ABSTRACT

Objective:

To analyze the demand and use of health services by Brazilian adolescents, according to sociodemographic characteristics.

Methods:

Cross-sectional study with data from the 2019 National School Health Survey, that assessed 124,898 adolescents aged 13 to 17 years. The crude and adjusted prevalence ratios (RPaj) by sex, age, and school administrative status and their 95% confidence intervals (95%CI) were calculated for the variables “search for a service or health professional”, “search for a Basic Health Unit” and “assistance at the Basic Health Unit”, using Poisson regression with robust variance.

Results:

The demand for a health service was reported by 56.56% (95%CI 55.82–57.29) of the adolescents and was lower among male students (RPaj: 0.95; 95%CI 0.94–0.95); those with black skin color (RPaj: 0.95; 95%CI 0.94–0.97), brown skin color (RPaj: 0.97; 95%CI 0.96–0.98), yellow skin color and indigenous ethnicity (RPaj: 0.95; 95%CI 0.94–0.97); public school students (RPaj: 0.90; 95%CI 0.89–0.90); and rural residents (RPaj: 0.96; 95%CI 0.94–0.98). A Basic Health Unit was the service sought by 74.08% (95%CI 73.21–74.94) of adolescents, more frequently among students of brown skin color (RPaj: 1.06; 95%CI 1.03–1.08), from public schools (RPaj: 1.32; 95%CI 1.29–1.35) and residing in rural areas (RPaj: 1.05; 95%CI 1,01–1,09). The main reason for seeking the Basic Health Unit was vaccination (27,93%; 95%CI 27,07–28,81).

Conclusion:

More than half of the adolescents searched for a health service, which means that this group has a high demand. However, health inequalities still persist and point to the importance of health care planning, reception conditions, and the quality of care provided.

Keywords:
Adolescent health; Health services accessibility; Unified health system; Health promotion

INTRODUCTION

Individuals go through a dynamic and complex process of maturation and physical, hormonal, psychic and social transformations during adolescence, which can predispose them to new experiences and health-risky behaviors¹1 Arain M, Haque M, Johal L, Mathur P, Nel W, Rais A, et al. Maturation of the adolescent brain. Neuropsychiatr Dis Treat 2013; 9: 449-61. https://doi.org/10.2147/NDT.S39776
https://doi.org/10.2147/NDT.S39776... ,²2 Ross DA, Hinton R, Melles-Brewer M, Engel D, Zeck W, Fagan L, et al. Adolescent well-being: a definition and conceptual framework. J Adolesc Health 2020; 67(4): 472-6. https://doi.org/10.1016/j.jadohealth.2020.06.042
https://doi.org/10.1016/j.jadohealth.202... .

Every year, thousands of adolescents die from preventable causes³3 Strong KL, Pedersen J, Johansson EW, Cao B, Diaz T, Guthold R, et al. Patterns and trends in causes of child and adolescent mortality 2000–2016: setting the scene for child health redesign. BMJ Glob Health 2021; 6(3): e004760. http://doi.org/10.1136/bmjgh-2020-004760
http://doi.org/10.1136/bmjgh-2020-004760... , which reinforces the need for a comprehensive health care and access to individual and collective health promotion actions, as well as disease and injuries prevention programs⁴4 Silva RF, Engstrom EM. Atenção integral à saúde do adolescente pela Atenção Primária à Saúde no território brasileiro: uma revisão integrativa. Interface (Botucatu) 2020; 24(Supl 1): e190548. https://doi.org/10.1590/Interface.190548
https://doi.org/10.1590/Interface.190548... ,⁵5 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Proteger e cuidar da saúde de adolescentes na atenção básica [Internet]. Brasília: Ministério da Saúde; 2017 [cited on Apr 27, 2022]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/proteger_cuidar_adolescentes_atencao_basica.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . In order for adolescents to be fully cared for, an organized, planned network with the participation of social actors and health professionals trained to assist them is needed; one that considers, above all, socioeconomic and cultural contexts⁶6 Barros RP, Holanda PRCM, Sousa ADS, Apostolico MR. Necessidades em saúde dos adolescentes na perspectiva dos profissionais da Atenção Primária à Saúde. Ciênc Saúde Colet 2021; 26(2): 425-34. https://doi.org/10.1590/1413-81232021262.40812020
https://doi.org/10.1590/1413-81232021262... .

The search for a health service can be defined as the entry of an individual into the health system, while use comprises the interaction between professionals and users, be it direct contact, such as consultations and hospitalizations, or indirect contact, such as performing exams⁷7 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... .

The demand and use of health services can be influenced by social determinants, once low-income, socially disadvantaged or marginalized adolescents are less likely to seek health services. On the other hand, white adolescents, enrolled in private schools and with high maternal educational level seek health services and professionals more often⁸8 Oliveira MM, Andrade SSCA, Campos MO, 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. https://doi.org/10.1590/0102-311X00165214
https://doi.org/10.1590/0102-311X0016521... ,⁹9 Oliveira MM, Andrade SSCA, Stopa SR, Malta DC. Procura por serviços ou profissionais de saúde entre adolescentes brasileiros, segundo a Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(suppl 1): e180003.supl.1. https://doi.org/10.1590/1980-549720180003.supl.1
https://doi.org/10.1590/1980-54972018000... . This is added to the difficulty of professionals in providing comprehensive care to adolescents, which impairs reception, bonding and the quality of care offered⁴4 Silva RF, Engstrom EM. Atenção integral à saúde do adolescente pela Atenção Primária à Saúde no território brasileiro: uma revisão integrativa. Interface (Botucatu) 2020; 24(Supl 1): e190548. https://doi.org/10.1590/Interface.190548
https://doi.org/10.1590/Interface.190548... .

Studies using data from the National School Health Survey (PeNSE) showed that 48.0% (95%CI 47.6–48.5) of adolescents looked for a health service or professional in 2012⁸8 Oliveira MM, Andrade SSCA, Campos MO, 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. https://doi.org/10.1590/0102-311X00165214
https://doi.org/10.1590/0102-311X0016521... and 56.7% (95%CI 55.2–58.3) in 2015⁹9 Oliveira MM, Andrade SSCA, Stopa SR, Malta DC. Procura por serviços ou profissionais de saúde entre adolescentes brasileiros, segundo a Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(suppl 1): e180003.supl.1. https://doi.org/10.1590/1980-549720180003.supl.1
https://doi.org/10.1590/1980-54972018000... , which shows an increase over the years. However, the monitoring of demand and use of health services must be continuous to enable decision-making, improve management and public policies and recognize the demands of this population, while identifying factors that influence the relationship with services and health professionals. Thus, it is expected that continuous, coordinated and guided care to adolescents will be promoted and improved, ensuring their rights and reducing health inequalities.

Therefore, this study aimed to analyze the demand for and use of health services by Brazilian adolescents, according to sociodemographic characteristics.

METHODS

Study design

This is a cross-sectional study that used data from the PeNSE 2019 survey.

Scenario

PeNSE is a survey carried out with adolescents in school age, conducted by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health and supported by the Ministry of Education. It is part of the Surveillance System for Risk and Protection Factors for Chronic Noncommunicable Diseases (NCDs) in Brazil and was the first national survey to address various aspects of adolescents’ lives, such as habits, care, risk and protection factors for health¹⁰10 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101852.pdf
https://biblioteca.ibge.gov.br/visualiza... .

The sampling plan was by conglomerates in two stages, in which schools corresponded to the first stage of selection and the groups of students enrolled corresponded to the second stage. The set of students from selected classes formed the sample. The plan was designed to estimate population parameters for students aged 13 to 17 years who were enrolled and regularly attending public and private schools, for the following geographic levels: Brazil, major regions, Federation Units (FU), capital cities and the Federal District. Details on the sampling process are provided in the PeNSE official publication¹⁰10 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101852.pdf
https://biblioteca.ibge.gov.br/visualiza... .

In 2019, data were collected at 4,242 schools, 6,612 classes, from 189,857 students enrolled and 183,264 attending students, 159,245 valid questionnaires and 125,123 questionnaires analyzed¹⁰10 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101852.pdf
https://biblioteca.ibge.gov.br/visualiza... .

PeNSE's database and questionnaires are available in public domain and for use on the IBGE website: https://www.ibge.gov.br/estatisticas/sociais/saude/9134-pesquisa-nacional-de-saude-do-escolar.html?edicao=31442&t=results.

Participants

Adolescents aged 13 to 17 years old, enrolled and regularly attending the 7^th to 9^th grade of elementary school and the 1^st to 3^rd grades of high school, including technical courses with integrated high school and normal/teaching courses, participated in the research; participants were from all shifts, from public and private schools in Brazil¹⁰10 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101852.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Data collection

Data were collected from April to September 2019 by means of the mobile collection device, which corresponds to a smartphone with the structured survey questionnaires. The IBGE technician distributed the devices to students present on the day of the interviews and instructed them on how to handle them. The student's questionnaire was self-administered and had specific fill-in instructions¹⁰10 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101852.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Study variables

This study included variables related to demand and use of health services and sociodemographic features that are described below.

Search for a health service or professional: prevalence of adolescents who sought a health service or professional to care for their health. “In the last 12 months, have you sought any health service or professional to care for your own health?” Answer options: yes; no.

Most frequently sought service: proportion of type of health service sought most frequently by adolescents to care for their health. “In the last 12 months, which health service did you visit most often?” Response options: Basic Health Unit (BHU); doctor's office or private clinic; hospital; others (dental office; office of other health specialty; medical specialty services or polyclinic; emergency room, Emergency Care Unit; laboratory or clinic for complementary tests; home care service; pharmacy).

Search for a BHU: proportion of adolescents who sought a BHU to care for their health in the last 12 months. “In the last 12 months, have you sought any BHU (Health Center or Family Health Unit/Family Health Strategy — FHS)?” Answer options: yes; no.

Assistance at the BHU: proportion of adolescents who were assisted when they sought a BHU. “Did you receive care the last time you went to a BHU (Health Center or Family Health Unit — FHS)?” Answer options: yes; no.

Reason for looking for a BHU: proportion of main reason adolescents sought a BHU. “What was the main reason for your visit to the BHU (Health Center or Family Health Unit — FHS) this last time?” Answer options: weight management support (gain or lose); accident or injury, rehabilitation or physical therapy; dentist or other oral health professional; psychologist or other mental health professional; vaccination; illness; others (support to smoking cessation; contraceptive methods; HIV, syphilis or hepatitis B test; prenatal care/pregnancy test; request for a medical certificate).

Figure 1 shows the flow of the PeNSE questionnaire regarding the aforementioned indicators.

The sociodemographic variables were: biological sex (male and female); age range (from 13 to 15; 16 and 17 years old); skin color (white, black, brown and others — yellow and indigenous); school network (private and public), and area of residence (urban and rural).

Data analysis

Prevalence values and respective 95% confidence intervals (95%CI) were estimated. For the variables “search for a health service or professional”, “search for a BHU” and “assistance at the BHU”, proportions were calculated according to sociodemographic variables and crude and adjusted prevalence ratios (PRc and PRa) by sex, age and school network⁸8 Oliveira MM, Andrade SSCA, Campos MO, 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. https://doi.org/10.1590/0102-311X00165214
https://doi.org/10.1590/0102-311X0016521... ,⁹9 Oliveira MM, Andrade SSCA, Stopa SR, Malta DC. Procura por serviços ou profissionais de saúde entre adolescentes brasileiros, segundo a Pesquisa Nacional de Saúde do Escolar de 2015. Rev Bras Epidemiol 2018; 21(suppl 1): e180003.supl.1. https://doi.org/10.1590/1980-549720180003.supl.1
https://doi.org/10.1590/1980-54972018000... and respective 95%CI, using Poisson regression models with robust variance. Results with p-value lower than or equal to 0.05 were considered significant. For all analyses, post-stratification weights were considered.

Analyses were performed using Data Analysis and Statistical Software (Stata), version 14.2, by means of the survey module, which considers post-stratification weights.

Ethical aspects

The students who agreed with the Free and Informed Consent Form, displayed on the first page of the questionnaire in the mobile collection device, participated in the research.

PeNSE was approved by the National Committee on Ethics in Research for Human Beings of the Ministry of Health (Opinion No. 3,249,268, of April 8, 2019).

RESULTS

A total of 124,898 adolescents aged between 13 and 17 years were evaluated. Of these, most were females (50.7%; 95%CI 49,9–51.4); aged between 13 and 15 years (64.7%; 95%CI 63.2–66.01); with brown skin color (43.6%; 95%CI 42.8–44.3), followed by white (36.0%; 95%CI 35.1–36.8), black (13.6%; IC95% 13,0–14.1), yellow skin and indigenous ethnicity (6.9%; 95%CI 6.5–7.2); living in the urban area (92.4%; 95%CI 90.6–93.6); and enrolled in public schools (85.5%; 95%CI 85.1–85.9).

The search for a health service or professional to care for their health was reported by 56.56% (95%CI 55.82– 57.29) of the adolescents and was lower among males (PRa: 0.95; 95%CI 0.94–0.95); those whose skin was black (PRa: 0.95; 95%CI 0.94–0.97), brown (PRa: 0.97; 95%CI 0.96–0.98), yellow, and those who were indigenous (PRa: 0.95; 95%CI 0.94–0.97); those enrolled in public schools (PRa: 0.90; 95%CI 0.89–0.90); and living in rural areas (PRa: 0.96; 95%CI 0.94–0.98). On the other hand, demand was higher among adolescents aged 16 and 17 years (PRa: 1.03; 95%CI 1.02–1.04) (Table 1).

Regarding the type of health service most frequently sought by adolescents, the results indicated that 35.97% (95%CI 34.98–36.97) looked for the BHU. It is noteworthy that public school students sought the BHU more frequently (40.75%; 95%CI 39.56–41,95) and those from private schools sought a doctor's office or private clinic (38.49%; 95%CI 37.52–39.46) (Figure 2).

When asked specifically about searching for a BHU, 74.08% (95%CI 73.21-74.94) of the adolescents sought care at this service, mainly brown-skinned students (PRa: 1,06; IC95% 1,03–1,08), from public schools (PRa: 1.32; 95%CI 1.29–1.35) and residing in rural areas (PRa: 1.05; 95%CI 1.01–1.09). By contrast, the BHU was less sought by males (PRa: 0.94; 95%CI 0.92–0.96). We found no difference according to age group (Table 2).

Among the adolescents who sought a BHU, 88.61% (95%CI 88.05–89.14) were seen, however the proportion was lower among males (PRa: 0.98; 95%CI 0.97–0.99) and those with black skin color (PRa: 0.98; 95%CI 0.95–0.99) (Table 3).

The main reasons why adolescents sought the BHU were: vaccination (27.93%; 95%CI 27.07–28.81); disease (19.98%; 95%CI 19.21–20.79); dental care (8.65%; 95%CI 8.15–9.17); accident or injury, physical therapy or rehabilitation (77.0%; 95%CI 6.56–7.46); support for weight control (6.29%; 95%CI 5.84–6.77); looking for a psychologist or mental health professional (3.36%; 95%CI 3.06–3.68); and other types of assistance, which included support to smoking cessation; contraceptive methods; HIV, syphilis or hepatitis B test; prenatal care/pregnancy test; request for a medical certificate (26.79%; 95%CI 25.93–27.66).

DISCUSSION

This study identified that 56.56% of adolescent students sought a health service or professional to care for their own health. This demand was lower among males, with black, brown, yellow skin color and indigenous ethnicity, enrolled in public school and who resided in rural areas. The most frequently sought type of service was the BHU. Of the adolescents who sought BHUs, 88.61% were assisted and vaccination was the main reason for this demand.

More than half of the adolescents looked for some health service or professional, which shows a high demand in this age group. This highlights the importance of planning, reception and the quality of services provided to this public¹¹11 Nunes BP, Flores TR, Duro SMS, Saes MO, Tomasi E, Santiago AD, et al. Utilização dos serviços de saúde por adolescentes: estudo transversal de base populacional, Pelotas-RS, 2012. Epidemiol Serv Saúde 2015; 24(3): 411-20. https://doi.org/10.5123/S1679-49742015000300007
https://doi.org/10.5123/S1679-4974201500... . The priority actions of services for the comprehensive care of adolescents should include health education, immunization, nutrition and psychological support, considering their biological, emotional and social development, which is also fundamental for the success of the sustainable development agenda¹²12 Laski L, Expert Consultative Group for Every Woman Every Child on Adolescent Health. Realising the health and wellbeing of adolescents. BMJ 2015; h4119. https://doi.org/10.1136/bmj.h4119
https://doi.org/10.1136/bmj.h4119... ,¹³13 Sheehan P, Sweeny K, Rasmussen B, Wils A, Friedman HS, Mahon J, et al. Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. Lancet 2017; 390(10104): 1792-806. https://doi.org/10.1016/S0140-6736(17)30872-3
https://doi.org/10.1016/S0140-6736(17)30... .

This study showed that male adolescents sought health services less frequently than female ones. Sociocultural issues make it difficult to adhere to care and practices for health promotion and prevention of diseases and injuries¹⁴14 Levorato CD, Mello LM, Silva AS, Nunes AA. Fatores associados à procura por serviços de saúde numa perspectiva relacional de gênero. Ciên Saúde Colet 2014; 19(4): 1263-74. https://doi.org/10.1590/1413-81232014194.01242013
https://doi.org/10.1590/1413-81232014194... ,¹⁵15 Szwarcwald CL, Stopa SR, Damacena GN, Almeida WS, Souza Júnior PRB, Vieira MLFP, et al. Changes in the pattern of health services use in Brazil between 2013 and 2019. Ciên Saúde Colet 2021; 26(suppl 1): 2515-28. https://doi.org/10.1590/1413-81232021266.1.43482020
https://doi.org/10.1590/1413-81232021266... . Historically, men are seen as virile, invulnerable and strong, and demanding for health services can be associated with weakness, fear and insecurity¹⁶16 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(3): 565-74. https://doi.org/10.1590/S0102-311X2007000300015
https://doi.org/10.1590/S0102-311X200700... . Therefore, the importance of expanding and improving access to and quality of health services is reinforced to serve them in their plurality and in a resolute way, contributing to the acceptance and adherence to services and health promotion actions¹⁷17 Pereira J, Klein C, Meyer DE. PNAISH: uma análise de sua dimensão educativa na perspectiva de gênero. Saúde Soc 2019; 28(2): 132-46. https://doi.org/10.1590/S0104-12902019170836
https://doi.org/10.1590/S0104-1290201917... . The importance of raising awareness about the demand for health services and professionals and the early encouragement of the development of healthy habits is added to this, as it will have repercussions in adult life¹⁸18 Martins MMF, Aquino R, Pamponet ML, Pinto Junior EP, Amorim LDAF. Adolescent and youth access to primary health care services in a city in the state of Bahia, Brazil. Cad Saúde Pública 2019; 35(1): e00044718. https://doi.org/10.1590/0102-311X00044718
https://doi.org/10.1590/0102-311X0004471... .

The search for and use of health services are also determined by situations of social vulnerability¹⁹19 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. https://doi.org/10.1590/S1413-80502013000400005
https://doi.org/10.1590/S1413-8050201300... . In this study, adolescents with black, brown, yellow skin color and indigenous ethnicity, enrolled in public schools and living in rural areas were the ones who least sought health services or professionals. This reflects the gaps in care due to socioeconomic and housing inequalities, as well as poor infrastructure, lack of transportation and difficulties for the State to cover all health demands in the most remote areas²⁰20 Arruda NM, Maia AG, Alves LC. Inequality in access to health services between urban and rural areas in Brazil: a disaggregation of factors from 1998 to 2008. Cad Saúde Pública 2018; 34(6): e00213816. https://doi.org/10.1590/0102-311X00213816
https://doi.org/10.1590/0102-311X0021381... . According to the 2019 National Health Survey (PNS), health care demand was lower among the low-income population and higher among those people with white skin and complete higher education²¹21 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde 2019: informações sobre domicílios, acesso e utilização dos serviços de saúde. Brasil, grandes regiões e unidades da federação [Internet]. Rio de Janeiro: IBGE; 2020 [cited on Apr 27, 2022]. Available from: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101748.pdf
https://biblioteca.ibge.gov.br/visualiza... . A study with data from the National Household Sample Survey (PNAD) also showed that the use of health services is uneven and higher socioeconomic classes have better access²²22 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. https://doi.org/10.1590/1413-8050/ea379
https://doi.org/10.1590/1413-8050/ea379... .

It is important to mention that students from private schools sought mainly doctors’ office or private clinics, which can be explained by better socioeconomic conditions, having a health insurance plan and greater access to private health services by the higher-income population²³23 Souza Júnior PRB, Szwarcwald CL, Damacena GN, Stopa SR, Vieira MLFP, Almeida WS de, et al. Health insurance coverage in Brazil: analyzing data from the National Health Survey, 2013 and 2019. Cien Saude Colet 2021; 26(suppl 1): 2529-41. https://doi.org/10.1590/1413-81232021266.1.43532020
https://doi.org/10.1590/1413-81232021266... . Hence the importance of investing and prioritizing the Unified Health System (Sistema Único de Saúde — SUS) to expand the offer and improve the quality of health services and its infrastructure, ensuring the principles of universalization, equity and integrality.

The broad access to primary health services by adolescents is a finding similar to those of other studies¹¹11 Nunes BP, Flores TR, Duro SMS, Saes MO, Tomasi E, Santiago AD, et al. Utilização dos serviços de saúde por adolescentes: estudo transversal de base populacional, Pelotas-RS, 2012. Epidemiol Serv Saúde 2015; 24(3): 411-20. https://doi.org/10.5123/S1679-49742015000300007
https://doi.org/10.5123/S1679-4974201500... ,¹⁸18 Martins MMF, Aquino R, Pamponet ML, Pinto Junior EP, Amorim LDAF. Adolescent and youth access to primary health care services in a city in the state of Bahia, Brazil. Cad Saúde Pública 2019; 35(1): e00044718. https://doi.org/10.1590/0102-311X00044718
https://doi.org/10.1590/0102-311X0004471... , which represents a step forward for the SUS, as it expands comprehensive health care and acts preventively. In this context, the BHUs, together with the Family Health Strategy teams, reorient the health care model and develop actions at the individual and collective levels, encompassing health promotion and protection, prevention of diseases and injuries, diagnosis, treatment, rehabilitation and health maintenance, being the population's first point of contact with the health system²⁴24 Giovanella L, Franco CM, Almeida PF. National Primary Health Care Policy: where are we headed to? Cien Saude Colet 2020; 25(4): 1475-82. https://doi.org/10.1590/1413-81232020254.01842020
https://doi.org/10.1590/1413-81232020254... . The BHU is also a primordial space for continuous, coordinated and oriented care for adolescents, which enables encounters and intersubjective exchanges that can produce dialogic relationships and promote care networks²⁵25 Fernandes ESF, Santos AM. Mismatches between professional education and care needs of the adolescents in Primary Health Care. Interface (Botucatu) 2020; 24: e190049. https://doi.org/10.1590/Interface.190049
https://doi.org/10.1590/Interface.190049... . The improvement and expansion of the Primary Health Care network has a positive impact on the promotion of comprehensive health of Brazilian adolescents.

So, the present study showed that students from public schools seek BHUs more often and most of them are assisted, which shows the BHUs’ role in guaranteeing the health rights of different population groups²⁶26 Giovanella L. Basic health care or primary health care? Cad Saude Publica 2018; 34(8): e00029818. https://doi.org/10.1590/0102-311X00029818
https://doi.org/10.1590/0102-311X0002981... , in addition to fulfilling the principle of universality, in which everyone has the right to health actions and services. Despite the expansion of coverage and improvement of the quality of Primary Health Care services in Brazil, there are still challenges that require a continuous capacity for innovation in the formulation and implementation of health policies, models and practices²⁷27 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Pública 2020; 44: e4. https://doi.org/10.26633/RPSP.2020.4
https://doi.org/10.26633/RPSP.2020.4... . Added to this, the underfunding of the SUS and the implementation of austerity policies such as the approval of Constitutional Amendment 95/2016, which reduced investments in social and health policies, contribute to the reduction in supply of services, the worsening of health indicators and the increase of inequalities²⁸28 Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoramento e projeções das metas de fatores de risco e proteção para o enfrentamento das doenças crônicas não transmissíveis nas capitais brasileiras. Ciênc Saúde Coletiva 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... .

Changes are also needed to improve the care offered to adolescents, including training of professionals to deal with and meet their needs, and the inclusion of practices that advocate dialogue, considering real demands of this public and ensuring their rights. Available appointment dates on the service's schedule and qualified reception without prejudice are expected elements of a comprehensive, effective and ethical Primary Health Care⁴4 Silva RF, Engstrom EM. Atenção integral à saúde do adolescente pela Atenção Primária à Saúde no território brasileiro: uma revisão integrativa. Interface (Botucatu) 2020; 24(Supl 1): e190548. https://doi.org/10.1590/Interface.190548
https://doi.org/10.1590/Interface.190548... .

Among the various individual and collective actions carried out at the BHUs, vaccination is one of the leading services. The SUS, through the National Immunization Program (PNI), guarantees the vaccination of the entire Brazilian population with equity, effectiveness, efficiency and safety, in addition to offering, in the National Vaccination Calendar, all vaccines recommended by the World Health Organization and special immunobiologicals for groups at higher risk²⁹29 Brasil. Ministério da Saúde. Secretaria de Vigilência em Saúde. Departamento de Vigilância Epidemiológica. Programa Nacional de Imunizações (PNI): 40 anos [Internet]. Brasília: Ministério da Saúde; 2013 [cited on Apr 27, 2022]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/programa_nacional_imunizacoes_pni40.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . Vaccination actions in Brazil are an important tool to promote the principles of SUS, enabling the poorest municipalities in Brazil to comply with the same vaccination schedule as the richest ones³⁰30 Domingues CMAS, Maranhão AGK, Teixeira AM, Fantinato FFS, Domingues RAS. The Brazilian National Immunization Program: 46 years of achievements and challenges. Cad Saúde Pública 2020; 36(suppl 2): e00222919. https://doi.org/10.1590/0102-311X00222919
https://doi.org/10.1590/0102-311X0022291... .

It is highlighted that schools are important for health promotion actions, for creating healthy environments and for consolidating public policies. As an example, there is the Health at School Program (PSE), created in 2007, consolidated as an important strategy for health promotion and disease prevention, having a positive impact on quality of life, learning conditions, and building citizenship. School health promotion initiatives are effective and can be enhanced by the active participation of Family Health teams³¹31 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção básica. Saúde na escola [Internet]. Brasília: Ministério da Saúde; 2009 [cited on Apr 27, 2022]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/cadernos_atencao_basica_24.pdf. Acesso em: 9 dez. 2021.
https://bvsms.saude.gov.br/bvs/publicaco... .

The development of actions that encourage the engagement of adolescents in continuous disease prevention and health promotion activities, with dynamic and proactive approaches, enables them to form autonomy and makes them co-responsible for their health³²32 Viegas SMF, Sampaio FC, Oliveira PP, Lanza FM, Oliveira VC, Santos WJ. Vaccination and adolescent knowledge: health education and disease prevention. Cien Saude Colet 2019; 24(2): 351-60. https://doi.org/10.1590/1413-81232018242.30812016
https://doi.org/10.1590/1413-81232018242... .

Some of the limitations of the study were memory bias and the self-administered questionnaire, which can lead to incorrect interpretations of questions by students and underestimations or overestimations of indicators. However, PeNSE was based on the main international surveys, such as the Global School-Based Student Health Survey, the Health Behavior in School-Aged Children and the Youth Risk Behavior Surveillance System, whose questionnaire was validated with satisfactory results in the reproducibility and validity analyses. Also, the research investigated students regularly enrolled and attending Brazilian education networks, excluding adolescents who do not have this educational bond and who may be more vulnerable. However, PeNSE also covers schools located in indigenous areas and places with remote access, with an increase in the sample of the 2019 edition, which made it possible to disaggregate it by large regions, FUs and municipalities within capitals. Therefore, even with limitations, the research represents the reality of adolescents aged 13 to 17 who attend school.

The results showed that adolescents search for and use health services, but that health inequalities still persist, mainly due to socioeconomic issues. This reinforces the need for investment in public policies, in Primary Health Care and in the SUS, in addition to expanding the offer and improving the quality of services, especially among adolescents, as they are in a phase of important psychobiological and social transformations, which makes them a strategic group for health promotion and prevention of diseases and injuries. Thus, adolescent care should encompass counseling, health promotion and disease prevention actions, considering their particularities, vulnerabilities, as well as the familial, social, economic and cultural context they are in.

ACKNOWLEDGMENTS:

To the National Council for Scientific and Technological Development (CNPq) for the junior post-doctorate scholarship to Alanna Gomes da Silva and the productivity scholarship to Deborah Carvalho Malta.

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