Adolescent mental health promotion in Latin American countries: an integrative literature review

Thaís Thaler Souza Ana Carolina de Almeida Amanda Dourado Souza Akahosi Fernandes Maria Fernanda Barboza Cid About the authors

Resumo

A Promoção em Saúde (PS) apresenta um fortalecimento recente dentro das políticas públicas e quando se trata da infância e adolescência na América Latina (AL) observa-se ainda forte consonância com as determinações internacionais. Considerando o aumento de prevalência de sofrimento psíquico nesta faixa etária e a construção histórica política dos países latino-americanos abordar a PS se torna mais urgente. O objetivo desta pesquisa foi identificar e analisar, por meio de uma revisão integrativa da literatura, produções acadêmicas que tratam de estratégias de PS mental de adolescentes na AL e, assim, visibilizar as ações e provocar reflexões dialogadas com as críticas Sulistas, representadas pela declaração de Bogotá. Após a aplicação dos critérios de inclusão e exclusão, foram selecionados 6 estudos. Identificou-se que o principal espaço onde as ações são desenvolvidas é a escola. Além disso, como medidas potenciais foram identificadas a capacitação dos profissionais, a ação grupal e o fortalecimento da atenção primária e territorial. Discute-se que a realidade socioeconômica estruturada historicamente da AL reflete uma organização própria das ações em PS. Com isso, a visibilização das estratégias que potencializam a baixo custo uma melhora na saúde mental de adolescentes pode contribuir com a reflexão atual.

Palavras-chave:
Promoção da Saúde; Adolescente; América Latina

Abstract

Health Promotion (HP) has recently been strengthened within public policies and still shows strong consonance with international determinations regarding childhood and adolescence in Latin America (LA). Debating HP becomes all the more urgent considering the increasing prevalence of psychological distress in this age group and the historical political construction of Latin American countries. This research aimed to identify and analyze, through an integrative review of the literature, the academic productions on strategies for mental HP of adolescents in LA and, thus, to visualize the actions and arouse reflections dialoguing with the Southern critics, represented by the Bogotá declaration. Six studies were selected after applying the inclusion and exclusion criteria. We identified that the main space where actions are developed is the school. The potential measures identified were professional training, group action, and strengthening primary and territorial care. We discussed that the historically structured socioeconomic reality of LA reflects an organization of HP actions. Furthermore, the visualization of strategies that enhance at low cost the improved mental health of adolescents can contribute to the current reflection.

Key words:
Health Promotion; Adolescents; Latin America

Introduction

The concept of Health Promotion (HP) and its practices became more widespread in the 1980s. Linked to “sustainable development” and “healthy public policies”, HP was quickly correlated to environmental, social, psychological, and physical factors resulting from living conditions. The resumption of this concept in the last 40 years occurred through the initiative of European countries, Canada, and the U.S., and aimed to reduce the high health costs promoted by the biomedical model, besides criticizing the efficiency of the current system11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42..

However, according to Spink22 Spink MJP. Psicologia Social e Saúde: trabalhando com a complexidade. Quaderns Psicol 2010; 12(1):41-56., due to the very political and social structure generated by capitalism and its characteristic of encouraging individualism as a way of surviving, HP conceptualization in recent years has varied throughout local and commercial interests, also influencing the amount of State interference that one should or should not have in actions of this nature, of individual’s “duty” in health and the objectives of using this practice. In other words, the support and incentive to HP range from more conservative aspects, with a historical movement of shrinking the State’s role and an increased individual responsibility regarding own health process, to more progressive perspectives of reflective movements and resistance to these constructions with a greater demand for support of public policy measures11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42.,22 Spink MJP. Psicologia Social e Saúde: trabalhando com a complexidade. Quaderns Psicol 2010; 12(1):41-56..

A robust and critical perspective of the concept has developed In Latin America (LA), with Social Medicine, and in Brazil, with Collective Health. Speaking of HP in LA leads to reflecting on colonization-derived concepts and encourages to question possibilities more compatible with a political context marked by varying vulnerabilities33 Borghi CMSO, Oliveira RM, Sevalho G. Determinação ou Determinantes Sociais da Saúde: Texto e Contexto na América Latina. Trab Educ Saúde 2018; 16(3):869-897..

Freitas44 Freitas CM. A vigilância da Saúde para a Promoção da Saúde. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 145-164. points out that if the publication of the Ottawa Charter in Canada in 1986 is the reference document for health promotion actions globally, in LA, the 1992 Bogotá Declaration has brought essential reflections on the discussion of HP linked to practices that are contextualized and assist in social transformation. In a nutshell, the Bogotá Declaration emphasizes the importance of breaking with the structures that maintain the status quo of inequality, encouraging democratic, equitable, and innovative actions44 Freitas CM. A vigilância da Saúde para a Promoção da Saúde. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 145-164..

The resistance of LA countries vis-à-vis this historical oppression of imposing concepts such as what it is to be developed and the standard of well-being and living well has created a marginalized creative power. Thus, according to Acosta55 Acosta A. O Bem Viver: uma alternativa ao desenvolvimento. In: Costa A, editor. O Bem Viver: uma oportunidade para imaginar outros mundos. São Paulo: Elefante Editora; 2016. p. 69-88., these post-developmental perspectives in LA countries aim to transcend “alternative developments” and enable “development alternatives”. Thus, currently, the concept of HP:

[...] is initially associated with a ‘set of values’: life, health, solidarity, equity, democracy, citizenship, development, participation, and partnership. It also refers to a ‘mix of strategies’: State (healthy public policies), community (strengthening community action), individual (development of personal skills), health system (reorientation of the health system) actions, and intersectoral partnerships; that is, it works with the idea of ‘multiple accountability’, either for the problems or for the solutions proposed for them.11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42.(p.20).

Despite the still very present “internationalist” influence in the concept identifiable in international conferences, political determinations, letters, and other political authorities, we have observed a movement towards the valorization of cultural knowledge and social participation and the promotion of partnerships with social movements involved with the environment and feminism, for example11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42..

However, a significant crossing of international determinations and the economic advantages of investment of this nature with this public is still identified when it comes to HP for adolescence. A manual produced by the World Health Organization66 Organização Mundial da Saúde (OMS). Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. Genebra: OMS; 2017. in partnership with other United Nations bodies, which provides comprehensive information on adolescent health for several countries, lists the reasons for the need to invest in adolescent health.

According to the document66 Organização Mundial da Saúde (OMS). Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. Genebra: OMS; 2017., HP is advantageous for the immediate health of adolescents and contributes to this state even in adulthood, reverberating to future generations. The document also states that investing in child and adolescent health promotion is the principle of human rights, to which almost all countries are signatories. The economic and demographic benefits of HP for adolescents are highlighted in the text66 Organização Mundial da Saúde (OMS). Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. Genebra: OMS; 2017. and justified with increasing productivity, lower health costs, and higher social capital.

Regarding the main adolescent health demands, mental health has been an emerging theme currently, since the prevalence of psychological distress in this population has increased significantly in recent years77 Rossi LM, Marcolino TQ, Speranza M, Cid MFB. Crise e saúde mental na adolescência: a história sob a ótica de quem vive. Cad Saude Publica 2019; 35(3):1-12.,88 Fatori D, Brentani A, Grisi SJFE, Miguel EC, Graeff-Martins AS. Prevalência de problemas de saúde mental na infância na atenção primária. Cien Saude Colet 2018; 23(9):3013-3020.. In this sense, studies point to the need to invest in public policies, research, and care strategies to promote adolescent mental health, especially when it comes to developing countries99 Patel V, Flisher AJ, Nikapota A, Malhotra S. Promoting child and adolescent mental health in low and middle income countries. J Child Psychol Psychiatry 2008; 49(3):313-334..

However, in the literature, the scientific production of mental health in low and middle-income countries represents only about 6% of this content, and this figure is even lower when specified for the mental health of children and adolescents1010 Saxena S, Paraje G, Sharan P, Karam G, Sadana R. The 10/90 divide in mental health research: trends over a 10-year period. Br J Psychiatry 2006; 188(1):81-82.. We find a field still under construction11 when thought from a more salutogenic perspective of the issue, focused on promotion and prevention. As an example, a study carried out in PHC Units (UBS) in the State of São Paulo by Fernandes1212 Fernandes ADSA. Cuidado em Saúde Mental Infantojuvenil na Atenção Básica à Saúde: práticas, desafios e perspectivas. 2015-2019 [tese]. São Carlos: Universidade Federal de São Carlos; 2019. found that actions to promote children’s mental health are still far from the care practices offered, even considering the most socially vulnerable territories plagued by poverty, drug trafficking, and violence.

Thus, the results indicate that the care for this population has been based exclusively on the perspective of health problems, with little regard for social determinants, which are directly related to health conditions, so that being in a context of vulnerability would mean increasing risks and the likelihood of impairing the development of children and adolescents1212 Fernandes ADSA. Cuidado em Saúde Mental Infantojuvenil na Atenção Básica à Saúde: práticas, desafios e perspectivas. 2015-2019 [tese]. São Carlos: Universidade Federal de São Carlos; 2019.,1313 Barata RB. Políticas para o enfrentamento das desigualdades. In: Barata RB, editor. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2009. p. 95-108..

In this sense, the recent strengthening of the HP concept globally and the more recent critical construction around the idea in LA countries11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42. reinforce the importance of reflecting on what has been proposed to and developed for adolescents, since when it is about child and adolescent mental health, its contemporaneity and conceptualization still under construction, we are faced with political crossings of historical denial and lack of appreciation and recognition of these subjects1414 Mendonça MHM. O desafio da política de atendimento à infância e à adolescência na construção de políticas públicas eqüitativas. Cad Saude Publica 2002; 18:S113-S120..

Therefore, this study aims to contribute and proposes to identify and analyze through an integrative literature review, academic productions that address strategies to promote the mental health of adolescents in LA to advance the construction of knowledge consistent with the historical-social context of this region of the American continent, marked by its young and vulnerable population curvature and, thus, to make visible the actions and stir reflections dialogued with Southern critics, represented by the Bogotá Declaration44 Freitas CM. A vigilância da Saúde para a Promoção da Saúde. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 145-164.,99 Patel V, Flisher AJ, Nikapota A, Malhotra S. Promoting child and adolescent mental health in low and middle income countries. J Child Psychol Psychiatry 2008; 49(3):313-334..

Methods

This is an integrative review of the literature, a research method that allows the synthesis and analysis of the existing production about a specific phenomenon. It also aims to produce new questions, reflections, and criticisms, identifying existing gaps and, consequently, advancing knowledge1515 Broome ME. Integrative literature reviews for the development of concepts. Concept development in nursing: foundations, techniques and applications. Philadelphia: WB Saunders Company; 2000.. This study adopted the following integrative review steps: 1) Identifying the research question; 2) Searching the scientific literature (for this step, inclusion and exclusion criteria were established for the material found, conducting the search in the databases and selecting studies); 3) Categorizing the results found; 4) Evaluating the selected papers; 5) Analyzing, interpreting and discussing the results; and 6) Synthesizing information and producing knowledge1616 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764..

To this end, the following research question was formulated: What has the literature produced on strategies to promote adolescent mental health in Latin America?

The search was carried out in the following databases: Virtual Health Library (BVS), Scopus, and Web of Science, from September 2019 to April 2020. The selected databases aimed to access the full content of the Ibero-American countries. The descriptors were selected from the Health Sciences Descriptors (DeCS) in English, Spanish, and Portuguese for the BVS, and for the other databases, the descriptors were identified in the Medical Subject Headings (MeSH) and searched for in English and Spanish. The descriptors identified in the DeCS and MeSH coincided, and they were: (“promoção de saúde” OR “health promotion” OR “promoción de la salud”) AND (“saúde mental” OR “mental health” OR “salud mental”) AND (adolescen*) for BVS, and for other databases (“health promotion” OR “promoción de la salud”) AND (“mental health” OR “salud mental”) AND (adolescen*).

The following inclusion criteria were adopted for selecting productions: papers in English, Spanish, and Portuguese, explaining in the title, summary, and keywords any strategy, action, or mental health promotion program for the adolescent public. After selecting the studies, only the countries of Latin America were selected through the “countries and territories” filter in the selected databases.

On the other hand, papers that were not fully available online, literature reviews, epidemiological surveys, correspondence, editorials, monographs, dissertations, and theses, were excluded from this review. It should also be noted that no time bracket was adopted for the search. In Figure 1, the flowchart followed by this study is illustrated below.

Figure 1
Scientific production search flowchart.

The selected papers were submitted to a descriptive analysis of their materials after carefully reading them in full, considering the variables year and country of production, theoretical references used, the objective of the published work, methods, and main results. Such analysis resulted in the configuration of thematic axes that will be presented in the next section.

Results

Charts 1 and 2 contain information related to the six papers composing the final sample selected for this study.

Chart 1
Identification of the selected papers.
Chart 2
Characterization of the selected papers.

Chart 1 shows that the studies identified in this review were developed in three LA countries - three in Brazil1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.

18 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.
-1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942., two in Chile2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.,2121 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122., and one in Colombia2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.. Five of them were published in the last decade1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.

18 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.

19 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.
-2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.,2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833. and only one in 20052121 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122.. Four publications were in Public and Collective Health.

A research methodology with a predominant experimental and quasi-experimental design2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.

21 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122.
-2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833. was observed mainly in non-Brazilian productions.

Four of the selected papers were built on the literature addressing the strengthening of individual coping skills based on coping and cognitive and behavioral strategies1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.

21 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122.
-2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.. The other two Brazilian studies are based on the perspective of Health Education1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.,1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.. Only one paper considered the community and parents to build the promotion actions, besides professionals and adolescents1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381., and two included only Health or Education professionals1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.,2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.. The other productions conducted interventions with a focus solely on adolescents1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.,2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.,2121 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122..

It is also noteworthy that three studies1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.,2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833. focused on the training of professionals who work with adolescents as a health promotion strategy with this audience: one paper carried out distance and class training with teachers to identify symptoms within psychological distress2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.; a second paper performed the training of teachers to work with adolescents concerning alcohol and other drugs; and a third paper worked with health professionals in order to build possibilities for better assistance to adolescent care in mental health1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.. Chart 3 presents the six thematic axes identified from the main results of the studies.

Chart 3
Thematic axes identified in the selected papers.

Despite seeking partnership with the school context in almost all studies, four of the selected papers had difficulties in network and intersectoral work1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.

18 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.

19 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.
-2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.. Among these impasses is the lack of support from school managers, which discouraged the participation of teachers who struggled to keep up with the mandatory schedule. The authors also mention a possible health vertical stance concerning technical-scientific knowledge not realizing a genuine partnership with other authorities and the community. Hardships regarding establishing partnerships within the territory, care disarticulations, a fragile relationship with the community, and low partnership with parents and legal guardians1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.

18 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.

19 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.
-2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250. are also reported.

The strength of the strategy of using groups with adolescents is mentioned in three of the selected papers1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.,2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.,2121 Bonhauser M, Fernandez G, Püschel K, Yañez F, Montero J, Thompson B, Coronado G. Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial. Health Promot Int 2005; 20(2):113-122., whose authors suggest that it is an interesting methodological possibility for this age group. The training of professionals working with adolescents was also an influential factor pointed out in the results of the studies analyzed and was identified in three papers1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942.,2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.. The teacher emerges among these professionals, who appeared in two of these actions1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,2222 Gómez-Restrepo C, Tamayo-Martínez N, Ayala-Corredor C, Carrasco-Gil A, Padilla-Muñoz A, Garzón DF, Borda JP, Verhelst P, Ramirez MP, González LM, Gil JF. Conocimiento adquirido y adherencia en un diplomado sobre la salud mental para docentes orientadores. Rev Salud Publica 2014; 16(6):821-833.. This relevance is justified in the studies by the school’s strategic location due to adolescents’ time in this context and the relationship and partnership represented by this space.

Shifting from the school territorial context to the social context, we identified crossings in the implementation of HP due to situations of vulnerability in the territory1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381.,1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942. in two of the studies analyzed. As an example, mention is made of the interference of trafficking in organizations in that context and violence and, consequently, the fear of teachers in developing actions that may generate conflicts and risks with this group1717 Pedroso RT, Hamann EM. Adequações do piloto do programa Unplugged#Tamojunto para promoção à saúde e prevenção de drogas em escolas brasileiras. Cien Saude Colet 2019; 24(2):371-381..

Difficulties related to strictness and difficulties in the operationalization of actions were also observed1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.,2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250.. The impossibility of paying particular attention to adolescents who demanded something more individualized after the interventions and difficulty accessing multimedia equipment1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103. were reported. The inflexible schedules to propose actions and attend all school classes and inadequacies regarding the local infrastructure were also mentioned as complicators in the implementation, which authors said hindered the development of more dynamic proposals, such as the “wheel” organization of adolescents1818 Lopes RNS, Takeshita IM, Freire AFS, Dias AAS. Extensão acadêmica multiprofissional: experiências na educação em saúde de jovens em ambiente escolar. Rev Univap 2019; 25(48):92-103.,2020 Cova F, Rincón P, Melipillán R. Evaluación de la eficacia de un programa preventivo para la depresión en adolescentes de sexo femenino. Terapia Psicol 2011; 29(2):245-250..

As the last thematic category raised, we identified a study that addresses PHC actions. This study pointed to the lack of actions developed at this level of health care, although health promotion actions are a priority agenda in PHC1919 Teixeira MR, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942..

Discussion

LA’s structures for financing and implementing programs are qualified by regional differences. Thus, the Latin American context is marked by coexisting public health systems that differ from each other, including the investment and valorization of primary care and actions in HP2323 Cortes FM, Coelho TCB, Sanabria CAP. Seguridade social na América Latina e financiamento da atenção primária de saúde. JMPHC 2019; 11(Supl. 1):e32s.,2424 Porto MFS, Pivetta F. Por uma promoção da Saúde Emancipatória em Territórios Urbanos Vulneráveis. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 207-229.. As a result, we can hypothesize that investments in scientific production on PHC and its HP actions accompany the meaning of health to local government bodies and how countries organize themselves politically to develop these actions, which could justify the concentration of scientific production in the three countries identified in this review.

In any case, the results of this study signal for the scarcity of academic productions focusing on HP among the adolescent population in LA. Five of the six studies identified are from the last decade, which indicates a possible scientific contemporaneity concerning this theme. Considering the global outlook, we could argue that, while the discussions on HP started in the 1970s, only the last World Conference on Health Promotion (2016)11 Buss PM. Uma introdução ao Conceito de Promoção da Sáude. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 19-42.,2525 Associação Brasileira de Saúde Coletiva (ABRASCO). 22ª Conferência Mundial de Promoção da Saúde [Internet]. 2016 [acessado 2020 jan 17]. Disponível em https://www.abrasco.org.br/site/noticias/saude-da-populacao/22a-conferencia-mundial-de-promocao-da-saude/13855/.
https://www.abrasco.org.br/site/noticias...
was held in a Latin American country. Thus, it appears that the field is still in its infancy and under construction, with possibly increasing participation and representation from LA countries.

Regarding the type of research adopted by the studies found, a predominance of productions with an experimental and quasi-experimental approach was identified, with an appreciation of the assessment processes of pre-established interventions by those who “apply” it, which is a traditional way to produce knowledge. In their discussions, the studies identified also presented conversations with European and North American references. None of the studies found used a participatory approach or conducted a survey of the demands of the target contexts in developing health promotion strategies. These factors have been debated as relevant in the development of actions of this type, which foster the active participation of the community and favor autonomous and singular constructions for certain contexts44 Freitas CM. A vigilância da Saúde para a Promoção da Saúde. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 145-164..

We also have the historical devaluation of adolescents’ knowledge, recent legal recognition, stigmatization, and exclusion from the knowledge construction process2626 Fernandes ADSA, Matsukura TS. Adolescentes inseridos em um CAPSi: alcances e limites deste dispositivo na saúde mental infantojuvenil. Temas Psicol 2016; 24(3):977-990.. Rossi et al.77 Rossi LM, Marcolino TQ, Speranza M, Cid MFB. Crise e saúde mental na adolescência: a história sob a ótica de quem vive. Cad Saude Publica 2019; 35(3):1-12. also point out the lack of scientific production in mental health “with” adolescents and not “about” this population, thus favoring a more practical, realistic, and possible construction of knowledge to effectively transform within the micropolitics of relationships, in this case, more meaningful and effective HP practices.

Regarding the location of the development of the research found, we observe that the school was the environment focused on five studies. Through its functioning mechanisms, the school represents a psychosocial perspective that can assist in social participation and citizenship. It is understood as a health-promoting space due to this potential to enable forms of existence in the world and new sociability possibilities2727 Tano BL, Hayashi MCPI. Saúde mental infantojuvenil e educação: análise bibliométrica da produção científica nacional e internacional (1968-2014). RECIIS 2015; 9(3):1-26..

Vieira et al.2828 Vieira MA, Estanislau GM, Bressan RF, Bordin IA. Saúde Mental na Escola. In: Estanislau G, Bressan R, editores. Saúde mental na escola. Porto Alegre: Artmed; 2014. p. 13-23. also define that schools are more accessible than health services and provide adolescents with less stigmatizing interventions. Also, the low demand for health services in this age group is highlighted1212 Fernandes ADSA. Cuidado em Saúde Mental Infantojuvenil na Atenção Básica à Saúde: práticas, desafios e perspectivas. 2015-2019 [tese]. São Carlos: Universidade Federal de São Carlos; 2019.. Therefore, developing actions in contexts that are already occupied and attended by adolescents can facilitate the preparation of actions targeting them, including HP actions.

In this sense, the partnership between the health and education sectors has shown a potential to be explored in HP actions with this age group, given the development of intersectoral practices, which transcend the school context only as a means of accessing the target population but also as a partner in developing shared and designed actions with and for this population. From this perspective, other care sectors can also be invited to compose insofar as the intersectoriality presents itself as a conceptual axis of HP to develop effective actions consistent with the practical realities2929 Rivera FJU, Artmann E. Promoção da Saúde e Planejamento Estratégico Situacional: intersetorialidade na busca de maior governabilidade. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 183- 206..

Addressing the possibilities of occupational therapy in mental health actions in the school context, Cid et al.30 claim that HP actions in this context are not clinical but intersectoral. They are triggered by the collaborative construction of care; that is, it is work developed with educators, family members, and the community to ensure school’s access and inclusion.

We did not find any study analyzing the art-culture sector as an enabler of prevention and promotion in mental health, considering the strategic aspect of the artistic-cultural field for mental health care and the “auspicious” nature of these initiatives3131 Amarante P, Freitas F, Nabuco ES, Pande MR. Da arteterapia nos serviços aos projetos culturais na cidade: a expansão dos projetos artístico-culturais da saúde mental no território. In: Amarante P, Nocan F, editores. Saúde Mental e Arte: Práticas, saberes e Debates. São Paulo: Zagadoni; 2012. p. 23-38.. Furthermore, in Latin American contexts, the relevance of the cultural aspect is highlighted as an essential pillar for developing the identity, creative processes, and resistance against social inequality. It is vital for developing and consolidating the independent identity of nations and well-being3232 Organização das Nações Unidas para a Educação, a Ciência e a Cultura (UNESCO). Declaración de México sobre las políticas culturales. conferencia mundial sobre las políticas culturales [Internet]. 1982 [acessado 2020 jan 17]. Disponível em: https://culturalrights.net/descargas/drets_culturals400.pdf.
https://culturalrights.net/descargas/dre...
. When aimed at youth, actions of this nature can empower both the individual and collective levels and foster reflections on being in the world3333 Silva CR, Cardinalli I, Silvestrini MS, Farias AZ, Prado ACSA, Ambrosio L, Oliveira MT, Paula BM. La terapia ocupacional y la cultura: miradas a la transformación social. Rev Chilena Terapia Ocupacional 2017; 17(1):105-113.. Scientific productions on children’s mental health and mental health actions through art and culture are incipient, especially when it comes to a more salutogenic perspective on health3434 Zarobe L, Bungay H. The role of arts activities in developing resilience and mental wellbeing in children and young people a rapid review of the literature. Perspect Public Health 2017;137(6):337-347..

Concerning the theoretical approaches selected as guiding interventions, it is crucial to highlight the predominant choice of preventive behavioral-cognitive studies found in this review. Selecting this subject-oriented perspective is in line with other studies developed in LA33 Borghi CMSO, Oliveira RM, Sevalho G. Determinação ou Determinantes Sociais da Saúde: Texto e Contexto na América Latina. Trab Educ Saúde 2018; 16(3):869-897.. When dealing specifically with the Latin American, African, and Asian contexts, we observe that countries of these continents, when trying to fit into the HP universal agendas, end up sticking to more normative, conservative, and bureaucratic aspects, including in the production of knowledge, since the proposed HP actions conducted by international organizations, or as in countries like Canada, do not delve into issues such as singularities of contexts in situations of vulnerability and injustice2424 Porto MFS, Pivetta F. Por uma promoção da Saúde Emancipatória em Territórios Urbanos Vulneráveis. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 207-229..

In this sense, a different perspective is identified in the Brazilian studies found that reported actions aimed at Health Education. If, on the one hand, health education is essential due to the informative content itself, the “informational-global”, on the other, it is necessary to trigger the expansion of this strategy, in line with what HP has developed in its most progressive current, that is, to promote a “communicational-local” to break with the “monocultures of knowledge”2424 Porto MFS, Pivetta F. Por uma promoção da Saúde Emancipatória em Territórios Urbanos Vulneráveis. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 207-229..

[...] the educational approach is fundamental in health promotion and disease prevention and cannot be tied to the modeling trends, strongly disseminated from the behavioral paradigm. The constructivist attitude seems to best contribute to people seeking and appropriate information that makes sense to them, mobilizing themselves authentically, and finding practical alternatives that allow them to overcome the situations that make them vulnerable.3535 Ayres JRCM, França Júnior I, Calazans GJ, Saletti Filho HC. O conceito de Vulnerabilidade e as práticas de Saúde: novas perspectivas e desafios. In: Czeresnia, D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: SciELO-Editora Fiocruz; 2009. p. 121-144.(p.140).

Hence, within health, the importance of the information tool to build health processes, using health education and cognitive-behavioral to this end, where health professionals would facilitate the transmission of specific knowledge. What is questioned is the limitation of these strategies when disregarding or underestimating the subjective aspects that can influence decision-making, besides the very behavioral shaping feature of risk in approaches like these, working in a distorted way as a moral technology and not exactly a health producer3636 Castiel LD, Dardet CA. Discursos sobre riscos e comportamentos Sadios Baseados em Evidências. In: Castiel LD, Dardet CA, editores. A saúde persecutória: os limites da responsabilidade. Rio de Janeiro: SciELO-Editora Fiocruz; 2007. p. 25-34..

A certain “similarity” was identified among the intervention strategies in the way these actions were developed, using conversation wheels, lectures, and workshops. By analyzing the papers’ results, using groups seems to be an exciting strategy for mental health promotion actions for adolescents. It is low cost, which, for LA countries, can be an important facilitator.

Another action facilitating strategy found by the studies was regarding investment in professional training of staff working with this age group, especially teachers who, in general, have good access to adolescents. It is important to emphasize that the training of educators on mental health processes is a low-cost strategy and can influence in the long run in reducing the stigmatizing aspects related to this audience3030 Cid MFB, Squassoni CE, Gasparini DA, Fernandes LHO. Saúde mental infantil e contexto escolar. Pro-Posi 2019; 30:e20170093..

Cid et al.3030 Cid MFB, Squassoni CE, Gasparini DA, Fernandes LHO. Saúde mental infantil e contexto escolar. Pro-Posi 2019; 30:e20170093. point out that there is little information available about teacher training on children’s mental health, generating insecurity in these professionals and difficulties in managing situations that appear related to young people with psychological distress. In this sense, intersectoral actions could contribute to exchanging knowledge, thus involving different actors and services to guide and ensure comprehensive care.

Among the challenges of the HP actions directed at the adolescent public, the identified studies reported structural weaknesses for operationalizing actions concerning vulnerabilities in the target contexts. On this subject, Souza et al.3737 Souza LB, Panúncio-Pinto MP, Fiorati RC. Crianças e adolescentes em vulnerabilidade social: bem-estar, saúde mental e participação em educação. Cad Bras Terapia Ocupacional 2019; 27(2):251-269. state that social inequality is the factor with the most significant impact on human health. Being in a context of vulnerability would mean limited access to material, symbolic, and cultural possibilities; that is, a population in this context lives on the sidelines of social possibilities, which directly impacts physical, cognitive, emotional, and occupational development.

Also, the lack of flexible schedules and a more democratic organization, including the participants in this process, represent a hindrance that could be solved with increasing communication and more structured intersectoral partnerships. Based on these results, we suggest that primary care should permanently consider collaborating with schools through continuing and structured actions within the school’s annual schedule.

According to Lancetti3838 Lancetti A. Clínica peripatética. São Paulo: Hucitec; 2006., the care complexity concept is reversed for mental health. The primary level would represent complexity while working with the family, support network, social actors, and territory. Therefore, thinking about HP actions in mental health in primary care traverses a complexity with an urgency to be discussed.

Conclusion

The results of this study identify a gap in the literature regarding adolescent HP production in LA. We could also observe the lack of proposals considering local demands and the participation of different actors, including adolescents, in defining the proposed strategies in dialogue with what has been produced globally on HP. We found no studies that considered the art-cultural sector for the production of these actions. The school was the main context of the actions, which signals the potential of this environment for developing effective HP strategies. We also point out that group-type interventions helping professionals dealing directly with adolescents can be a low-cost strategy for Latin American countries.

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Publication Dates

  • Publication in this collection
    02 July 2021
  • Date of issue
    July 2021

History

  • Received
    30 May 2020
  • Accepted
    31 Mar 2021
  • Published
    02 Apr 2021
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