The health status of adolescents in Ecuador and the country’s response to the need for differentiated healthcare for adolescents

Traffic injuries, suicide, and violence

The most common cause of death in 2011 among adolescent girls was suicide (13% of all deaths), as opposed to traffic injuries among adolescent boys (19%) [9]. Traffic injuries were the second most common cause of death for girls (8%). For boys, violence was the second most common cause (12%), and suicide the third (7%).

Mental health and suicide

There is a growing recognition worldwide that mental ill health among adolescents has been a neglected issue [5]. The indicators for Ecuador are definitely a matter of concern. The country is among those with the highest suicide rates among young people in the Americas region. Further, these rates have been increasing [14]. Rates are higher for women than for men in the age group 10–19 (7.1% vs 6.4%), but higher for men in the age group 15–24 (13.0% vs 9.3%). A 2007 school-based health survey among students aged 13 to 15 years found that 17% in the cities of Guayaquil, 17.5% in Quito, and 19.4% in Zamora had considered attempting suicide during the preceding 12 months [15].

Violence

Another major national concern is Ecuador’s high level of violence among adolescents. The school survey quoted above found that 34.8% of students in Guayaquil, 36.2% in Quito, and 36.1% in Zamora had been physically attacked one or more times during the preceding 12 months. Girls and women also have a high risk of being exposed to violence by their partners. The lifetime prevalence of intimate partner violence (IPV) is estimated at 35% for physical violence, 14.5% for sexual violence, and 43.4% for psychological violence (INEC 2011 quoted in [16]).

Alcohol use

Alcohol consumption often starts early among adolescents in Ecuador. A national survey of drug use among students in 2008 found that the mean age for trying alcohol for the first time was 12.8 years [17]. In 2014, the Ministry of Public Health reported that 45.6% of the Ecuadorian population (47.2% of men and 43.9% of women) between 10 and 19 years, and 21.3% of children between 10 and 14 years declared that they had tried alcohol. Some 12.9% of 10–14-year-olds reported having been drunk at least once. As many as 24% of adolescents 13 to 15 years old in Guayaquil, 27.7% in Quito, and 27.8% in Zamora, said they had consumed so much alcohol that they had been “really” drunk one or more times in their lives [15]. Having tried alcohol early is more common among adolescents in indigenous groups and in the poorest quintile of the population [18].

Overweight and obesity

The 2007 school-based survey also found that 28.6% of the 13- to 15-year-old students in Quito were overweight and 7.3% were obese [15]. A study of a group of urban and rural Ecuadorian adolescents reported that dyslipidemia, abdominal obesity, and overweight conditions were prevalent in 34.2, 19.7, and 18.0%, respectively, of the population and that 59% of Ecuadorian adolescents have poor levels of physical fitness [19]. Just over a fourth of Ecuadorians between 10 and 18 years old exceeded the recommended minimum level of physical activity [18].

Early child bearing and adolescent maternal health

The major national issue concerning adolescents’ SRH is the high rate of teenage pregnancies. The National Demographic and Maternal and Child Health Survey (ENDEMAIN) in 2004 found that more than 20% of Ecuadorian women surveyed (age 15–49) had had a child or had been pregnant when they were adolescents [20]. Early pregnancies carry elevated risks of complications both for mother and the child, and are considered an obstacle to the social and economic development of families and communities [21, 22]. Some 4% of deaths among female adolescents in Ecuador are due to complications during pregnancy and birth [9].

According to 2010 statistics from National Statistics and Census Institute (Instituto Nacional de Estadística y Censos—INEC), 44.1% of mothers had their first child when they were 15 to 17 years old, and 2.4% had their first child when they were between 12 and 14 years old. Some 3.4% of the approximately 3.6 million mothers in Ecuador in 2010 were between 12 and 19 years old, which corresponds to a reported figure of 122 301 adolescent mothers [20]. The percentage of adolescents in the age group 15–19 with a least one child increased from 14.84% in 1990 to 17.53 in 2010 [20]. Data from 2013 on births show that 19.48% of all births corresponded to women aged 15 to 19, and 0.76% corresponded to girls under the age of 15 [20].

Child bearing, socioeconomic level, and school attendance

In 2012, some 84% of Ecuadorians between 15 and 17 years old went to school, but three out of 10 were lagging behind in their studies—that is, not attending the grade levels corresponding to their ages. Of these, half were from indigenous communities [20]. The proportion of mothers younger than 19 years is highest in groups with low income and low education. Forty-seven percent of adolescents who were of low socioeconomic status became mothers or were pregnant during adolescence. About 70% of Ecuadorian mothers who became pregnant during adolescence already had quit school before becoming pregnant. Of the remaining 30%, some 12% continued their studies, whereas 18% interrupted their studies because of the pregnancy. Apparently 70% of those who interrupted their studies did not return to school [20].

Sexual activity and contraceptive use

As can be expected, the high number of pregnant adolescents is due to a combination of early sexual activity and low or inadequate use of contraception. The ENSANUT survey in 2012 found that almost six of 10 women between 15 and 24 years old had had a sexual experience. Some 54.6% of them had had this experience before they were married. This represents a considerable increase from 2004, when only 46.7% of those aged 15 to 24 had had a sexual experience, and 37.2% reported having had a sexual experience before marriage [20]. The school-based survey quoted above found that 26.0% of boys and 7.1% of girls aged 13 to 15 in Guayaquil had had sexual intercourse at least once [15]. The corresponding figures were 23.4% of boys and 8.1% of girls in Quito and 33.7% of boys and 9.9% of girls in Zamora 13 to 15 years had had sexual intercourse at least once.

According to the ENDEMAIN study in 2004, almost all adolescents (97%) knew about modern contraception methods; 47% were using them at the time of the survey, and 13.5% used them during their first sexual relationship (22). At the time of the ESANUT 2012 survey, the percentage of adolescents (15 to 19 years) reporting the use of contraception had increased to 68.9% [23]. Overall, the use of modern contraception has almost tripled over the last two decades among adolescents [23]. A national study found that 89% of those who were sexually active before they were 17 years old had not used a condom during their first sexual encounter (González-Rozada, 2010 quoted in MCDS 2014).

A study conducted in six secondary schools in the city of Cuenca, Ecuador, and in 20 secondary schools in Cochabamba in Bolivia found that sexually active adolescents (aged 14 to 18) who consider gender equality as important reported higher current use of contraceptives within the couples they had formed. They also were more likely to describe their last sexual intercourse as a positive experience, and considered it easier to talk with their partners about sexuality, in comparison to sexually experienced adolescents who were less positively inclined towards issues of gender equality [24].

Sexual violence

Research shows that a relatively high number of sexual relations result from violence or are accepted under circumstances where one of the partners, normally the girl, does not feel she can refuse [25]. Some 14.6% of the Ecuadorian women aged 15 to 49 reported in 2004 that they had experienced sexual violence in their lifetimes [25]. Less than a third (27.6%) of the students in a high school survey conducted in Rumiñahui County in the Province of Pichincha believed that it was acceptable to refuse sex at any time, and less than a quarter (23.4%) of students believed that it was not acceptable to refuse to sex under any circumstance, whereas half (49.0%) believed that the right of refusal depended on the situation [26].

Association between gender-based violence and early pregnancy

There seems to be an association between gender-based violence and pregnancy before age 18. Intimate partner violence is more common among those who become pregnant in early adolescence than it is among those who do so later. According to a governmental report published in 2014, women who became pregnant during adolescence are between 1.55 and 1.66 times more likely to be abused physically or psychologically by their partners or ex-partners than women who did not experience pregnancies during adolescence [20]. Having suffered from sexual abuse during childhood or adolescence was found to be a risk factor for adolescent pregnancy in a study conducted in Ecuador’s Amazon basin [27]. Likewise, a hospital-based study in Quito found that sexual abuse was more than three times as common among pregnant adolescents as compared to adolescent women who were not pregnant (14.9% vs 4.5%) [28].

Indigenous groups are more vulnerable

Some 9% of Ecuadorians from 0 to17 years old belong to indigenous groups, and 8% belong to Afro-Ecuadorian groups [9]. Adolescents from these groups, tend to score lower for all indicators of health, education, access to services, and poverty. For example, members of these groups have higher school drop-out rates, higher rates of teenage pregnancy and sexually transmitted infections (STIs), including HIV, lower rates of skilled medical care during child delivery, and higher rates of tobacco and alcohol use [29]. Some 66.7% of adolescent girls aged 15 to 19 in the Amazonian province of Orellana were pregnant at the time of the 2004 survey, as compared to 13.9% of adolescents in the most populous province of Guayas (ENDEMAIN 2004 quoted in Cabrero et al., 2010).

Gender issues

Gender inequality, for both girls and boys, is intensified by cultural norms (the “machismo”) that expects boys to be aggressive and dominant and girls to be submissive and obedient. This limits their ability to protect themselves and leaves them vulnerable to a wide range of health risks.

What we may conclude from the data presented above is that adolescents in Ecuador have a high risk of being exposed to violence, have worrying levels of mental illness, and are vulnerable to alcohol abuse, obesity, and insufficient physical activity. In addition, there is a pattern of early sexual debut with a lack of or limited knowledge on how to protect themselves and prevent unintended pregnancies, leading to increased adolescent fertility. International research has demonstrated that these issues often are connected. For example, alcohol use and intimate partner violence tend to be associated with early sexual debut and low use of contraception [30]. Research on female suicide has suggested that intimate partner violence and adolescent pregnancy are risk factors and that females who commit suicide are more likely to have experienced sexual abuse [14]. The situation of adolescents in Ecuador underscores the need to reach out to them with health information and to make health services youth-friendly and hence attractive to this age group.

Sources of information

Adolescents have limited access to information and to adult-led teaching on health matters. A survey conducted in seven high schools in 2005 in the province of Pichincha found that the most important source for general information about SRH was the media (83% of respondents). Only 14% reported that they received information from school. 60.9% responded that they had conversed with their parents about SRH, but only 11% cited their parents as information sources. Lack of trust and embarrassment were given as the main reasons for not discussing SRH with parents. Two percent reported obtaining SRH information from their friends. When it came to information, more specifically about family planning, school was the main source of information (23%) [26]. While only a small proportion of adolescents reported receiving information on SRH from their parents, a national UNFPA survey on perceptions surrounding family planning and contraception found that a large majority of the population is in favour of giving adolescents access to contraception, and in favour of providing adolescents with information about its use [31].

Barriers to the use of SRH services and access to information (structural, economic, socio-cultural)

Adolescents and young people face a wide range of barriers that can limit their access to health services. A study conducted on behalf of the Regional Andean Committee for the Prevention of Adolescent Pregnancies, divided the barriers of access into three main groups: sociocultural, institutional, and political (national or territorial) [7]. The last group includes legal and regulatory barriers. Low availability of health services, high costs, low quality, and lack of resources—including human resources—are some of the main barriers on the supply side.

Adolescence is commonly seen in Ecuador as a period prone to risks and problems, especially in matters of sexuality. Even though the UNFPA data presented above indicate that many people accept that adolescents should be able to access contraception, adolescents often encounter strict norms and moralistic attitudes from adults [9]. Gender relations are characterized by machismo (sexism), homophobia, and the expectation that women should become mothers early. Instead of providing information and encouraging/supporting their daughters to protect themselves from sexual and reproductive health problems, parents and guardians tend to try to prevent young women from having contact with men [9]. For many Ecuadorians, the only acceptable way for young women to avoid pregnancy is for them “not to go with men”. The national study of 2011 found that 68% of women and 61% of men did not approve of sexual relationships among adolescents [31]. These attitudes also are common among health workers [7, 32, 33]. Given this, one of the main barriers to adolescent access to contraception—and a major reason for the gap between knowledge about contraception and its actual use—is the attitude of health workers who believe that contraception is not an adequate response to sexual activity among adolescents [20].

At the same time, maternity is the natural horizon for many young women, and in particular for those from poorer regions, as motherhood allows them to be materially and symbolically acknowledged by their families, communities, and the State. Maternity also gives young women rights and services guaranteed by the Government [20]. Studies have found that many adolescents girls believe that for them there are no good alternatives to early motherhood for being acknowledged as adults and as responsible persons [7, 34]. This confluence between limited access to services and information on sexual and reproductive health on the one hand, and the idealization of motherhood on the other, leaves adolescents vulnerable not only to early pregnancies but also to sexually transmitted infections and to sexual violence.

Introduction and scaling up of differentiated health care for young people (2007–2011)

The following section describes the development in Ecuador of differentiated health services for adolescents. This differentiated approach was conceived to respond to the challenges and needs described above. In 1988, Ecuador saw the start of a historic process with the opening of a ‘Servicio de atencion integral para adolescentes embarazadas’ (Service for the integrated care of pregnancy adolescents) at the Isidro Ayora de Quito Obstetrics-Gynaecology Hospital. The establishment of this service made visible the demand and the need for health services among adolescents. In 1992, the National Programme for Adolescent Health developed a manual of norms and procedures for comprehensive adolescent health care. The manual was developed by medical professionals and employed a biomedical approach [10]. In 2005, the National Policy for Sexual and Reproductive Health identified adolescent pregnancies as a priority issue and stated that services for them must be strengthened [35]. However, until 2007, only three public health units other than the Isidro Ayora hospital, were in place to provide differentiated care for adolescents [7]. The adolescent friendly services at Hospital Isidro Ayora in Quito, as well as three primary level units, were initiated and continued on the initiative of individuals and groups particularly interested in the addressing the health problems of adolescent. The model was not expanded nor replicated until 2007 mainly because of lack of political will.

In 2007, the Andean Plan and the National Plan for the Prevention of Adolescent Pregnancy [13] and in 2009, the New Guidelines for Comprehensive Care of Adolescent Health, were launched [11]. The National Plan for Adolescent Pregnancy Prevention uses a rights-based approach and is founded on the assumption that for adolescents to exercise their reproductive rights they not only need access to a network of services but also must be empowered to take control of their sexuality. A primary issue addressed by the plan was the urgent need for information on vulnerable or marginalized groups requiring priority attention. These included young adolescents (10–14 years); adolescents with little education; those out of school; rural and indigenous groups; those living in isolated areas of the country; as well as migrants, internally displaced persons, and refugees.

The 2009 Guidelines for Comprehensive Care for Adolescent Health promoted care based on: (i) differentiated services delivered with a comprehensive, intercultural, participatory, and rights-based approach; and (ii) friendly care characterized by respect, confidentiality, positive attitudes among health care workers, and appropriate skills and competencies among such workers. The model of differentiated health care was named Servicios de Atención Diferenciada para Adolescentes (SADA). This new focus aimed to facilitate access of adolescents (10–19 years old) to health services. The Ministry of Public Health (Ministerio de Salud Pública—MSP) promoted the implementation of differentiated services for the integrated care of adolescents in first-level health units and in hospitals based on a “normative package” for such care (norms, protocols, and quality standards) and on sensitization of and capacity building of the multi-disciplinary personnel in health establishments. The guidelines referred to above state that differentiated services should include “trained full time personnel who provide care grounded in rights-based, gender-sensitive, culturally-sensitive, participative and integrated approach”, and that they should do this in a “placed adapted to the needs and preferences of adolescents, and assigned to their use only” [11].

To address the problem of early pregnancies, the Government formulated the National Inter-sectoral Strategy for Family Planning and the Prevention of Adolescent Pregnancies (in Spanish Estrategia Nacional Intersectorial de Planificación Familiar y Prevención de Embarazo en Adolescentes (ENIPLA) in 2011. This framework called for action in four areas:1) maintaining adolescents in the education system and strengthening comprehensive sex education, 2) improving adolescents’ access to SRH services including methods of contraception, 3) family and community action, social dialogue and co-responsibility, and 4) promoting changes in sociocultural patterns.

Also in 2011, a major shift in policy was announced as the Ministry of Public Health launched a model for the provision of integrated family and community health care (Modelo de atención integral del sistema nacional de salud familiar comunitario e intercultural (MAIS-FCI)). MAIS conceptualizes bio-psycho-social quality care with an emphasis on prevention and promotion that pays attention to every person in an integrated way and supports human development. The MAIS framework gives priority to integrated care throughout the lifecycle and to family and community medicine, which, by consequence, meant the abolition of vertical programmes. As can be expected, this had an effect on the differentiated approach taken for adolescents. At the national level, the adolescent programme was dis-established, and at local level, the transition process was affected by a lack of guidance from the new model in terms of management of the SADAs. However, in the National Plan for Wellbeing (2013–2017) there is a call to guarantee effective access to integrated services for sexual and reproductive health [9].

Achievements of the differentiated services programme

A survey was carried out by the Ministry of Public Health in collaboration with UNFPA to map the status and the achievements of the SADAs, in 2012 [36]. Responses were received from 74 of the 158 SADAs which reports suggested were in place in 2011 (a 46.8% response rate), and from 14 of 24 provinces (a response rate of 58%). In addition, responses were received from 26 new health facilities that had initiated SADAs during the year before the survey, bringing the total number of SADAs that responded to 100 (out of the composite total number of 184). Some of the SADAs which did not respond had allegedly stopped offering differentiated services for adolescents due to staff shortages or reorganizations.

The survey results showed that the number of SADAs gradually increased from 38 in 2008 to 97 in 2009, to 139 in 2010, to 158 in 2011. In 2011, all 24 provinces had differentiated care for adolescents. There were only two to three SADAs in each of five provinces and four SADAs in each of nine other provinces. Further, there were 27 SADAs in Guayas, 29 in Pichincha, and 15 in Manabi. This means that these three most populous provinces, which together had 52.5% of the country’s population in 2010, had 38.5% of the SADAs in 2012 [36].

Of the 14 responding provinces, 11 reported significant increases in service use by adolescents, and two reported a decrease (Pichincha, down 30%, and Cotopaxi, down 9%). From 2008 to 2011, the number of prevention services offered increased in these 100 units from 138,787 visits to 264,924, this represented a 90.9% increase. A large part (57.5%) of this increase, however, occurred in one province: Guayas, which has 25% of the nation’s population, reporting 72,521 more consultancies in 2011 (from 63,792 visits to 136,313). This means that for the rest of the country, the increase was 71.5% (53,616 more consultancies, up from 74,995 to 128,611). The trend was the same for the two other types of services covered by the survey (consultancies for morbidity and pregnancy) [36].

The survey found that in 2011, 1061 health professionals were sensitized and trained to attend to adolescents in these 100 units. A third (32%) were medical doctors; 20% were obstetricians; 14% were nurses or odontologists; 4% were psychologists; and 2% were social workers and nutritionists [36].

In terms of community sensitization about the SADAs and the need to prevent adolescent pregnancies, 63,004 persons were reported to have attended educational activities (almost one third of them in Guayas). These activities were offered to adolescents (in 83% of the cases), to fathers and mothers (11%), to teachers (2%), and to others such as police officers, firemen, civil defence officials, and community leaders (4%) [36]. The survey did not collect data on the extent that disadvantaged groups benefitted.

The elements and achievements described above preceded the institutionalization of integrated care for adolescents within the first level of MAIS-FCI. The rationale for this new approach, as stated above, was to reduce tendencies towards the fragmentation and segmentation of services and systems in a way that might compromise the quality of service provision and lead to inequalities in access to services. This meant a move away from differentiated care for particular groups towards an approach in which all groups—in theory—would receive the same level of care throughout their lifecycles.

Consequently, the capacity building, the support systems and the follow-up for the SADAs were discontinued. It also meant that local health authorities in many cases no longer considered adolescents as a group that should receive differentiated care. That fairly quickly led to a situation wherein staff who had been trained to care for adolescents felt ignored and rudderless, and found themselves no longer in a position where they could use the skills for which they had been trained [36]. Interviews with health personnel who had been trained to provide differentiated services for adolescents indicated that they subsequently had to work with all groups of patients and were confused about their roles [36].

Consultations held with health personnel in the context of this study confirmed that some of the problems caused by the transition from SADAs to MAIS, were: uncertainty related to the competencies needed to serve the broader population; lack of technical skills; discontinuation at the central level of management and follow-up of training and implementation; loss of data collected by the SADAs; and dismantling of the SADAs by local authorities. Reportedly, some facilities in some places continue to offer differentiated care for adolescents within the MAIS framework while also extending services to the population as a whole. However, at times this continued differentiated care takes place under difficult conditions, such as the loss of dedicated time slots and/or work spaces. Continuation of adolescent-targeted care now may depend to a large degree on the presence of committed persons and on local management willing to assign young people priority.

Meanwhile, data on the uptake of services and on how the transition from the previous model has been perceived by adolescents are scarce. One important reason for this is that reports are no longer collected from the information system previously established by the SADAs.