Improving and sustaining adolescent access to primary care in a socioeconomically vulnerable urban community in Brazil: outcomes of a quality improvement initiative

Abstract

Background

Ensuring effective inclusion of adolescents in primary care remains a major challenge within health systems. Despite structural efforts, adolescents still face barriers like stigma, low health literacy and limited access to preventive care.

Aim

To assess the implementation of an initiative aimed at strengthening adolescent access to and use of primary care services.

Methods

We conducted a quality improvement (QI) study in a socioeconomically vulnerable community (Paraisópolis, São Paulo, Brazil). The initiative was divided into three phases: preintervention (October 2022–March 2023), intervention (April 2023–March 2024) and postintervention (April 2024–September 2024). The Model for Improvement was used to build capability in healthcare teams, providing them with evidence-based QI strategies to improve adolescent care, and complemented by principles of implementation science to enhance the adoption and sustainability of QI interventions.

Results

The percentage of adolescents accessing primary care increased by 29.8% during the intervention period (10.4%–13.5%), sustaining this improvement in the postintervention period (13.8%). Human papillomavirus vaccine administration steadily improved (from 52.0% to 64.4% to 72.4%). Consultations with physicians (from 3.4% to 5.7% to 8.1%), nurses (from 3.2% to 8.2% to 11.0%), multidisciplinary professionals (from 0.6% to 0.8% to 0.7%) and odontologists (from 1.5% to 4.4% to 4.3%) increased across all participating health centres.

Conclusion

Applying systematic and structured QI methodologies and implementation science strategies can enhance adolescent engagement in primary healthcare in limited-resource urban settings in Brazil. Our initiative offers a scalable, evidence-based and sustainable approach to strengthening adolescent health access, aiming for equitable service delivery.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Adolescents continue to face persistent barriers to accessing and using healthcare services, particularly in socioeconomically vulnerable communities. Evidence remains limited on how to implement and sustain structured, scalable initiatives that measurably improve adolescent access to routine primary care.

WHAT THIS STUDY ADDS

• This study evaluates a community-based quality improvement initiative that combined the Model for Improvement with implementation support to increase adolescent access to primary care. Adolescent access increased by 29.8% (10.4%–13.5%) and remained above baseline after the intervention (13.8%), suggesting sustained engagement beyond the active implementation period.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The results show that structured capability-building and intersectoral partnerships can improve adolescent access to primary care, providing a pragmatic model that could inform the scale-up of adolescent-focused service delivery strategies.

Background

Adolescence is a vital stage in human development, marked by physical, emotional and social changes that demand attention from healthcare systems.^{1 2} However, adolescents often face significant barriers when accessing primary care services, including, but not limited to, a lack of tailored health education, inadequate environments for discussing sensitive topics such as mental health and sexual and reproductive health, and social stigma that discourages help-seeking behaviours.^{2 3}

In urban communities affected by socioeconomic vulnerability, these challenges are intensified by limited access to health services, community violence, underinvestment in adolescent-specific education, structural inequalities, weak intersectoral coordination and fragmented support networks across sectors.^{3 4} In these contexts, health initiatives must contend with urgent socioeconomic demands, often needing adaptable, community-involved strategies that can manage competing priorities and limited resources.^{5 6}

Despite growing attention to adolescent health in international and national policy frameworks,^{2 5 7 8} there is a limited body of implementation science research evaluating quality improvement (QI) interventions tailored explicitly for adolescents within primary care settings. Existing literature highlights the importance of educational strategies and interprofessional collaboration^{2 5 7 8}; however, evidence remains scarce on how to effectively structure, monitor and sustain interventions at the community level.39,11

To address these gaps, we developed a community-based QI initiative called ‘Come Together’ (from the Portuguese: “Chega Junto”—CJ), aimed at increasing adolescent access to and use of primary care services. This study aims to evaluate the effectiveness of the CJ initiative in improving adolescent engagement with the Brazilian primary health system.

Methods

Context

The CJ initiative was launched in Paraisópolis, one of the most densely populated and socioeconomically vulnerable neighbourhoods in São Paulo city,¹² with an estimated population of nearly 60 000 residents (about 13 000 adolescents). Paraisópolis faces serious challenges in adolescent health, including low participation in preventive care, low vaccination rates, exposure to sexually transmitted diseases, high teenage pregnancy rates, use of alcohol and drugs, and under-reporting of mental health issues (Sources: electronic unified health system (Sistema Único de Saúde electrónico or e-SUS)¹³ and the São Paulo integrated healthcare management system (Sistema Integrado de Gestão de Assistência à Saúde or SIGA).

Study design

A QI initiative, conducted between March 2023 and February 2024. For this report, we followed the Standards for Quality Improvement Reporting Excellence (version 2.0).¹⁴ The initiative used the Model for Improvement framework,^{15 16} coupled with a pragmatic application. Data were collected continuously during the 12-month intervention and analysed retrospectively to evaluate the initiative’s outcomes.

Settings and participants

The project was conducted in three health centres in Paraisópolis, where the multiprofessional primary health team actively participated in the QI interventions.

The capability-building strategy was carried out by a team composed of professionals with expertise in adolescent health and QI.

The activities were focused on children and adolescents aged 9–19 years living in the territory. We include 9-year-olds because the indicators’ data are aggregated at the SIGA level.

Intervention

The intervention was structured into four thematic implementation 2-months steps, each focused on a specific set of adolescent health priorities: (1) adolescent access to health services, (2) health promotion and vaccination, (3) gender and sexuality and (4) social skills and life planning. An additional fifth sustainability step focused on consolidating and scaling successful practices.

At the start of each cycle, primary care teams received a framework outlining the objectives, core activities and expected outputs. They received support materials, practical tools for organising activities, and curated educational texts to guide discussions and service redesign. These materials were combined with ongoing mentoring through in-person and virtual learning sessions (LS). The in-person LS were mainly focused on strengthening clinical reasoning, communication skills and sensitivity to adolescent experiences, and the virtual LS supported ongoing reflection, shared problem-solving and the adaptation of strategies to emerging needs. This approach ensured that teams were not only trained conceptually but also had access to concrete strategies, examples and resources to facilitate the integration of adolescent-centred activities into daily practice.

Enabling the environment for change

To support the intervention, an enabling environment was established through weekly planning meetings, coaching support and leadership engagement. Teams additionally received mentoring on measurement systems, leadership strategies and communication tools. Integration between care providers and community stakeholders was fostered to ensure coordinated action and sustainability.

Implementation approach

The core implementation strategy relied on a combination of two methodologies: (1) the Model for Improvement supported the use of driver diagrams, the identification of change ideas, and the execution of Plan, Do, Study, Act (PDSA) cycles; and (2) Implementation science involved a mix of in-person and virtual LS, virtual immersion weeks, technical visits, specific coaching, frameworks and ongoing support for frontline teams, with a strong focus on adoption and sustainability.

Table 1 summarises the driver diagram, changes in ideas, PDSA cycles and the main learning from the CJ initiative during its implementation.

Table 1. Driver diagram of the Chega Junto initiative.

Project objective	Primary drivers	Change ideas (secondary drivers)	Before intervention	PDSA (52)	Learning
Increase the access of adolescents aged 9–19 to the Paraisópolis public health system (April 2023–March 2024).	Build capacity of professionals in primary care network regarding adolescent care	Conduct training sessions on growth, development, sexual and reproductive health, and psychosocial issues	Professionals lacked specific training to address the unique needs of adolescents	3	Training expanded the capacity of primary care teams to address adolescent-specific needs, improving confidence and consistency in health promotion delivery
		Invest in peer education methodology	Educational efforts relied solely on adult-led approaches, limiting resonance with adolescent audiences	5	Peer education proved effective in increasing adolescent engagement, particularly when messages were co-created and led by youth from the same community
	Expand adolescent awareness and adherence to self-care	Promote adolescent participation in planning, execution and evaluation of health actions	Adolescents were rarely involved in shaping health services, leading to low relevance and engagement	3	Youth participation enhanced the relevance and acceptability of interventions, fostering a sense of ownership and sustained interest in health activities
		Develop a scalable Adolescent Health Promotion Framework	There was no unified framework to guide consistent, comprehensive adolescent health actions across teams	2	A standardised guide helped align practices across different teams, while maintaining flexibility to adapt to local contexts
		Implement socio-educational activities	Health promotion was limited to informational materials, lacking interactive or youth-centred approaches	2	Interactive activities (eg, games, group discussions) increased health literacy and created safe spaces for adolescents to ask questions and express concerns
		Facilitate critical reflection on sexual and reproductive health	Conversations on sexuality were avoided or overly clinical, creating discomfort and perpetuating stigma	2	Structured reflections encouraged adolescents to explore topics often surrounded by stigma, improving their autonomy in health-related decision-making
		Share risk information and STI/HIV prevention	Preventive messages were fragmented and often failed to reach adolescents in language they understood	4	Engaging parents is critical for HPV vaccine uptake
	Identify adolescent health needs and standardise care	Map adolescent health profiles via school surveys and focus groups	Services lacked structured tools to understand adolescent perspectives and needs at the community level	5	Local data collection provided valuable insights into adolescent perceptions, informing targeted interventions and revealing gaps in service outreach
		Identify reasons for seeking care and access barriers	Barriers to access were assumed rather than documented, limiting targeted improvement efforts	4	Mapping motivations and barriers helped tailor communication and service flows to adolescents’ realities, increasing perceived relevance and trust in the system
		Recognise nutritional disorders and risk factors	Nutritional concerns in adolescents were overlooked, with limited screening or tailored guidance	1	Training on nutrition improved early detection and referral, especially in cases of obesity and undernutrition often overlooked in adolescent care
		Address substance abuse and risky behaviours	Risk behaviours were addressed reactively rather than through prevention or early dialogue	1	Approaches that combined harm reduction with open dialogue were more effective in building trust and initiating conversations around drug use and risk
		Design gamified and artistic prevention strategies	Educational strategies were not adapted to adolescent learning styles or interests	4	Creative tools, such as games and artistic expressions, enhanced engagement, particularly among younger adolescents, making prevention more relatable
	Strengthen intersectoral coordination to ensure integrated care	Improve system response capacity for adolescent health	Services were not organised to accommodate adolescent-specific demands, leading to fragmented care	4	Streamlining internal flows and strengthening professional roles made the system more responsive to the specific demands of adolescent users
		Map existing resources across sectors	Intersectoral assets (schools, social protection, culture) were disconnected from health actions	4	Identifying and articulating local education, culture and social protection services expanded the support network and enabled timely referrals
		Develop shared care flows	Care was siloed across professionals and services, lacking coordination and continuity	4	Co-created care pathways improved continuity, especially for adolescents with chronic conditions or recurring needs, by aligning roles and responsibilities
		Promote intersectoral vaccine coverage strategies	Vaccination efforts were limited to clinic-based settings, missing opportunities in schools and the community	4	School-based and community-integrated approaches proved more effective than facility-based vaccination alone, particularly for increasing HPV uptake

HPV, human papillomavirus; PDSA, Plan, Do, Study, Act; STI, sexually transmitted infection.

Measurement

A comprehensive set of indicators was established to track progress. The main outcome centred on improving adolescents’ access to primary care services. Process indicators included human papillomavirus (HPV) vaccination administration and the number of adolescent consultations with various healthcare professionals. Balancing indicators tracked the number of notifications related to self-harm and/or suicidal thoughts, and teenage pregnancy. The definitions of these indicators are described in online supplemental table S1. Participating centres submitted data monthly, which was reviewed to provide feedback and coaching.

Analysis

We used run chart analysis to identify monthly changes from baseline. The study design included three phases: a 6-month preintervention period (October 2022–March 2023), a 12-month intervention period (April 2023–March 2024) and a 6-month postintervention follow-up (April 2024–September 2024). Per cent changes were analysed across these phases. Run charts were developed in RStudio.

Results

A total of 72 professionals from the three participating health centres received 57.5 hours of structured capacity-building training, including 5 physicians, 12 nurses, 35 community health workers, 6 nutritionists, 3 psychologists, 2 dentists and 9 other technical professionals. These professionals actively participated in iterative PDSA cycles aligned with the project driver diagram, demonstrating how change ideas were progressively tested and refined (table 1).

Over the intervention, these change ideas were implemented and gradually integrated into routine practice, improving the system’s ability to meet adolescent-specific needs and supporting lasting improvements in access, vaccination coverage and multidisciplinary care delivery. The initiative also enhanced collaboration across sectors, establishing partnerships with five public schools, two community living centres and two socio-educational services, thereby expanding the scope of adolescent health efforts beyond clinical settings and into everyday community environments.

After the intervention period, there was a 29.8% increase (3.1 percentage points) in the proportion of adolescents accessing primary healthcare when compared with the preintervention baseline (10.4%–13.5%) (figure 1). During the postintervention follow-up, the percentage of adolescent engagement remained above the preintervention baseline (13.8%), though with slight fluctuations, suggesting partial sustainability of the gains.

Figure 1. Adolescent access to primary healthcare between October 2022 and September 2024 in the community of Paraisópolis (São Paulo, Brazil).

One of the key strategies of the intervention was to increase HPV vaccination administration. Figure 2 shows the proportion of adolescents who received at least one dose of the HPV vaccine during the studied period. The number of vaccine administrations rose steadily (from 52.0% to 64.4% to 72.4%).

Figure 2. Number of human papillomavirus vaccine doses administered (9–14 years) between October 2022 and September 2024 in the community of Paraisópolis (São Paulo, Brazil).

Adolescent care across professional roles

Figure 3A–D shows the increasing trend in the proportion of adolescent consultations conducted by physicians (from 3.4% to 5.7% to 8.1%), nurses (from 3.2% to 8.2% to 11.0%), multidisciplinary teams (from 0.6% to 0.8% to 0.7) and odontologists (from 1.5% to 4.4% to 4.3%).

Figure 3. Adolescent consultations by professional category between October 2022 and September 2024 in the community of Paraisópolis (São Paulo, Brazil): (A) consultation with nurses; (B) consultation with physicians; (C) consultation with the multiprofessional team; and (D) consultation with dentists.

Balancing indicators: mental health and adolescent pregnancy

Among the balancing indicators, there was a reported increase in the number of cases during the intervention, from 0.05% to 0.33% (run chart not shown).

Regarding adolescent pregnancy, data evidenced no variation in the number of pregnant adolescents seeking care during the intervention, maintaining a percentage of 10.9% (run chart not shown).

Discussion

Our initiative demonstrated a meaningful increase in adolescent participation in primary care services, with a 29.8% rise in access. This gain was accompanied by educational and preventive activities addressing key areas such as sexual, reproductive and mental health, which are historically marked by barriers to access, particularly in socioeconomically vulnerable settings. The increase in participation is therefore significant not only in quantitative terms, but also in reducing structural and relational barriers that have long limited adolescents’ presence in primary care settings. Additionally, the CJ initiative resulted in improvements across multiple service indicators. HPV vaccination administration increased steadily throughout the intervention, addressing a well-documented challenge in adolescent immunisation. Consultations with a range of health professionals also increased, indicating broader engagement across entry points within the system. Together, our results suggest that structured QI strategies, supported by implementation science tools, can produce measurable and meaningful changes in a relatively short period of time, even in resource-constrained contexts.

The observed improvements have significant implications for adolescent health outcomes and the development of effective, tailored public health policies. By increasing access and enabling timely interventions, the project helped eliminate barriers such as stigma, a lack of tailored information and service fragmentation—factors that often hinder adolescents’ engagement with the healthcare system.^{3 4} The CJ’s focused efforts may serve as a model for other Brazilian communities and for international adaptation.

Implications for public health

The project aligns with national health guidelines that emphasise comprehensive care for adolescents as part of the broader strategy for universal health coverage under the Brazilian Health System.^{5 6} The increased access and immunisation coverage not only contribute to improved individual outcomes but also lower long-term costs by preventing more severe complications such as HPV-related diseases, including the risk of cancer.¹⁷ By shifting service use towards preventive care, our QI initiative could prevent costly complications in adulthood, saving the health system and society money. National and international studies reinforce that early engagement of adolescents in sexual and reproductive health services helps prevent sexually transmitted infections.^{17 18}

Similarly, incorporating mental health detection and support into primary care, as demonstrated in global youth mental health models, lowers the risk of long-term, disabling conditions that can increase overall healthcare costs.¹⁹ Moreover, CJ’s strategy, including the preventive assessment by the odontological team, aligns with broader national policies in oral adolescent health programmes, which have expanded access but still struggle to close relative gaps in service use.²⁰ Therefore, beyond immediate gains, CJ may offer a scalable way to improve population health while decreasing inequities and health system costs throughout the lifespan.

Family, school and community engagement

Equally important is how CJ mobilised families, schools and community stakeholders to foster a supportive environment for adolescent health. In a systematic review by Ninsiima et al,¹⁸ the authors highlight that educating youth through community outreaches and school-based health education programmes can facilitate the utilisation and scale-up of the service. National surveys confirm that Brazilian adolescents have a high demand for health services but still face persistent inequalities in access.^{4 20 21} Our QI approach helped normalise care-seeking behaviours, reduced stigma around sensitive issues and taboo topics, and boosted adolescents’ trust in primary care teams.²²

Evidence also shows that school-based vaccination programmes consistently achieve higher uptake than clinic-based models, and that provider recommendation, parental endorsement and family communication are crucial for vaccine initiation and completion.²³

Vaccination

Before CJ, HPV vaccine uptake in Paraisópolis was only 34.7%, well below the national average and the Ministry of Health’s goal. Moura et al²⁴ demonstrated, in an exploratory analysis, the heterogeneity of HPV coverage across Brazilian microregions. Low educational level, low income, rural residence, limited access to information and health services, and barriers from religious dogmas have been identified as key individual obstacles to accessing and using the HPV vaccine.24,26 Traditional efforts—such as one-time school campaigns or isolated awareness programmes—have shown small short-term gains but often lacked long-term sustainability once external support stopped.²⁷ The success of CJ can be attributed to its focus on an ongoing support system that includes regular coaching, performance feedback and leadership involvement, while remaining adaptable locally through iterative improvement. This method aligns with systematic reviews indicating that multicomponent interventions, especially those combining provider engagement, reminders and education, are most effective in achieving sustained improvements in vaccination.27,29

Importantly, integrating culturally responsive education and addressing mistrust among minority and disadvantaged groups is essential since vaccination rates are lowest in these populations.³⁰ As described by da Silva et al,²¹ despite the demands of adolescents in primary care having increased in the last decade, they are still lower among males, people of black, brown and yellow skin colour and indigenous ethnicity.

Adolescent engagement in primary care services

Using diverse points of care enabled adolescents to discuss their concerns with trusted professionals, thereby strengthening continuity of care and fostering a psychological safety environment. These trends indicate improved organisational capacity and staff engagement in adolescent-centred care. Community health workers played a particularly vital role, given their daily presence in the community and their close relationships with families. Their ability to recognise emerging needs, anticipate vulnerabilities and support adolescents in navigating the health system helped create a more humanised and responsive model of care. By strengthening adolescents’ autonomy in seeking services, community health workers helped ensure that care was not only accessible but also meaningful and aligned with each young person’s lived experience.

The rise in multidisciplinary consultations is consistent with global recommendations for adolescent-friendly services, which emphasise diversifying care touchpoints and interprofessional teamwork to reduce physicians’ workload and improve accessibility.^{2 17 20} This model not only supports clinical care but also enables earlier detection of behavioural risks, developmental issues, nutritional problems, dental care and emerging mental health conditions that can be overlooked in routine medical visits.^{30 31}

The Brazilian National School Health Survey showed that 48.0% of adolescents looked for a health service or professional in 2012³² and 56.7% in 2015,³³ which shows an increase over the years, but still shows significant disparities based on sex, race and socioeconomic status.²¹ Multilevel analyses confirm that factors such as maternal education and family income strongly predict service use, while contextual effects of school or neighbourhood are comparatively weaker.³⁴ Similar inequalities have been observed in oral health, where national policy expanded coverage but persistent gaps remained,²⁰ and in cancer and HIV outcomes, where disadvantaged adolescents face disproportionate burdens due to late diagnosis, low health literacy and limited access to services.^{18 33} These disparities reveal the importance of integrating multidisciplinary, equity-focused models into primary care.

Furthermore, evidence from systematic reviews also confirms that service utilisation improves when interventions are multicomponent, provider-inclusive and continuously monitored with real-time data dashboards.^{28 29} Using publicity and a user-friendly platform such as e-SUS and SIGA, the CJ was able to track key fidelity indicators, study and plan adjustments when necessary in a timely fashion and reinforce the effectiveness of changes and provide positive feedback to the frontline team.

Among the balancing indicators, the slight increase in the number of notifications of self-harm and suicide-related behaviours is an unexpected but potentially insightful trend. Adolescents appeared more willing to seek support and report their experiences, a shift that could be attributed to the project’s mental health promotion component. Indeed, this increase should not be interpreted as a rise in self-harm or suicide-related incidents, but rather as a reflection of heightened awareness, improved detection and greater openness to disclosure among adolescents. In other words, the project appears to have strengthened teams’ capacity to identify and appropriately document these situations, rather than signalling a worsening of underlying risk.

Limitations and strengths

The CJ initiative is not exempt from limitations. First, the study design was observational and non-randomised, limiting causal inference. The improvements observed could be partially influenced by external factors, such as changes in municipal policies. However, the continuous monitoring of indicators, combined with the controlled nature of the intervention environment, helps mitigate this concern. Second, the project relied heavily on routine data sources, which, although robust, may suffer from under-reporting or delays in data validation. Finally, despite the adolescents’ involvement in several activities of our initiative, they did not participate in decision-making. Further QI initiatives should include an adolescent-centred model to better understand adolescents’ visions and opinions, including qualitative indicators such as affective and psychological outcomes.

A key strength of this initiative lies in its focus on sustainability. By monitoring indicators during the post implementation period, the project demonstrated that improvements were sustained over time. This continuity suggests that the initiative strengthened institutional and team-level capacity, rather than generating short-term gains dependent on external support.

Another strength was the intentional emphasis on workforce development: by directing the intervention toward primary care professionals and equipping them with practical tools, frameworks and implementation strategies, the project ensured that the practices introduced could be integrated into routine workflows regardless of the project’s duration.

Conclusion

The CJ initiative achieved meaningful and lasting improvements in adolescent access to healthcare and preventive services within a complex urban environment. By using improvement science tools, fostering intersectoral partnerships and emphasising adolescent-centred care, the project provides a replicable model for reducing health disparities in vulnerable populations. Its success highlights the importance of targeted, data-driven and locally tailored interventions. The lessons generated here are relevant not only for Brazil but also for other countries facing similar challenges related to inequity, resource constraints and the need to sustain change beyond externally driven projects. In this sense, the initiative contributes to broader discussions on how primary care systems can be strengthened through strategies that are context-responsive, community-grounded and built to last.

Data availability statement

Data are available upon reasonable request.