Abstract

A cross-sectional study in conjunction with a health extension program was conducted with 605 adolescents aged between 13 and 18 years from 22 public schools in Divinópolis, Brazil. The aim of the study was to determine the vaccination status of the adolescents and their level of knowledge of communicable and vaccine-preventable diseases. Three-stage cluster sampling was used comprising schools, classes, and students. The findings show that vaccination coverage among adolescents was 45.1% and yellow fever was shown to have the lowest coverage rate (64%). The most mentioned diseases when the adolescents were asked which vaccinations they had had were infantile paralysis (60.7%), yellow fever (56%), tetanus (34%), and measles (28.6%). Extension activities were conducted with 6,650 people, comprising vaccination (2,334 doses administered), aimed at expanding vaccination coverage, and health education activities with 2,839 adolescents directed at sexually transmitted diseases, family planning; and licit and illicit drugs. The study had a positive impact in terms of the expansion of vaccination coverage and the extension activities played an essential role in increasing the adolescents’ knowledge of the themes addressed.

Key words
Public health; School health; Vaccination; Vaccination coverage; Health education

Introduction

Adolescents are one of the priority groups of Brazil's National Immunization Program (NIP) due to their susceptibility to certain vaccine-preventable diseases and, primarily, to the low level of vaccination coverage among this age group¹1. Araújo TME, Sá LC, Silva AAS, Costa JP. Cobertura vacinal e fatores relacionados à vacinação dos adolescentes residentes na área norte de Teresina/PI. Rev. Eletr. Enf. [periódico na Internet]. 2010[acessado 2015 Jul 12];12(3):502-10. Disponível em: http://www.fen.ufg.br/revista/v12/n3/v12n3a13.htm.http://dx.doi.org/10.5216/ree.v12i3.6934
http://www.fen.ufg.br/revista/v12/n3/v12... .

Adolescence is marked by important changes and needs. It is a phase that involves moments of choice and decision and often permeated by negative aspects such as increased exposure to risk factors related to the social circumstances adolescents can find themselves in, such as violence, drugs, and precocious sexual experiences²2. Queiroz MVO, Lucena NBF, Brasil EGM, Gomes ILV. Cuidado ao adolescente na atenção primária: discurso dos profissionais sobre o enfoque da integralidade. Rev Rene [periódico na Internet]. 2011[Acessado 2015 Fev 15];12(n. esp.):1036-44. Disponível em: http://www.revistarene.ufc.br/vol12n4_esp_pdf/a20v12esp_n4.pdf
http://www.revistarene.ufc.br/vol12n4_es... .

In view of this, the Ministry of Health advocates and provides immunization to adolescents against hepatitis B (three doses), diphtheria and tetanus (one dose every 10 years), yellow fever (two doses), measles, mumps and rubella (the two-dose MMR vaccine), and HPV, provided to girls aged between nine and 13 years and boys aged between 12 and 13 years and, up to 2020, between boys and girls aged between nine and 13 years. Brazil provides around 300 million doses of vaccine each year, making it one of the countries that most provides vaccines via the public health system. Other age groups and specific population groups besides adolescents have their own vaccine schedules. The child vaccine schedule has 15 types of vaccines and the adult, older adult, and pregnant women schedules have four, while the indigenous population and groups with special vaccination requirements have their own specific schedules³3. Brasil. Ministério da Saúde (MS). Manual de Normas e Procedimentos para Vacinação. [Internet] Brasília: MS; 2014. [acessado 2014 Dez 05]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_procedimentos_vacinacao.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

Under current health policy, vaccination is carried out preferably via the primary healthcare (PHC) system³3. Brasil. Ministério da Saúde (MS). Manual de Normas e Procedimentos para Vacinação. [Internet] Brasília: MS; 2014. [acessado 2014 Dez 05]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_procedimentos_vacinacao.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , more specifically through the Family Health Strategy (FHS), which is organized around multiprofessional health team responsible for the population of a predetermined area. The FHS aims to expand healthcare via actions directed at health promotion and maintenance, disease prevention, diagnosis, treatment, recovery, and rehabilitation⁴4. Viegas SMF, Penna CMM. O SUS é universal, mas vivemos de cotas. Cien Saude Colet [periódico na Internet]. 2013[acessado 2015 Jun 16];18(1):181-190. Disponível em: http://www.scielo.br/pdf/csc/v18n1/19.pdf
http://www.scielo.br/pdf/csc/v18n1/19.pd... .

However, gaps still exist in the provision of health services to adolescents, impeding the resolution of health issues specific to this age group. Healthcare lacks a systematic approach and service delivery tends to be based on meeting spontaneous demands, showing that the organization of work with this age group leaves much to be desired⁵5. Costa RF, Queiroz MVO, Zeitoune RCG. Cuidado aos adolescentes na atenção primária: perspectivas de integralidade. Esc. Anna Nery [periódico na Internet]. set 2012; 16(3). 2012. [acessado 2015 Fev 15]. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452012000300006&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... . In this respect, low levels of demand for PHC services and adherence to PHC programs and actions and reluctance to being vaccinated may be considered factors that limit vaccination coverage among adolescents²2. Queiroz MVO, Lucena NBF, Brasil EGM, Gomes ILV. Cuidado ao adolescente na atenção primária: discurso dos profissionais sobre o enfoque da integralidade. Rev Rene [periódico na Internet]. 2011[Acessado 2015 Fev 15];12(n. esp.):1036-44. Disponível em: http://www.revistarene.ufc.br/vol12n4_esp_pdf/a20v12esp_n4.pdf
http://www.revistarene.ufc.br/vol12n4_es... ^,55. Costa RF, Queiroz MVO, Zeitoune RCG. Cuidado aos adolescentes na atenção primária: perspectivas de integralidade. Esc. Anna Nery [periódico na Internet]. set 2012; 16(3). 2012. [acessado 2015 Fev 15]. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452012000300006&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... ^,66. Pereira AK, Silveira CG, Gonçalves RCB, Marinho PA, Pereira LM. Cobertura vacinal dos adolescentes da área de abrangência do centro de saúde cachoeirinha na região nordeste de Belo Horizonte-MG. Rev Médica Minas Gerais [periódico na Internet] 2013[acessado 04 jun 2015]; 23(3):284-289. Disponível em: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=702897&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... , justifying the choice of this age group as study participants.

A study conducted in Belo Horizonte reported that vaccination coverage amongadolescents aged between 10 and 19 years was only 36.2 %⁶6. Pereira AK, Silveira CG, Gonçalves RCB, Marinho PA, Pereira LM. Cobertura vacinal dos adolescentes da área de abrangência do centro de saúde cachoeirinha na região nordeste de Belo Horizonte-MG. Rev Médica Minas Gerais [periódico na Internet] 2013[acessado 04 jun 2015]; 23(3):284-289. Disponível em: http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=702897&indexSearch=ID
http://bases.bireme.br/cgi-bin/wxislind.... .

The School Health Program (Programa Saúde na Escola - PSE) was created to promote permanent integration and coordination between the education and health sectors. The program aims to improve the health of school children and contribute to health promotion and disease and risk prevention with a view to tackling the vulnerabilities that children and adolescents in the public education system experience. One of the components of the PSE is student health monitoring and assessment, including vaccination and disease status⁷7. Brasil. Ministério da Saúde (MS). Orientações básicas de atenção integral à saúde de adolescentes nas escolas e unidades básicas de saúde. Brasília: Editora do Ministério da Saúde [Internet]; 2013[Acessado 2014 Dez 05]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/orientacao_basica_saude_adolescente.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

In light of the above, this study asked the following questions: What is the vaccination coverage rate among students in the ninth year of primary education in public schools in Divinópolis in the State of Minas Gerais, considering the child and adolescent basic vaccine schedule? What knowledge do adolescents have about communicable diseases and vaccination?

The aim of this study was to determine the vaccination status of ninth year students from public schools in Divinópolis and their level of knowledge of communicable and vaccine-preventable diseases.

Methods

A cross-sectional study was conducted in conjunction with a health extension program with adolescents aged between 13 and 18 years enrolled in the ninth year of primary education in municipal and state public schools in Divinópolis, Minas Gerais, Brazil. The study involved a total of 605 students from 22 schools and was undertaken between September 2013 and February 2015.

The municipality was chosen to be the study area because it is the administrative center of the Regional Health Superintendency and hub of the Expanded West Region of the State of Minas Gerais, made up of 54 municipalities grouped into six micro regions. Divinópolis has a population of 232,945 people (IBGE, 2016) and has low FHS population coverage (27.24%), with 32 FHS teams, according to data for October 2016 obtained from the portal of the Primary Care Department.

Data was collected using a 28-item structured interview guide comprising questions addressing the following aspects: socioeconomic status and demographic characteristics; knowledge about vaccination, communicable diseases(including sexually transmitted infections), vaccination-preventable diseases included in the NIP child and adolescent schedule, and hepatitis B and its possible forms of transmission and prevention; and fear of injections. Data processing and analysis was undertaken using the software programs EpiInfo™ 7.2 and Statistical Package for Social Science (SPSS) 22.0, respectively. A descriptive analysis was performed calculating average, absolute, and relative frequencies and the standard deviation of the variables. Univariate analysis was conducted using Pearson's chi-squared test and adopting a significance level of 0.05 (CI_95%) to determine the factors associated with vaccination.

The appropriate sample size was calculated based on the comparison of proportions and adopting a significance level of 0.05, power of 80%, and prevalence of unvaccinated adolescents of approximately 35% to obtain a representative sample of the population of ninth year school children in public schools in Divinópolis.

Three-stage cluster sampling (schools, classes, students) was used to determine sample size in order to capture the total number of schools, total number of ninth year classes, and total number of students enrolled in the ninth year. The distribution of the schools in the sample was proportional to the number of municipal and state schools in Divinópolis with ninth year classes, resulting in a proportional representation of all schools across the different education regions of the municipality: central, northeast, northwest, southeast, southwest, and west.

The cross-sectional study (items 1 and 2) was conducted in conjunction with a health extension program (items 3, 4, 5, and 6) in the following stages: 1. Estimation of vaccination coverage among ninth year students in public schools in Divinópolis; 2. Determination of student knowledge about communicable diseases and vaccination; 3. Identification of students from the fifth to ninth years, teachers, and school staff susceptible to vaccine-preventable diseases; 4. Provision of the vaccines on the child and adolescent and adult vaccine schedules at the schools; 5. Assessment of vaccine acceptance; 6. Health education actions addressing the study theme.

The information about vaccination coverage for the vaccines on the basic adolescent vaccine schedule – hepatitis B, dupla adulto (dT) or tetanus and diphtheria double vaccine, yellow fever (YF), and the MMR vaccine (MMR) – was collected from the students’ immunization record cards. The analysis of vaccination status included the following: adolescents who presented their immunization record card (n = 535 or 88.4%); and all vaccines advocated for adolescents according to the NIP vaccination schedule.

The target audience of the vaccination and health education interventions undertaken under the health extension program comprised 6,650 children, adolescents, teachers, and staff from the 22 public schools. The aim of these interventions was to improve vaccination coverage rates through vaccination and educational actions addressing the study theme and themes proposed by the study participants on the interview guide: sexually transmitted diseases (STDs); family planning; and licit and illicit drugs.

The education activities were guided by the “Critical Health Education” intervention model, one of the strategies resulting from the Alma-Ata Declaration⁸8. Melo ASE, Filho ONM, Chaves HV. Conceitos básicos em intervenção grupal. Encontro Revista de Psicologia [periódico na Internet] 2014[acessado 2015 mar 16];17(26). Disponível em: https://psibr.com.br/leituras/psicologia-clínica/conceitos-basicos-em-intervencao-grupal
https://psibr.com.br/leituras/psicologia... to attain the goal of health for all by the year 2000. Critical Health Education seeks to value community participation, which in the case of this study involves dialectical interaction with the school community, in order to develop individual autonomy and a sense of responsibility for adopting healthy lifestyles. In this sense, it is the group that defines the priority themes and individuals who will participate in the educational activities.

The method used for the educational activities was group education⁹9. Carta de Ottawa. Primeira Conferência Internacional sobre Promoção da Saúde. Ottawa, novembro de 1986. [Internet] [acessado 2015 mar 16] Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/carta_ottawa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... , addressing the themes defined by the adolescents. First, a group activity was used to promote interaction between the adolescents, followed by a conversation circle. The group education method allows adolescents to participate actively in the learning process, leading them to build new concepts, reflect upon the theme in question, and exchange knowledge, making them feel free to express ideas and opinions.

The study was carried out in accordance with the ethical principles of nonmaleficence, beneficence, justice, fairness, and participant autonomy laid out in the National Health Council Resolution466/2012. Authorization was obtained from the directors of the educational institutions that took part in the study and the parents/guardians and adolescents signed an informed consent form and informed assent form, respectively. Students who did not present their immunization record card due to loss or damage, but who presented the informed consent form were allowed to participate in the study but were excluded from the vaccination coverage analysis to avoid information bias. The cross-sectional study and health extension program was approved by the Research Ethics Committee of the São João del-Rei Federal University.

Results

Six hundred and five adolescents from a total of 2,283schoolchildren enrolled in the ninth year in the municipality's 22 public schools participated in the study. Participants were aged between 13 and 18 years and had an average age of 14.35years (SD = 8.52). Table 1 shows the profile of the study participants and the variables analyzed in relation to vaccination.

Vaccination coverage was determined based on the assessment of 475 immunization record cards (78.8%.CI 95%: 75.0% – 81.7%), since 130 adolescents did not present their cards. Table 2 shows vaccination coverage by age group.

Vaccination coverage for all vaccines on the national adolescent vaccine schedule among the 475 participants who presented their immunization record card was only 45.1%.

The majority of adolescents and adults who refused vaccination (0.2% of the sample) reported “fear of injections”. Despite being a subjective variable, this result shows that there was a statistically significant difference and that this may have influenced the adolescents’ (mainly > 14 years) decision to refuse vaccination during the extension actions.

Table 3 shows the adolescents’ knowledge about the vaccines on the immunization record card.

The most mentioned diseases when the adolescents were asked which vaccinations they had had were infantile paralysis (60.7%; CI 95%: 56.6% – 64.6%), followed by yellow fever(56.0%; CI 95%: 52% – 60%), tetanus(34.0%; CI 95%: 30.3% – 38.0%), and measles (28.6%; CI 95%: 25.1% – 32.4%).Twenty-seven point four percent (CI 95%: 24% – 31.2%) did not know. A small percentage of the adolescents (14.4%; CI 95%: 11.7% – 17.5%) mentioned dengue fever, for which a vaccine is not yet available through the public health system, and nonvaccine-preventable diseases such as syphilis (2.8%; CI 95%: 1.7% – 4.6%) and HIV/AIDS (1.0%; CI 95% 0.4% – 2.3%). It is important to note that the adolescents were allowed to mention more than one disease or infection.

With regard to Hepatitis B, 48.6% (n = 294; CI 95%: 44.6% – 52.7%) of the adolescents reported having received information or advice about this disease. Table 4 shows the adolescents’ knowledge about forms of transmission of Hepatitis B.

Despite the lack of knowledge among the adolescents regarding Hepatitis B and its forms of transmission, the findings show that Hepatitis B vaccination coverage was high (93.3%; CI 95%: 90,5% – 95,3%). Although the majority identified some forms of transmission of the disease, a significant proportion mentioned other factors that are not associated with the transmission of hepatitis B, such as shaking hands, kissing on the mouth, swimming pools, and the toilet seat.

The results show that 70.1% (n = 424; CI 95%: 66.2%-73.7%) of the adolescents who seek health services for vaccination go to the health center nearest to their house, 14.9% (n = 90; CI 95%: 12.2% – 18%) use a health center in another neighborhood, 9.3% (n = 56; CI 95%: 7.1%-11.9%)use private clinics, 4.3%get vaccinated only during vaccination campaigns (n = 26; CI 95%: 2.9%-6.3%), 6.1% failed to answer (n = 37; CI 95%: 4.4%-8.4%), and 2.1% (n = 13; CI 95%: 1.2%-3.7%) used other points of vaccination, such their father's workplace and military police battalion. Adolescents where allowed to mark more than one place of vaccination.

Extension activities

The extension program reached 6,650 people (children, adolescents, teachers, and school staff) from the 22 public schools, resulting in the administration of a total of 2,334 vaccine doses (Hepatitis B, YF, MMR, and tetanus and diphtheria), of which 1,923 were administered to adolescents aged between 13 and 18 years. Table 5 shows the number of doses by education region.

Given that the HPV and Influenza vaccination campaigns took place during the data collection period, these vaccines were also included in extension actions for the vaccination of susceptible children and adolescents. However, these vaccines did not comprise the vaccination status analysis.

Of the 6,650 people who participated in the extension activities, children and adolescents whose immunization record cards were not up-to-date and who were not authorized by their parents/guardians to have the vaccinations/failed to bring a signed authorization letter (n = 146 or 2.2%) and those who refused to be vaccinated were given a letter informing their parents that their immunization record card was not up-to-date and requesting them to take their children to the FHS or care center closest to their home to be vaccinated.

A total of 2,283 adolescents from the ninth year and 556 from the eight year participated in the health education actions, comprising all adolescents from all the ninth year classes present on the days the actions took place and some of the eight year classes, at the request of the school principals. The themes comprised those most suggested by the adolescents on the interview guide: licit and illicit drugs (51.4%); STDs (50.6%), and family planning and contraceptive methods (45.8%).

The group activities lasted an average of 35 minutes. At the end of the group activities, the researchers offered to talk to participants on an individual basis and in some schools special attention was given to certain adolescents according to their own specific needs.

The group activity designed to promote participant interaction facilitated communication between the researchers and adolescents, arousing greater interest in the theme, thus fostering sharing and learning. The adolescents felt free to talk about their experiences and clarify doubts by asking questions when requested during both the group activities and individual sessions.

Discussion

The findings of the present study show that the majority of participants were girls, presented an immunization record card, and thought that vaccination was important. Overall vaccination coverage was low (45.1%), with yellow fever and tetanus and diphtheria showing the lowest coverage rates (64.0% and 74.7%, respectively).

Vaccine adherence was greatest among the 10 to 14 year age group, which may be attributed to the following factors: health prevention practices directed at children; greater participation of the family in the health of lower age groups because during this phase adolescents tend to feel independent, meaning that they tend not to value actions directed towards risk and disease prevention and adolescent health protection¹⁰10. Carvalho AMC, Araujo TME. Fatores Associados à cobertura amarílico vacinal em adolescentes. Acta Paul Enferm [periódico na Internet] 2010[acessado 2015 Mar 15]; 23(6):796-802. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002010000600013&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... .

It is known that adolescents account for only a small proportion of PHC service users. A study that investigated health professionals’ perceptions of the provision of PHC services to adolescents showed that they thought that services were flawed because they were not geared to the specific needs and characteristics of this group²2. Queiroz MVO, Lucena NBF, Brasil EGM, Gomes ILV. Cuidado ao adolescente na atenção primária: discurso dos profissionais sobre o enfoque da integralidade. Rev Rene [periódico na Internet]. 2011[Acessado 2015 Fev 15];12(n. esp.):1036-44. Disponível em: http://www.revistarene.ufc.br/vol12n4_esp_pdf/a20v12esp_n4.pdf
http://www.revistarene.ufc.br/vol12n4_es... .

A systematic literature review of factors influencing the completion of multi-dose adolescent vaccine schedules showed that the administration of vaccines in schools is associated with higher schedule completion rates, given that only a small proportion of adolescents seek care at health centers¹¹11. Gallagher KE, Kadokura E, Eckert LO, Miyake S, Mounier-Jack S, Aldea M, Ross DA, Watson-Jones D. Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review. BMC Public Health [serial on the Internet] 2016[cited 2016 Jun 5]; 16(1):172. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26895838
http://www.ncbi.nlm.nih.gov/pubmed/26895... .

Gaps still exist in the provision of health services to adolescents, impeding the resolution of health issues specific to this age group. Healthcare lacks a systematic approach and service delivery tends to be based on meeting spontaneous demands, showing that the organization of work with this age group leaves much to be desired⁵5. Costa RF, Queiroz MVO, Zeitoune RCG. Cuidado aos adolescentes na atenção primária: perspectivas de integralidade. Esc. Anna Nery [periódico na Internet]. set 2012; 16(3). 2012. [acessado 2015 Fev 15]. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452012000300006&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... .

Data from the 2014 National Immunization Survey-Teen (NIS-Teen)conducted by the Centers for Disease Control and Prevention (CDC) with 20,827 adolescents aged between 13 and 17 years show that despite increases compared to the previous year, vaccination coverage for tetanus, diphtheria and acellular pertussis (dTpa), meningococcal disease, and human papillomavirus infection, remained under 80% (79.3%, 60.0%, and 41.7%, respectively)¹²12. Reagan-Steiner S, Yankey D, Jeyarajah J, Elam-Evans LD, Singleton JA, Curtis CR, MacNeil J, Markowitz LE, Stokley S. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years--United States, 2014. MMWR Morb Mortal Wkly Rep. [serial on the Internet] 2015[cited 2016 Jun 5]; 64(29):784-792. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml... .

Although 12.6% of the sample reported having adverse reactions following vaccination, the occurrence of these events is generally lower amongadolescents¹³13. Silva SS, Oliveira VC, Ribeiro HCTC, Alves TGS, Cavalcante RB, Guimarães EAA. Análise dos eventos adversos após aplicação de vacinas em Minas Gerais, 2011: um estudo transversal. Epidemiol. Serv. Saúde [periódico na Internet] jan-mar 2016 [acessado 04 jun 2016]; 25(1):45-54. Disponível em: http://scielo.iec.pa.gov.br/pdf/ess/v25n1/v25n1a05.pdf
http://scielo.iec.pa.gov.br/pdf/ess/v25n... . It is assumed that the events reported by the adolescents of this study refer to local reactions such as pain at the site of injection, normally associated with the tetanus and diphtheria vaccine administered every 10 years.

Fear of injections is expected and considered normal during certain phases of development as a form of protection in people who feel at risk and there are situations in which fear interferes in the adolescent's daily decisions and activities¹⁴14. Schoen TH, Vitalle MSS. Tenho medo de quê? Rev Paul Pediatr [periódico na Internet] 2012 [acessado 2015 Dez 17]; 30(1):72-78. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-05822012000100011&lng=en
http://www.scielo.br/scielo.php?script=s... .

The results of the present study are similar to those found by research into vaccination coverage among a group of adolescents from a municipal school in the State of Pará, which showed that 77.6% of interviewees confirmed having knowledge about the definition and utility of the vaccine, while only 7.47% had knowledge about the adolescent vaccine schedule¹⁵15. Lemos EO, Pedrosa DR, Raniére PSG, Pires CAA, Queiroz AM. Avaliação do cumprimento do calendário de vacinação dos adolescentes de uma escola municipal. Rev Adolesc. Saúde [periódico na Internet]. abr/jun 2013[acessado 2015 jun 04]; 10(2):23-29. Disponível em: http://www.adolescenciaesaude.com/detalhe_artigo.asp?id=365#
http://www.adolescenciaesaude.com/detalh... .

One factor that could explain the low rate of vaccination coverage among adolescents found by the present study is the lack of knowledge about the vaccines and communicable and vaccination-preventable diseases. Although almost 100% of the adolescents thought that vaccination was important, the large majority lacked knowledge about the vaccination schedule, mentioning, for example, being vaccinated against diseases or infections that are not vaccination-preventable, such as HIV-AIDS, syphilis, candidiasis, gonorrhea, and herpes simplex, and vaccination against dengue fever, which is still not available on the public health system. A study conducted in the State of Piauí, found that 60.2% participants reported that they were unaware of the adolescent vaccine schedule¹⁶16. Carvalho AMC, Araujo TME. Conhecimento do adolescente sobre vacina no ambiente da Estratégia Saúde da Família. Rev Bras Enferm [periódico na Internet] 2012[acessado 2015 Jun 04]; 65(2):229-235. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672012000200005&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... .

Corroborating the findings of the present study regarding knowledge of vaccines, previous studies reported that 48.6% of participants cited the yellow fever vaccine and only one-third were aware of both the hepatitis B and tetanus vaccines¹⁶16. Carvalho AMC, Araujo TME. Conhecimento do adolescente sobre vacina no ambiente da Estratégia Saúde da Família. Rev Bras Enferm [periódico na Internet] 2012[acessado 2015 Jun 04]; 65(2):229-235. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672012000200005&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... ^,1717. Carvalho AMC, Araújo TME. Fatores associados à cobertura vacinal em adolescentes. Acta Paul Enferm [periódico na Internet] 2010 [acessado 2013 Ago 5]; 23(6):796-802. Disponível em: http://www.scielo.br/pdf/ape/v23n6/13.pdf.
http://www.scielo.br/pdf/ape/v23n6/13.pd... . A study conducted in the State of Pará showed that only 26.87% of participants were aware of the existence of a vaccine against hepatitis B¹⁵15. Lemos EO, Pedrosa DR, Raniére PSG, Pires CAA, Queiroz AM. Avaliação do cumprimento do calendário de vacinação dos adolescentes de uma escola municipal. Rev Adolesc. Saúde [periódico na Internet]. abr/jun 2013[acessado 2015 jun 04]; 10(2):23-29. Disponível em: http://www.adolescenciaesaude.com/detalhe_artigo.asp?id=365#
http://www.adolescenciaesaude.com/detalh... , while a study carried out in Teresina found that hepatitis B was the third best-known vaccine after the rubella and yellow fever vaccines¹⁶16. Carvalho AMC, Araujo TME. Conhecimento do adolescente sobre vacina no ambiente da Estratégia Saúde da Família. Rev Bras Enferm [periódico na Internet] 2012[acessado 2015 Jun 04]; 65(2):229-235. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672012000200005&lng=en&nrm=iso
http://www.scielo.br/scielo.php?script=s... . Greater knowledge about the rubella and yellow fever vaccines may be due to national campaigns against these diseases with widespread media coverage.

Studies conducted with adolescents in Paraná¹⁸18. Pudelco P, Koehler AE, Bisetto LHL. Impacto da vacinação na redução da hepatite B no Paraná. Rev Gaúcha Enferm [periódico na Internet]2014 mar [acessado 2015 Ago 8]; 35(1):78-86. Disponível em: http://www.scielo.br/scielo.php?script=sci_serial&pid=1983-1447&lng=pt&nrm=iso
http://www.scielo.br/scielo.php?script=s... and Piauí¹⁷17. Carvalho AMC, Araújo TME. Fatores associados à cobertura vacinal em adolescentes. Acta Paul Enferm [periódico na Internet] 2010 [acessado 2013 Ago 5]; 23(6):796-802. Disponível em: http://www.scielo.br/pdf/ape/v23n6/13.pdf.
http://www.scielo.br/pdf/ape/v23n6/13.pd... also revealed lower vaccination coverage for hepatitis Bin the 15 to 19 year age group, compared to the 10 to 14 year group, while research in China found that hepatitis B coverage among people under the age of 20 was 93.3%¹⁹19. Bödeker B, Remschmidt C, Schmich P, Wichmann O. Why are older adults and individuals with underlying chronic diseases in Germany not vaccinated against flu? A population-based study. BMC Public Health [serial on the Internet] 2015[cited 2016 Jun 5]; 7(15):618. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26148480
http://www.ncbi.nlm.nih.gov/pubmed/26148... .

Hepatitis B is one of the world's biggest public health problems, with 240 million people chronically infected with the virus. Around 2 billion people have been infected with the hepatitis B virus across the globe and approximately 780,000 people die each year from the disease. Rates of chronic infection are high in the State of Amazonas and some parts of Eastern and Central Europe. The virus is transmitted through contact with the blood or other body fluids of an infected person and via vertical transmission²⁰20. Organização Mundial de Saúde (OMS). Novas diretrizes da OMS no enfrentamento da hepatite B. Brasília: OMS; 2015. [acessado 2015 Jun 04]. Disponível em: http://hepato.com/p_hepatite_b/018_hbv_port.php
http://hepato.com/p_hepatite_b/018_hbv_p... ^,2121. Centers for Disease Control and Prevention. CDC Division of Viral Hepatitis. [acessado 2015 Jun 04]. Disponível em: http://www.cdc.gov/hepatitis/
http://www.cdc.gov/hepatitis/... .

Low hepatitis B vaccination coverage among adolescents is worrying, particularly in the 15 to 18 year age group. Bearing in mind that the hepatitis B vaccine was included on the NIP basic vaccine in 1997 for everyone under the age of one and expanded to the 1 to 19 years age group in 2001, it is clear that missed opportunities for vaccination continue to occur. Health professionals need to pay close attention to young people's immunization record cards and, at every opportunity, make the most of immunization information systems and offer all vaccines to those who are eligible¹²12. Reagan-Steiner S, Yankey D, Jeyarajah J, Elam-Evans LD, Singleton JA, Curtis CR, MacNeil J, Markowitz LE, Stokley S. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years--United States, 2014. MMWR Morb Mortal Wkly Rep. [serial on the Internet] 2015[cited 2016 Jun 5]; 64(29):784-792. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml... .

Given the greater exposure of this group to risk factors such as multiple sexual partners and irregular condom use, increasing vulnerability to sexually transmitted diseases, the use and abuse of alcohol and other drugs, and sense of invulnerability to diseases²²22. Furlan MCR, Rissardo LK, Oliveira RG, Ferrer ALM, Marcon SS. Impact of the compulsory school vaccination against hepatitis B in adolescents: exploratory-descriptive study. Online Brazilian Journal of Nursing [serial on the Internet] aug 2010[cited 2016 Jun 5];9(2). Available from: http://www.objnursing.uff.br/index.php/nursing/rt/printerFriendly/j.1676-4285.2010.2912/662
http://www.objnursing.uff.br/index.php/n... , immunization of adolescents against hepatitis B is particularly important.

The findings show that population coverage of the FHS teams during the study periodwas approximately 25% and that vaccination coverage among adolescents aged between 13 and 18 years was 45.1%, showing lower than expected adherence to vaccine-preventable disease prevention actions. Although the extension program brought the children's and adolescents’ immunization records up to date, these activities are known to be isolated. It is therefore vital to ensure systematic monitoring of the vaccination status of this group by health teams.

In light of the above, greater attention is needed on the part of health professionals to develop actions that foster the engagement of adolescents in risk and disease prevention and health promotion actions. By adopting a dynamic and proactive approach, the knowledge acquired through these actions helps adolescents develop greater autonomy and therefore become co-responsible for their own health. In this respect, it is necessary to consider incorporating monitoring and follow-up of adolescent vaccination into the everyday practice of PHC services.

Conclusion

A process of social transformation was observed during the study and extension activities, expanding vaccination coverage among the children, adolescents, staff, and teachers of the 22 public schools to 91%. The activities also had an impact on the education of these age groups through the knowledge shared and acquired regarding the importance of immunization and communicable and vaccination-preventable diseases.

The school population and all those who participated in the cross-sectional study and extension interventions strengthened their attitudes towards risk and disease prevention in a process that should be ongoing, in which it is understood that health education should be permanent and built, throughout life, within workplace and social relations and between people throughout society. Continuous learning engenders new conceptions, attitudes, and possibilities in recreating one's own way of being and caring for oneself.

In this sense, undertaking this study with adolescents enabled knowledge of the factors associated with a preventive action, which is vaccination against communicable diseases in the proposed study setting, as well as vaccination intervention when necessary.

This study in conjunction with extension generates knowledge about a given object and the reality investigated, and also provides that interventions should be implemented to change this reality. This study demonstrates its social role not only in the generation of knowledge, but also through the effectiveness of the interventions in creating a positive impact on the results achieved.

This study provides important inputs to the field of health by demonstrating that the implementation of risk and disease prevention actions in settings outside the walls of the health center, such as schools, reinforces the concepts of a new way “doing health”, based on the concept of health surveillance, and can change realities.

References

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