Contexts of vulnerabilities experienced by adolescents: challenges to public policies

Objectives: to understand the context of vulnerability experienced by adolescents from the perspective of health professionals from the Family Health Strategy. Methods: a descriptive-exploratory qualitative study developed with 80 Family Health Strategy professionals in the Midwest region of Brazil. Data collection was developed from July to September 2018 through a focus group, and submitted to Thematic Analysis. Results: it was understood that the vulnerability experienced by adolescents is not an exposure to something isolated, but is linked to risk and protection factors, socioeconomic and cultural contexts, public and health policies. Final Considerations: there are still gaps in public policies for this population, which impacts on the access and development of promotion actions by health professionals.


INTRODUCTION
Adolescence is a phase of the life cycle characterized by the transition from childhood to adulthood, in which young people undergo physical, sexual and cognitive changes (1)(2) . These occur in a complex context of family, friend groups, society, political and economic contexts, and cultural influences that have implications for current and future health (3) . In addition, young people faced pressures related to sexuality, personal and group identity, value formulation, lifestyles, career plans, personal relationships and new social roles (3) .
These simultaneous, individual transformations, plus external factors such as the environment, family, socioeconomic and cultural context, access to different public and social support services and work organization can lead this public to vulnerable reality (2) . As a consequence, can contribute to physical and mental health problems, the occurrence of unplanned early pregnancy, illness, psychological distress, poor school performance, unemployment, relationship difficulties, drug use, malnutrition, obesity, violence, among others (4) .
In this context, an Indian study found that approximately 10 to 30% of young people suffer from conditions that affect their health. Especially due to the vulnerability of this phase, such as nutritional disorders, tobacco use, harmful alcohol use, use of other substances, high-risk sexual behavior, stress, mental disorders, injuries from external causes (traffic accident, suicides, different types), which needs attention when planning public policies (5) . In turn, a study conducted in the city of Caruaru, state of Pernambuco found that domestic violence and weakened affective relationships were the most identified contexts of vulnerability (6) .
According to the WHO report (7) on adolescent population health, the leading causes of death among adolescents worldwide are injuries due to motor vehicle accidents, AIDS, suicide, infectious respiratory diseases and interpersonal violence. However, the data showed improvement in health-related behaviors, such as condom use in sexual intercourse and decreased smoking.
Vulnerability can be understood as a condition inherent to the human being, which is characterized as the state of being in danger or exposed to potential damage due to a fragility linked to individual existence (8) . However, vulnerable human beings may possess or be supported to build the capacities needed to change their condition. It is based on this last statement that vulnerability is not just a natural condition that does not allow contestation, since this condition is associated with individual and also collective situations and contexts (9) .
When we identify vulnerabilities, we can better understand the event and, therefore, propose better and more sensitive strategies and actions for health promotion and prevention. This enhances the possibilities of reality transformation, better and more effective public policies for adolescent care.
Therefore, adolescence is seen as an important moment of investment and intervention in health (7) . According to the literature on the subject, although there was an increase in investments in public policies that directly impacted the health promotion and prevention of this population, mainly related to the reduction of tobacco use, other issues still need to be addressed such as mental health, nutrition and lifestyles (10) . WHO (7) proposes some action strategies, including strengthening adolescent health advocacy and incorporating a focus on adolescents in all health policies, strategies and programs, supporting interventions that go beyond the adolescent, promoting universal health coverage for this population, intersectoral integration of adolescent care services and financing, and development of priority research. Thus, adolescents belong to a population that requires special attention from public policies, so that they fully meet their specificities and needs. Therefore, they should emphasize coping actions in the face of vulnerability situations (2) .
In this regard, there is the service network of the Brazilian Unified Health System (SUS -Sistema Único de Saúde), especially in Primary Health Care (PHC), a privileged space for the identification, reception, care, care and protection of vulnerable adolescents (11) . However, it is observed that adolescent health care is permeated by challenges, especially due to the reduced spontaneous demand by healthy young people for health services. Moreover, the transfer of adolescents from pediatric services to adults also contributes to the care "gap" for this population (12) .
Thus, understanding the context of vulnerability experienced by adolescents and their families in the territory from the perspectives of FHS professionals can enable better access to this population, as well as the deepening of knowledge to support the promotion of changes and improvement of health care in the territory.

OBJECTIVES
To understand the context of vulnerability experienced by adolescents from the perspective of Family Health Strategy professionals.

Ethical aspects
After authorization by the Health Office, the study was approved by the Standing Research Ethics Committee of Universidade Federal do Mato Grosso do Sul according to Resolution 466/12. All study participants were informed about the objectives, data collection and analysis procedure, and signed the Informed Consent Form. To ensure confidentiality and anonymity, the members' names were expressed by the letter U, indicating unity, followed by the Arabic number referring to the order in which the focus groups were performed (e.g., U1).

Theoretical-methodological framework
Data analysis was based on the conceptual representation of vulnerability (13) , which defines its analysis based on three interconnected individual, social and programmatic/institutional dimensions. Thus, the concept of vulnerability can be understood as the exposure of the individual to various factors and/or events, in which these dimensions are interrelated, which allows multidimensional analyzes of the influence on their health, not only in illness but in mental, psychological, social and physical states. In turn, for systematization and data processing, Thematic Analysis was used (14) .

Type of study
This is a descriptive-exploratory study of qualitative nature. Checklist, Consolidated Criteria for Reporting Qualitative Research (COREQ).

Methodological procedures
After authorization granted by the Department of Health, all Family Health Strategy (FHS) services were visited and all health professionals and managers who met the inclusion criteria were invited to participate in the study. Each FHS service independently structured the group of professionals who would participate in the study, without interference from the researchers.

Study setting
The study was conducted in eight FHS services in a health region in the state capital of Mato Grosso do Sul. This health sanitary region is composed of a total of 14 FHS services, covering a territory that contains a large number of adolescents and vulnerable situations, mainly economic and social.

Data source
The study informants were managers and health professionals who met the following criteria: being a health professional (nurse, nursing technician, Community Health Agents (CHA) or endemic, doctors, psychologists, social workers and oral health professionals) or FHS service manager, and have been working at the study site for at least one month. As exclusion criteria, it was established to be away or on vacation at the time of data collection. In all participating health services, professionals were refused to participate in the study because they were not comfortable talking about the topic in groups or did not find their participation relevant.

Collection and organization of data
Data were collected from July to September 2018, through focus group, which is a method that uses the group interview strategy. It was generated from an initial and auxiliary question that encourages participants to discuss and dialogue, in order to gather knowledge, ideas and hypothesis on the research subject (15) .
A single focus group was held with the group of professionals elected by each FHS service, in their own work environment, on a previously scheduled day, during office hours, in a private location, recorded on digital audio media, and average duration of one hour each. The focus groups were conducted by a team of four trained researchers who had no relationship with the service, three nurses and one undergraduate nursing student. Each focus group was attended by at least three of these researchers.
A semi-structured questionnaire developed by the researchers was used to guide the study. The guiding question was: "We would like, from your experience in the territory assisted by your teams, to indicate and describe the situations of vulnerability that adolescents and their families experience, which directly and indirectly affect their mental or physical health". Field notes were made by one of the researchers during focus groups to complement the collected data. Focus group achievements occurred until additional information ceased to emerge and data became repetitive, and the research objective had already been achieved.

Data analysis
All interviews transcribed in full were submitted to Thematic Analysis by two independent researchers, following the steps of pre-analysis, material exploration, data treatment and inference of results (14) . In the pre-analysis, a thorough and exhaustive reading of the printed content was performed. Afterwards, messages were coded by means of color, and then the core of meaning was learned: vulnerability as a multicausal phenomenon. Subsequently, the codes were grouped according to similarities, emerging three thematic categories: "Territorial adversities and socioeconomic context", "Weaknesses of resources and support devices" and "Accessibility to health services".
The age range of the participants ranged from 23 years to over 60 years, with working time in FHS service from at least one month to 17 years. Most had higher education, followed by high school, technical and elementary education.
Given the analysis of the collected data, vulnerability can be understood as a phenomenon that involves plurality in adolescence. In this study, the results will discuss the phenomenon of vulnerability related to individual, social and programmatic variables, encompassing social structure, socioeconomic and cultural contexts, interpersonal relations, public and health policies.

Territorial adversities and socioeconomic context
The organization of the territory and the socioeconomic and cultural context were indicated by professionals as important elements in the emergence of situations of vulnerability and its consequences. In their reports, context and situations of poverty experienced by adolescents were mentioned as one of the main factors that can reinforce the condition of vulnerability experienced by them. They associated poverty not only with the individual purchasing power of each family, but also with access to basic life needs such as sanitation, housing conditions, supply of electricity, among others. "normal". Adolescents and other family members often experience these situations as scenarios of poverty, misery, limited access to common goods and services from birth. Professionals pointed out that the ease of access to alcohol and drugs may be related to the presence of trafficking sites in the territory, which also facilitates the insertion in trafficking and crime. Another factor related to the use of alcohol and other drugs is the consumption within their own family, being emphasized by the participants as a factor that exposes them to the vulnerability or use of these substances.
There is even a case that was reported, a child at the time of our area, was already a teenager, the family had this issue of alcohol in the family, violence, the father spanks the mother. (U2) The children's father is a drug user; the mother went out with him [father] at dawn. And that the children would wake up crying two hours in the morning looking for their parents. (U5) In this sense, professionals pointed out that the absence of effective measures, both public and local, to manage and meet the demands related to the use of alcohol and other drugs, increase the consequences of mental illness of adolescents.

Weaknesses of resources and support devices
Participants highlighted the absence or fragility of support networks to offer actions, activities and projects aimed at adolescents, especially in the counter-shift, focusing on health promotion, which seek to minimize exposure to vulnerability and its harms.
In this sense, the lack of activities to occupy time and continuous education of the adolescent, whether within the family, school or social environment, was indicated as an important factor for them to experience situations that reinforce the condition of vulnerability in the context in which they are inserted. They also highlighted the lack of investments in sound public policies that involve education, health, culture and social assistance, which can develop continuous support networks and devices that provide a space for better development of adolescents. Thus, many times, when the family or adolescent seek the health unit, a health problem has already been established.
The school and investment in projects related to it were described as an important device for adolescent care and support, since, from the perspective of the participants, the school has a fundamental role in the formation, not only in terms of knowledge and professional qualification, but also as a citizen, generating mechanisms to protect them.
These kids would be in school studying, eating better, might be learning something that could really help them and help us as well. I see like this; the State has no interest so that situations like this can be avoided. (U5) And just as it was put here, this education has to have access to all. Sometimes you go to the house, get there, many can't go to the Early Childhood Center. "Ah, but mom stays all day at home." But is it better for this child to have access to education, or a full-time school, than to stay home watching scenes that will bring a lot of trauma to this child and future teenager? So really get access. The mother is at home all day, yes, but it is her or the child's right to participate in a project in the afternoon or in the morning and everyone has access to these projects. (U2)

Accessibility to health services
The relationship of health services with adolescents and their families was also discussed by participants as a factor that interferes with the exposure of this population to vulnerable conditions. It is noticed in the reports that, during the development and growth of the child to the adolescence phase, the frequency of consultations and trips to the health unit is decreasing. This is mainly when the recommended age range of the national vaccination program becomes more widely spaced, so that they rarely go to health facilities. This fact influences the interaction with the health team, and is referred to as one of the main obstacles in access and communication with adolescents. Likewise, the inefficiency of public policies aimed at this population and its needs were also indicated as an obstacle to access, which directly impacts the adolescent's bond with the FHS. Above all, home visits of CHAs were considered by them to be insufficient and fast, justified by the high demand for work that precludes greater attention to this population.
Only I see that the state has to be a continuous job. We go once in the house, once a month. Sometimes it may seem little to us, but a month goes by quickly and soon we are here again to review this case. Only for them it's a long time. So if we tell recently, and come back in a month, a lot can happen during that month. But for us who are here, dedicating ourselves to an exclusive family, dedicating ourselves to an exclusive family, it doesn't matter, according to the possibility of work we have. (U2) Another factor informed by the interviewees was the unpreparedness of health professionals to deal with the possible situations of vulnerability that adolescents and their families experience. It is difficult to know how to act in these situations, referring to their actions as temporary and non-resolving measures.

DISCUSSION
From the analysis of the results, it is observed that the way the territory is organized, the different socioeconomic and cultural contexts, the fragility of resources and support devices, the access to health services and the organization of public policies of Contexts of vulnerabilities experienced by adolescents: challenges to public policies Gasparetto AS, Bonfim TA, Teston EF, Marcheti PM, Galera SAF, Giacon-Arruda BCC.
influence the exposure. of adolescents to social and programmatic vulnerability and, consequently, in the organization of care for this public. Thus, the results obtained in this study corroborate the multidetermination of vulnerability, being related not only to the lack or precarious access to financial income, but also to the weaknesses of affective-relational bonds and unequal access to public goods and services (9,13) . Therefore, the influence of the territory and the socioeconomic circumstance were indicated in the present study as contexts in which there is a strong relationship of social and programmatic vulnerability. It is mainly associated with poverty characterized by low economic power, poor access to basic living conditions and educational, social and health care. These results corroborate the study that pointed out that the health deficits of adolescents related to the experience of vulnerability situations are associated with the economic, political and cultural relations that shape the social structure. Thus, a better financial situation can subsidize essential resources to overcome factors extrinsic to the vulnerability experienced, such as access to education, quality housing, adequate food, among others (16) .
Associated with the poverty scenario, the presence of trafficking sites in the territory has been described as a facilitator in the insertion of adolescents to alcohol and drug use, and also in the inclination of adolescents and their families to trafficking and criminality. In Brazil, a survey indicated that the main vulnerabilities that affect children and adolescents are problems related to alcoholism and conflicts between couples, making children witness to aggression and all forms of violence (2) . With regard to the health sector, especially in the performance of professionals who make up the FHS teams, the possibility of early identification of the main social and programmatic vulnerability factors stands out. They operate in places with limited coverage area and are linked to the population.
Moreover, the individual dimension, such as the personality and behavior of adolescents, can make them more vulnerable to involvement with crime, early trafficking and theft (16) . Exposure to violence leads to poorly adapted cognitive coping patterns, which in turn lead to psychological and behavioral problems (17) . In this sense, the participants of this research highlighted that there is a lack of public policies and effective measures to deal with the issues of alcohol and drug use, crime and trafficking.
Given the scenario of poverty and the use of alcohol and drugs, the main consequences highlighted by the participants of this study were early and consecutive pregnancies, prostitution, domestic violence and STI illness. At the beginning of the adolescent's sexual life, it is common to find unprotected sexual practices, supported by insufficient communication and information, also due to myths and taboos that permeate this theme (18) .
In this regard, we see the need to strengthen integrated actions among adolescents, families and professionals, with a view to developing joint actions aimed at the early identification of.
In this sense, research shows that the presence of social projects involving sports and other body practices has contributed to the increase of the social bond and the socialization of adolescents in the community. This process can minimize the vulnerability to which the adolescent is subjected, protecting them from situations of violence while not in school (19)(20) .
Although in the context of public policies there are already intersectoral actions aimed at health promotion and disease prevention for this population, such as the Health at School Program (PSE -Programa Saúde na Escola), there is still a discontinuity of the proposed actions, which impacts directly in the effectiveness of these actions. One of the benefits of the partnership between the health and education sectors is the fundamental role that the school plays in the education of adolescents, especially since the school is the main institution that complements the education given by the family (18) .
With regard to current health programs, the focus is on reducing the epidemiological rates of illness in childhood and adulthood, creating a gap in monitoring the development of adolescents. Thus, the search for health services by this group sometimes occurs at times of demand for relief of signs and symptoms of disease or illness or pregnancy (21) . This low demand for health services was also justified by the difficulty of using a language and communication of health professionals, which effectively reaches adolescents. Therefore, rethinking strategies that bring adolescents closer to health services is an indispensable necessity, as is the active search at different points in the network.
Thus, a proposal for comprehensive health care for adolescents is to intervene in this process through actions that offer listening, satisfaction of their needs and permission to develop skills and abilities, making them part of social networks based on coping perspectives. and minimizing vulnerability (21) .
Professionals also pointed out that they sometimes feel powerless and unprepared to communicate properly with this audience and to deal with situations of vulnerability referring to the feeling of performing only temporary and non-resolving actions. In this context, Continuing Education policies are necessary for professionals who act routinely in this context, in order to provide opportunities for discussion, identification of gaps and especially the elaboration of intervention strategies. It is suggested the use of active methodologies and tools that help the discussion of the main problems and weaknesses, in order to facilitate the planning of actions.
It must be considered that the minimization of the situations of vulnerability in which adolescents are found can be achieved through actions that promote their overcoming, helping them to live their experiences and build their life projects. Both differences and specificities should be considered when planning health interventions, as life circumstances produce distinct situations of vulnerability (22) .

Study limitations
It was not possible to validate the results found with the participants in a second meeting, due to their work routine. To minimize this limitation, at the end of each focus group conducted in the units, a synthesis of what was discussed was scored by the principal investigator and, thus, a revalidation was confirmed by the group. Another measure was the analysis of the data by two independent researchers.

Contributions to health and public policies
It is believed that health professionals need support from public policies and subsidies to promote changes in the care process of Contexts of vulnerabilities experienced by adolescents: challenges to public policies Gasparetto AS, Bonfim TA, Teston EF, Marcheti PM, Galera SAF, Giacon-Arruda BCC.
for the adolescent population that experiences the different dimensions of vulnerability. Thus, the evidence and elements identified in this study provide input for reflection on the planning of public health policies that meet the needs of adolescents and enable the principles of qualified, comprehensive, equitable and humanized care to be strengthened.

FINAL CONSIDERATIONS
This study allowed us to understand the context experienced by adolescents from the perspective of FHS professionals, in the different dimensions, individual, social and programmatic of vulnerability. These dimensions involve a variety of factors such as social structure, socioeconomic and cultural contexts, interpersonal relationships, public and health policies.
Thus, adolescence is marked by associated individual and collective issues that directly impact health production. It is considered that there are still gaps in the structuring of public policies and intersectoral actions aimed at this public and their families, as well as the unpreparedness reported by health professionals in fully assisting adolescents. This denotes the need to incorporate training and/or qualification processes as a way of equipping them to assist vulnerable populations served in the context of Primary Health Care.