Sociodemographic and health situation of teenage students

Rev Bras Enferm [Internet]. 2019;72(4):1007-12. http://dx.doi.org/10.1590/0034-7167-2018-0725 ABSTRACT Objective: To verify the association between sex (male and female) and sociodemographic, reproductive and sexual variables in teenagers and identify the highest rates of social and health issues among them. Method: This was a cross-sectional study conducted with 239 adolescents enrolled in a public school of Salvador, Bahia, Brazil, whose data were produced by applying a structured form processed in Stata. Results: The research indicated an association between females and higher education level (p = 0.02), living with both parents (p = 0.02) and a higher rate of mental, social and behavioral issues. Being a man was associated with sexual initiation (p = 0.00), which occurred before they turned 14 years old (p = 0.05). Conclusion: The study variables behave, depending on sex, with smaller or greater chances of experiencing harmful situations, this understanding being essential for subsidizing educational activities that promote the quality of life of teenagers. Descriptors: Teenager; Sex; Health; Education; Nursing in Public Health.


INTRODUCTION
In Brazil, approximately 11% of the population is between the ages of 10 and 19 years old, representing 21 million adolescents. Of these, 10,367,477 are girls and 10,716,158 are boys (1) . This phase constitutes a peculiar moment of human development. It is a period of anatomical, physiological and social changes related to the appearance of sexual characteristics, the discovery of sexuality, the structuring of personality, environmental adaptation and social integration. During it, individuals become vulnerable to situations that compromise their health and quality of life, and that may even lead them to death. These situations differ between the sexes. In general, girls are more exposed to sexual exploitation, while boys, to urban violence (1) , leading thus to a higher risk of homicide, traffic accidents and involvement in drug trafficking.
It is worth noting that urban violence, inserted in structural violence, is related to social inequities, affecting especially socioeconomically disadvantaged individuals, as shown by studies conducted in Peru, the United States and the Soviet Union (2)(3) . The implications of this kind of violence for teenagers are revealed by the difference between homicide rates in the general population (20/100 thousand) and among those aged between 15 and 19 years old (43.2/100 thousand) (1) .
Social inequalities are also elements of vulnerability among teenagers, in relation to the consumption of alcohol and drugs and domestic and school violence, according to an international research carried out in the African continent (4)(5) . These situations also manifest themselves differently between the sexes. Girls are more exposed to sexual forms of domestic violence, whereas boys are more exposed to physical aggression, school violence and the consumption of alcohol and other drugs (4,6) .
This difference between the sexes is not limited to the sphere of violence and other social issues. It has also been associated with other variables, such as those related to health (2,4,7) . To investigate these differences, it is important to question: what is the association between the sex of teenage students and their sociodemographic, sexual and reproductive variables, as well as social and health issues?

OBJECTIVE
To verify the association between the sex of teenagers (male and female) and their sociodemographic, sexual and reproductive variables, and identify the prevalence of social and health issues in this population.

Ethical aspects
Regarding the ethical issues concerning research involving human beings, the principles established by resolution 466/2012 were considered. All the teenagers who participated in the study signed the informed assent form, upon signing of the informed consent by their guardians in two ways. It is worth noting that this activity and the research that generated the data presented in this article are linked to the parent project titled "Universidade e escola pública: buscando estratégias para enfrentar os fatores que interferem no processo ensino/aprendizagem" [Public universities and schools: seeking strategies to address the factors that interfere with the educational/learning process]. This project was approved by the Research Ethics Committee of the Federal University of Bahia's School of Nursing (CEPEE/UFBA).

Study design, location and period
This was a cross-sectional study, carried out in a public school located in a peripheral district of the city of Salvador, Bahia, Brazil, with 239 teenagers.

Population or sample: inclusion and exclusion criteria
According to the sampling plan, which was stratified in relation to the number of students per class, a sample with 210 students would be enough, assuming a maximum sampling error equal to 2.35%. However, the sample consisted of 239 students, those who could not be contacted after two consecutive attempts having been excluded. As criteria for inclusion, the following were adopted: being enrolled at the school selected, attending academic activities in the data collection period and being between 10 and 19 years old.
Activities in the ACCS (Curricular Action in Community and in Society) called "Interdisciplinary and transdisciplinary approach to violence-related health issues" were developed alongside the participants. This component is part of the curricular structure of the Federal University of Bahia's undergraduate courses, which has the goal of training students in various areas of knowledge, based on the integration between education, research and extension, for the recognition of situations of violence as causes associated with health issues.

Study protocol
Data collection was conducted between October 2014 and January 2015, by applying a standardized form consisting of six domains, including: sociodemographic variables, sexual and reproductive health and use of alcohol and drugs. The instrument was tested and adjusted to meet the objectives proposed.
Sex (male and female) was adopted as the study's dependent variable. The independent variables were: sociodemographic variables (age, religion, ethnicity, education level, who they lived with, work); reproductive and sexual variables (sexual intercourse, age of first sexual intercourse, regular use of condom, pregnancy); and social and health issues (mental disorders, health issues, social and behavioral isolation and trouble at school).

Analysis of the results and statistics
The variables relating to social and health issues were grouped according to the Drug Use Screening Inventory (DUSI). This instrument was adapted and validated in Brazil to be used with teenagers by researchers at the Federal University of São Paulo (Unifesp). It consists of an initial table that discusses the frequency of consumption of psychoactive substances, followed by 149 questions divided into 10 domains, with the aim of quantifying the intensity of the teenagers' issues. This quantification by domain is estimated according to the sum of positive responses. For this manuscript, four domains were used: mental disorders (investigates anxiety, depression and antisocial behavior); health issues (investigates accidents and diseases); behavioral and social isolation (investigates social skills and interactions); trouble at school (investigates academic performance) (8) .
The data were stored in an Excel worksheet and subsequently transported to Stata version 12 to perform the analyses. An exploratory analysis was initially conducted to evaluate the variables' frequency distribution, with the purpose of characterizing the sample according to gender. To identify the association between the dependent and independent variables, Pearson's Chi-square Test (2) was used. Student's t-test was used to analyze the variables related to social and health issues.

RESULTS
Of the 239 students, most were male (53.97%), aged 14 years old or less (59.83%); they had no religion (53.14%); self-proclaimed themselves as black (76.57%); and were in the 6th or 7th grade of middle school (64.85%). In relation to who they lived with, 44.77% (n = 107) of the teenagers were inserted in a nuclear family, consisting of a father and a mother figure. The others belonged to families consisting of one parent, grandparents, uncles, aunts and others. It should be noted that, independently of family structure, nearly 5% of the teenagers reported working to financially support their family. Among these, there was a predominance of males.
Considering the stratification of these variables according to sex (Table 1), there was a statistically significant positive association between women and the following variables: higher education level (p = 0.02) and living with both parents (p = 0.02).
With regard to the sexual and reproductive aspects, the study revealed that 87 (36.40%) of the respondents had already had their first sexual experience, which occurred when they were younger than 14 years old for 82.76% of these. In relation to the use of condoms as a strategy for prevention of sexually transmitted infections (STIS) and unwanted pregnancy, 18.41% reported using them always or almost always. The rate of pregnant women or of men who had impregnated their partner was approximately 2%. However, no respondents declared having living children and/or being pregnant at the time of data collection.
The stratification of the variables according to sex (Table 2) showed a statistically significant association between men and having already had their first sexual experience (p = 0.00), before turning 14 years old (p = 0.05).
With regard to social and health issues (Table 3), identified by applying the DUSI, the study found, with statistical significance, that the highest rates of issues related to mental, physical and behavioral disorders and social isolation were associated with women. Therefore, women are more prone to develop issues in three of the four domains investigated. The only category in which the rates for men were higher, compared to women, was trouble at school; however, there was no statistical significance. This may be related to the prevalence of the use of alcohol and marijuana, which was around 25.5% and 2%, respectively.

DISCUSSION
In the sample studied, there was a predominance (54%) of men. An equivalent percentage was disclosed by Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira (INEP) in 2014, in which males represented 52% of students enrolled in primary education in schools of Bahia, Brazil (9) .
Other surveys conducted with teenage students from public schools in Pernambuco and Salvador, Brazil, confirmed the predominance of males and black individuals among public school students (6,10) . Specifically regarding the ethnicity variable, a research conducted in Victoria, Espírito Santo, Brazil, confirms the predominance of black individuals among teenagers enrolled in public schools, corresponding to 72%, similar to that found in the present study (76.57%). Still in relation to the aforementioned research, it should be noted that it was conducted in a school situated in a peripheral district of the municipality, which brings together students of the lower classes (11) , a context that is similar to the study in question.
The results indicate a significant percentage of teenagers who have to work to support their family, revealing the precariousness of their economic conditions. A study about teenage workers, carried out with 8,813 individuals at the national level, states that these are mostly male and black, residing in the the country's Northeastern region (12) . This configuration supports the relationship between black ethnicity and socioeconomic inequities, historically rooted in the violation of fundamental rights such as high-quality education.
A study conducted with secondary data from the National Research by Sample of Domiciles (PNAD) showed that there is a relationship between teenage workers and school performance, since the school absence rate for those who combine work and study is 3.6 times higher (12) . This evidence corroborates the findings of this study, since the teenagers in the sample, especially the boys, had school-related issues, such as: concentration difficulties, non-compliance with the tasks, absenteeism, low performance and failing classes.
Another factor that can also be associated with school issues is the prevalence of the consumption of alcohol (25.5%) and other drugs. A study conducted with teenage students from Maceió, Alagoas, Brazil, found a similar prevalence of alcohol consumption in the past month (23.3%), male teens having been those most often involved in consumption, leading to a greater number of school-related issues on their part (13) .
A trend analysis held in Barcelona, Spain, showed that teenagers tend to have low academic performance when they use drugs, or when they have friends who use them (14) . Thus, early contact with drugs is related to high failing and truancy rates (13)(14) , which can also justify the existing disproportion in this study between the number of students enrolled in the initial grades when compared to grades 8 and 9. Of the total sample, 64.85% were in the 6th or 7th grade of middle school. It should be noted that Law No. 13,106, of 17 March 2015, qualifies the sale or supply of alcohol to teenagers as a crime, a measure that changed the wording adopted by the Statute of the Child and Adolescent (ECA), which used to treat it as a misdemeanor (15) . Despite this reformulation, consumption is not inhibited, considering the high proportion of teenagers who drink alcohol.
With regard to religion, 53.14% reported not following any doctrine, men having been those who most often had some kind of religion. Differently from what was found in this study, a research indicates women to be more religious than men, and also ratifies the influence of religion in the choice of chastity (16) . This cultural influence could be related to the fact women are sexually initiated later in life, which may be associated with the preservation of "purity". Similarly to this study, a research carried out with 2,225 Spanish teenagers, aged between 12 and 17 years old and belonging to public and private schools, indicated that boys start having sexual relations earlier, with around 14 years of age (17) . A review of the literature highlights the social construction of masculinity, which influences the need to prove one's manhood through early sexual initiation (18) . Unlike boys, girls are not raised to enjoy sexual freedom.
The study also shows that being a girl is a factor associated with living with both parents, since this traditional family model tends to reproduce the gender ideology that girls must safeguard their sexuality. Thus, the presence of the parents and the teenagers' living environment have great influence on the age of sexual initiation (18) .
Still with regard to the exercise of sexuality, the rate of teenagers who had already been sexually initiated is alarming (36.40%). The percentage found is higher than the nationwide study conducted with 74,589 teenagers, of which 28.1% reported having already started the exercise of sexuality (19) . The results of both studies converge to the fact that the teenagers' sexual initiation was statistically different for both sexes. This was an expected result, seeing as this is an event where gender relations act inexorably, as already stated.
It should be noted that the quantity (18.41%) of teenagers who frequently used condoms was well below the proportion found in other studies. The prevalence found by a survey conducted in the United States with 134 students, which had the aim of investigating violence in romantic relationships and sexual risk behaviors among male teenagers, corresponded to 36% (20) . In Brazil, a study conducted throughout the national territory, with the purpose of describing the sexual behavior of Brazilian students, found that about 75% of the teenagers reported the use of condom in their last sexual intercourse (21) .
The lack of frequency of the use of condoms is associated with this population's vulnerability to the onset of STIS and/or unwanted pregnancies (22) . An international research indicates the lack of knowledge about STIS on the part of teenagers and young adults (23) . This supports the need for health education as a strategy to promote the knowledge and conscious decisionmaking of teenagers.
In relation to this, a research conducted with Spanish teenagers showed a high percentage of students who had used contraception methods in their first sexual intercourse, the condom having been the method of choice for most of them. The girls, differently from what was found in this study, composed the group who used prophylactic methods most often and who had the most access to information on this subject (17) .
Still concerning the sexual and reproductive variables, the prevalence of pregnancy found in this study was small compared to the findings of other studies (3,20) . It is important to highlight possible expositions to abortion, since almost 2% of the respondents made no mention of pregnancy, and none of them declared having living children. A research conducted in Maceió, Alagoas, Brazil, with 201 teenagers who had been subjected to incomplete abortion via uterine curettage, showed that the interruption occurred, for the most part, due to the pregnancy being unwanted (3) . Given this context, the need to address this issue is emphasized, since it may expose teenage girls to a situation of unsafe abortion, leading to the risk of death.
In addition to the findings presented, the study offers evidence that the rates of impairment of mental, physical and behavioral health were higher for the female teenage population. National and international studies show that women are more prone to mental illness than men (1,7) . A cross-sectional study that gathered 172 notifications of violence of teenagers aged from 12 to 14 years old in Campo Grande, Mato Grosso do Sul, Brazil, showed that this issue, which affects mostly women (94.8%), leads to predisposition for the appearance of some sort of mental disorder, such as post-traumatic stress disorder and behavioral disorder (24) . In this sense, the experience of violence, especially in a domestic context, can be related to the onset of mental illness in women. The greater propensity of the female teenagers in this study for the onset of these diseases, compared to men, justifies the fact of their social and behavioral isolation rates being higher, since these signals are associated with depressive disorders.
This also relates to the social role of women, which is centered on multiple responsibilities, such as domestic activities and, when it comes to teenagers, participation in their siblings' education, the blame for any flaws in this process being often placed on them. They are also less encouraged to develop activities outside the home environment and play sports, being thus more prone to the development of certain diseases, such as obesity (25) .
Given the above, we highlight the role of gender inequality in the onset of mental diseases in women. A research with the purpose of discussing the social determinants of violence in the health of vulnerable populations of Latin America indicates that the violence imposed on children or teenagers, practiced primarily and indiscriminately within the family by people whom the victim shares an emotional bond with, reproduces the oppression adults face in their daily lives (2) . Experiencing such harmful situation triggers the onset of illnesses in those involved, women being the main victims of this phenomenon (26) .
In this context, we report the need for strategies that intervene in the process of construction of gender inequality, which subjugates women in particular, since it interferes with their way of being and living, compromising their health and quality of life. We stress the importance of education as an opportunity of change of culture, the school being the most suited space for it.

Limitation of the study
Although the research identified significant associations between sex and the variables described, the study design did not allow us to establish a casualty relationship, showing the need for additional studies to fill this gap. Another limitation concerns regionality, because the fact the results refer to the specificities of teenage students from Bahia does not allow their generalization.

Contributions to the fields of nursing and health
by revealing a greater exposure of women to social and health issues, the scientific evidence found may contribute to the development of strategies with the purpose of reducing the vulnerability factors of women. To this end, the process of education and health with a focus on gender inequality is emphasized, health professionals − especially nurses, due to their more frequent opportunities for contact with teenagers − being potential agents of social transformation.

CONCLUSIONS
The study found that female teenagers had higher rates of health, behavioral, social and mental issues, while men had higher rates of trouble at school. The girls also had higher chances of living with both parents, and higher education level. Males, on the other hand, were associated with already having had their first sexual experience, before turning 14 years old.
It is therefore considered that the study variables behave, depending on sex, with smaller or greater chances of experiencing harmful situations, this understanding being essential for subsidizing educational activities that promote the quality of life of teenagers. In view of the predominance of black individuals in the population studied, it is necessary that such actions consider ethnic-racial issues and their relation with social and gender inequities.