignored in the speeches. There are discourses that confront the hegemonic and must be valued because they show that it is possible to facilitate access with strategies focused on the users.

Like other studies (Checa; Tapia, 2016CHECA, S.; TAPIA, S. (Coord.). Derechos sexuales y reproductivos de los y las adolescentes: diálogos posibles entre los jóvenes y los servicios de salud. Buenos Aires: Sociedad Argentina de Pediatría, 2016. Disponível em: <Disponível em: http://bit.ly/2zuc7xt >. Acesso em: 29 ago. 2019.
http://bit.ly/2zuc7xt... ; Global…, 2018GLOBAL Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization, Washington, DC, 24 set.2018. Maternal, newborn, child and adolescent health. Disponível em: <Disponível em: http://bit.ly/2NGachQ >. Acesso em: 29 ago. 2019.
http://bit.ly/2NGachQ... ), in the discursive production of adolescents their expectations are to receive humanized attention that respects the principles of responsiveness -dignity, confidentiality, autonomy, immediate attention, choice, installations and communication- (Gilson, 2014GILSON, L. Aceitabilidade, confiança e equidade. In: MCINTYRE, D.; MOONEY, G. (Org.). Aspectos econômicos da equidade em saúde. Rio de Janeiro: Editora Fiocruz, 2014. p. 163-190.). In opposition to the stereotyped image of adolescents, they produce discourses against hegemonic statements about abortion and inequality of care, thus claiming their right to opportune and quality access to the HS.

Trust appears as an important value in the formation of links between professionals and adolescents, built on the basis of the interpersonal relationship and the quality and opportunity of services. The training of professionals is identified as a strategy for raising awareness and incorporating the information and tools necessary for the care of adolescents.

Some forms of abuse of power in the HS appear, which requires sensitization processes that involve the agents (managers, professionals and users) to understand that this is a violation of rights, as well as to (re)produce practices that combat them. In many cases, adolescents are double victims; on the one hand, parents/representatives may be the first barrier to overcome by denying them the possibility of going to the HS, and on the other, the obstructed access to HS.

The discursive production of professionals is permeated by organizational culture. This can directly or indirectly impede adolescents’ access to HS, reinforcing patterns that reproduce norms established by the legal route, as well as those instituted by the organizational task (Rivera, 2006RIVERA, F. J. U. Análisis estratégico en salud y gestión a través de la escucha. Rio de Janeiro: Editoral Fiocruz, 2006.). At the same time, it can promote the creation of more flexible and humanized spaces. The gaps between the perspectives of professionals and adolescents, influenced by the organizational culture, stand out as key elements for (re)thinking about how the HS can facilitate access for this population, with new institutional positions that prioritize communicative actions and struggles for changes in the legal framework. In the case of health and access to HS, it is necessary to think in broad frameworks, supported by the right, that give sustenance and legitimacy to care and, at the same time, protect users with instruments that are opposed to the unethical, non-communicative use of care practices for adolescents, which constitutes a great challenge (Artmann; Rivera, 2006ARTMANN, E.; RIVERA, F. J. U. Humanização no atendimento em saúde e gestão comunicativa. In: DESLANDES, S. F. (Org.). Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro: Editora Fiocruz, 2006. p. 49-83.).

CDA as a theory can contribute to acceptability studies because it allows us to understand how practice in health systems is being influenced by social structures, and at the same time identify the counter-hegemonic discourses produced in the everyday life of HS, which can modify health service practices, as well as the dimensions of the social structure. Another aspect is that it makes it possible to capture the social gap between health systems (by the discourse of professionals) and adolescents and to analyze them from a complementary perspective and not as a counterpart. CDA’s interest in situations of inequality and abuse of power makes it possible to give a voice to minority groups (such as adolescents) by identifying strategies for achieving equity in access to HS.

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