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“Fostering Autonomy” for Adolescents to Access Health Services: A Need for Clarifications

  • Julien Brisson
    Correspondence
    Address correspondence to: Julien Brisson, Department of Social & Preventive Medicine, School of Public Health, University of Montreal, 3039, Pav 7101 av. du Parc, Montréal QC, H3N 1X9, Canada.
    Affiliations
    Bioethics Programs, Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Canada
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  • Vardit Ravitsky
    Affiliations
    Bioethics Programs, Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Canada
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  • Bryn Williams-Jones
    Affiliations
    Bioethics Programs, Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Canada
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      The global health literature studying adolescent health issues has shown that adolescents are among the groups that least use health services despite having serious health-related needs [
      • Patton G.
      • Sawyer S.
      • Santelli J.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. To help promote adolescent health, the World Health Organization's Global Accelerate Action for the Health of Adolescents advocates implementing measures to “foster the autonomy” of adolescents to access health services ([
      ], p.93). The argument is persuasive: protect the well-being of adolescents. However, there are significant challenges to understanding what is actually meant by “fostering autonomy” and the possible or necessary steps required for adolescents to be able to both choose and have access to health services. For example, fostering autonomy could entail the development of decision-making skills (e.g., knowing how, when, and where to access health services) or the implementation of enabling policies to make health services more accessible for adolescents, such as removing financial or geographic barriers that impede access.
      To clarify the World Health Organization's concept of “fostering autonomy” for adolescents to access health services, we present in Table 1 clarifications meant to help provide orientation and guide researchers, policy makers, and health professionals involved in adolescent medicine and health research. The first part is centered on education, and the second focuses on policies. In each subsection, an explanation is provided on how to foster adolescent autonomy to access health services.
      Table 1Categories to “foster the autonomy” of adolescents to access health services
      Fostering autonomy through education
      1. Education to improve health literacy
       To access health services, adolescents must first have health literacy: health-related knowledge, an understanding of what constitutes health problems, and of possible remedies. As a group, adolescents have specific prevalent health-related needs (e.g., mental health). Thus, they must possess the knowledge to recognize when they are experiencing health problems, such as symptoms, and understanding what issues would require medical or other attention.
      2. Education about local health systems
       It is crucial to educate adolescents about their local health systems and how they can access health services. Greater health literacy can enable an adolescent experiencing a health problem to first recognize the problem and then know how to navigate their local health systems to access appropriate services.
      3. Education about rights and restrictions to access health services
      Health literacy and knowledge of one's local health system do not automatically translate into the ability to independently access health services. Some countries have strict parental consent laws, whereas in other countries there are parental consent laws that support adolescents exercising autonomy to access health services. Hence, adolescents' autonomy can be fostered by educating them about their rights and existing local restrictions to access health services.
      Fostering autonomy through policies
      4. Development of enabling policies for adolescents
       The best educational and health literacy program will be insufficient if it is not complemented by policies that enable adolescents to actualize their knowledge and autonomy. Structural factors may prevent adolescents from accessing health services (e.g., stringent parental consent laws, high cost for services, restricted hours for clinics). Policy change is needed to remove these barriers and allow adolescents to access health services.
      5. Training healthcare professionals
       As adolescents constitute a unique group of patients (e.g., emerging autonomy, distinctive health needs), healthcare workers should have specific training to interact appropriately with adolescent patients. Within such training, healthcare workers need to develop the skills to foster adolescents' autonomy in accessing and using health services and to make health-related decisions (e.g., ask them suitable questions so that they can make an informed decision regarding a particular form of treatment). Training must also be provided regarding adolescents' evolving capacities. Healthcare professionals need to learn developmentally appropriate strategies to involve parents in supporting adolescent health and their emerging autonomy.
      The concept of autonomy can have many different meanings that are interrelated but have different import. For example, in some contexts, autonomy is synonymous with independence, whereas in others, it represents agency (i.e., having a genuine ability to make choices) [
      ]. When engaging in initiatives to foster or promote adolescent autonomy to access health services, the distinction between the various meanings of autonomy should be considered. Simultaneously, consideration must be paid to the wide normal developmental variability among adolescents between the ages of 10 and 20 years to develop age-appropriate initiatives related to their autonomy.
      Exploring ways to “foster autonomy” should involve adolescents by meaningfully engaging them on topics that directly impact them [
      • Mabaso Z.
      • Erogbogbo T.
      • Toure K.
      Young people’s contribution to the Global strategy for women’s, children’s and adolescents’ health (2016–2030).
      ]. They should, for example, know what initiatives are being developed and, with what means, to help foster their autonomy to access health services. Furthermore, within each initiative, it is important to consider and make explicit the articulation of different categories or views of autonomy. For example, historically, in sex education for adolescents in schools, much attention was given to prevention through health literacy (e.g., how to use condoms). However, there has not been the same attention to knowledge development regarding how to access sexual and reproductive health services, such as clearly explaining how to get an HIV test or access contraceptives in a clinic [
      • Chandra-Mouli V.
      • McCarraher D.R.
      • Phillips S.J.
      • et al.
      Contraception for adolescents in low and middle income countries: Needs, barriers, and access.
      ].
      While education initiatives to foster adolescents' autonomy to access health services may be conducted in schools, it is crucial not to ignore the possibly highly beneficial role of adults in adolescents' life (e.g., parents, caregivers, teachers, other family members, social workers) in being well-positioned to promote and foster the development of adolescents' autonomy to access health services. For example, in Colombia, there is Profamilia, which is a network of nonprofit clinics across the country which provides accessible sexual and reproductive health services to the population. Trained health workers (e.g., psychologists, social workers, nurses) often go to underprivileged neighborhoods to present to young people, including their parents, the available services at Profamilia. The workers answer any questions adolescents and their parents might have regarding access to Profamilia's services, such as the costs of services based on the type of health insurance parents have or clarifying information (e.g., parental fear that contraceptives can harm adolescents). This example highlights the interconnection of different categories to foster adolescents' autonomy to access health services and the pertinence of involving parents of adolescents on the topic.
      There is a strong ethical justification to foster the autonomy of adolescents to access health services; adolescents represent a vulnerable population, no longer children but not yet adults. Based on bioethical principles of non-maleficence and beneficence, it is unethical to withhold information or impede adolescents' access to appropriate services that can help address their health issues. While health systems can be complex to access and navigate, even for adults, adolescents should not have to wait to become adults in order to be able to understand how to access and use appropriate health services. Fostering adolescents' autonomy to access health services needs to be a comprehensive process: adolescents need knowledge about health, about how to access health services (and the limits), and these initiatives have to be complemented by the reduction of barriers and implementation of facilitating policies to improve access (policy change).

      Acknowledgments

      This work was supported by Julien Brisson's Canadian Doctoral Award to Honor Nelson Mandela given by the Canadian Institutes of Health Research (CIHR) grant number: 201610GSD-385545-283387.

      Funding Sources

      This work was supported by the first author's Canadian Doctoral Award to Honour Nelson Mandela given by the Canadian Institutes of Health Research (CIHR).

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