Key words:

# Introduction

Much has been written and thought about adolescence and being a teenager in the last 25 years in Collective Health, through the multidisciplinary approach of demography, epidemiology, sociology, anthropology, psychology, and medicine, significantly enriching the understanding of this particular phase of life. One of the great turnabouts of scientific knowledge on the subject in this period was its recognition as a unique opportunity, which carries the gains obtained from early childhood and, in some cases, provides a second chance for the promotion and strengthening of well-being and health, which will affect adult life and the next generation11 The Lancet. Campaign on Child and Adolescent Health. Editorial. Lancet 2020; 395(10218):89..

Traditionally, adolescence is defined as the second decade of life, extending from 10 to 19 years. It is marked by a complex biopsychosocial growth and development process manifested through anatomical, physiological, psychological, and social transformations22 Word Health Organization (WHO). Young People´s Health - a Challenge for Society. Report of a WHO Study Group on Young People and Health for All. Geneva: WHO; 1986. (Technical Report Series 731). From the perspective of the Brazilian legislation, the Statute of Children and Adolescents (ECA) considers an adolescent as any individual aged between 12 and 18 years33 Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 14 jul.. However, it is reductionist to understand this period of life from an exclusively chronological criterion, as it is characterized by being a plural stage, where experiences and contexts, with their particularities, existing and activated resources differ among social groups, generating different concepts and understandings of what it means to be a teenager.

https://www.unicef.org/brazil/situacao-d...
. In education, in 2017, 12.8% adolescents aged 15-17 years were school dropouts; 28.2% had a High School two-year age-grade lag, with emphasis on the North (41.4%) and Northeast (36.2%) regions of the country. Data from the National Institute of Educational Studies and Research/Ministry of Education, in 2017 show that 6.1% dropped out of high school due to poverty, violence, and pregnancy, the main reasons for dropout. The Brazilian teenage pregnancy rate is high for Latin America, with 400 thousand cases/year55 Bouzas ICS, Cader AS, Leão L. Gravidez na adolescência: uma revisão sistemática do impacto da idade materna nas complicações clínicas, obstétricas e neonatais na primeira fase da adolescência. Adolesc Saúde 2014; 11(3):7-21.. The scenario of poverty, sexual and work exploitation, violence (psychological, physical, sexual, and neglect), alcohol and drug use, mental health problems, unprotected sex, and bullying are the harmful factors affecting this phase of life the most66 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar 2015. Rio de Janeiro: IBGE; 2016..

The 1990s are a milestone for public policies targeting adolescents, with the enactment of the Statute for Children and Adolescents33 Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 14 jul., which, together with the legal systems of the 1988 Federal Constitution and the Organic Health Laws, legitimized a new paradigm and understanding of adolescents in society. Adolescents were now social and autonomous subjects and should be included in the decisions of the State99 Leão LS. Saúde do adolescente: atenção integral no plano da utopia [tese]. Recife: Fiocruz; 2005.,1010 Kerbauy MTM. Políticas de Juventude: Políticas Públicas ou Políticas Governamentais? Estudos de Sociologia 2005; 19:193-203.. An increase in public policies targeting adolescents and young people was observed in the 1995-2002 period, but still with actions very much focused on crime from a perspective of crime prevention, trafficking, and violence risks99 Leão LS. Saúde do adolescente: atenção integral no plano da utopia [tese]. Recife: Fiocruz; 2005.,1111 Horta NC, Sena RR. Abordagem ao adolescente e ao jovem nas Políticas Públicas de saúde no Brasil: um estudo de revisão. Physis 2010; 20(2):475-495..

The Adolescent Health Program1212 Brasil. Ministério da Saúde (MS). Programa Saúde do Adolescente, Bases Programáticas. Brasília: MS; 1996. was a milestone for public policies in the country, culminating in the National Policy for Comprehensive Care for Adolescent and Youth Health1313 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Integral à Saúde do Adolescente e Jovem. Brasília: MS; 2006., which triggered specific orientations and guidelines for adolescents at the national level1414 Brasil. Ministério da Saúde (MS). Diretrizes Nacionais para atenção integral à saúde dos adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília: MS; 2010.,1515 Brasil. Ministério da Saúde (MS). Saúde integral de adolescentes e jovens: orientações para a organização de serviços de saúde. Brasília: Editora do Ministério da Saúde; 2007. and became the basis of the reflection on the current adolescent health care. This policy presupposed comprehensive care with priority for preventive activities, without prejudice to care services, and the organization of services for implementing these health practices, highlighting the importance of health promotion and the need to establish intersectoral and interdisciplinary work processes. The focus switched to health promotion and youth leadership, with the following priority issues: healthy growth and development, sexual and reproductive health, and reducing violence and accident-related morbimortality.

The historical course of the main themes, policies, and actions aimed at adolescents in Brazil underlie the central question that moves the paper, which is understanding the development of scientific knowledge on adolescence expressed in publications from 1996 to 2020 in the Journal Ciência & Saúde Coletiva (C&SC).

# Methods

This is an integrative review study whose method consists of a synthesis of the findings presented by the studies on a given theme, allowing an expanded analysis of the production of knowledge of the investigated theme, namely, adolescence, and the identification of existing gaps2020 Ercole FF, Melo LS, Alcoforado CLGC. Integrative review versus systematic review. Reme Rev Min Enferm 2014; 18(1):9-12..

A bibliographic search was carried out on the SciELO database (March 17, 2020) with the following string word search strategy: “Adolesc \$”, located in title, abstract, and keywords only in papers from Journal Ciência & Saúde Coletiva published in the last 25 years (1996-2020). The following exclusion criteria were defined: (1) not investigating, prioritizing, or targeting the adolescent age group. While aimed at adolescence, few papers were excluded because they focused on adults/institutions addressing the age group; (2) the type of material (“press release” and book review); and (3) other reasons. The papers were excluded following the consensus of at least two researchers.

A total of 969 scientific papers were identified, of which 484 were excluded due to duplication. The 485 publications’ abstracts were analyzed from an Excel spreadsheet, underpinning the results presented in Figure 1, where 53 works were excluded due to the adopted criteria. In the end, 432 publications were analyzed from the abstracts according to the following categories: age group (child+adolescent, adolescent, adolescent+adult); type of sample studied (population, school, and health services); study location; type of methodology (cross-sectional, cohort, qualitative, theoretical, bibliographic review, and document analysis); analysis by gender, skin color, and social stratum; risk and protection factor. The text was viewed in full to determine eligibility only in specific cases.

Figure 1
Flowchart of identification and selection of papers on adolescence published in Journal Ciência & Saúde Coletiva (1996-2020).

The proportion of the number of papers analyzed here (432) against the Journal’s total number of publications up to March 2020 (5,900) was considered for the analysis of the inclusion of adolescence vis-à-vis other themes addressed in the Journal and the characterization of the selected publications, besides the description of the categories according to the three eight-year temporal blocks: 1996-2003, 2004-2011 and 2012-2019, and 2020 was considered separately since only abstracts published in the first three months of the year were included.

We analyzed the most common themes addressed in the titles of the papers, which were categorized into recurrent and specific (cited more and less than five times over the years, respectively), creating a word cloud, that is, a digital chart for data qualitative analysis that shows the degree of frequency of words in a text. The more the word is used, the more striking is the representation of that word in the chart2121 De Paolo CA, Wilkinson K. Get your head into the clouds: Using word clouds for analyzing qualitative assessment data. TechTrends 2014; 58(3):38-44.. A total of 148 words recurring words from titles in Portuguese were included. Articles, pronouns, and conjunctions were excluded. The chart was prepared using the Tableau data visualization program2222 Murphy SA. How data visualization supports academic library assessment: Three examples from The Ohio State University Libraries using Tableau. College & Research Libraries News 2015; 76(9):482-486..

A qualitative analysis of the abstracts’ main issues was also carried out, with more than one theme per paper. The risk and protection factors addressed were pointed out. The entire analysis was carried out according to the three temporal blocks. The results are categorized as follows: (1) adolescents’ attributes; (2) family’s attributes; (3) peer relationships; (4) social scope; (5) health conditions and diseases; (6) accidents and violence; (7) professional and service activities; and (8) others.

# Results

## Papers on adolescence in the Journal Ciência & Saúde Coletiva (C&SC)

The Journal C&SC started to be published in 1996 with one issue per year, gradually increasing until it became monthly in 2011. Of the 432 selected works, 7.3% of the papers published by the Journal during the 25 years targeted the theme. Although the first study focusing on the topic of adolescents was only published in 1999, a growing increase in the number of publications has been observed over the years (Figure 2). The Journal published 367 papers in the first period (1996-2003), including all topics and 18 on adolescents (4.9%); 2,109 papers in the second period (2004-2011), 136 of which were on adolescents (6.2%); 3,312 papers in the third period (2012-2019), of which 271 were on adolescents (8.2%). It appears that, in the last period, the absolute number of papers on the theme is 15 times greater than in the first, and a proportional increase, evidencing the growing interest in the theme. This elevating trend is upheld in 2020 since seven papers on adolescents have been published in the three issues of the Journal in the first three months of the year.

Figure 2
Absolute number of papers aimed at the adolescent population published per year and per period in the Journal Ciência & Saúde Coletiva, 1996-2019*.

## Characterization of publications

Most of the 432 studies analyzed are exclusively for the adolescent population (68%). A smaller proportion brought the theme in a child and adolescent approach (22%), and only a small number also included adults (2%). In the analysis by period, the number of works focusing exclusively on adolescence has increased over the years, from 55% in the first period to 72% in the third. Conversely, those that included children and adolescents decreased from 44% in the first period to 16% in the second, suggesting an increase in the projection of studies focused on adolescence’s particularities as a specific field.

Most of the studies were carried out with samples of adolescents in the school environment (28%), followed by hospital or health services (19%). Jobs targeting the general population (12%) and young offenders (3%) were also mentioned to a lesser extent. An increase in the number of studies with adolescents in schools from the first period (17%) to the third period (29%) was observed. A decrease from the first period (11%) to the third (1%) was noted regarding adolescent offenders. In general, most of the sample is made up of Brazilian adolescents. Among the selected abstracts, 4% are from studies involving international populations. The countries cited were Mexico (the most frequent), Argentina, the United States, Portugal, Cape Verde, Chile, Spain, and Portugal. Among all the studies carried out in Brazil, 7% show data with representativeness from all over the national territory.

As for the methodological design, more than half of the papers on adolescents are quantitative (55.8%), emphasizing epidemiological surveys (39.3%); followed by qualitative studies (17.3%), bibliographic review (10.1%), and to a lesser extent, the eminently descriptive (based on secondary data), theoretical, quantitative-qualitative, scale validation, intervention, and study case methods.

An increased number of quantitative papers was published during the three periods (1996-2003, 2004-2011, and 2012-2019): 17% in the first period, 50% in the second, and 60% in the third, unlike qualitative studies, with slight variation over the periods, 11%, 24%, and 14%, respectively. The number of studies mentioning the approach of quantitative and qualitative methods on the theme of adolescence has decreased over time by 17%, 3%, and 2%, respectively.

Almost half of the abstracts had analyses by gender, but few were dedicated to studying in-depth the particularities of a single gender. When this specificity occurred, females prevailed. The analysis by the adolescents’ skin color is even more incipient (3% of the abstracts show this appreciation). The reference to the LGBTI+ population appeared in less than 1% of adolescents’ studies, only after 2004. Concerning social strata, approximately 15% of studies reported this analysis.

When analyzing the titles of publications, the ten words that appear most often in decreasing order are adolescents, health, Brazil, children, factors, schoolchildren, violence, study, associated, and Brazilians. Among the words with lower repetitions are care, men, indicators, mothers, overweight, reproductive, dental, and disorders (Figure 3). The words that stand out in the 1996-2003 period are health, adolescents, children, and prevention. In the second period (2004-2012), the first 10 most frequent words are adolescents, health, children, violence, school, Brazil, study, social, and factors. In the third period (2013-2019), the first ten most cited words are adolescents, health, Brazil, factors, schoolchildren, associated, children, study, and violence. The words adolescents, health, violence, and children were recurrent in the three periods. As can be seen in the word cloud (Figure 3), the titles’ analysis shows that the themes or context most frequently cited in papers about adolescents over C&SC’s 25 years are related to health, violence, children, and schoolchildren, emphasizing the Brazilian context. Larger words have more repetitions in headings, and smaller words have a lower frequency.

Figure 3
Most frequent words in the titles of the 432 publications.

Regarding studies on violence, it can be seen that 61% of the papers published on adolescents in the 1996-2003 period brought up this topic (11 works), which increased significantly (sevenfold) in the 2012-2020 period (77 works).

In another analysis focused on the themes addressed in the publications’ abstracts, a progressive variability of words is observed over time, pointing to greater thematic diversity and in-depth analysis of adolescent issues. The predominance and variety of terms in the 2012-2020 period are evident, the little variation observed in the 1996-2003 period, and the intermediate level observed in the 2003-2011 period. Chart 1 shows the main categories found. It should be noted that a paper may be included in more than one category in the analysis.

Chart 1
Main themes addressed in the analyzed publications*.

The following themes especially stand out among all the most enunciated: (1) food/nutrition, physical activity, and pregnancy, among the individual attributes; (2) socioeconomic standard/income and quality of life, from the perspective of social scope; (3) drug use, health/oral disease, and obesity/overweight in the health conditions category; (4) and several types of violence. Themes related to family attributes, peer relationships, professional/health services activities, and other institutions are the least mentioned (Chart 1).

Eight thematic issues on the theme of adolescence were published throughout Journal C&SC’s existence, which corresponds to 4.5% of the total of 176 issues of the Journal until March 2020. Each volume contains editorials and specific papers on the topic addressed. The choice of thematic numbers reflects the demand for publications that reach the Journal and is also a way of inducing reflections relevant to the field. Three thematic numbers were jointly organized by Brazilian, Canadian, and Portuguese researchers, evidencing the search for internationalized research (v.12, n.5, 2007; v.19, n.3, 2014; v.23, n.9, 2018).

The data presented in Chart 2 are restricted to those underpinning the Journal’s core on the theme of adolescence, excluding those of free themes published at the end of each issue. All productions presented in the thematic numbers are from the late 2000s onwards. Two other thematic numbers address the age range from the school’s perspective and are not detailed, which addresses the National School Health Survey (PeNSE) (v.15, n.0, S2, 2010) and the National School Food Program: limits and possibilities for healthy eating (v.18, n.4, 2013).

Chart 2
Thematic issues of the Journal C&SC on adolescence.

The themes diversify between 2007 and 2019, adapting to public health’s multidisciplinary nature, a strong point of the investigated journal. In 2007, the editorial’s priority was the vital interaction between the social environment, family, and individuals, the relevance of physical and emotional integrity, and the action of family and services in children and adolescent care. The theme of quality of life has been present as of this year and will regularly remain in later publications.

The theme of resilience appears in the editorial, although it was still in the initial phase of its incorporation in the Brazilian scenario. In 2009, the editorial focused on the mental health of children and adolescents. It criticizes the poorly structured and disseminated mental health policies for the age group and substandard professional training. The editors require the implementation of a community-based care network and improvements in the mental health care model for the age group. Violence and adverse events that affect mental health are pointed out.

In 2011, priority was given to professionals working with children and adolescents, seeking to articulate different methodological approaches, knowledge, and regions of the country. The development from preterm birth to adolescence was sought, and health education and the evaluation of health care and humanization programs stand out. The interaction between biological and environmental aspects was reinforced. Health and living conditions were analyzed in the 2014 editorial, comparing similar and different cultural contexts inside and outside the country, pointing out the relevance of policies, programs, and projects on protecting and preventing diseases and conditions for impoverished people.

Two issues were launched in 2015. The first (v.20, n.1) highlights the social inequalities and the culture of violence that are a risk for delinquency, assault, deaths, and institutionalization of children and adolescents. Quality of life is the central element. Violence and psychosocial risks, homicides, and suicides are crucial issues. The second issue published this year is the first exclusively aimed at adolescents (v20, n.11), pointing out relevant issues at the physical and emotional level, such as physical development, food, oral health, quality of life, school life, professionalization, social inequality, mental health problems (depression, bullying, and drug abuse), violence, homelessness, work exploitation, sexually transmitted diseases, and unplanned pregnancies. The subject of masculinity is unprecedently addressed in the editorial. Prevention and health promotion actions and youth participation and leadership aiming at health self-care are recommended. The editors consider that the “health system must see the removal of adolescence from the figure of social problems’ scapegoat as one of its missions”2323 Assis SG, Avanci JQ, Duarte C. Adolescência e saúde coletiva: entre o risco e o protagonismo juvenil. Cien Saude Colet 2015; 20(11):3296..

In 2018, a volume was entirely aimed at adolescence and youth, addressing macro-structural issues such as social disruption, politics and corruption, freedom of choice as an offense, civil and police violence as a solution to social problems, and meritocracy among unequal as a market salvationist panacea. Adolescents and young people are seen as leaders of social, cultural, political, and economic processes, based on national and international reality. The socio-educational and prison systems, the sustainable development goals (SDGs) in the 2030 Agenda, health policies, and violence are addressed, among other topics. The political situation in the late 2010s is criticized for the lack of public resources for social policies, which are scarce in the name of fiscal adjustments. In this scenario, “the drastic restriction of possible life horizons is the challenge that young people will not be able to overcome without public support”2424 Moreira MR, Ribeiro JM, Motta JIJ, Hartz Z. Adolescência e Juventude: políticas públicas e condições de vida e saúde em perspectiva internacional. Cien Saude Colet 2018, 23(9):2782.. The editors demand a more massive public investment in childhood and adolescence.

The 2019 Journal covers children and adolescents from the perspective of public policies and commitments to the SDG’s 2030 Agenda, seen as a historic opportunity to improve children’s and adolescents’ rights and well-being, especially the most disadvantaged, ensuring a healthy world for girls and boys. The vulnerabilities of these stages of development originate from the broader social environment, from households and communities directly impacted by austerity policies and fiscal authority measures. Issues such as high morbidity and mortality due to assault, legal age for criminal responsibility, the statute of disarmament, extreme poverty, hunger, racism must be addressed. Providing quality health and education, promoting peaceful and inclusive societies, are considered agendas of commitments to the present and the future.

# Discussion

The results show a significant growth of studies on adolescence in the C&SC in the last 25 years, which reflects its robust inclusion and rise in the field of public health, a fifteen-fold increase in recent years compared to the beginning of the Journal’s publication. Interestingly, while an increase in the number of studies explicitly addressing adolescence has been noted, the number of studies, including children and adolescents, inversely declined, which reveals investment focused on adolescence’s specifics, as found in international surveys2525 Levesque RJR. Reviews in Research on Adolescence: Genres, Trends, and Challenges. Adolescent Research Review 2016; 1(1):3-13..

The analysis of the trend of publications of themes in the period is aligned with national and international bibliography, prioritizing themes such as food/obesity/physical activity, drug use, and violence, emphasizing risk aspects2525 Levesque RJR. Reviews in Research on Adolescence: Genres, Trends, and Challenges. Adolescent Research Review 2016; 1(1):3-13.. The perspective of Brazilian social inequality is also highlighted through socioeconomic standard/income and quality of life analyses. Noteworthy is the interdisciplinary effort of oral health authors in publishing various texts from the perspective of public health. A low frequency of reflections on adolescent offenders, sexuality, LGBTI+ population, and racial and ethnic issues is observed. A topic that is also rarely addressed is the relationship between globalization and virtual social networks in adolescents’ lifestyle, behavior, values, and health.

Despite the negligible representativeness of abstracts on adolescent offenders, this was one of the focuses of C&SC’s 2018 editorial. The health of children and adolescents deprived of their liberty was the subject of an editorial in The Lancet Child and Adolescent Health2626 The Lancet Child & adolescent health. Youth without freedom. Lancet Child Adolesc Health 2020; 4(1):1. journal, which highlighted the relevance of the global study on children deprived of their liberty conducted by the United Nations2727 Nowak M. The United Nations global study on children deprived of liberty. Seventy-fourth session. Promotion and protection of the rights of children. New York: UN; 2019.. Another example of relevant and emerging themes is ‘masculinity’, which, while found in only three abstracts analyzed, one of them in the 2015 editorial, reinforces the importance of this issue for public health.

Concerning the method, a significant increase in research with quantitative methods and a decline in papers with methodological triangulation is observed. Public health has predominantly followed a positivist approach based on epidemiology. However, the relevance of qualitative studies is highlighted by international journals, which also point to the difficulty in the publication of these studies in high impact medical and health journals2828 Braun V, Clarke V. Novel insights into patients' life-worlds: the value of qualitative research. Lancet Psychiatry 2019; 6(9):720-721.. Quantitative and qualitative approaches are combined but less commonly published. International authors reinforce that using this type of research strategy is essential to understanding complex phenomena and point to an increase in interest in this approach involving different disciplines2929 Ridde V, Sardan JPO. A mixed methods contribution to the study of health public policies: complementarities and difficulties. BMC Health Services Research 2015; 15(S3):S7.. Qualitative studies have been in place since the onset of the C&SC publication and continue to this today, bringing essential contributions to the field of public health and showing the Journal’s commitment to comprehensive approaches. Concerning the combination of qualitative and quantitative approaches, the Journal C&SC has a higher volume of papers in the first period, reducing the number of publications in recent years. One may ask whether the number of abstracts reflects the actual amount of research combining different research methods, or whether researchers divide the papers into qualitative and quantitative for publication.

A concern that has been highlighted recently in the C&SC is the reflection on the need to adopt public policies to combat and overcome the country’s geographic, social, and ethnic inequalities and celebrate the richness of the diversity of the adolescent phase. On this issue, the Editorial of the Lancet Magazine11 The Lancet. Campaign on Child and Adolescent Health. Editorial. Lancet 2020; 395(10218):89. warns that the economic, political, commercial, and environmental aspects, so essential for the health of children and adolescents, have changed dramatically, introducing emergency themes such as climate problems, migration, growing conflicts, policies and agendas that distance themselves from the provision of social safety networks and poverty reduction, continued commercial exploitation of children and young people, which lead to unhealthy diets and exposure to alcohol and tobacco products. Lancet believes that, as of 2020, children and adolescents must receive particular attention to ensure a sustainable and healthy future for everyone11 The Lancet. Campaign on Child and Adolescent Health. Editorial. Lancet 2020; 395(10218):89.. This challenge arises not only for Journal Ciência & Saúde Coletiva, the target of the analyses in this paper, but the Brazilian society that must advance towards systemic, intricate knowledge and that turns to aspects of health promotion of adolescents, following the existing national norms and laws, but still in the implementation phase.

The analyses presented in this chapter were based on the themes collected in the papers’ abstracts and titles, which hinders understanding the paper as a whole. Some themes and analyses relevant to public health may have been presented in the paper’s body and not in the abstract. These limitations refer to the reduced space for writing the abstract and the information it contains.

# Acknowledgments

We are grateful to FAPERJ Post-doctoral Nota 10 program for the grant to F Serpeloni.

# References

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# Publication Dates

• Publication in this collection
04 Dec 2020
• Date of issue
Dec 2020