ABSTRACT

Risk behaviours in adolescence have a short- and long-term impact on health. Analysing health data from the Southern Common Market (Mercosur) countries can strengthen surveillance and support public policies. To compare the prevalence of health indicators among adolescents in Mercosur countries. A descriptive study was conducted using data from the Global School-based Student Health Survey in Argentina (2018), Paraguay (2017), and Uruguay (2019), as well as from the National Survey of School Health in Brazil (2015 and 2019). Prevalence and 95% confidence intervals of indicators were analysed for the total adolescent population and by gender. Alcohol experimentation before the age of 14 was higher in Argentina, while drunkenness was higher in Brazil. Current cigarette smoking and any tobacco product use were higher in Argentina. Regular physical activity was lower in Brazil. Sedentary behaviour was higher in Uruguay. Brazil had the lowest condom use at last sexual intercourse. There were differences in health risk behaviours among adolescents in the studied countries. These results can assist governmental entities in these countries in promoting the exchange of best practices.

KEYWORDS
Adolescent health; Health risk behaviors; Health surveys; Mercosur; Public health surveillance

Introduction

Around 40 million adolescents aged between 10 and 19 live in the Southern Common Market (Mercosur) countries (Argentina, Brazil, Paraguay and Uruguay), which represents almost 40% of the adolescent population in Latin America and the Caribbean¹1 United Nations International Children’s Emergency Fund. Adolescents. Investing in a safe, healthy and productive transition from childhood to adulthood is critical [Internet]. [local desconhecido]: Unicef; 2024 [acesso em 2023 set 23]. Disponível em: https://data.unicef.org/topic/adolescents/overview/
https://data.unicef.org/topic/adolescent... . These countries differ in the way they offer health services, as well as in their political and administrative organisation. All of this has an impact on the population’s way of life and health²2 Instituto Social del MERCOSUR. Saúde [Internet]. Paraguay: Mercosur; 2023 [acesso em 2023 set 23]. Disponível em: https://www.ismercosur.org/pt/saude/
https://www.ismercosur.org/pt/saude/... , especially in adolescence because it is a phase of physical and psychological transformation that is influenced by the social, economic, cultural and family context³3 Inchley JCD, Budisavljevic S, Torsheim T, et al., editores. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report [Internet]. Geneva: WHO Regional Office for Europe; 2020 [acesso em 2023 jun 12]. Disponível em: https://iris.who.int/bitstream/handle/10665/332104/9789289055017-eng.pdf
https://iris.who.int/bitstream/handle/10... .

These scenarios can predispose adolescents to new experiences and health risk behaviours, such as drug use, sedentary lifestyles, risky sexual behaviour and accidents³3 Inchley JCD, Budisavljevic S, Torsheim T, et al., editores. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report [Internet]. Geneva: WHO Regional Office for Europe; 2020 [acesso em 2023 jun 12]. Disponível em: https://iris.who.int/bitstream/handle/10665/332104/9789289055017-eng.pdf
https://iris.who.int/bitstream/handle/10... . These behaviours are the main precursors to the development of various diseases and illnesses, contributing to an increase in morbidity and mortality among young people⁴4 Uddin R, Lee EY, Khan SR, et al. Clustering of lifestyle risk factors for non-communicable diseases in 304,779 adolescents from 89 countries: A global perspective. Prev Med. 2020;131:105955. DOI: https://doi.org/10.1016/j.ypmed.2019.105955
https://doi.org/10.1016/j.ypmed.2019.105... .

Globally, adolescents have demonstrated multiple behavioural risk factors. A study of 89 countries showed that 34.9% of adolescents had three or more simultaneous behavioural risk factors, and in the Americas, the prevalence was 56.2%⁴4 Uddin R, Lee EY, Khan SR, et al. Clustering of lifestyle risk factors for non-communicable diseases in 304,779 adolescents from 89 countries: A global perspective. Prev Med. 2020;131:105955. DOI: https://doi.org/10.1016/j.ypmed.2019.105955
https://doi.org/10.1016/j.ypmed.2019.105... . Many of these factors are related, for example, to Chronic NonCommunicable Diseases (CNCDs), the main causes of death in the world⁵5 World Health Organization. Noncommunicable diseases: progress monitor 2020. [Internet]. Geneva: WHO; 2020 [acesso em 2023 jun 12]. Disponível em: https://iris.who.int/handle/10665/330805
https://iris.who.int/handle/10665/330805... , with a higher occurrence in lowand middle-income countries⁶6 Wang Y, Wang J. Modelling and prediction of global non-communicable diseases. BMC Public Health. 2020;20(1):822. DOI: https://doi.org/10.1186/s12889-020-08890-4
https://doi.org/10.1186/s12889-020-08890... . Although these deaths are concentrated in adulthood, risk factors for NCDs have been observed among children and adolescents⁷7 Rodrigues STP, Matozinhos FP, Gratão LHA, et al. Coexistence of risk factors for cardiovascular diseases among Brazilian adolescents: Individual characteristics and school environment. PLoS ONE. 2021;16(7):e0254838. DOI: https://doi.org/10.1371/journal.pone.0254838
https://doi.org/10.1371/journal.pone.025... .

In view of this, international efforts have been made to support the development of policies and programmes for health promotion and disease prevention among adolescents, as well as the monitoring of risk factors and diseases. From this perspective, the Mercosur countries have also dedicated themselves to the process of adolescent health surveillance through epidemiological surveys, such as the Global School-based Student Health Survey (GSHS)⁸8 World Health Organization. GSHS questionnaire [Internet]. [local desconhecido]: WHO; 2023 [acesso em 2023 set 23]. Disponível em: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-school-based-student-health-survey/questionnaire
https://www.who.int/teams/noncommunicabl... , and in Brazil, with the National School Health Survey (PeNSE)⁹9 Instituto Brasileiro de Geografia e Estatística. PeNSE – Pesquisa Nacional de Saúde do Escolar [Internet]. [Rio de Janeiro]: IBGE; 2022 [acesso em 2023 out 23]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/educacao/9134-pesquisa-nacional-de-saude-do-escolar.html
https://www.ibge.gov.br/estatisticas/soc... , which is similar in scope to the GSHS.

This makes it possible to analyse and compare the main health indicators of adolescents that predispose them to the main causes of morbidity and mortality. In this way, it is possible to prioritise interventions based on identified health problems, promote the reduction of inequalities and support future analyses to delve deeper into the causes or factors involved in risk behaviours. The integration provided by Mercosur goes beyond the initial objectives based on economics and encompasses the social and health dimensions. In this context, this international agreement also aims to exchange and jointly implement health care actions based on information representative of their populations of interest, mainly from epidemiological surveys¹⁰10 Ministério da Saúde (BR), Assessoria de Assuntos Internacionais de Saúde. Saúde e Política Externa: os 20 anos da Assessoria de Assuntos Internacionais de Saúde (1998-2018) [Internet]. Brasília, DF: Ministério da Saúde; 2018 [acesso em 2023 out 23]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/saude_politica_externa_20_anos_aisa.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

This study is also aligned with the 2030 Agenda¹¹11 Cruz DKA, Nóbrega AAD, Montenegro MDMS, et al. Os Objetivos de Desenvolvimento Sustentável e as fontes de dados para o monitoramento das metas no Brasil. Epidemiol Serv Saúde. 2022;31(esp1):e20211047. DOI: https://doi.org/10.1590/SS2237-9622202200010.especial
https://doi.org/10.1590/SS2237-962220220... , which has specific targets for improving the health and well-being of adolescents, making it essential to monitor, compare and share strategies in favour of a global effort for this public. Therefore, analysing the health data of these countries with a focus on adolescents helps to strengthen their surveillance systems, learn about the health situation and collaborate in the development of effective public policies for health promotion and disease and illness prevention. The aim was therefore to compare the prevalence of adolescent health indicators in the Mercosur countries.

Material and methods

Study design

Cross-sectional study, with secondary analysis of data from the GSHS conducted in Argentina in 2018, Paraguay in 2017 and Uruguay in 2019, and the PeNSE carried out in Brazil in 2015 and 2019.

THE GSHS

The GSHS was developed in 2003 by the World Health Organisation (WHO) at the US Centers for Disease Control and Prevention (CDC)¹²12 Organización Panamericana de la Salud. GSHS – Global School-based Student Health Survey [Internet]. [local desconhecido]: Opas; 2018 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/documents/global-school-based-student-health-survey-gshs-overview
https://www.paho.org/en/documents/global... . The survey comprises ten thematic modules on the main aspects influencing adolescent health, at least six of which need to be investigated by the participating countries¹²12 Organización Panamericana de la Salud. GSHS – Global School-based Student Health Survey [Internet]. [local desconhecido]: Opas; 2018 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/documents/global-school-based-student-health-survey-gshs-overview
https://www.paho.org/en/documents/global... .

Argentina, Uruguay and Paraguay were supported by the Pan American Health Organisation (PAHO)/WHO and the CDC for the development of the survey. In Argentina, three editions (2007, 2012 and 2018) of the Encuesta Mundial de Salud Escolar (EMSE) were carried out. The survey was developed by the Argentine Ministry of Health and Social Development, with the collaboration of the National and Provincial Ministries of Education¹³13 Ministerio de Salud (Argentina). 3o Encuesta Mundial de Salud Escolar. Argentina; 2018.. In Uruguay, there have also been three editions of EMSE (2006, 2012 and 2019), developed by the country’s Ministry of Public Health and Ministry of Social Development¹⁴14 Ministerio de Salud Pública (Uruguay). Encuesta mundial de salud en estudiantes. EMSE 2019. Informe final [Internet]. [local desconhecido]: Ministerio de Salud Pública; 2019 [acesso em 2023 set 13]. 116 p. Disponível em: https://www.gub.uy/ministerio-salud-publica/sites/ministerio-salud-publica/files/documentos/publicaciones/MSP_ENCUESTA_MUNDIAL_SALUD_ESTUDIANTES_2019.pdf
https://www.gub.uy/ministerio-salud-publ... . In Paraguay, EMSE was developed for the first time in 2017 by the country’s Ministry of Public Health and Social Welfare and the Ministry of Education and Sciences, also supported by PAHO/WHO and the CDC¹⁵15 Organización Panamericana de la Salud; Organización Mundial de la Salud. Encuesta Global de Salud Escolar (GSHS) Paraguay 2017 [Internet]. Asunción: Opas; OMS; 2017 [acesso em 2023 nov 23]. 78 p. Disponível em: https://dvent.mspbs.gov.py/encuesta-global-de-salud-escolar-gshs-2017/
https://dvent.mspbs.gov.py/encuesta-glob... . The most recent surveys in each country were representative of adolescents aged 13 to 17.

THE PENSE

In Brazil, PeNSE is carried out by the Brazilian Institute of Geography and Statistics (IBGE) at the Ministry of Health, with four editions (2009, 2012, 2015 and 2019). Its questionnaire addresses aspects of adolescent health, such as risk and protective factors for their health, use of services, among others⁹9 Instituto Brasileiro de Geografia e Estatística. PeNSE – Pesquisa Nacional de Saúde do Escolar [Internet]. [Rio de Janeiro]: IBGE; 2022 [acesso em 2023 out 23]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/educacao/9134-pesquisa-nacional-de-saude-do-escolar.html
https://www.ibge.gov.br/estatisticas/soc... . In the 2015 edition, PeNSE carried out two different sampling plans: a representative sample of students in the 9th year of primary school, ensuring comparability with previous years, and a second sample (sample 2) of students aged 13 to 17, to generate data comparable to the GSHS¹⁶16 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [acesso em 2023 nov 23]. 132 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=297870
https://biblioteca.ibge.gov.br/index.php... . In 2019, the sample was representative of schoolage children aged 13 to 17¹⁷17 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [acesso em 2023 nov 23]. 156 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101852
https://biblioteca.ibge.gov.br/index.php... .

Study population and PeNSE and GSHS sampling

The data came from questionnaires answered by adolescents aged 13 to 17 who were attending class and who were recruited through a standardised sample selection process with a common methodology¹²12 Organización Panamericana de la Salud. GSHS – Global School-based Student Health Survey [Internet]. [local desconhecido]: Opas; 2018 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/documents/global-school-based-student-health-survey-gshs-overview
https://www.paho.org/en/documents/global... ,¹⁶16 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [acesso em 2023 nov 23]. 132 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=297870
https://biblioteca.ibge.gov.br/index.php... ,¹⁷17 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [acesso em 2023 nov 23]. 156 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101852
https://biblioteca.ibge.gov.br/index.php... . The surveys in the aforementioned countries had twostage cluster sampling plans, with schools corresponding to the first stage of selection and classes of students enrolled in the second. All the students in the selected classes were invited to take part in the survey, and those who agreed made up the student sample¹²12 Organización Panamericana de la Salud. GSHS – Global School-based Student Health Survey [Internet]. [local desconhecido]: Opas; 2018 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/documents/global-school-based-student-health-survey-gshs-overview
https://www.paho.org/en/documents/global... ,¹⁶16 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [acesso em 2023 nov 23]. 132 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=297870
https://biblioteca.ibge.gov.br/index.php... ,¹⁷17 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [acesso em 2023 nov 23]. 156 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101852
https://biblioteca.ibge.gov.br/index.php... .

PeNSE and GSHS data collection

In both surveys, the questionnaire was selfapplied during a class period. In Brazil, data was collected using a smartphone¹⁶16 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [acesso em 2023 nov 23]. 132 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=297870
https://biblioteca.ibge.gov.br/index.php... ,¹⁷17 Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde do escolar: 2019 [Internet]. Rio de Janeiro: IBGE; 2021 [acesso em 2023 nov 23]. 156 p. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101852
https://biblioteca.ibge.gov.br/index.php... . The other countries used scannable paper questionnaires filled in by pencil¹²12 Organización Panamericana de la Salud. GSHS – Global School-based Student Health Survey [Internet]. [local desconhecido]: Opas; 2018 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/documents/global-school-based-student-health-survey-gshs-overview
https://www.paho.org/en/documents/global... . The response rates for schools, students and the number of students participating in each country can be seen in table 1. Estimates of the Brazilian response rates were calculated based on the expected, collected, and validated values. For this study, we used the data available on the GSHS¹⁸18 Organización Panamericana de la Salud. Global School-Based Student Health Survey Results Tool [Internet]. [local desconhecido]: Opas; 2020 [acesso em 2023 set 23]. Disponível em: https://www.paho.org/en/enlace/global-school-based-student-health-survey-results-tool
https://www.paho.org/en/enlace/global-sc... and PeNSE⁹9 Instituto Brasileiro de Geografia e Estatística. PeNSE – Pesquisa Nacional de Saúde do Escolar [Internet]. [Rio de Janeiro]: IBGE; 2022 [acesso em 2023 out 23]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/educacao/9134-pesquisa-nacional-de-saude-do-escolar.html
https://www.ibge.gov.br/estatisticas/soc... platforms.

Variables in this study

The description of the variables is shown in box 1 (health indicators of adolescents participating in the GSHS and PeNSE), whose answers were dichotomized (yes/no).

Analysing the data from this study

For all the indicators, the prevalence rates and their respective 95% Confidence Intervals (CI) were analysed for the total population of school-age children, considering gender (female and male) for each country. The comparison between the countries’ prevalence rates was made using the 95% CI, considering the non-occurrence of overlapping intervals as statistically significant differences.

Due to the change in the structure of some questions in the PeNSE questionnaire, the 2015 edition was used to keep the comparison between the variables of interest: regular Physical Activity (PA), involvement in a physical fight and report of serious injury. For the others, the 2019 edition was used.

The health indicators for adolescents in each country were organised in Microsoft Excel spreadsheets version 16®, and the PeNSE data was analysed in Stata, version 14.2, using the survey module, which considers poststratification weights.

Ethical aspects of the GSHS and PeNSE

All the countries that carry out the GSHS obtain ethical approvals from their national government agencies and institutional ethics committees. The PeNSE editions were approved by the National Research Ethics Committee. Students who agreed to take part in the surveys signed an informed consent form. For the GSHS, passive parental consent was also obtained. In the case of this study, the data used is in the public domain and is available on the platforms mentioned, without the need for prior authorisation for use.

Results

The characterisation of the gender and age group of the adolescents participating in the surveys in each country can be seen in table 2.

Regarding current alcohol consumption, the highest prevalence rates were among adolescents in Argentina (54.1%; 95% CI 52.7-55.4%) and Uruguay (54.6%; 95% CI 51.6-57.5%). School-age children in Argentina had a higher prevalence of early alcohol experimentation (65.7%; 95% CI 64.3-67%) while the prevalence of drunkenness was higher in Brazil (47%; 95% CI 46-47.9%) (table 3).

Current cigarette consumption and the use of any tobacco product were highest among school-age children in Argentina (19%; 95% CI 18-20% and 20.4%; 95% CI 19.4-21.5% respectively). Brazil, on the other hand, had the lowest prevalence of cigarette use (table 3). These results require caution due to the lack of data from Paraguay.

Regular PA practice (7.6%; 95% CI 6.9-8.4%) and participation in physical education classes (8.9%; 95% CI 8.3-9.5%) were less prevalent among Brazilian adolescents. Sedentary behaviour was more prevalent among Uruguayan adolescents (62.9%; 95% CI 61-64.8%) (table 3).

Regarding mental health, the absence of a close friend was lower among Brazilian adolescents (4%; 95% CI 3.7-4.3%). Regarding sexual behaviour, the lowest prevalence of adolescents who had had sexual intercourse in their lifetime was in Paraguay (29.5%; 95% CI 25.5-33.9%), as well as the lowest occurrence of early sexual initiation (23.5%; 95% CI 19.5-27.9%), followed by adolescents from Uruguay (25.8%; 95% CI 21.8-30.3%). In Brazil, there was the lowest prevalence of condom use at last intercourse (59.1%; 95% CI 58-60.3%) (table 3).

The prevalence of involvement in a physical fight was higher in Argentina (24.6%; 95% CI 23.4-25.9%), and the report of severe injury was lower in Brazil (12.8%; 95% CI 11.7-13.9%) (table 3).

According to gender, current alcohol consumption was more prevalent among girls in Uruguay (58.3%; 95% CI 55.1-61.3%) compared to boys (49.7%; 95% CI 45.9-53.6%). A comparable situation occurred in Brazil (30.1%; 95% CI 29.2-31% among girls and 26%; 95% CI 25-26.9% among boys). The prevalence of early experimentation with alcoholic beverages was lower among male adolescents in Brazil (32.3%; 95% CI 31.5-33.2%) and higher among adolescents of the same gender in Argentina (69.2%; 95% CI 67.5-70.9%). Episodes of drunkenness were similar between genders in each country (table 4).

The prevalence of current cigarette consumption (20.5%; 95% CI 19.3-21.8%) and the use of any tobacco product (21.8%; 95% CI 20.5-23%) were higher among Argentinian girls (note the absence of these data in Paraguay).

Regular PA practice was higher among boys in all countries. Participation in physical education classes was also higher among boys in Argentina, Paraguay, and Brazil. There was a gender difference in sedentary behaviour, which was higher among Argentinian girls (57.7%; 95% CI 55.9-59.5%) and Brazilian girls (54.3%; 95% CI 53.4-55.2%).

The absence of close friends had similar prevalence rates in both genders in all countries. Regarding sexual behaviour, boys in Argentina, Paraguay and Brazil had the highest prevalence of sexual intercourse in life compared to girls. Early sexual intercourse and condom use were higher among boys in Argentina, Brazil, and Uruguay.

Boys reported more physical fights than girls in all countries. Reports of severe injury were more frequent among boys in Argentina (38.3%; 95% CI 36.6-40.1%) and Paraguay (43.2%; 95% CI 39.8-46.7%).

Discussion

Argentinian and Uruguayan adolescents showed higher rates of experimentation and recent alcohol consumption, and more episodes of drunkenness were reported by Brazilians. The prevalence of smoking was higher in Argentina and significantly lower among adolescents in Brazil. The practice of regular PA and participation in physical education classes were also lower among adolescents from Brazil. Uruguayans were the ones who showed the most sedentary behaviour, and Paraguayan adolescents showed the lowest prevalence of sexual intercourse in their lives. Brazilians, on the other hand, reported less condom use during their last sexual encounter. Involvement in physical fights was higher in Argentina, and the occurrence of serious injury was lower in Brazil.

Regarding gender differences, girls had a higher prevalence of recent alcohol consumption (except in Paraguay). As for sexual behaviour in Argentina, Paraguay and Brazil, there were more reports of sexual intercourse throughout life compared to girls. Early sexual initiation and condom use were more frequent among boys in Argentina, Brazil and Uruguay. Boys also showed a higher prevalence of involvement in physical fights and regular PA practice.

More than half of Uruguayan and Argentinian adolescents reported recent alcohol consumption. This is double the general prevalence (25%) in a study of 57 lowand middle-income countries in the world¹⁹19 Ma C, Bovet P, Yang L, et al. Alcohol use among young adolescents in low-income and middle-income countries: a population-based study. Lancet Child Adolesc Health. 2018;2(6):415-429. DOI: https://doi.org/10.1016/s2352-4642(18)30112-3
https://doi.org/10.1016/s2352-4642(18)30... . In Argentina, although there are interventions to control alcoholic beverages for this public, there isn’t really a national policy, with legal regulations on alcohol sponsorship and restrictions on local sales²⁰20 World Health Organization. Global status report on alcohol and health 2018. Geneva: WHO; 2018.. Uruguay emphasises the availability, ease of access and tolerance of alcohol consumption as part of a culture of collective pleasure²¹21 Junta Nacional de Drogas (Uruguay), Observatório Uruguayo de Drogas. VIII Encuesta Nacional sobre Consumo de Drogas en Estudiantes de Enseñanza Media. Informe de investigación. [local desconhecido]: Junta Nacional de Drogas; 2020. 116 p..

The same pattern of alcohol use between countries was observed when comparing adolescents by gender. However, there was a higher prevalence of current alcohol consumption among Uruguayan, Argentinian and Brazilian women, which has also been observed in European studies²⁰20 World Health Organization. Global status report on alcohol and health 2018. Geneva: WHO; 2018.. The increase in alcohol consumption among adolescent girls may be related to greater social tolerance²²22 Keyes KM, Miech R. Age, period, and cohort effects in heavy episodic drinking in the US from 1985 to 2009. Drug Alcohol Depend. 2013;132(1-2):140-148. DOI: https://doi.org/10.1016/j.drugalcdep.2013.01.019
https://doi.org/10.1016/j.drugalcdep.201... , marketing incentives²³23 Petticrew M, Shemilt I, Lorenc T, et al. Alcohol advertising and public health: systems perspectives versus narrow perspectives. J Epidemiol Community Health. 2017;71(3):308-312. DOI: https://doi.org/10.1136/jech-2016-207644
https://doi.org/10.1136/jech-2016-207644... and social media²⁴24 Brunborg GS, Skogen JC, Burdzovic AJ. Time spent on social media and alcohol use among adolescents: A longitudinal study. Addict Behav. 2022;130:107294. DOI: https://doi.org/10.1016/j.addbeh.2022.107294
https://doi.org/10.1016/j.addbeh.2022.10... .

In Argentina, early alcohol consumption was also higher, which corroborates a previous study in the country²⁵25 Biolatto S, Drogo C, Pardal MA, et al. Uso de sustancias psicoactivas en estudiantes de escuelas secundarias de Rosario (Argentina). Acta Toxicol Argent [Internet]. 2020 [acesso em 2023 out 21];28(2):45-52. Disponível em: https://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1851-37432020000200045&lng=es&nrm=iso&tlng=es
https://www.scielo.org.ar/scielo.php?scr... . Although the legal age is 18 and over, alcohol is easily accessible and is the most consumed substance among school-age children²⁵25 Biolatto S, Drogo C, Pardal MA, et al. Uso de sustancias psicoactivas en estudiantes de escuelas secundarias de Rosario (Argentina). Acta Toxicol Argent [Internet]. 2020 [acesso em 2023 out 21];28(2):45-52. Disponível em: https://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1851-37432020000200045&lng=es&nrm=iso&tlng=es
https://www.scielo.org.ar/scielo.php?scr... . These findings may be related to its widespread social acceptance not only in Argentina, but also in Brazil and in most other countries³3 Inchley JCD, Budisavljevic S, Torsheim T, et al., editores. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report [Internet]. Geneva: WHO Regional Office for Europe; 2020 [acesso em 2023 jun 12]. Disponível em: https://iris.who.int/bitstream/handle/10665/332104/9789289055017-eng.pdf
https://iris.who.int/bitstream/handle/10... , which highlights the flaws in controlling alcohol consumption among adolescents.

On the other hand, the highest prevalence of reported episodes of drunkenness in life was observed among Brazilian adolescents, who have even shown an increase in this practice in recent years²⁶26 Ferreira ACM, Silva AGD, Sá ACMGND, et al. Fatores de risco e proteção para as doenças crônicas não transmissíveis entre escolares brasileiros: Pesquisa Nacional de Saúde do Escolar 2015 e 2019. REME Rev Min Enferm. 2022;26. DOI: https://doi.org/10.35699/2316-9389.2022.38620
https://doi.org/10.35699/2316-9389.2022.... . Drunkenness is facilitated by access to alcohol at parties, bars, among peers and even family members, which indicates the normalisation of this consumption among adolescents and failures in family supervision²⁷27 Malta DC, Silva AGD, Prates EJS, et al. Convergence in alcohol abuse in Brazilian capitals between genders, 2006 to 2019: what population surveys show. Rev Bras Epidemiol. 2021;24(supl1):e210022. DOI: https://doi.org/10.1590/1980-549720210022.supl.1
https://doi.org/10.1590/1980-54972021002... . High prevalences of excessive alcohol consumption have also been found in Russia, Angola and other Latin American countries such as Bolivia and Peru²⁰20 World Health Organization. Global status report on alcohol and health 2018. Geneva: WHO; 2018.. This behaviour can lead to serious problems such as physical fights, accidents, unprotected sex²⁸28 Moura LRD, Santos KFD, Souza HGD, et al. Fatores sociodemográficos e comportamentos de risco associados ao consumo do álcool: um recorte do Erica. Saúde debate. 2018;42(esp4):145-155. DOI: https://doi.org/10.1590/0103-11042018s411
https://doi.org/10.1590/0103-11042018s41... and alcohol intoxication²⁷27 Malta DC, Silva AGD, Prates EJS, et al. Convergence in alcohol abuse in Brazilian capitals between genders, 2006 to 2019: what population surveys show. Rev Bras Epidemiol. 2021;24(supl1):e210022. DOI: https://doi.org/10.1590/1980-549720210022.supl.1
https://doi.org/10.1590/1980-54972021002... .

Smoking is the main risk factor for several chronic diseases²⁹29 Peacock A, Leung J, Larney S, et al. Global statistics on alcohol, tobacco and illicit drug use: 2017 status report. Addiction. 2018;113(10):1905-1026. DOI: https://doi.org/10.1111/add.14234
https://doi.org/10.1111/add.14234... , and in adolescence it becomes even more worrying, since it is during this phase that the smoking habit begins and consolidates³⁰30 Hall WD, Patton G, Stockings E, et al. Why young people’s substance use matters for global health. Lancet Psychiatry. 2016;3(3):265-279. DOI: https://doi.org/10.1016/s2215-0366(16)00013-4
https://doi.org/10.1016/s2215-0366(16)00... . The lower prevalence of cigarette use among Brazilian school-age children may be related to the adoption of regulatory measures recommended by the WHO, making Brazil a world reference in tobacco control³¹31 Malta DC, Duncan BB, Barros MBDA, et al. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Ciênc saúde coletiva. 2018;23(10):3115-3122. DOI: https://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/10.1590/1413-81232018231... .

However, the higher prevalence of the use of other tobacco products observed in Argentina is already a global concern, especially electronic cigarettes³²32 World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. Geneva: WHO; 2021. 212 p.. Although tobacco products are banned for people under 18 in the countries studied, and e-cigarettes were banned for any age group at the time of the research, adolescents have been using these devices mainly influenced by the media, flavours, aromas, the perception that they are less harmful and pressure from friends³³33 Lourdes TGR, Hamid HAA, Yusoff MF, et al. Factors associated with e-cigarette usage and the reasons for initiation among Malaysian adolescents. Asia Pac J Public Health. 2019;31(supl7):44S-52S. DOI: https://doi.org/10.1177/1010539519870663
https://doi.org/10.1177/1010539519870663... , in addition to their use being associated with alcohol consumption³⁴34 Rothrock AN, Andris H, Swetland SB, et al. Association of e-cigarettes with adolescent alcohol use and binge drinking-drunkenness: A systematic review and meta-analysis. Am J Drug Alcohol Abuse. 2020;46(6):684-698. DOI: https://doi.org/10.1080/00952990.2020.1771723
https://doi.org/10.1080/00952990.2020.17... . In Brazil, although the use of conventional cigarettes is stable, there is a high prevalence of the use of other tobacco products, such as hookahs and electronic cigarettes³⁵35 Malta DC, Gomes CS, Alves FTA, et al. O uso de cigarro, narguilé, cigarro eletrônico e outros indicadores do tabaco entre escolares brasileiros: dados da Pesquisa Nacional de Saúde do Escolar 2019. Rev Bras Epidemiol. 2022;25:e220014. DOI: https://doi.org/10.1590/1980-549720220014.2
https://doi.org/10.1590/1980-54972022001... , which can be attributed to the weakening of control policies in recent years³⁶36 Silva TPR, Matozinhos FP, Gratão LHA, et al. Coexistence of risk factors for cardiovascular diseases among Brazilian adolescents: Individual characteristics and school environment. PLoS One. 2021;16(7):e0254838. DOI: https://doi.org/10.1371/journal.pone.0254838
https://doi.org/10.1371/journal.pone.025... .

Sexual practice was more common in Uruguay and Argentina, with slightly higher prevalence rates than in 67 lowand middleincome countries (40.6%)³⁷37 Mahumud RA, Rahman MdA, Gow J, et al. The global and regional burden of sexual behaviors and food insecurity and their combined association on the magnitude of suicidal behaviors among 121,248 adolescent girls: An international observational study in 67 lowand middle-income and high-income countries. J Affect Disord. 2022;298:481-491. DOI: https://doi.org/10.1016/j.jad.2021.11.023
https://doi.org/10.1016/j.jad.2021.11.02... . This behaviour is conditioned by cognitive and emotional development, as well as the influences exerted by peers, parents, culture, and social norms. Socioeconomic barriers can jeopardise access to quality information, increasing the vulnerability of certain groups. Although both countries have more structured legal frameworks compared to other Mercosur members³⁸38 Cavazotti Aires D. Educação sexual: um direito humano. Leis vigentes na Argentina, Brasil, Paraguai e Uruguai. Rev Fac Der. 2021;50:1-23. DOI: https://doi.org/10.22187/rfd2021n50a16
https://doi.org/10.22187/rfd2021n50a16... and show good results in related indicators, such as reducing teenage pregnancies³⁸38 Cavazotti Aires D. Educação sexual: um direito humano. Leis vigentes na Argentina, Brasil, Paraguai e Uruguai. Rev Fac Der. 2021;50:1-23. DOI: https://doi.org/10.22187/rfd2021n50a16
https://doi.org/10.22187/rfd2021n50a16... ,³⁹39 United Nations International Children’s Emergency Fund. Argentina. La salud sexual y reproductiva es un derecho de las adolescencias [Internet]. [local desconhecido]: Unicef; 2024 [acesso em 2023 out 21]. Disponível em: https://www.unicef.org/argentina/historias/la-salud-sexual-y-reproductiva-es-un-derecho-de-las-adolescencias
https://www.unicef.org/argentina/histori... , efforts to reduce inequalities in access to sexual and reproductive rights are still needed³⁹39 United Nations International Children’s Emergency Fund. Argentina. La salud sexual y reproductiva es un derecho de las adolescencias [Internet]. [local desconhecido]: Unicef; 2024 [acesso em 2023 out 21]. Disponível em: https://www.unicef.org/argentina/historias/la-salud-sexual-y-reproductiva-es-un-derecho-de-las-adolescencias
https://www.unicef.org/argentina/histori... .

Boys had a higher prevalence of sex in life, consistent with previous findings⁴⁰40 Jing Z, Li J, Wang Y, et al. Prevalence and trends of sexual behaviors among young adolescents aged 12 years to 15 years in Low and Middle-Income Countries: Population-based study. JMIR Public Health Surveill. 2023;9:e45236. DOI: https://doi.org/10.2196/45236
https://doi.org/10.2196/45236... . The social pressure for boys to start having sex as proof of their masculinity is a marked gender difference. While girls tend to start their sex lives later, in stable relationships, boys tend to start earlier, in casual relationships⁴¹41 Oliveira-Campos M, Oliveira MMD, Silva SUD, et al. Fatores de risco e proteção para as doenças crônicas não transmissíveis em adolescentes nas capitais brasileiras. Rev Bras Epidemiol. 2018;21(supl1):e180002. DOI: https://doi.org/10.1590/1980-549720180002.supl.1
https://doi.org/10.1590/1980-54972018000... .

Early sexual initiation was higher among adolescents in Brazil and Argentina, according to a study carried out on the triple border (Brazil, Argentina and Paraguay)⁴²42 Priotto E, Führ A, Gomes L, et al. Iniciação sexual e práticas contraceptivas de adolescentes na tríplice fronteira entre Brasil, Argentina e Paraguai. Rev Panam Salud Publica. 2018;1-9. DOI: https://doi.org/10.26633/RPSP.2018.16
https://doi.org/10.26633/RPSP.2018.16... . This practice is considered risky behaviour because it is associated with Sexually Transmitted Infections (STIs), unplanned pregnancy, unsafe abortion⁴³43 Melesse DY, Mutua MK, Choudhury A, et al. Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind? BMJ Glob Health. 2020;5(1):e002231. DOI: https://doi.org/10.1136/bmjgh-2019-002231
https://doi.org/10.1136/bmjgh-2019-00223... , as well as mental health problems⁴⁴44 Lanari D, Mangiavacchi L, Pasqualini M. Adolescent sexual behaviour and academic performance of Italian students. Genus. 2020;76(1):21. DOI: https://doi.org/10.1186/s41118-020-00093-4
https://doi.org/10.1186/s41118-020-00093... . The prevalence of this indicator in these countries was higher than the average found in a study of 50 countries⁴⁵45 Kushal SA, Amin YM, Reza S, et al. Regional and sex differences in the prevalence and correlates of early sexual initiation among adolescents aged 12–15 years in 50 Countries. J Adolesc Health. 2022;70(4):607-616. DOI: https://doi.org/10.1016/j.jadohealth.2021.10.027
https://doi.org/10.1016/j.jadohealth.202... . These differences may be related to religious, social and cultural factors and deserve further exploration to understand and reduce these prevalences⁴⁵45 Kushal SA, Amin YM, Reza S, et al. Regional and sex differences in the prevalence and correlates of early sexual initiation among adolescents aged 12–15 years in 50 Countries. J Adolesc Health. 2022;70(4):607-616. DOI: https://doi.org/10.1016/j.jadohealth.2021.10.027
https://doi.org/10.1016/j.jadohealth.202... . Psychosocial factors such as loneliness, bullying, tobacco, alcohol and drug use are associated with early sexual initiation, with little global variation⁴⁵45 Kushal SA, Amin YM, Reza S, et al. Regional and sex differences in the prevalence and correlates of early sexual initiation among adolescents aged 12–15 years in 50 Countries. J Adolesc Health. 2022;70(4):607-616. DOI: https://doi.org/10.1016/j.jadohealth.2021.10.027
https://doi.org/10.1016/j.jadohealth.202... .

Regarding gender differences, other studies have also highlighted that males have a higher prevalence of early sexual initiation⁴²42 Priotto E, Führ A, Gomes L, et al. Iniciação sexual e práticas contraceptivas de adolescentes na tríplice fronteira entre Brasil, Argentina e Paraguai. Rev Panam Salud Publica. 2018;1-9. DOI: https://doi.org/10.26633/RPSP.2018.16
https://doi.org/10.26633/RPSP.2018.16... ,⁴⁵45 Kushal SA, Amin YM, Reza S, et al. Regional and sex differences in the prevalence and correlates of early sexual initiation among adolescents aged 12–15 years in 50 Countries. J Adolesc Health. 2022;70(4):607-616. DOI: https://doi.org/10.1016/j.jadohealth.2021.10.027
https://doi.org/10.1016/j.jadohealth.202... . This scenario stems from a culture that encourages boys to start having sex and condemns girls who do⁴⁶46 Felisbino-Mendes MS, Paula TFD, Machado ÍE, et al. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol. 2018;21(supl1):e180013. DOI: https://doi.org/10.1590/1980-549720180013.supl.1
https://doi.org/10.1590/1980-54972018001... .

Brazilian adolescents had a lower prevalence of condom use during their last sexual intercourse, indicating that almost 40% of them had unprotected sex the last time (table 3). Similar results were found in Brazil with a population aged over 15⁴⁶46 Felisbino-Mendes MS, Paula TFD, Machado ÍE, et al. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol. 2018;21(supl1):e180013. DOI: https://doi.org/10.1590/1980-549720180013.supl.1
https://doi.org/10.1590/1980-54972018001... and among adolescents in other countries⁴⁰40 Jing Z, Li J, Wang Y, et al. Prevalence and trends of sexual behaviors among young adolescents aged 12 years to 15 years in Low and Middle-Income Countries: Population-based study. JMIR Public Health Surveill. 2023;9:e45236. DOI: https://doi.org/10.2196/45236
https://doi.org/10.2196/45236... . Factors related to the non-use of condoms include the idea that this method reduces sexual pleasure, the idea that there is a low risk of contracting STIs, trust in a stable partner⁴⁷47 Ajayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities. BMC Public Health. 2019;19(1):1207. DOI: https://doi.org/10.1186/s12889-019-7543-1
https://doi.org/10.1186/s12889-019-7543-... , and the unavailability of condoms⁴⁸48 Moreira ADS, Alves JSDS, Melo GCD, et al. Fatores associados ao não uso de preservativo por adolescentes brasileiros: uma revisão sistemática. RSD. 2022;11(5):e54011528450. DOI: https://doi.org/10.33448/rsd-v11i5.28450
https://doi.org/10.33448/rsd-v11i5.28450... .

Condoms are distributed free of charge by Brazil’s Unified Health System⁴⁹49 Ministério da Saúde (BR), Departamento de HIV, Aids, Tuberculose, Hepatites Virais e Infecções Sexualmente Transmissíveis. Usar preservativos masculinos, femininos e gel lubrificantes. Gov.br [Internet]. 2022 ago 16 [acesso em 2023 out 21]. Disponível em: https://www.gov.br/aids/pt-br/assuntos/prevencao-combinada/usar-preservativos-masculinos-femininos-e-gel-lubrificantes
https://www.gov.br/aids/pt-br/assuntos/p... , but measures in favour of condom use should be expanded. Sex education in Brazil is seen as controversial, often influenced by religious and ideological concepts, and not as a consolidated public policy. Quality sex education should promote knowledge of the body and types of relationships³⁸38 Cavazotti Aires D. Educação sexual: um direito humano. Leis vigentes na Argentina, Brasil, Paraguai e Uruguai. Rev Fac Der. 2021;50:1-23. DOI: https://doi.org/10.22187/rfd2021n50a16
https://doi.org/10.22187/rfd2021n50a16... . Adolescents’ decision-making process is multifaceted and involves both rational and emotional thoughts, so initiatives in this context need to consider the complexity of this choice⁵⁰50 Davids EL, Zembe Y, De Vries PJ, et al. Exploring condom use decision-making among adolescents: the synergistic role of affective and rational processes. BMC Public Health. 2021;21(1):1894. DOI: https://doi.org/10.1186/s12889-021-11926-y
https://doi.org/10.1186/s12889-021-11926... .

Gender is also a factor related to condom use, with females being more likely not to use this method⁴⁶46 Felisbino-Mendes MS, Paula TFD, Machado ÍE, et al. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol. 2018;21(supl1):e180013. DOI: https://doi.org/10.1590/1980-549720180013.supl.1
https://doi.org/10.1590/1980-54972018001... as identified in the current study. This gender inequality is probably due to the establishment of stable partnerships and the use of other contraceptive methods, which leaves adolescents more vulnerable to STIs⁴⁶46 Felisbino-Mendes MS, Paula TFD, Machado ÍE, et al. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol. 2018;21(supl1):e180013. DOI: https://doi.org/10.1590/1980-549720180013.supl.1
https://doi.org/10.1590/1980-54972018001... .

In general, the prevalence of physical fighting between the countries analysed was close, slightly higher in Argentina, indicating that almost a quarter of Argentinian adolescents had been involved in a physical fight in the previous year (table 3). A review of lowand middle-income countries, including Argentina and Uruguay, found worse prevalence rates in African, some Oceanic and Asian countries⁵¹51 Nivette A, Sutherland A, Eisner M, et al. Sex differences in adolescent physical aggression: Evidence from sixty‐three low‐and middle‐income countries. Aggress Behav. 2019;45(1):82-92. DOI: https://doi.org/10.1002/ab.21799
https://doi.org/10.1002/ab.21799... . Factors related to physical violence among adolescents include alcohol and illicit drug use, living in violent places, family conflicts and depressive symptoms⁵²52 Romeiro JS, Corrêa MM, Pazó R, et al. Violência física e fatores associados em participantes da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc saúde coletiva. 2021;26(2):611-624. DOI: https://doi.org/10.1590/1413-81232021262.04552020
https://doi.org/10.1590/1413-81232021262... .

Male gender is considered to be a factor associated with involvement in physical fights⁵²52 Romeiro JS, Corrêa MM, Pazó R, et al. Violência física e fatores associados em participantes da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc saúde coletiva. 2021;26(2):611-624. DOI: https://doi.org/10.1590/1413-81232021262.04552020
https://doi.org/10.1590/1413-81232021262... , which corroborates this study. In general, boys seek social superiority through physical aggression in favour of relationships, followers, reputation and popularity⁵³53 Hoff KE, Reese-Weber M, Joel Schneider W, et al. The association between high status positions and aggressive behavior in early adolescence. J Sch Psychol. 2009;47(6):395-426. DOI: https://doi.org/10.1016/j.jsp.2009.07.003
https://doi.org/10.1016/j.jsp.2009.07.00... . Adolescent girls, on the other hand, tend to be more tolerant and friendly, avoiding violence⁵⁴54 Van Lange PA, Kruglanski AW, Higgins ET. Handbook of theories of social psychology. London: SAGE Publications Ltd, 2012. DOI: https://doi.org/10.4135/9781446249215
https://doi.org/10.4135/9781446249215... .

The prevalence of reports of severe injury was lower among Brazilian adolescents. The other countries showed similar figures, close to 35% (table 3), higher than Canada (31.4%)⁵⁵55 MacNabb K, Smith N, Robinson A, et al. Self-reported injuries among Canadian adolescents: rates and key correlates. Health Promot Chronic Dis Prev Can. 2022;42(5):199-208. DOI: https://doi.org/10.24095/hpcdp.42.5.03
https://doi.org/10.24095/hpcdp.42.5.03... and lower than Mauritius (39%)⁵⁶56 Mireku DO, Sarfo JO, Ansah EW, et al. Prevalence and Correlates of Serious Injuries among Adolescents in Mauritius. Scientific World J. 2021;2021:3733762. DOI: https://doi.org/10.1155/2021/3733762
https://doi.org/10.1155/2021/3733762... . Most of these injuries occur unintentionally⁵⁵55 MacNabb K, Smith N, Robinson A, et al. Self-reported injuries among Canadian adolescents: rates and key correlates. Health Promot Chronic Dis Prev Can. 2022;42(5):199-208. DOI: https://doi.org/10.24095/hpcdp.42.5.03
https://doi.org/10.24095/hpcdp.42.5.03... , but are related to hunger, physical fights, missing school without permission, absence of close friends, use of illicit⁵⁶56 Mireku DO, Sarfo JO, Ansah EW, et al. Prevalence and Correlates of Serious Injuries among Adolescents in Mauritius. Scientific World J. 2021;2021:3733762. DOI: https://doi.org/10.1155/2021/3733762
https://doi.org/10.1155/2021/3733762... and licit⁵⁵55 MacNabb K, Smith N, Robinson A, et al. Self-reported injuries among Canadian adolescents: rates and key correlates. Health Promot Chronic Dis Prev Can. 2022;42(5):199-208. DOI: https://doi.org/10.24095/hpcdp.42.5.03
https://doi.org/10.24095/hpcdp.42.5.03... ,⁵⁶56 Mireku DO, Sarfo JO, Ansah EW, et al. Prevalence and Correlates of Serious Injuries among Adolescents in Mauritius. Scientific World J. 2021;2021:3733762. DOI: https://doi.org/10.1155/2021/3733762
https://doi.org/10.1155/2021/3733762... drugs and anxiety⁵⁵55 MacNabb K, Smith N, Robinson A, et al. Self-reported injuries among Canadian adolescents: rates and key correlates. Health Promot Chronic Dis Prev Can. 2022;42(5):199-208. DOI: https://doi.org/10.24095/hpcdp.42.5.03
https://doi.org/10.24095/hpcdp.42.5.03... .

Brazil was the country with the fewest reports of regular PA practice. In 50 lowand middle-income countries, this prevalence was higher (14.9 per cent)⁵⁷57 Zhan X, Clark CCT, Bao R, et al. Association between physical education classes and physical activity among 187,386 adolescents aged 13–17 years from 50 lowand middle-income countries. J Pediatr (Rio J). 2021;97(5):571-578. DOI: https://doi.org/10.1016/j.jped.2020.11.009
https://doi.org/10.1016/j.jped.2020.11.0... , but still lower, making it a global public health problem. There is controversy over the influence of the country’s economic development on adolescents’ PA routine⁵⁸58 Ma C, Zhang Y, Zhao M, et al. Physical activity and sedentary behavior among young adolescents in 68 LMICs, and their relationships with National Economic Development. IJERPH. 2020;17(21):7752. DOI: https://doi.org/10.3390/ijerph17217752
https://doi.org/10.3390/ijerph17217752... . However, it is believed that the growing sedentary behaviour is linked to greater access to the internet, computer games, mobile phones and TV⁵⁸58 Ma C, Zhang Y, Zhao M, et al. Physical activity and sedentary behavior among young adolescents in 68 LMICs, and their relationships with National Economic Development. IJERPH. 2020;17(21):7752. DOI: https://doi.org/10.3390/ijerph17217752
https://doi.org/10.3390/ijerph17217752... .

In Brazil, lower prevalence rates of participation in physical education classes were also found, considerably lower than those found in other lowand middle-income countries (24.1%)⁵⁷57 Zhan X, Clark CCT, Bao R, et al. Association between physical education classes and physical activity among 187,386 adolescents aged 13–17 years from 50 lowand middle-income countries. J Pediatr (Rio J). 2021;97(5):571-578. DOI: https://doi.org/10.1016/j.jped.2020.11.009
https://doi.org/10.1016/j.jped.2020.11.0... . In fact, lower participation in these classes has previously been associated with insufficient PA⁵⁷57 Zhan X, Clark CCT, Bao R, et al. Association between physical education classes and physical activity among 187,386 adolescents aged 13–17 years from 50 lowand middle-income countries. J Pediatr (Rio J). 2021;97(5):571-578. DOI: https://doi.org/10.1016/j.jped.2020.11.009
https://doi.org/10.1016/j.jped.2020.11.0... . Measures that promote the creation of active environments, such as establishing a minimum number of hours of PA in school curricula, can therefore contribute to increasing the practice of these activities⁵⁹59 Ferrar KE, Olds TS, Walters JL. All the stereotypes confirmed: Differences in how Australian boys and girls use their time. Health Educ Behav. 2012;39(5):589-595. DOI: https://doi.org/10.1177/1090198111423942
https://doi.org/10.1177/1090198111423942... .

In all countries, there was a significant variation in the practice of regular PA and participation in physical education classes between genders, with lower levels among girls. These findings corroborate a previous study with Latin countries, including those in Mercosur⁶⁰60 Brazo-Sayavera J, Aubert S, Barnes JD, et al. Gender differences in physical activity and sedentary behavior: Results from over 200,000 Latin-American children and adolescents. PLoS ONE. 2021;16(8):e0255353. DOI: https://doi.org/10.1371/journal.pone.0255353
https://doi.org/10.1371/journal.pone.025... . In this context, it is important to consider the influence of gender roles. Latin American women were once considered the adult group with the highest levels of physical inactivity in the world⁶¹61 Guthold R, Stevens GA, Riley LM, et al. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health. 2018;6(10):e1077-e1086. DOI: https://doi.org/10.1016/s2214-109x(18)30357-7
https://doi.org/10.1016/s2214-109x(18)30... . Social barriers such as stereotypes, body image insecurity and cultural acceptability can reduce enthusiasm for PA⁶²62 The Lancet Public Health. Time to tackle the physical activity gender gap. Lancet Public Health. 2019;4(8):e360. DOI: https://doi.org/10.1016/s2468-2667(19)30135-5
https://doi.org/10.1016/s2468-2667(19)30... .

In this respect, the prevalence of sedentary behaviour was high in all countries. Three of them had more than half of their adolescent population with sedentary behaviour (except Paraguay) (table 3). The worst scenario was observed in Uruguay, where more than 60 per cent of school-age children reported this habit. Sedentary behaviour is associated with poorer mental health⁶³63 Sampasa-Kanyinga H, Colman I, Goldfield GS, et al. Combinations of physical activity, sedentary time, and sleep duration and their associations with depressive symptoms and other mental health problems in children and adolescents: a systematic review. Int J Behav Nutr Phys Act. 2020;17(1):72. DOI: https://doi.org/10.1186/s12966-020-00976-x
https://doi.org/10.1186/s12966-020-00976... and a higher risk of mortality from cardiovascular causes, cancer, and type 2 diabetes⁶⁴64 Patterson R, McNamara E, Tainio M, et al. Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis. Eur J Epidemiol. 2018;33(9):811-829. DOI: https://doi.org/10.1007/s10654-018-0380-1
https://doi.org/10.1007/s10654-018-0380-... . Initiatives to promote sports in leisure time and in communities⁵⁸58 Ma C, Zhang Y, Zhao M, et al. Physical activity and sedentary behavior among young adolescents in 68 LMICs, and their relationships with National Economic Development. IJERPH. 2020;17(21):7752. DOI: https://doi.org/10.3390/ijerph17217752
https://doi.org/10.3390/ijerph17217752... or social facilities can help to minimise this situation.

The study’s limitations include the exclusion of adolescents outside of school. However, similar studies have been carried out all over the world⁸8 World Health Organization. GSHS questionnaire [Internet]. [local desconhecido]: WHO; 2023 [acesso em 2023 set 23]. Disponível em: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-school-based-student-health-survey/questionnaire
https://www.who.int/teams/noncommunicabl... , as they are facilitated by the integration of the health and education sectors, with schools being a favoured location for monitoring pupils’ health indicators³3 Inchley JCD, Budisavljevic S, Torsheim T, et al., editores. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report [Internet]. Geneva: WHO Regional Office for Europe; 2020 [acesso em 2023 jun 12]. Disponível em: https://iris.who.int/bitstream/handle/10665/332104/9789289055017-eng.pdf
https://iris.who.int/bitstream/handle/10... . In addition, the strata used for sample calculation increase the representativeness of the target audience. Another limitation refers to information bias, with the possibility of collecting underor over-reported information, since these are questionnaire data. However, selfreported behaviour among adolescents has validity⁶⁵65 Brener ND, Billy JOG, Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. J Adolesc Health. 2003;33(6):436-457. DOI: https://doi.org/10.1016/s1054-139x(03)00052-1
https://doi.org/10.1016/s1054-139x(03)00... , and the anonymous nature of the survey can reduce this tendency. The size of the study populations should also be considered, since there is great variability. It should also be noted that the structure of some PeNSE questions has changed, making it necessary to use data from the 2015 edition.

Conclusions

There were differences between the health indicators of adolescents in the Mercosur countries. Argentina had a higher prevalence of early experimentation with alcoholic beverages, current cigarette consumption, use of any tobacco product and involvement in a physical fight. Like Uruguay, Argentina also had a higher prevalence of current alcohol consumption. Uruguay had a higher prevalence of sedentary behaviour. Brazil had a higher prevalence of drunkenness, lower prevalence of smoking, absence of a close friend, regular PA, participation in physical education classes, condom use during last sexual intercourse and serious injuries. In Paraguay, a lower prevalence of lifetime sexual intercourse was found. The lack of data on tobacco use in Paraguay should be considered, as it may be higher, equal or lower than in the other countries studied.

The better performance in terms of cigarette consumption and serious injuries in Brazil, sedentary behaviour in Paraguay and condom use in all but Brazil could lead to strategies being shared in these areas. These results can help government bodies in the countries analysed to promote the exchange of good practices, according to the performance of the indicators in each territory, since this exchange is one of the purposes of Mercosur.

References

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