Adolescent and youth health policies in the Portuguese-Brazilian context : specificities and approximations

Resumo O objetivo deste artigo é caracterizar a produção científica sobre políticas e programas de saúde de adolescentes no Brasil e em Portugal no período 2010-2017. Estudo de revisão da literatura, baseado no método de “Scoping Review”. A questão de investigação: como se caracteriza a produção científica sobre políticas e programas de saúde de adolescentes do Brasil e de Portugal? As buscas foram realizadas no mês de outubro de 2017, nas plataformas BVS, EBSCO e Google Acadêmico. Foram selecionados 22 estudos, 17 brasileiros e 5 portugueses. Foram identificadas sete categorias temáticas transversais: avaliação de políticas e programas; promoção e educação para a saúde; saúde mental; saúde sexual e reprodutiva; violência; saúde bucal e saúde nutricional. Conclui-se que, embora em contextos sociais distintos, as temáticas refletem áreas tradicionais de intervenção das políticas e programas, com exceção daquelas decorrentes do fenômeno da violência estrutural, marcadamente presente na realidade brasileira. Ainda, ausência de temáticas emergentes como identidades de gênero, fluxos migratórios e morbimortalidade por causas externas, revelando possível vazio assistencial das políticas e programas e um campo necessário a ser explorado. Palavras-chave Adolescente, Saúde do adolescente, Políticas públicas, Programas nacionais de saúde, Atenção integral à saúde Abstract Objective: To characterize the scientific production on adolescent health policies and programs in Brazil and Portugal in the period 20102017. Method: This is a literature review based on the Scoping Review method. The research guidingquestion was: “How is the scientific production on adolescent health policies and programs in Brazil and Portugal characterized?”Search was carried out in October 2017 on the BVS, EBSCO and Google Scholar platforms. Results: Twentytwo studies were selected, namely, 17 Brazilian and 5 Portuguese. Seven cross-cutting thematic categories were identified, as follows: policy and program evaluation; health promotion and education; mental health; sexual and reproductive health; violence; oral health and nutritional health. We canconclude that, albeit in different social contexts, the themes reflect traditional areas of intervention of policies and programs, except for those arising from the phenomenon of structural violence, markedly present in the Brazilian reality. Also, the lack of emerging issues such as gender identities, migratory flows, and morbimortality from external causes reveal a possible care gap in policies and programs and a necessary field to be explored.


Introduction
This study aims to characterize the scientific production of adolescent health policies and programs in Brazil and Portugal.In a globalized and multicultural context, where multiple identities and ways of conceiving the stages of adolescence and youth converge and circulate, we decided to follow the classifications adopted by the PanAmerican Health Organization 1 and World Health Organization 2 .According to these organizations, adolescence and youth are differentiated by their physiological, psychological and sociological specificities.Thus, adolescence is a fundamental biological process during which cognitive development and personality structure are accelerated.It is divided into two stages of pre-adolescence (10-14 years) and adolescence itself (15-19 years).Youth is conceived as a sociological category, which indicates the process of preparation for the individual to assume its adult role in society, both in the family and the professional sphere, extending from 15 to 24 years.
Despite generational and cultural diversities, as well as the legal frameworks of adolescence and youth between Brazil and Portugal, this study focused on health systems, especially the political-institutional arrangements structured as public policies and programs provided to this population, considering their health needs.Of this universe, the School Health Program has been highlighted in Brazil since 2007 3 and the National Guidelines for Adolescent and Youth Comprehensive Healthcare in the promotion, protection, and recovery of health 4 , implemented in 2010, based on several legal and normative drivers of policies and programs for this segment [5][6][7] .Portugal has the recently updated National Child and Youth Health Program (PNSIJ) 8 and the Portuguese Institute of Sports and Youth, with a Youth Knowledge Center, a project that gathers virtually a network of information and knowledge aimed at youth 9 .Like Brazil, Portugal has been developing the National School Health Program since 2009 10 .
The analysis of the results of the research in the light of the programmatic milestones of each country was based on the theoretical perspective of Giovanella et al. 11 , in which the concept of public policy is associated with a civilizing process of social justice and the role of the state in action, that is, the process of building a governmental action for a sector, which involves resources, stakeholders, arenas, ideas and negotiation.
It is assumed that the social determinants of health establish different demands, needs, and responses of social protection systems, which directly affects the spectrum and scope of sectoral public policies.In other words, class society and social, political, ethnic, racial, migratory and gender disparities actively determine the distribution of resources, access to opportunities, and therefore the health conditions of a given population.
Thus, the realities of the two countries establish very different boundaries.On the other hand, the common element that supports the proposed comparative perspective is the structuring concept of public policy whose constitution embodies the role of universalizing human rights, in this case, enabling broader mechanisms to guarantee the rights of adolescents and young people.

Methods
This is a literature review study, based on the Scoping Review method 12,13 .This is a type of method used when the goal is to map essential productions in the field of interest, where different study designs are useful.Scoping Review proposes to carry out five steps, plus a sixth optional one, namely: (1) identification of the research question; (2) identification of relevant studies; (3) selection of studies; (4) data extraction; (5)  summarization and reporting of results; and (6) presentation of the results for validation of the research.
The research question of this study was: "How is academic, scientific production characterized by adolescent health policies and programs in Brazil and Portugal?"The search strategy considered empirical and theoretical works, including theses, dissertations, editorials and gray literature.The period established considered the publications from 2010 to 2017.This time frame was chosen because of the period of implementation of the national health policies geared to this population segment, namely, 2010 in Brazil and 2013 in Portugal.
Data sources accessed were Lilacs (Latin American and Caribbean Literature in Health Sciences), Ibecs (Spanish Bibliographical Index of Health Sciences), Medline (Medical Literature Analysis and Retrieval System Online), Cochrane Library, SciELO (Scientific Electronic Library Online), Adolec Brasil (Adolescents Database), EBSCO and the Google Scholar tool.The Health Sciences Descriptors (DeCS) and Medical Sub-ject Headings (MeSH) used were: adolescent; adolescent health; health policy; public policy; national health programs; adolescent health program; child and adolescent comprehensive health care; adolescent health services.
A filter to identify studies conducted in the two countries of interest, Brazil, and Portugal, was activated.Besides, to assist in the selection of studies, the inclusion criterion established was the need to address some adolescent health policy or program, and then exclude those studies that did not establish a link between their results/ discussion and some adolescent health policy or program.
The research was carried out in October 2017, by two researchers, independently.Later, the results of each search were compared, and any disagreement was resolved by consensus.In other words, the researchers compared their search results, checking differences of findings, always aiming to include as many studies as possible.Figure 1 shows the process of search, exclusion, and selection of the studies found.
For the data extraction stage, an instrument structured in Excel was used to identify and describe items such as year of publication, authorship, country, research subjects, type of study and subject matter.This tool allowed the summary, data interpretation and the primary numerical analysis of the scope, nature, and distribution of the studies incorporated in the review.The results were then compiled and communicated to provide an overview of all the material, through a thematic construction, organized according to the nature of the studies.The results were finally shared with colleagues of the research group to verify, through a subjective and straightforward process, whether they were representative of the realities investigated.

Results
Twenty-two studies published between the years 2010 and 2017 were analyzed according to the year of publication, authorship, country, subjects, method and theme (Chart 1).
The numerical analysis shows that most of the selected studies addressed the context of health policies and programs of Brazilian adolescents (n = 17), based on a theoretical analysis (n = 12), mainly literature review studies (n = 5), theoretical essays (n = 4) and documentary analysis (n = 3).Among the five empirical studies conducted in Brazil, four were qualitative.
Of the five studies on adolescent health policies and programs conducted in Portugal, three were empirical, involving mixed -quantitative and qualitative, retrospective and Delphi -methodological design.Of the theoretical studies (n = 2), one performed a documentary analysis and the other a theoretical essay.No literature review study on this topic was found in Portugal.
The most significant number of studies was published in 2013, both in Brazil (n = 4) and in Portugal (n = 2).Regarding language, most studies were published in Portuguese (n = 19).There were also two studies published in English and one in Spanish.The participants of the empirical studies analyzed were adolescents, members of the government, civil society, experts, teachers, and managers.
From the reading and the analysis of the studies, it was possible to identify different thematic categories cross-cuttingto the actual field of adolescent health policies and programs in Brazil and Portugal.Table 1 shows the classification of the studies and the "n" for each country.

Evaluation of policies and programs
The studies suggest discussing the proposals, actions and effectiveness of specific policies and programs.In Brazil, all studies address health policies, from their construction to their effective implementation.In general, they emphasize the importance of considering the adolescent not only as a problem generator but as a subject with the potential to contribute to the development of the country 14 .In this context, they affirm that considering the social, cultural and collective Chart 1. Mapping of the literature published between 2010 and 2017 in the area of adolescent health policies and programs in Brazil and Portugal selected for analysis -Porto Alegre (RS), Brazil, 2017.realms of the realities in which these adolescents are inserted 18 and considering the participation and co-responsibility of adolescents 20 may result in more inclusive and effective policies 21 .

BRAZIL
A Portuguese study evaluates a specific program geared to adolescents with behavioral changes, thus describing a more focused perspective.However, in the same way as the Brazilian studies, it was concerned with considering the potential of adolescents and the specificities of the life context, anchored in the process of co-construction and networking 33 .

Health promotion and education
The category of health promotion and education focuses mainly on aspects of school health policies in both countries.The school environment is described as a strategic space for the development and implementation of health promotion practices since school plays a vital role in the construction of values and the very development of the citizenship of these adolescents 26 .The topics covered are mainly related to physical and mental health, lifestyle, environment, and education / sexual and reproductive health 34 .
They also discuss the scope of extracurricular activities in aiding the development and promotion of adolescent health.The extra-class period, when experienced by unattended adolescents, may predispose to an increased vulnerability concerning contact with child labor situations, inducement to drug trafficking or victimization by direct violence.With the same perception of strategic space for the development of a comprehensive formation for life, the extracurricular spaces can be opportunities for health promotion and education 15 .
Outside of school, health promotion and education activities are understood as strategic for health and individual, group and social well-being.Priority activities, according to adolescents, family, school, and society encompass learning about healthy lifestyles, civics, and responsibilities, listening and dialogue, as well as social participation 32 .

Mental health
The category of mental health was related to the social context in which adolescents live, mainly in Brazil.Concern about the use of drugs and other substances, with the increasing medicalization of life, exposes punitive and institutionalizing solutions, reinforcing the importance of public policies, curbing the excesses of this process and strengthening the role of health agencies 29 .The worse the social conditions, the higher the number of intercurrences and psychiatric hospitalizations reported, challenging public policies to show the best way to intervene with these adolescents, observing their particularities and overcoming the limited availability of resources 30 .
Emotional and behavioral disorders are frequently addressed in the literature on adolescent health 19 .This is a period of extensive and profound physical, but also psychological transformations.The program for development of social skills responds to this challenge.Focused on assertiveness, self-control, cooperation, and empathy, through four central axes -communication, assertive behavior, cooperation and emotional self-control -it proposes to contribute to self-knowledge among adolescents, establishing positive interpersonal relationships and personal valuation 35 .

Sexual and reproductive health
The studies address issues related to the role of the State in adolescent comprehensive health education and promotion actions based on the realities evidenced and responding to the needs of this population.The Brazilian reality is marked by the lack of essential resources and exposes adolescents to vulnerabilities mainly linked to social aspects, sexuality, psychoemotional situation and violence.Adolescent pregnancy appears in this reality as a public health issue, lacking public policies that include adolescents in their entirety, mainly about the complexity of motherhood at this stage of life 25 .
When becoming pregnant, adolescents are obliged to mature, while experiencing intense prejudice related to concerns about their maternal capacity 25 .However, Duarte 22 shows the lack of public policies aimed at the guidance and support of male adolescents in the exercise of paternity.Pregnancy in Brazilian society is still predominantly interpreted and related to women, leaving out the teenage fathers and over-blaming mothers.On the other hand, Carvalho & Figueiredo's study 31 discusses educational aspects of sexual and reproductive health, questioning the role of the State, the family, and society in this process.In general, it sustains the role of the State as a promoter of education in conditions of equality and equity, starting from the school's leading role as a socializing and value-making institution.Criticism is in the perception of the right and parental responsibility of education, mainly related to the controversial theme of sexual and reproductive education, reducing State interference in the educational guidelines of schools, configuring these as primarily instructional space.

Violence
Violence is characterized as a violation of fundamental rights, which unequally affects regions and populations according to the characteristics of the social class, gender, ethnicity, skin color, and age.The three studies included in this category were carried out in Brazil, and no study on this subject was identified in Portugal 17,23,27 .
Based on an exclusionary economic model formed by a young population, Brazil experiences significant levels of violence of different natures, especially among the adolescent population.In this context, criticisms to the State in the way it has been developing and managing its public policies, as well as the lack of analysis of these policies and public plans, to monitor the effectiveness of its methods and results, are characterized as a priority research topic 27 .Along the same lines, Fonseca et al. 23 address the high rates of violation of adolescent rights evidenced as abandonment, early work, sexual exploitation and daily violence, which takes place in family and school contexts strongly tied to economic and social issues.The challenges range from parental guidance to the establishment of community shelters and programs, as well as investment in research and articulation of new intervention proposals.
Adolescent victims of situations of violence, neglect, and abandonment, most of the time, do not find in the State a protection network capable of responding to their needs and protect their situation of social vulnerability.Many of these adolescents end up entering the universe of law infringement and directed to be placed under socio-educational measures.In this context, the focus should be on public policies capable of helping adolescents overcome their condition of exclusion, as a focus on social reintegration, from educational and professional activities.However, what is observed is the predominance of punitive measures, organized by poor social policies, with actions in an incipient network, showing the need to move forward concerning the situation of adolescents serving socio-educational measures 17 .

Oral health
The studies discuss educational actions that overcome the logic of unidirectional, dogmatic and authoritarian communication, in the promotion of oral health.According to Silva et al. 28 , reflective and critical education, which questions oral health issues, considering the complexity of social determinants can contribute to the development of a critical, autonomous and emancipatory awareness of adolescents rather than stimulate self-care.In this line, Celeste's study 16 emphasizes the importance of the role of public policies in the prevention of oral health problems.

Nutritional health
The study of Freitas et al. 24 discusses the problem related to the increasing prevalence of overweight and obesity in adolescents, emphasizing the need to establish public health promotion policies and programs, aiming to set healthy eating habits and regular practice of physical activity.This theme takes on a leading role in a reality that until recently has been marked by hunger and malnutrition, as is the case in Brazil, currently demanding educational programs about the nutritional values of foods and the importance of preventing overweight and obesity, in the context of chronic noncommunicable diseases and their consequences.

Discussion
Despite the predominance of the theoretical papers on aspects cross-cutting to health policies, we note the relevance and pertinence of producing evaluative studies, especially those based on documentary studies.From this set, a fundamental aspect is highlighted, usually subtracted from the decision-making and management processes, that is, the participation of the individuals involved.The fact that adolescents and young people do not have the civilian age of majority or full autonomy does not disqualify their participation; instead, it must be a condition for the successful planning of actions, serving as an exercise and learning of citizenship.
In 2017, the National Council for the Rights of Children and Adolescents issued a resolution applicable nationwide, within the framework of the State and Municipal Councils, on the active participation of adolescents and youth in their collegiate and plenary meetings 36 .In Portugal, the Portuguese Institute of Sports and Youth is currently about to approve the National Youth Plan, with open consultation for suggestions of the young people 37 .
One noticeable difference between countries was the scope on which the policy was assessed.Considering Brazil's continental dimensions and, above all, the social inequality burdening on the social determinants of health, studies addressed macro-policies under the lenses of intersectoriality and equity of resources and service, whereas in Portugal the only study is about a focused program.No studies are discussing or reviewing adolescent-related public policies in Portugal.
As for the cross-cutting themes prevalent in the studies, we observed a parity distribution among the axes that respond to the higher demands of policymakers and decision-makers concerning adolescence and youth: sexual and reproductive health, mental health and violence, as well as the presence of studies addressing services provided to this population, such as oral and nutritional health.These demands and themes have a specific approach -health education, and a privileged locus of intervention -school.Unlike other life cycles, where children are included, health promotion and the prevention of health problems in the adolescent population, as studies show, is shared, if not outsourced to education and its agents.Despite the relevance of the articulation of health and education policies and school's centrality, the health and clinical responsibility of the population is incumbent upon the health network in all its levels of care, emphasizing, therefore, the importance of the primary health care actions in the territory and with the health facilities and health teams.
In this context, we interpret the presence of Brazilian studies addressing oral health and the nutritional health of adolescents and young people.Oral health had a substantial inflection in the territories from its introduction in the Family Health Teams 38 .Likewise, specific guidelines of the Brazilian reality influenced the production of papers on violence and mental health.The first is increasingly alarming.In Brazil, the violent death of young people has been proliferating since the 1980s.According to Cerqueira 39 , the cost of well-being associated with lethal violence affecting young people reaches 1.5% of GDP each year.Morbimortalityis exacerbated by association with other factors such as low schooling, school dropout, poor introduction in the world of work, alcohol and other drugs abuse, exposure to violence and accidents, unprotected sexual activity, generally exposing a situation of iniquities arising from inequalities of income, ethnicity, gender, sexual orientation, gender identity and territoriality.The problem is even more severe and an emergency when we consider the substantial decline in the proportion of young people in the general population.This setting indicates that adolescents and young people aged 10-24 years represent 29% of global population, 80% of whom live in developing countries, such as Brazil 40 .The vulnerability of adolescents and young people requires a comprehensive and broad perspective on the horizon of public policies that effectively care for and protect them.
The lack of Portuguese production addressing policies to combat violence may be related to living conditions and access to necessary policies that guarantee adolescent and young population a favorable level of social security, understood here as a broader concept, not only with the absence of risk, but with a particular condition of predictability and certainty about the future.According to Scherer 41 , the safety category has an intimate relationship with protection, which aims to ensure a set of guarantees, preserving individuals from the most diverse possible risks during their lifetime.
This trend is repeated in the production that addressed the theme of mental health.While in Brazil authors discuss the mental health strongly associated with the above social conditions, the reality is different in Portugal, and the only study is concerned with the development of social skills for behavioral problems.With a population of 10,562,178, mostly consisting of adults and elderly, children and adolescents (0-14 years) account for 14.88% of the population, while young people (15-24 years) account for 10.86% 42 .
Such demographic distribution pattern may perhaps explain the emphasis placed on the child segment in the reformulation of the Portuguese health policy held in 2013 concerning mental health 8 .The text points out that the new National Children and Youth Health Program "on the one hand, responds to the need to improve quality standards, harmonizing the contents of health actions with new scientific evidence and new morbidities, and on the other, to a greater relevance of pre-existing health issues."The document emphasizes the new focus on issues related to child development, emotional and behavioral disorders and ill-treatment, with no reference to mental health and other subjects concerning the young population.
Although they are considered to be healthy people, adolescents and young people are generally conceived as a "risk group", especially regarding exposure to alcohol and other drugs and the exercise of sexuality.The latter theme was addressed by three papers 22,25,31 , located in the category of sexual and reproductive health.The Brazilian papers pointed out the role of public policies in protecting and caring for "vulnerable motherhood", that is, about the living conditions of boys and girls and their newborns, given the consequences and risks involved, especially in poor populations.Given the urgency of actions in this area in Brazil, basic guidelines for sexual health and reproductive health linked to the mother and child care network were launched in 2015 43 .Also under development is the "Protect and care" strategy, which aims to improve the comprehensive national primary care response, especially vis-à-vis the issues of the service organization, development and growth, and sexual and reproductive health.
The focus on Portuguese production refers to the role of education in dealing with this complex issue, holding other public authorities such as health agencies accountable.Thus, in Portugal, sexual education was established in schools in 2009 through Law Nº 60/2009 44 .This legislation is part of the National Reproductive Health Program (PNSR), established in 2007, covering family planning, prenatal care surveillance and diagnosis, voluntary termination of pregnancy and medically assisted procreation 45 .
The Sexual and Reproductive Health of adolescents and young people is a topic that deserves to be better studied by the academy, managers and health professionals.Underlying the discussion is the respect for human rights, from the perspective of adolescent/youth's universe that must encompass all agendas and policies.Thus, Novaes 46 points out that, from the perspective of youth demands, human rights refer to a concept that considers the diversity of rights -civil, economic, cultural, social, political and other.In this perspective, the author says that the concept of adolescents and young people as subjects of rights is anchored in the understanding of the indivisibility of individuals and collective rights and expresses the significant challenge of contemporary democracies to articulate equality and diversity in the planning and implementation of public policies.

Final considerations
This study addressed the scientific production on public health policies and programs geared to the adolescent and young population in Brazil and Portugal.The set of works shows an early production and intermittent flow in this thematic field.Evaluative studies, recurrent modeling in the field of Policy and Program objectives, as well as empirical studies, were scarce compared to the theoretical ones.These characteristics indicate a greater investigative interest in the cross-cutting thematic areas to the detriment of the field (policies and programs).Thus, the corpus of analysis consisted of papers that secondarily addressed the field of policies and programs, analyzing it in a complementary way to the priority study objects.This characteristic of production demanded the analysis of the approach of themes underlying the public agendas, seeking connections between the guidelines that sustain them and their relationship with the national social contexts, in their peculiarities in meeting the demands and needs of their adolescents and young people.
This trend can be explained by the recent implementation in the two countries of legislation, guidelines and policies structured and specific to adolescent and youth health.However, it can be affirmed that both countries already have robust and structuring programmatic frameworks for the proper extended coverage of actions in the states and regions, which is a fertile field for the research and production of knowledge.The interest to focus on relevant themes that permeate health actions is also justified by the complexity of direct care for adolescents and young people.
Although in different social contexts, the themes reflect traditional areas of intervention of policies and programs in the field of adolescent and youth health, except for those arising from the event of structural violence, which is present in the Brazilian reality.There was also a lack of emerging themes that affect adolescent and young population's health, such as gender identities, migratory flows and morbimortality due to external causes, including suicide, revealing a possible lack of care of policies and programs, and a necessary field to be explored by scientific production.In this regard, critical knowledge and the general appropriation of the policy itself is fundamental because it emanates technical and care-related guidelines, as well as budget resources that directly affect the local management of health services.

Collaborations
R Schaefer e CRD Nora searched the databases.

Table 1 .
Cross-sectional thematic categories identified from the literature review selected in the area of adolescent health policies and programs in Brazil and Portugal -Porto Alegre (RS), Brazil, 2017.