Abstract

Objective

To characterize the scientific production on adolescent health policies and programs in Brazil and Portugal in the period 2010-2017.

Method

This is a literature review based on the Scoping Review method. The research guidingquestion was: “How is the scientific production on adolescent health policies and programs in Brazil and Portugal characterized?”Search was carried out in October 2017 on the BVS, EBSCO and Google Scholar platforms.

Results

Twenty-two studies were selected, namely, 17 Brazilian and 5 Portuguese. Seven cross-cutting thematic categories were identified, as follows: policy and program evaluation; health promotion and education; mental health; sexual and reproductive health; violence; oral health and nutritional health. We canconclude that, albeit in different social contexts, the themes reflect traditional areas of intervention of policies and programs, except for those arising from the phenomenon of structural violence, markedly present in the Brazilian reality. Also, the lack of emerging issues such as gender identities, migratory flows, and morbimortality from external causes reveal a possible care gap in policies and programs and a necessary field to be explored.

Adolescent; Adolescent health; Public policies; National health programs; comprehensive health care

Introduction

This study aims to characterize the scientific production of adolescent health policies and programs in Brazil and Portugal. In a globalized and multicultural context, where multiple identities and ways of conceiving the stages of adolescence and youth converge and circulate, we decided to follow the classifications adopted by the PanAmerican Health Organization¹1. Organização Pan-Americana da Saúde (PAHO), Organização Mundial da Saúde (OMS). Plano de Ação para Prevenção da Obesidade em Crianças e Adolescentes. Washington: PAHO; 2014. [acessado 2017 Out 31]. Disponível em: http://www.paho.org/bra/images/stories/UTFGCV/planofactionchildobesity-por.pdf?ua=1
http://www.paho.org/bra/images/stories/U... and World Health Organization²2. World Health Organization (WHO). Adolescent Friendly Health Services: an agenda for change. Geneva: WHO; 2002. [acessado 2017 Out 31]. Disponível em: http://www.who.int/maternal_child_adolescent/documents/fch_cah_02_14/en
http://www.who.int/maternal_child_adoles... . According to these organizations, adolescence and youth are differentiated by their physiological, psychological and sociological specificities. Thus, adolescence is a fundamental biological process during which cognitive development and personality structure are accelerated. It is divided into two stages of pre-adolescence (10-14 years) and adolescence itself (15-19 years). Youth is conceived as a sociological category, which indicates the process of preparation for the individual to assume its adult role in society, both in the family and the professional sphere, extending from 15 to 24 years.

Despite generational and cultural diversities, as well as the legal frameworks of adolescence and youth between Brazil and Portugal, this study focused on health systems, especially the political-institutional arrangements structured as public policies and programs provided to this population, considering their health needs.Of this universe, the School Health Program has been highlighted in Brazil since 2007³3. Brasil. Decreto nº 6.286, de 5 de dezembro de 2007. Institui o Programa Saúde na Escola – PSE e dá outras previdências. Diário Oficial da União; 5 dez. and the National Guidelines for Adolescent and Youth Comprehensive Healthcare in the promotion, protection, and recovery of health⁴4. Brasil. Estatuto da Criança e do Adolescente e legislação pertinente [compilação de Centro de Apoio Operacional da Infância e da Juventude]. Porto Alegre: Ministério Público do Rio Grande do Sul, Procuradoria Geral de Justiça; 2010., implemented in 2010, based on several legal and normative drivers of policies and programs for this segment⁵5. Brasil. Ministério da Saúde (MS). Diretrizes Nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília: MS; 2010.

6. Brasil. Ministério da Saúde (MS). Saúde Integral de Adolescentes e Jovens. Orientações para a organização de serviços de saúde. Brasília: MS; 2007.-⁷7. Brasil. Lei nº 12.852, de 5 de agosto de 2013. Institui o Estatuto da Juventude e dispõe sobre os direitos dos jovens, os princípios e diretrizes das políticas públicas de juventude e o Sistema Nacional de Juventude – SINAJUVE. Diário Oficial da União 2013; 5 ago.. Portugal has the recently updated National Child and Youth Health Program (PNSIJ)⁸8. Portugal. Direção-Geral da Saúde. Norma nº 010/2013 de 31/05/2013. Programa Nacional de Saúde Infantil e Juvenil. 2013 [acessado 2017 Out 31]. Disponível em: https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0102013-de-31052013.aspx
https://www.dgs.pt/directrizes-da-dgs/no... and the Portuguese Institute of Sports and Youth, with a Youth Knowledge Center, a project that gathers virtually a network of information and knowledge aimed at youth⁹9. Portugal. Norma da Direção-Geral da Saúde nº010/2013. Saúde Infantil e Juvenil: Programa Nacional. Direção-Geral da Saúde; 2013.. Like Brazil, Portugal has been developing the National School Health Program since 2009¹⁰10. Portugal. Lei nº 60 de 6 de agosto de 2009. Programa Nacional de Saúde Escolar - Saúde Sexual e Reprodutiva - Educação Sexual em Meio Escolar. Direção-Geral de Saúde; 2009..

The analysis of the results of the research in the light of the programmatic milestones of each country was based on the theoretical perspective of Giovanella et al.¹¹11. Giovanella L, Lobato LVC, Noronha JC, Carvalho AI. Políticas e Sistema de Saúde no Brasil. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2012., in which the concept of public policy is associated with a civilizing process of social justice and the role of the state in action, that is, the process of building a governmental action for a sector, which involves resources, stakeholders, arenas, ideas and negotiation.

It is assumed that the social determinants of health establish different demands, needs, and responses of social protection systems, which directly affects the spectrum and scope of sectoral public policies. In other words, class society and social, political, ethnic, racial, migratory and gender disparities actively determine the distribution of resources, access to opportunities, and therefore the health conditions of a given population.

Thus, the realities of the two countries establish very different boundaries. On the other hand, the common element that supports the proposed comparative perspective is the structuring concept of public policy whose constitution embodies the role of universalizing human rights, in this case, enabling broader mechanisms to guarantee the rights of adolescents and young people.

Methods

This is a literature review study, based on the Scoping Review method¹²12. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International J Soc Res Methodol 2007; 8(1):19-32.,¹³13. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci 2010; 5:69.. This is a type of method used when the goal is to map essential productions in the field of interest, where different study designs are useful. Scoping Review proposes to carry out five steps, plus a sixth optional one, namely: (1) identification of the research question; (2) identification of relevant studies; (3) selection of studies; (4) data extraction; (5) summarization and reporting of results; and (6) presentation of the results for validation of the research.

The research question of this study was: “How is academic, scientific production characterized by adolescent health policies and programs in Brazil and Portugal?” The search strategy considered empirical and theoretical works, including theses, dissertations, editorials and gray literature. The period established considered the publications from 2010 to 2017. This time frame was chosen because of the period of implementation of the national health policies geared to this population segment, namely, 2010 in Brazil and 2013 in Portugal.

Data sources accessed were Lilacs (Latin American and Caribbean Literature in Health Sciences), Ibecs (Spanish Bibliographical Index of Health Sciences), Medline (Medical Literature Analysis and Retrieval System Online), Cochrane Library, SciELO (Scientific Electronic Library Online), Adolec Brasil (Adolescents Database), EBSCO and the Google Scholar tool. The Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) used were: adolescent; adolescent health; health policy; public policy; national health programs; adolescent health program; child and adolescent comprehensive health care; adolescent health services.

A filter to identify studies conducted in the two countries of interest, Brazil, and Portugal, was activated. Besides, to assist in the selection of studies, the inclusion criterion established was the need to address some adolescent health policy or program, and then exclude those studies that did not establish a link between their results/discussion and some adolescent health policy or program.

The research was carried out in October 2017, by two researchers, independently. Later, the results of each search were compared, and any disagreement was resolved by consensus. In other words, the researchers compared their search results, checking differences of findings, always aiming to include as many studies as possible. Figure 1 shows the process of search, exclusion, and selection of the studies found.

For the data extraction stage, an instrument structured in Excel was used to identify and describe items such as year of publication, authorship, country, research subjects, type of study and subject matter. This tool allowed the summary, data interpretation and the primary numerical analysis of the scope, nature, and distribution of the studies incorporated in the review. The results were then compiled and communicated to provide an overview of all the material, through a thematic construction, organized according to the nature of the studies. The results were finally shared with colleagues of the research group to verify, through a subjective and straightforward process, whether they were representative of the realities investigated.

Results

Twenty-two studies published between the years 2010 and 2017 were analyzed according to the year of publication, authorship, country, subjects, method and theme (Chart 1).

The numerical analysis shows that most of the selected studies addressed the context of health policies and programs of Brazilian adolescents (n = 17), based on a theoretical analysis (n = 12), mainly literature review studies (n = 5), theoretical essays (n = 4) and documentary analysis (n = 3). Among the five empirical studies conducted in Brazil, four were qualitative.

Of the five studies on adolescent health policies and programs conducted in Portugal, three were empirical, involving mixed – quantitative and qualitative, retrospective and Delphi – methodological design. Of the theoretical studies (n = 2), one performed a documentary analysis and the other a theoretical essay. No literature review study on this topic was found in Portugal.

The most significant number of studies was published in 2013, both in Brazil (n = 4) and in Portugal (n = 2). Regarding language, most studies were published in Portuguese (n = 19). There were also two studies published in English and one in Spanish. The participants of the empirical studies analyzed were adolescents, members of the government, civil society, experts, teachers, and managers.

From the reading and the analysis of the studies, it was possible to identify different thematic categories cross-cuttingto the actual field of adolescent health policies and programs in Brazil and Portugal. Table 1 shows the classification of the studies and the “n” for each country.

Evaluation of policies and programs

The studies suggest discussing the proposals, actions and effectiveness of specific policies and programs. In Brazil, all studies address health policies, from their construction to their effective implementation. In general, they emphasize the importance of considering the adolescent not only as a problem generator but as a subject with the potential to contribute to the development of the country¹⁴14. Horta NC, Sena RR. Abordagem ao adolescente e ao jovem nas políticas públicas de saúde no Brasil: um estudo de revisão. Physis 2010; 20(2):475-495.. In this context, they affirm that considering the social, cultural and collective realms of the realities in which these adolescents are inserted¹⁸18. Cavalcanti PB, Dantas ACS, Carvalho RN. Contornos e sinergias entre a política de Saúde e o adolescente privado de liberdade: intersetorialidade como desafio. Textos & Contextos 2011; 10(2):399-410. and considering the participation and co-responsibility of adolescents²⁰20. Lopez SB, Moreira MCN. Quando uma proposição não se converte em política? O caso da Política Nacional de Atenção Integral à Saúde de Adolescentes e Jovens - PNAISAJ. Cien Saude Colet 2013; 18(4):1179-1186. may result in more inclusive and effective policies²¹21. Lopez SB, Moreira MCN. Políticas Nacionais de Atenção Integral à Saúde de Adolescentes e Jovens e à Saúde do Homem: interlocuções políticas e masculinidade. Cien Saude Colet 2013; 18(3):743-752..

A Portuguese study evaluates a specific program geared to adolescents with behavioral changes, thus describing a more focused perspective. However, in the same way as the Brazilian studies, it was concerned with considering the potential of adolescents and the specificities of the life context, anchored in the process of co-construction and networking³³33. Patrão IAM, Rita JS. Intervenção Multifamiliar com Adolescentes com Alterações de Comportamento: Proposta de um Programa de Intervenção. Psychology, Community & Health 2013; 2(3):334-345,.

Health promotion and education

The category of health promotion and education focuses mainly on aspects of school health policies in both countries. The school environment is described as a strategic space for the development and implementation of health promotion practices since school plays a vital role in the construction of values and the very development of the citizenship of these adolescents²⁶26. Oliveira LB, Schoeninger D, Pressi P, Raulino C, Paravisi AP, Nothaft S. Programa saúde na escola: uma possibilidade de atuação do enfermeiro na promoção da saúde dos escolares. Brazilian Journal of Surgery and Clinical Research 2015; 11(3):190-191.. The topics covered are mainly related to physical and mental health, lifestyle, environment, and education / sexual and reproductive health³⁴34. Riso B. A construção da escola como lugar de saúde: contributo para uma reflexão sobre as políticas de saúde escolar na sociedade portuguesa contemporânea. Educação, Sociedade & Culturas 2013; 38:77-97..

They also discuss the scope of extracurricular activities in aiding the development and promotion of adolescent health. The extra-class period, when experienced by unattended adolescents, may predispose to an increased vulnerability concerning contact with child labor situations, inducement to drug trafficking or victimization by direct violence. With the same perception of strategic space for the development of a comprehensive formation for life, the extracurricular spaces can be opportunities for health promotion and education¹⁵15. Matias NCF. A importância de políticas públicas além da escola formal para o desenvolvimento infantil e adolescente: Uma revisão de literatura. Interação em Psicologia 2010; 14(1):93-102..

Outside of school, health promotion and education activities are understood as strategic for health and individual, group and social well-being. Priority activities, according to adolescents, family, school, and society encompass learning about healthy lifestyles, civics, and responsibilities, listening and dialogue, as well as social participation³²32. Matos MG, Santos T, Gaspar T. Promoção da saúde nos adolescentes portugueses: orientações técnicas e políticas para uma intervenção – Exercício Delphi. Journal of Child and Adolescent Psychology 2012; 3(1):137-155..

Mental health

The category of mental health was related to the social context in which adolescents live, mainly in Brazil. Concern about the use of drugs and other substances, with the increasing medicalization of life, exposes punitive and institutionalizing solutions, reinforcing the importance of public policies, curbing the excesses of this process and strengthening the role of health agencies²⁹29. Assis DAD, Silva AA, Torres T. Políticas de saúde mental, álcool e outras drogas e de criança e adolescente no Legislativo. Saúde em Debate 2017; 41(112):255-272.. The worse the social conditions, the higher the number of intercurrences and psychiatric hospitalizations reported, challenging public policies to show the best way to intervene with these adolescents, observing their particularities and overcoming the limited availability of resources³⁰30. Januário SS, Neves Peixoto FS, Lima NN, Nascimento VB, Sousa DF, Pereira Luz DC, Silva CG, Rolim Neto ML. Mental health and public policies implemented in the Northeast of Brazil: a systematic review with meta-analysis. Int J Soc Psychiatry 2017; 63(1):21-32..

Emotional and behavioral disorders are frequently addressed in the literature on adolescent health¹⁹19. Santos DCM, Jorge MSB, Freitas CHA, Queiroz MVO. Adolescentes em sofrimentopsíquico e a política de saúde mental infanto-juvenil. Acta Paul Enferm 2011; 24(6):845-850.. This is a period of extensive and profound physical, but also psychological transformations. The program for development of social skills responds to this challenge. Focused on assertiveness, self-control, cooperation, and empathy, through four central axes – communication, assertive behavior, cooperation and emotional self-control –it proposes to contribute to self-knowledge among adolescents, establishing positive interpersonal relationships and personal valuation³⁵35. Loureiro C, Santos MR, Frederico-Ferreira M. Conceção do programa de intervenção em enfermagem ‘Melhorar competências com os outros’. Revista Portuguesa de Enfermagem de Saúde Mental 2015; (Ed. Esp. 2):27-32..

Sexual and reproductive health

The studies address issues related to the role of the State in adolescent comprehensive health education and promotion actions based on the realities evidenced and responding to the needs of this population. The Brazilian reality is marked by the lack of essential resources and exposes adolescents to vulnerabilities mainly linked to social aspects, sexuality, psychoemotional situation and violence. Adolescent pregnancy appears in this reality as a public health issue, lacking public policies that include adolescents in their entirety, mainly about the complexity of motherhood at this stage of life²⁵25. Lima CC, Souza ACL, Rotella C, Silva DM, Santos D, Assunção DS, Maximino T, Castro VM, Luca Neto VN, Nascimento Neto WG. Políticas de atenção ao adolescente nos trilhos da ciência para uma atenção integral ao adolescente e jovem brasileiro. Pediatria Moderna 2015; 51(4):127-131..

When becoming pregnant, adolescents are obliged to mature, while experiencing intense prejudice related to concerns about their maternal capacity²⁵25. Lima CC, Souza ACL, Rotella C, Silva DM, Santos D, Assunção DS, Maximino T, Castro VM, Luca Neto VN, Nascimento Neto WG. Políticas de atenção ao adolescente nos trilhos da ciência para uma atenção integral ao adolescente e jovem brasileiro. Pediatria Moderna 2015; 51(4):127-131.. However, Duarte²²22. Duarte JB. La relevancia del conocimiento de las representaciones sociales de los adolescentes varones acerca de la paternidad en la adolescencia para el desarrollo de políticas públicas relevance of awareness of social. Subjetividad y Procesos Cognitivos 2013; 17(2):17-36. shows the lack of public policies aimed at the guidance and support of male adolescents in the exercise of paternity. Pregnancy in Brazilian society is still predominantly interpreted and related to women, leaving out the teenage fathers and over-blaming mothers.

On the other hand, Carvalho & Figueiredo’s study³¹31. Carvalho LM, Figueiredo CC. Configurações de conhecimento e política na regulação da educação sexual em meio escolar. Educação, Sociedade & Culturas 2011; (34):67-88. discusses educational aspects of sexual and reproductive health, questioning the role of the State, the family, and society in this process. In general, it sustains the role of the State as a promoter of education in conditions of equality and equity, starting from the school’s leading role as a socializing and value-making institution. Criticism is in the perception of the right and parental responsibility of education, mainly related to the controversial theme of sexual and reproductive education, reducing State interference in the educational guidelines of schools, configuring these as primarily instructional space.

Violence

Violence is characterized as a violation of fundamental rights, which unequally affects regions and populations according to the characteristics of the social class, gender, ethnicity, skin color, and age. The three studies included in this category were carried out in Brazil, and no study on this subject was identified in Portugal¹⁷17. Cruz LR, Welzbacher AI, Freitas CLS, Costa LXS, Lorini RA. Medidas socioeducativas em meio aberto no município de Santa Cruz do Sul/RS: entre as diretrizes legais e as políticas sociais públicas. Pesquisas e Práticas Psicossociais 2010: 5(1):112-119.,²³23. Fonseca FF, Sena RKR, Santos RLA, Dias VD, Costa SM. As vulnerabilidades na infância e adolescência e as políticas públicas brasileiras de intervenção. Rev. Paul. Pediatr. 2013; 31(2):258-264.,²⁷27. Barbiani R. Violação de direitos de crianças e adolescentes no Brasil: interfaces com a política de saúde. Saúde Debate 2016; 40(109):200-211..

Based on an exclusionary economic model formed by a young population, Brazil experiences significant levels of violence of different natures, especially among the adolescent population. In this context, criticisms to the State in the way it has been developing and managing its public policies, as well as the lack of analysis of these policies and public plans, to monitor the effectiveness of its methods and results, are characterized as a priority research topic²⁷27. Barbiani R. Violação de direitos de crianças e adolescentes no Brasil: interfaces com a política de saúde. Saúde Debate 2016; 40(109):200-211.. Along the same lines, Fonseca et al.²³23. Fonseca FF, Sena RKR, Santos RLA, Dias VD, Costa SM. As vulnerabilidades na infância e adolescência e as políticas públicas brasileiras de intervenção. Rev. Paul. Pediatr. 2013; 31(2):258-264. address the high rates of violation of adolescent rights evidenced as abandonment, early work, sexual exploitation and daily violence, which takes place in family and school contexts strongly tied to economic and social issues. The challenges range from parental guidance to the establishment of community shelters and programs, as well as investment in research and articulation of new intervention proposals.

Adolescent victims of situations of violence, neglect, and abandonment, most of the time, do not find in the State a protection network capable of responding to their needs and protect their situation of social vulnerability. Many of these adolescents end up entering the universe of law infringement and directed to be placed under socio-educational measures. In this context, the focus should be on public policies capable of helping adolescents overcome their condition of exclusion, as a focus on social reintegration, from educational and professional activities. However, what is observed is the predominance of punitive measures, organized by poor social policies, with actions in an incipient network, showing the need to move forward concerning the situation of adolescents serving socio-educational measures¹⁷17. Cruz LR, Welzbacher AI, Freitas CLS, Costa LXS, Lorini RA. Medidas socioeducativas em meio aberto no município de Santa Cruz do Sul/RS: entre as diretrizes legais e as políticas sociais públicas. Pesquisas e Práticas Psicossociais 2010: 5(1):112-119..

Oral health

The studies discuss educational actions that overcome the logic of unidirectional, dogmatic and authoritarian communication, in the promotion of oral health. According to Silva et al.²⁸28. Silva GG, Carcereri DL, Amante CJ. Estudo qualitativo sobre um programa de educação em saúde bucal. Cad. Saúde Colet. 2017; 25(1):7-13., reflective and critical education, which questions oral health issues, considering the complexity of social determinants can contribute to the development of a critical, autonomous and emancipatory awareness of adolescents rather than stimulate self-care. In this line, Celeste’s study¹⁶16. Celeste RK, Nadanovsky P. How much of the income inequality effect can be explained by public policy? Evidence from oral health in Brazil. Health Policy 2010; 97(2-3):250-258. emphasizes the importance of the role of public policies in the prevention of oral health problems.

Nutritional health

The study of Freitas et al.²⁴24. Freitas LKP, Cunha Junior AT, Knackfuss MI, Medeiros HJ. Obesidade em adolescentes e as políticas públicas de nutrição. Cien Saude Colet 2014; 19(6):1755-1762. discusses the problem related to the increasing prevalence of overweight and obesity in adolescents, emphasizing the need to establish public health promotion policies and programs, aiming to set healthy eating habits and regular practice of physical activity. This theme takes on a leading role in a reality that until recently has been marked by hunger and malnutrition, as is the case in Brazil, currently demanding educational programs about the nutritional values of foods and the importance of preventing overweight and obesity, in the context of chronic noncommunicable diseases and their consequences.

Discussion

Despite the predominance of the theoretical papers on aspects cross-cutting to health policies, we note the relevance and pertinence of producing evaluative studies, especially those based on documentary studies. From this set, a fundamental aspect is highlighted, usually subtracted from the decision-making and management processes, that is, the participation of the individuals involved. The fact that adolescents and young people do not have the civilian age of majority or full autonomy does not disqualify their participation; instead, it must be a condition for the successful planning of actions, serving as an exercise and learning of citizenship.

In 2017, the National Council for the Rights of Children and Adolescents issued a resolution applicable nationwide, within the framework of the State and Municipal Councils, on the active participation of adolescents and youth in their collegiate and plenary meetings³⁶36. Brasil. Resolução nº 191, de 7 de junho de 2017. Dispõe sobre a participação de adolescentes no Conselho Nacional dos Direitos da Criança e do Adolescente – CONANDA. Diário Oficial da União 2017; 7 jun.. In Portugal, the Portuguese Institute of Sports and Youth is currently about to approve the National Youth Plan, with open consultation for suggestions of the young people³⁷37. Portugal. Direção-Geral da Educação. Questionário: Plano Nacional da Juventude. Lisboa: Direção-Geral da Educação; 2017..

One noticeable difference between countries was the scope on which the policy was assessed. Considering Brazil’s continental dimensions and, above all, the social inequality burdening on the social determinants of health, studies addressed macro-policies under the lenses of intersectoriality and equity of resources and service, whereas in Portugal the only study is about a focused program. No studies are discussing or reviewing adolescent-related public policies in Portugal.

As for the cross-cutting themes prevalent in the studies, we observed a parity distribution among the axes that respond to the higher demands of policymakers and decision-makers concerning adolescence and youth: sexual and reproductive health, mental health and violence, as well as the presence of studies addressing services provided to this population, such as oral and nutritional health. These demands and themes have a specific approach – health education, and a privileged locus of intervention – school. Unlike other life cycles, where children are included, health promotion and the prevention of health problems in the adolescent population, as studies show, is shared, if not outsourced to education and its agents. Despite the relevance of the articulation of health and education policies and school’s centrality, the health and clinical responsibility of the population is incumbent upon the health network in all its levels of care, emphasizing, therefore, the importance of the primary health care actions in the territory and with the health facilities and health teams.

In this context, we interpret the presence of Brazilian studies addressing oral health and the nutritional health of adolescents and young people. Oral health had a substantial inflection in the territories from its introduction in the Family Health Teams³⁸38. Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Estabelece a revisão de diretrizes da Política Nacional de Atenção Básica (PNAB), no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 21 set.. Likewise, specific guidelines of the Brazilian reality influenced the production of papers on violence and mental health. The first is increasingly alarming. In Brazil, the violent death of young people has been proliferating since the 1980s. According to Cerqueira³⁹39. Cerqueira DRC. Mapa dos Homicídios Ocultos no Brasil. Rio de Janeiro: IPEA; 2013. (Texto para Discussão, nº 1848)., the cost of well-being associated with lethal violence affecting young people reaches 1.5% of GDP each year. Morbimortalityis exacerbated by association with other factors such as low schooling, school dropout, poor introduction in the world of work, alcohol and other drugs abuse, exposure to violence and accidents, unprotected sexual activity, generally exposing a situation of iniquities arising from inequalities of income, ethnicity, gender, sexual orientation, gender identity and territoriality. The problem is even more severe and an emergency when we consider the substantial decline in the proportion of young people in the general population. This setting indicates that adolescents and young people aged 10-24 years represent 29% of global population, 80% of whom live in developing countries, such as Brazil⁴⁰40. Brasil. Ministério da Saúde (MS). Núcleo de Atenção Integral à Saúde do Adolescente (NASAD). 2008. [acessado 2017 Out 31]. Disponível em: http://www.saude.df.gov.br/sobre-a-secretaria/subsecretarias/463-nucleo-de-atencao-integral-a-saude-do-adolescente-nasad.html
http://www.saude.df.gov.br/sobre-a-secre... . The vulnerability of adolescents and young people requires a comprehensive and broad perspective on the horizon of public policies that effectively care for and protect them.

The lack of Portuguese production addressing policies to combat violence may be related to living conditions and access to necessary policies that guarantee adolescent and young population a favorable level of social security, understood here as a broader concept, not only with the absence of risk, but with a particular condition of predictability and certainty about the future. According to Scherer⁴¹41. Scherer GA. Serviço Social e Arte: Juventudes e Direitos Humanos em Cena. São Paulo: Ed. Cortez; 2013., the safety category has an intimate relationship with protection, which aims to ensure a set of guarantees, preserving individuals from the most diverse possible risks during their lifetime.

This trend is repeated in the production that addressed the theme of mental health. While in Brazil authors discuss the mental health strongly associated with the above social conditions, the reality is different in Portugal, and the only study is concerned with the development of social skills for behavioral problems. With a population of 10,562,178, mostly consisting of adults and elderly, children and adolescents (0-14 years) account for 14.88% of the population, while young people (15-24 years) account for 10.86%⁴²42. Portugal. Instituto Nacional de Estatística. Censos 2011. [acessado 2017 Out 31]. Disponível em: http://censos.ine.pt/xportal/xmain?xpgid=censos2011_apresentacao&xpid=CENSOS
http://censos.ine.pt/xportal/xmain?xpgid... .

Such demographic distribution pattern may perhaps explain the emphasis placed on the child segment in the reformulation of the Portuguese health policy held in 2013 concerning mental health⁸8. Portugal. Direção-Geral da Saúde. Norma nº 010/2013 de 31/05/2013. Programa Nacional de Saúde Infantil e Juvenil. 2013 [acessado 2017 Out 31]. Disponível em: https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0102013-de-31052013.aspx
https://www.dgs.pt/directrizes-da-dgs/no... . The text points out that the new National Children and Youth Health Program “on the one hand, responds to the need to improve quality standards, harmonizing the contents of health actions with new scientific evidence and new morbidities, and on the other, to a greater relevance of pre-existing health issues.” The document emphasizes the new focus on issues related to child development, emotional and behavioral disorders and ill-treatment, with no reference to mental health and other subjects concerning the young population.

Although they are considered to be healthy people, adolescents and young people are generally conceived as a “risk group”, especially regarding exposure to alcohol and other drugs and the exercise of sexuality. The latter theme was addressed by three papers²²22. Duarte JB. La relevancia del conocimiento de las representaciones sociales de los adolescentes varones acerca de la paternidad en la adolescencia para el desarrollo de políticas públicas relevance of awareness of social. Subjetividad y Procesos Cognitivos 2013; 17(2):17-36.,²⁵25. Lima CC, Souza ACL, Rotella C, Silva DM, Santos D, Assunção DS, Maximino T, Castro VM, Luca Neto VN, Nascimento Neto WG. Políticas de atenção ao adolescente nos trilhos da ciência para uma atenção integral ao adolescente e jovem brasileiro. Pediatria Moderna 2015; 51(4):127-131.,³¹31. Carvalho LM, Figueiredo CC. Configurações de conhecimento e política na regulação da educação sexual em meio escolar. Educação, Sociedade & Culturas 2011; (34):67-88., located in the category of sexual and reproductive health. The Brazilian papers pointed out the role of public policies in protecting and caring for “vulnerable motherhood”, that is, about the living conditions of boys and girls and their newborns, given the consequences and risks involved, especially in poor populations. Given the urgency of actions in this area in Brazil, basic guidelines for sexual health and reproductive health linked to the mother and child care network were launched in 2015⁴³43. Brasil. Ministério da Saúde (MS). Cuidando de Adolescentes: orientações básicas para a saúde sexual e a saúde reprodutiva. Brasília: MS; 2015.. Also under development is the “Protect and care” strategy, which aims to improve the comprehensive national primary care response, especially vis-à-vis the issues of the service organization, development and growth, and sexual and reproductive health.

The focus on Portuguese production refers to the role of education in dealing with this complex issue, holding other public authorities such as health agencies accountable. Thus, in Portugal, sexual education was established in schools in 2009 through Law Nº 60/2009⁴⁴44. Portugal. Assembleia da República. Lei n.º 60/2009, de 6 de Agosto. Estabelece o regime de aplicação da educação sexual em meio escolar; 2009.. This legislation is part of the National Reproductive Health Program (PNSR), established in 2007, covering family planning, prenatal care surveillance and diagnosis, voluntary termination of pregnancy and medically assisted procreation⁴⁵45. Portugal. Direção-Geral da Saúde. Programa Nacional de saúde reprodutiva. [acessado 2017 Out 31]. Disponível em: http://www.saudereprodutiva.dgs.pt/
http://www.saudereprodutiva.dgs.pt/... .

The Sexual and Reproductive Health of adolescents and young people is a topic that deserves to be better studied by the academy, managers and health professionals. Underlying the discussion is the respect for human rights, from the perspective of adolescent/youth’s universe that must encompass all agendas and policies. Thus, Novaes⁴⁶46. Novaes RCR. Introdução. In: Castro JA, Aquino LMC, Andrade CC, organizadores. Juventude e Políticas Sociais no Brasil. Brasília: IPEA; 2009. points out that, from the perspective of youth demands, human rights refer to a concept that considers the diversity of rights – civil, economic, cultural, social, political and other. In this perspective, the author says that the concept of adolescents and young people as subjects of rights is anchored in the understanding of the indivisibility of individuals and collective rights and expresses the significant challenge of contemporary democracies to articulate equality and diversity in the planning and implementation of public policies.

Final considerations

This study addressed the scientific production on public health policies and programs geared to the adolescent and young population in Brazil and Portugal. The set of works shows an early production and intermittent flow in this thematic field. Evaluative studies, recurrent modeling in the field of Policy and Program objectives, as well as empirical studies, were scarce compared to the theoretical ones. These characteristics indicate a greater investigative interest in the cross-cutting thematic areas to the detriment of the field (policies and programs).Thus, the corpus of analysis consisted of papers that secondarily addressed the field of policies and programs, analyzing it in a complementary way to the priority study objects. This characteristic of production demanded the analysis of the approach of themes underlying the public agendas, seeking connections between the guidelines that sustain them and their relationship with the national social contexts, in their peculiarities in meeting the demands and needs of their adolescents and young people.

This trend can be explained by the recent implementation in the two countries of legislation, guidelines and policies structured and specific to adolescent and youth health. However, it can be affirmed that both countries already have robust and structuring programmatic frameworks for the proper extended coverage of actions in the states and regions, which is a fertile field for the research and production of knowledge. The interest to focus on relevant themes that permeate health actions is also justified by the complexity of direct care for adolescents and young people.

Although in different social contexts, the themes reflect traditional areas of intervention of policies and programs in the field of adolescent and youth health, except for those arising from the event of structural violence, which is present in the Brazilian reality. There was also a lack of emerging themes that affect adolescent and young population’s health, such as gender identities, migratory flows and morbimortality due to external causes, including suicide, revealing a possible lack of care of policies and programs, and a necessary field to be explored by scientific production. In this regard, critical knowledge and the general appropriation of the policy itself is fundamental because it emanates technical and care-related guidelines, as well as budget resources that directly affect the local management of health services.

References

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