ABSTRACT:

Introduction:

Knowing the profile of individuals who demand health services or professionals could help in the improvement and reorganization of services. However, this subject is still underexplored among adolescents. This study aimed to describe and identify characteristics related to the demand for health services or professionals by Brazilian students.

Methods:

Using data from the 2015 National School Health Survey, the prevalence and respective 95% confidence intervals (95%CI) of the demand for health services or professionals among students were estimated, and Poisson regression adjusted by age and region of residence was used to identify the associated factors.

Results:

More than half of the students demanded for health services or professionals in the last year, with a higher demand among females. The characteristics associated with the outcome were sociodemographic (female, white, private school), family (maternal schooling of 12 years or more, having meals with parents/guardians and parents’ knowledge of the adolescent’s activities in their free time), risk behaviors (alcohol consumption and sexual intercourse without a condom) and health-related issues (physical violence, wheezing, toothache, hygiene habits, and attitude to one’s own weight).

Conclusion:

Organizing health services in a way that takes the particularities of this population into account may provide a space to deal with subjects related to the risks to which it is exposed.

Keywords:
School health; Adolescent behavior; Adolescent; Health services

INTRODUCTION

The demand for health services is influenced both by the characteristics and needs of individuals and by the offer of services, ease of access, financial resources and availability and linkage of health professionals¹1. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública. 2004; 20(Supl. 2): S190-8. http://dx.doi.org/10.1590/S0102-311X2004000800014
http://dx.doi.org/10.1590/S0102-311X2004... . The demand for health services can occur directly, such as medical visits and hospitalizations, or indirectly, such as for conducting preventive and diagnostic exams¹1. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública. 2004; 20(Supl. 2): S190-8. http://dx.doi.org/10.1590/S0102-311X2004000800014
http://dx.doi.org/10.1590/S0102-311X2004... ^,22. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saúde Pública. 2007; 23: 2490-502. http://dx.doi.org/10.1590/S0102-311X2007001000023
http://dx.doi.org/10.1590/S0102-311X2007... ^,33. Ribeiro MCSA, Barata RB, Almeida MF, Silva ZP. Perfil sociodemográfico e padrão de utilização de serviços de saúde para usuários e não-usuários do SUS - PNAD 2003. Ciênc Saúde Colet. 2006; 11(4): 1011-122. http://dx.doi.org/10.1590/S1413-81232006000400022
http://dx.doi.org/10.1590/S1413-81232006... . Although the use of health services is a widely explored topic among Brazilian adults and elderly people, even in surveys with national coverage⁴4. Araújo MEA, Silva MT, Andrade KRC, Galvão TF, Pereira MG. Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise. Epidemiol Serv Saúde. 2017; 26(3): 589-604. http://dx.doi.org/10.5123/s1679-49742017000300016
http://dx.doi.org/10.5123/s1679-49742017... , investigations among adolescents are still infrequent.

Among the studies with local, in the study carried out in Niterói, in 2001, which approached the relationship between adolescents and health services (n = 457), it was demonstrated that of the 210 adolescents who reported the need for care in a health service, 166 (79.1%) reported having actually sought the service in the last 3 months, and differences were observed according to school type (public and private) and sex⁵5. Claro LBL, March C, Mascarenhas MTM, Castro IAB, Rosa MLG. Adolescentes e suas relações com serviços de saúde: estudo transversal em escolares de Niterói, Rio de Janeiro, Brasil. Cad Saúde Pública. 2006; 22: 1565-74. http://dx.doi.org/10.1590/S0102-311X2006000800005
http://dx.doi.org/10.1590/S0102-311X2006... . In Pelotas, in 2012, 23.0% of adolescents reported using some health service in the last 30 days prior to the survey⁶6. Nunes BP, Flores TR, Duro SMS, Saes MO, Tomasi E, Santiago AD, et al. Adolescent use of health services: a population-based cross-sectional study Pelotas-RS, Brazil, 2012. Epidemiol Serv Saúde. 2015; 24(3): 411-20. http://dx.doi.org/10.5123/S1679-49742015000300007
http://dx.doi.org/10.5123/S1679-49742015... .

Since 2012, the National School Health Survey (PeNSE) has included the theme of the demand for health services and/or professionals⁷7. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar. PeNSE 2012. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013.. Analyzing these data, Oliveira et al. emphasized, for the first time, with a national coverage among students in the 9^th year of Primary Education, that the search for a health service or professional in the last 12 months prior to the survey was 48.0%. The authors identified that, in addition to individual and behavioral characteristics, family and health-related aspects were associated with the demand for health services by schoolchildren⁸8. Oliveira MM, Andrade SSCA, Oliveira-Campos M, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública. 2015; 31(8): 1603-14. http://dx.doi.org/10.1590/0102-311X00165214
http://dx.doi.org/10.1590/0102-311X00165... . In the analysis of the data referring to the demand for health services in the 2015 edition of PeNSE, it is expected that this percentage has increased, adopting as reference an increase in the supply of services through the expansion of the coverage of the Family Health Strategy, which has grew from 53.75% in January 2012 to 63.72% in December 2015⁹9. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Histórico da Cobertura da Saúde da Família [Internet]. [citado 13 dez. 2017]. Disponível em: http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php
http://dab.saude.gov.br/portaldab/histor... .

It is important to monitor the demand for health services in order to identify determinants and conditions related to health risk behaviors for adolescents, in order to contribute to the development of public health policies and encourage the adoption of preventive measures¹⁰10. Chiavegatto Filho ADP, Wang Y-P, Malik AM, Takaoka J, Viana MC, Andrade LH. Determinantes de uso de serviços de saúde: análise multinível da região metropolitana de São Paulo. Rev Saúde Pública. 2015; 49: 1-12. http://dx.doi.org/10.1590/S0034-8910.2015049005246
http://dx.doi.org/10.1590/S0034-8910.201... ^,1111. Deslandes SF. Concepções em pesquisa social: articulações com o campo da avaliação em serviços de saúde. Cad Saúde Pública. 1997; 13: 103-7. http://dx.doi.org/10.1590/S0102-311X1997000100020
http://dx.doi.org/10.1590/S0102-311X1997... ^,1212. Fernandes LCL, Bertoldi AD, Barros AJD. Utilização dos serviços de saúde pela população coberta pela Estratégia de Saúde da Família. Rev Saúde Pública. 2009; 43: 595-603. http://dx.doi.org/10.1590/S0034-89102009005000040
http://dx.doi.org/10.1590/S0034-89102009... ^,1313. Mendes ACG, Araújo Júnior JLCA, Furtado BMAS, Duarte PO, Santiago RF, Costa TR. Avaliação da satisfação dos usuários com a qualidade do atendimento nas grandes emergências do Recife, Pernambuco, Brasil. Rev Bras Saúde Materno Infant. 2009; 9: 157-65. http://dx.doi.org/10.1590/S1519-38292009000200005
http://dx.doi.org/10.1590/S1519-38292009... ^,1414. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005; 83: 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
https://doi.org/10.1111/j.1468-0009.2005... . In 2015, in addition to the representative sample of students from the 9^th year of Primary Education, PeNSE had a second sample, representative of students aged from 13 to 17 years. This study allowed us to evaluate the use of services of schoolchildren with this age group. The objectives were to describe and identify characteristics related to the demand for health services or health professionals by Brazilian students.

METHODS

This is a cross-sectional study using PeNSE data from 2015, made publicly available on the website of the Brazilian Institute of Geography and Statistics (IBGE)⁽²⁾(1)https://www.ibge.gov.br/home/estatistica/populacao/pense/2015/default.shtm. PeNSE is a triennial school-based survey conducted by IBGE in partnership with the Ministry of Health, with support from the Ministry of Education⁷7. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar. PeNSE 2012. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013.^,1515. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016.^,1616. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2009. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2009.^,1717. Oliveira MM, Oliveira-Campos M, Andreazzi MAR, Malta DC. Características da Pesquisa Nacional de Saúde do Escolar-PeNSE. Epidem Serv Saúde. 2017; 26(3): 605-16. http://dx.doi.org/10.5123/s1679-49742017000300017
http://dx.doi.org/10.5123/s1679-49742017... .

In 2015, the samples were representative for both 9^th grade students (Sample 1) and 6^th grade students from elementary school to the 3^rd year of high school, which is representative of students aged 13 to 17 years (Sample 2)⁷7. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar. PeNSE 2012. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013.^,1515. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016.^,1717. Oliveira MM, Oliveira-Campos M, Andreazzi MAR, Malta DC. Características da Pesquisa Nacional de Saúde do Escolar-PeNSE. Epidem Serv Saúde. 2017; 26(3): 605-16. http://dx.doi.org/10.5123/s1679-49742017000300017
http://dx.doi.org/10.5123/s1679-49742017... . The analyzes in this study were performed using data from Sample 2.

The sample plan of Sample 2 was defined in five geographic strata, referring to each Greater Region of the country, aiming to represent Brazil and its Major Regions. The sample of each geographic stratum was allocated proportionally to the number of schools according to the type (private and public) of the schools registered in the 2013 School Census. Sample 2 was composed of 10,926 valid interviews with students in the 6^th to 9^th grades (old 5^th to 8^th grade) of Primary Education and in the 1^st to 3^rd year of Secondary Education (morning, afternoon and evening shifts) of public and private schools, with at least 15 students enrolled in the chosen series¹⁵15. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016..

For the strata, the sample was selected in three stages: by IBGE agencies, by the size and by the eligible classes in the selected schools. All students in the selected classes that were present on the day of the interview were included in the sample¹⁵15. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016..

The students answered a self-administered structured questionnaire in a smartphone. After the data collection, the sample weights were calculated so that the sample was representative for Brazil, the five Regions, and the federation units. For more details, please refer to the 2015 PeNSE report¹⁵15. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016..

The search for health services or health professionals was described using the indicator “Percentage of schoolchildren who searched for a health service or professional in the 12 months prior to the survey: no and yes”, which is the dependent variable.

The independent variables potentially associated with the outcome were:

The prevalence, as well as their respective 95% confidence intervals (95%CI), of the demand for health services or health professionals among schoolchildren were estimated according to the independent variables. The magnitudes of the associations were estimated using the prevalence ratios (RPs) by the Poisson regression model. The first category of each variable was used as reference. Initially, a bivariate analysis was performed. Then, the variables that were associated with significance level p ≤ 0.20 were selected for the multiple model.

Data analyses were performed using Stata software version 14.0 (Stata Corp., College Station, USA) using the survey command for complex sampling. PeNSE was approved by the National Commission for Ethics in Research of the Ministry of Health, under Opinion No. 1.006.467, dated March 30^th, 2015.

RESULTS

The demand for health services or professionals in the last 12 months among students aged 13 to 17 years was 56.7% (95%CI 55.2 - 58.3). Regarding the sociodemographic characteristics, the demand was higher for females (61,1%; 95%CI 59.2 - 63.0), for adolescents aged 16 years (63.6%; 95%CI 60.9 - 66.2), white skin color/race (60.4%; 95%CI 58.4 - 62.3), private school students (69.9%; 95%CI 67.5 - 72.2) and residents of the Southeast Region (59.6%; 95%CI 57.1 - 62.2). In relation to family characteristics, there was an increase in demand among youngsters with high maternal schooling, reaching 65.3% (95%CI 62.4 - 68.0) for children of mothers with higher education, who live with both parents (58.5%; 95%CI 56.4 - 60.6), who have meals with their guardians (57.6%; 95%CI 56.0 - 59.3), who did not miss classes without permission from their guardians (57.7%; 95%CI 55.8 - 59.5) and among those whose parents had knowledge of what they did on their free time (60.3%; 95%CI 58.8 - 61.8), as shown in Table 1.

Regarding risk behaviors, the demand was higher among adolescents who consume alcohol (62.4%; 95%CI 52.3 - 62.5), who use drugs (63.2%; 95%CI 60.0 - 64.7) and who had sexual intercourse without a condom (60.4%; 95%CI 57.0 - 64.1); there was no difference for current smoking. Regarding health issues, the demand was greater among those who suffered some injury (60.8%; 95%CI 57.4 - 64.1) or physical violence (63.7%; 95%CI 61.0 - 66.3) and those who felt alone at times (59.8%; 95%CI 57.9 - 61.7), as well as those who reported chest wheezing (66.2%; 95%CI 63.8 - 68.5) and toothache (59.5%; 95%CI 56.6 - 62.2). On the other hand, the demand was lower among those who did not do anything in relation to their own body weight (51.2%; 95%CI 48.8 - 53.5) and among those who assessed their health status as very good (54.1%; 95%CI 51.5 - 56.6) (Table 1).

Table 2 presents the results of the bivariate and multiple regression analyzes, adjusted for age and Region of residence. Adolescents whose mothers had completed secondary education (PR = 1.19; p = 0.003) or higher education (PR = 1.21; p = 0.002), had meals with their parents (PR = 1.09; p < 0.015) and those whose guardians, most of the times or always, have knowledge about what they do in their free time (PR = 1.19; p < 0.001) were associated with a greater demand for health services or health professionals. Also, adolescents who reported current alcohol consumption (PR = 1.10; p < 0.001), practicing unprotected sexual intercourse (PR = 1.09; p = 0.018), suffering physical violence (PR = 1.09; p = 0.007), chest wheezing (PR = 1.15; p < 0.001), toothache (PR = 1.07; p = 0.018), the habit of washing hands (PR = 1.09; p < 0.001), as well as those trying to lose (PR = 1.09; p = 0.005), gain (PR = 1.10; p = 0.004) or maintain weight (PR = 1.16; p < 0.001), were also related to greater demand for services or health professionals.

On the other hand, being male (PR = 0.86; p < 0.001), having black (PR = 0.86; p < 0.001) and yellow skin color/race (PR = 0.87; p = 0.029) and being a public school student (PR = 0.87; p < 0.001) were factors associated with lower demand for health services or professionals.

DISCUSSION

More than half of the Brazilian students aged 13 to 17 years sought a health service or professional in the last 12 months. This prevalence was higher than that observed in the study with data from PeNSE 2012, which estimated a prevalence of 48.0%⁸8. Oliveira MM, Andrade SSCA, Oliveira-Campos M, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública. 2015; 31(8): 1603-14. http://dx.doi.org/10.1590/0102-311X00165214
http://dx.doi.org/10.1590/0102-311X00165... , but similar to the findings of a systematic review on the use of health services in Brazil⁴4. Araújo MEA, Silva MT, Andrade KRC, Galvão TF, Pereira MG. Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise. Epidemiol Serv Saúde. 2017; 26(3): 589-604. http://dx.doi.org/10.5123/s1679-49742017000300016
http://dx.doi.org/10.5123/s1679-49742017... . Studies that address this issue are relevant because they guide health services to adapt their work processes to meet the specific demands of each phase of the individual’s life cycle.

Female students showed greater demand for health services or professionals. The findings are similar to the aforementioned study⁸8. Oliveira MM, Andrade SSCA, Oliveira-Campos M, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública. 2015; 31(8): 1603-14. http://dx.doi.org/10.1590/0102-311X00165214
http://dx.doi.org/10.1590/0102-311X00165... , as well as to the studies that evaluated the adult population⁴4. Araújo MEA, Silva MT, Andrade KRC, Galvão TF, Pereira MG. Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise. Epidemiol Serv Saúde. 2017; 26(3): 589-604. http://dx.doi.org/10.5123/s1679-49742017000300016
http://dx.doi.org/10.5123/s1679-49742017... ^,1818. Luz TCB, Malta DC, Sá NNB, Silva MMA, Lima-Costa MF. Violências e acidentes entre adultos mais velhos em comparação aos mais jovens: evidências do Sistema de Vigilância de Violências e Acidentes (VIVA), Brasil. Cad Saúde Pública. 2011; 27: 2135-42. http://dx.doi.org/10.1590/S0102-311X2011001100007
http://dx.doi.org/10.1590/S0102-311X2011... ^,1919. Gomes R, Nascimento EF, Araújo FC. Por que os homens buscam menos os serviços de saúde do que as mulheres? As explicações de homens com baixa escolaridade e homens com ensino superior. Cad Saúde Pública. 2007; 23: 565-74. http://dx.doi.org/10.1590/S0102-311X2007000300015
http://dx.doi.org/10.1590/S0102-311X2007... ^,2020. Moraes SA, Lopes DA, Freitas IC. Sex-specific differences in prevalence and in the factors associated to the search for health services in a population based epidemiological study. Rev Bras Epidemiol. 2014; 17(2): 323-40. http://dx.doi.org/10.1590/1809-4503201400020004ENG
http://dx.doi.org/10.1590/1809-450320140... . The demand for healthcare among females has been attributed to the concern with self-care⁴4. Araújo MEA, Silva MT, Andrade KRC, Galvão TF, Pereira MG. Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise. Epidemiol Serv Saúde. 2017; 26(3): 589-604. http://dx.doi.org/10.5123/s1679-49742017000300016
http://dx.doi.org/10.5123/s1679-49742017... ^,2020. Moraes SA, Lopes DA, Freitas IC. Sex-specific differences in prevalence and in the factors associated to the search for health services in a population based epidemiological study. Rev Bras Epidemiol. 2014; 17(2): 323-40. http://dx.doi.org/10.1590/1809-4503201400020004ENG
http://dx.doi.org/10.1590/1809-450320140... ^,2121. Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados à procura por serviços de saúde numa perspectiva relacional de gênero. Ciênc Saúde Coletiva. 2014; 19(4). http://dx.doi.org/10.1590/1413-81232014194.01242013
http://dx.doi.org/10.1590/1413-812320141... ^,2222. Castanheira CHC, Pimenta AM, Lana FCF, Malta DC. Utilização de serviços públicos e privados de saúde pela população de Belo Horizonte. Rev Bras Epidemiol. 2014; 17: 256-66. http://dx.doi.org/10.1590/1809-4503201400050020
http://dx.doi.org/10.1590/1809-450320140... , and these findings indicate that such a practice occurs since adolescence. The fact that men seek health services with a lower frequency can result in late diagnoses, which could hamper the control and treatment of diseases²³23. Silva VLQ. Sexualidade masculina e saúde do homem na estratégia de saúde da família: trabalhando com a equipe a pesquisa-ação. São Paulo: Universidade de São Paulo; 2010.. It is necessary to go beyond the common sense that men are strong beings, who hardly gets sick and, consequently, seek health services less frequently²¹21. Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados à procura por serviços de saúde numa perspectiva relacional de gênero. Ciênc Saúde Coletiva. 2014; 19(4). http://dx.doi.org/10.1590/1413-81232014194.01242013
http://dx.doi.org/10.1590/1413-812320141... .

Adolescents of white race/skin color, who studied in private schools and had mothers with higher level of schooling presented a high association with the demand for health services or professionals. Considering such characteristics as income proxy, the effects are similar to those presented by studies among adults²⁴24. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios. Um panorama da saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010.. Research indicates that individuals belonging to lower income groups seek less health services regardless of age²⁵25. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva. 2011; 16: 3807-16. http://dx.doi.org/10.1590/S1413-81232011001000016
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http://dx.doi.org/10.1590/S1415-790X2013... . Data from the National Household Sample Survey (PNAD) indicate an increase in the use of health services and point to a reduction in the inequalities of access to primary health care²⁹29. Andrade MV, Noronha KVMS, Menezes RM, Souza MN, Reis CB, Martins DR, et al. Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008. Econ Apl. 2013; 17(4): 623-45. http://dx.doi.org/10.1590/S1413-80502013000400005
http://dx.doi.org/10.1590/S1413-80502013... ^-3030. Politi R. Desigualdade na utilização de serviços de saúde entre adultos: uma análise dos fatores de concentração da demanda. Econ Apl. 2014; 18(1): 117-37. http://dx.doi.org/10.1590/1413-8050/ea379
http://dx.doi.org/10.1590/1413-8050/ea37... , but such inequalities persist, mainly in relation to income. These differences may relate the demand for care, which is higher among people with lower income³¹31. Almeida APSC, Nunes BP, Duro SMS, Facchini LA. Determinantes socioeconômicos do acesso a serviços de saúde em idosos: revisão sistemática. Rev Saúde Pública. 2017; 51: 50. https://doi.org/10.1590/S1518-8787.2017051006661
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http://dx.doi.org/10.1590/1413-812320152... .

The relationship with the family, evidenced by the association of the meals with parents or guardians and their knowledge about the students’ activities on their free time, was important in the demand for health services. These characteristics are relevant in several studies among adolescents⁸8. Oliveira MM, Andrade SSCA, Oliveira-Campos M, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública. 2015; 31(8): 1603-14. http://dx.doi.org/10.1590/0102-311X00165214
http://dx.doi.org/10.1590/0102-311X00165... ^,3535. Freire MCM, Leles CR, Sardinha LMV, Paludetto Junior M, Malta DC, Peres MA. Dor dentária e fatores associados em adolescentes brasileiros: a Pesquisa Nacional de Saúde do Escolar (PeNSE), Brasil, 2009. Cad Saúde Pública. 2012; 28(Supl.): S133-45. http://dx.doi.org/10.1590/S0102-311X2012001300014
http://dx.doi.org/10.1590/S0102-311X2012... ^,3636. Smetana JG, Campione-Barr N, Metzger A. Adolescent development in interpersonal and societal contexts. Annu Rev Psychol. 2006; 57: 255-84. https://doi.org/10.1146/annurev.psych.57.102904.190124
https://doi.org/10.1146/annurev.psych.57... . The family has a protective role with adolescents, not only in stimulating the search for health services or professionals, but also in relation to safe sexual practices³⁷37. Oliveira-Campos M, Giatti L, Malta D, Barreto SM. Contextual factors associated with sexual behavior among Brazilian adolescents. Ann Epidemiol. 2013; 23: 629-35. https://doi.org/10.1016/j.annepidem.2013.03.009
https://doi.org/10.1016/j.annepidem.2013... and non-consumption of alcohol, tobacco and other drugs³⁸38. Horta R, Horta B, Costa A, Prado R, Oliveira-Campos M, Malta D. Uso na vida de substâncias ilícitas e fatores associados entre escolares brasileiros. Pesquisa Nacional de Saúde do Escolar (PeNSE 2012). Rev Bras Epidem. 2014; 17(Supl. 1): 31-45. http://dx.doi.org/10.1590/1809-4503201400050004
http://dx.doi.org/10.1590/1809-450320140... , for example.

Adolescents who reported current alcohol use sought health services more frequently. In the study that dealt with the alcohol consumption pattern of adult users of Primary Health Care (PHC) services in the city of Bebedouro, São Paulo, it was identified that 78% of the users were abstinent or were in a low risk use situation, and 22% made problematic use of alcohol. According to the authors, PHC is a space not only for identifying alcohol-related harm, but also for implementing strategies to reduce it, especially among individuals who are more susceptible to morbidity and mortality related to alcohol use³⁹39. Vargas D, Bittencourt MN, Barroso LP. Padrões de consumo de álcool de usuários de serviços de atenção primaria a saúde de um município brasileiro. Ciênc Saúde Coletiva. 2014; 19(1). http://dx.doi.org/10.1590/1413-81232014191.1972
http://dx.doi.org/10.1590/1413-812320141... .

On the other hand, smoking and drug use did not remain associated with the demand for health services or professionals in the multiple model. The hypothesis for this is that adolescents who consume tobacco products and try drugs also make use of alcohol. The use of these individual substances alone is rare, as described above³⁹39. Vargas D, Bittencourt MN, Barroso LP. Padrões de consumo de álcool de usuários de serviços de atenção primaria a saúde de um município brasileiro. Ciênc Saúde Coletiva. 2014; 19(1). http://dx.doi.org/10.1590/1413-81232014191.1972
http://dx.doi.org/10.1590/1413-812320141... .

Adolescent sexual life begins earlier and earlier, associated with unprotected sex and to a largest number of partners throughout life⁴⁰40. Shafii T, Stovel K, Holmes K. Association between condom use at sexual debut and subsequent sexual trajectories: a longitudinal study using biomarkers. Am J Public Health. 2007; 97: 1090-5. https://dx.doi.org/10.2105%2FAJPH.2005.068437
https://dx.doi.org/10.2105%2FAJPH.2005.0... . In the present study, the practice of sexual intercourse without a condom was associated with the outcome. An explanatory hypothesis is that adolescents who do not use condoms may have later concerns about a sexually transmitted infection or even an unwanted pregnancy due to non-use or inappropriate condom use⁴¹41. Granero R, Poni ES, Sánchez Z. Sexuality among 7th, 8th and 9th grade students in the state of Lara, Venezuela. The Global School Health Survey, 2003-2004. P R Health Sci J. 2007; 26: 213-9.. Health services should be able to accommodate adolescents seeking health care, and to seize this opportunity to address this issue.

Travassos et al. argue that the demand for health services is higher among those who have health needs or who are ill¹1. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública. 2004; 20(Supl. 2): S190-8. http://dx.doi.org/10.1590/S0102-311X2004000800014
http://dx.doi.org/10.1590/S0102-311X2004... . They also highlight aspects such as the disease’s severity and urgency. PeNSE data corroborate the study cited, since the adolescents interviewed who sought health services were also those who reported health problems/conditions, such as asthma, wheezing, physical violence in the last few days and toothache, as well as those who were trying to lose, gain or maintain weight. The individual’s behavior towards the disease²⁶26. Travassos C, Viacava F, Fernandes C, Almeida CM. Desigualdades geográficas e sociais na utilização de serviços de saúde no Brasil. Ciênc Saúde Coletiva. 2000; 5: 133-49. http://dx.doi.org/10.1590/S1413-81232000000100012
http://dx.doi.org/10.1590/S1413-81232000... ^,4242. Curtis V, Cairncross S, Yonli R. Domestic hygiene and diarrhoea - pinpointing the problem. Trop Med Int Health. 2000; 5: 22-32.^,4343. Cardoso SMM, Rodrigues AP. Promoção da saúde a partir das demandas relacionadas à higiene e saúde na escola." Revista de Ciência e Inovação. 2016;1(2):93-104. [citado 12 set. 2017]. Disponível em: http://periodicos.iffarroupilha.edu.br/index.php/cienciainovacao/article/view/99
http://periodicos.iffarroupilha.edu.br/i... ^,4444. Vingilis E, Wade T, Seeley J. Predictors of adolescent health care utilization. J Adolesc. 2007; 30(5): 773-800. https://doi.org/10.1016/j.adolescence.2006.10.001
https://doi.org/10.1016/j.adolescence.20... and the search for health promotion and prevention practices are health needs described as determinants of access and use of health services⁴²42. Curtis V, Cairncross S, Yonli R. Domestic hygiene and diarrhoea - pinpointing the problem. Trop Med Int Health. 2000; 5: 22-32.^,4343. Cardoso SMM, Rodrigues AP. Promoção da saúde a partir das demandas relacionadas à higiene e saúde na escola." Revista de Ciência e Inovação. 2016;1(2):93-104. [citado 12 set. 2017]. Disponível em: http://periodicos.iffarroupilha.edu.br/index.php/cienciainovacao/article/view/99
http://periodicos.iffarroupilha.edu.br/i... . There is evidence of increased demand for health services in the case of accidents, injuries and rehabilitation; on the other hand, there was a decrease in the demand for prevention actions²⁵25. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva. 2011; 16: 3807-16. http://dx.doi.org/10.1590/S1413-81232011001000016
http://dx.doi.org/10.1590/S1413-81232011... . The habit of washing hands before meals and after going to the bathroom was associated with the demand for health services. The promotion of these practices is a component that has broad implications on the general health of individuals⁴²42. Curtis V, Cairncross S, Yonli R. Domestic hygiene and diarrhoea - pinpointing the problem. Trop Med Int Health. 2000; 5: 22-32. and is indicative of healthy habits⁴³43. Cardoso SMM, Rodrigues AP. Promoção da saúde a partir das demandas relacionadas à higiene e saúde na escola." Revista de Ciência e Inovação. 2016;1(2):93-104. [citado 12 set. 2017]. Disponível em: http://periodicos.iffarroupilha.edu.br/index.php/cienciainovacao/article/view/99
http://periodicos.iffarroupilha.edu.br/i... .

The choice of adjusting for age was made due to evidence of the increase in the demand for health services and professionals with the increase in the age of adolescents⁸8. Oliveira MM, Andrade SSCA, Oliveira-Campos M, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública. 2015; 31(8): 1603-14. http://dx.doi.org/10.1590/0102-311X00165214
http://dx.doi.org/10.1590/0102-311X00165... ^,4444. Vingilis E, Wade T, Seeley J. Predictors of adolescent health care utilization. J Adolesc. 2007; 30(5): 773-800. https://doi.org/10.1016/j.adolescence.2006.10.001
https://doi.org/10.1016/j.adolescence.20... . Regarding the Region of residence, adequacy was necessary, because in Brazil, despite the reduction of inequality in the last decades, there is still an unbalanced distribution of health services (which are concentrated in the Southeast)⁴⁵45. Cambota JN. Desigualdades sociais na utilização de cuidados de saúde no Brasil e seus determinantes [Internet]. São Paulo: Universidade de São Paulo; 2012 [citado 12 set. 2017]. Disponível em: http://www.teses.usp.br/teses/disponiveis/12/12140/tde-11062012-190139/ https://doi.org/10.11606/T.12.2012.tde-11062012-190139
http://www.teses.usp.br/teses/disponivei... ^,4646. Scheffer M (Coord). Demografia Médica no Brasil 2015. Departamento de Medicina Preventiva, Faculdade de Medicina da USP. Conselho Regional de Medicina do Estado de São Paulo. Conselho Federal de Medicina. São Paulo: 2015. 284 p. ISBN: 978-85-89656-22-1 https://www.usp.br/agen/wp-content/uploads/DemografiaMedica30nov2015.pdf
https://www.usp.br/agen/wp-content/uploa... .

Contrary to what was verified among students from Niterói, Rio de Janeiro, in 2001⁵5. Claro LBL, March C, Mascarenhas MTM, Castro IAB, Rosa MLG. Adolescentes e suas relações com serviços de saúde: estudo transversal em escolares de Niterói, Rio de Janeiro, Brasil. Cad Saúde Pública. 2006; 22: 1565-74. http://dx.doi.org/10.1590/S0102-311X2006000800005
http://dx.doi.org/10.1590/S0102-311X2006... , health self-assessment did not remain associated with the outcome studied. However, it is emphasized that both the cited study and this study used other variables in the multiple model.

As a limitation of this study, it is noteworthy that PeNSE is representative of adolescents who attended school and who were present on the day of questionnaire application. School absenteeism itself may be related to the demand for health services or professionals. This is a cross-sectional study and, by its very nature, it is not possible to infer whether the demand for health services was the cause or the consequence of some of the associated variables¹⁷17. Oliveira MM, Oliveira-Campos M, Andreazzi MAR, Malta DC. Características da Pesquisa Nacional de Saúde do Escolar-PeNSE. Epidem Serv Saúde. 2017; 26(3): 605-16. http://dx.doi.org/10.5123/s1679-49742017000300017
http://dx.doi.org/10.5123/s1679-49742017... . In addition, the high prevalence of demand for health services may be due to the greater time investigated (360 days); however, long recall periods result in a greater likelihood of individuals forgetting to mention the demand for health services⁴4. Araújo MEA, Silva MT, Andrade KRC, Galvão TF, Pereira MG. Prevalência de utilização de serviços de saúde no Brasil: revisão sistemática e metanálise. Epidemiol Serv Saúde. 2017; 26(3): 589-604. http://dx.doi.org/10.5123/s1679-49742017000300016
http://dx.doi.org/10.5123/s1679-49742017... .

A strong point that can be highlighted in the present study is the possibility of evaluating and monitoring the indicator of service use among adolescents, since this population has been historically at the margin of the health system. It is also worth noting that demand for health services increased by almost 10% for this population group, with one hypothesis being the expansion of the Family Health Strategy⁹9. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Histórico da Cobertura da Saúde da Família [Internet]. [citado 13 dez. 2017]. Disponível em: http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php
http://dab.saude.gov.br/portaldab/histor... ^,4747. Atun R, Andrade LOM, Almeida G, Cotlear D, Dmytraczenko T, Frenz P, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015; 385(9974): 1230-47. https://doi.org/10.1016/S0140-6736(14)61646-9
https://doi.org/10.1016/S0140-6736(14)61... and the Health in School Program⁴⁸48. Sousa MC, Esperidião MA, Medina MG. A intersetorialidade no Programa Saúde na Escola: avaliação do processo político-gerencial e das práticas de trabalho. Ciênc Saúde Coletiva. 2017; 22(6): 1781-90. http://dx.doi.org/10.1590/1413-81232017226.24262016
http://dx.doi.org/10.1590/1413-812320172... ^,4949. Teixeira MB, Casanova A, Oliveira CCM, Engstrom EM, Bodstein RCA. Avaliação das práticas de promoção da saúde: um olhar das equipes participantes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde Debate. 2014; 38(Esp.): 52-68. http://dx.doi.org/10.5935/0103-1104.2014S005
http://dx.doi.org/10.5935/0103-1104.2014... , which enabled spaces aimed at meeting demands and at health education.

CONCLUSION

Studies on the demand for health services and professionals by adolescents are relevant since they are infrequent and can contribute to the organization of care²⁵25. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva. 2011; 16: 3807-16. http://dx.doi.org/10.1590/S1413-81232011001000016
http://dx.doi.org/10.1590/S1413-81232011... and to the planning of programs and policies for this population. In addition, they can guide the Health in School Program (PSE) to address issues such as health promotion and integral education (promotion, prevention, diagnosis and recovery and training), with a view to comprehensive health care for children, adolescents and young people in basic public education, through the intersectoral articulation of public health and education networks and other social networks.

As well as among adults, female adolescents, private school students with more educated mothers, who present risk behaviors, and who reported suffering from a health problem sought more health services. Another important point was the general increase in demand when compared to results from the survey’s previous edition.

It is important to take into account the characteristics of these adolescents, both regarding the organization of health services and the adequate training of professionals in health care, allowing a space of approach to deal with subjects related to the risks to which these adolescents are exposed.

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