Concepts and issues related to adolescent health in nursing education

Highlights: (1) 31.6% of faculty have no specific education in adolescent health. (2) 18.9% of faculty have no educational/pedagogical training. (3) Progress is needed in the use of active methodologies and interactive multimedia. (4) Knowledge of laws and policies for the adolescent population must be expanded. (5) Current and relevant adolescent health issues need to be addressed in nursing education.

settings, as advocated in the Global Strategic Directions on Nursing and Midwifery 2021-2025 (7) .
The Region of the Americas have significant disparities in nursing education, expressed in the discrepancies in the proportions of professionals in certain geographic regions or types of services and also in the levels of training and competencies of these professionals, factors that affect the capacity of the nursing workforce and the quality of care provided (8) .
Given this context, improving nursing education will have a positive impact on population health.
Nursing education programs also must be capable of ensuring effective student learning, as well as meeting quality standards and health care needs (7) .
Attention to curriculum is paramount in the context of the recent pandemic, which has imposed significant changes in the teaching model and impacted the quality of education (9) . If, on the one hand, the COVID-19 pandemic imposed important changes in education (9) , on the other, it points out the need for health and education systems to turn their attention to vulnerable groups, making it imperative for nursing education to become a space to respond to health inequalities (10) .
To address these inequalities, health professionals and services must develop competencies and skills as not to become an obstacle to advancing universal health for adolescents (2) . Nurses and other profesionals,

Method Study design, place and period
This is a cross-sectional and observational study conducted in Colombia, Ecuador and Peru, in 2021.

Participants
All nursing schools in the three countries were considered eligible, with a total of 113 schools, of which 47 in Colombia, 24 in Ecuador and 42 in Peru (12) .

Data collection
Invitation was sent by email to all schools registered in the PAHO Directory of Nursing Schools to participate in the study (12) . Prior to data collection, the authors held meetings with the participants to present the project and clarify any doubts. All 113 schools registered in the Directory were invited to participate in the orientation meetings, however attendance was optional. As an additional resource, the authors provided a video presentation of the project and survey response guidelines.
The dean, course coordinator and faculty of disciplines in related areas of adolescent's health were invited to respond the instrument.
Invitation was sent to the schools, regardless of their participation in the orientation meetings. Response of the instrument was requested in within one week, with a reminder sent after this deadline and a new reminder after 15 days. Moreover, contacts were established with collaborating universities to further disseminate the survey.

Data was collected by the researchers between
October and November 2021, using the SurveyMonkey tool. Average time to complete the instrument was one and a half hours.

Data processing and analysis
The answers obtained were entered into a spreadsheet, forming an electronic database, and then exported export to IBM SPSS Statistics software, version 28. The nursing programs were characterized by descriptive analysis. All 95 schools were considered in the analysis, even though some items were not answered by all participants.

Ethical aspects
The project was approved by the Pan American  Regarding the teaching program structure, curricula should be competency-based and ensure effective learning aligned with the population's health needs (7) .
Curriculum preparation and updating, according to the schools, is a collective process, that involves various participants increasing the chances of a successful The virtual nursing education imposed by the pandemic, has shown different experiences for firstand final-year students, as those at the beginning of the course predominantly learn theoretical concepts, whereas those finalizing the course have activities focused on clinical training. Besides these differences, the quality of student-professor interaction is an essential point of attention when incorporating such technologies (24) .
As for the teaching of adolescent health topics, Demand for health services can be affected by several conditions, such as gender, education and social profile (25) , with community services being a key point of care, generally due to illness, to the detriment of health promotion actions (4) . Among the factors limiting this population's access to health services are long waiting periods, lack of care prioritization, and geographic barriers (4) .
As for comprehensive adolescent care, besides issues related to health accessibility, one must consider the complexity of actions and the possibility of intersectoral interventions, as observed in alcohol consumption, in which the relationship between health service practices and school, and the harmonized family relationship are protective factors for adolescents (26) .
Among the neglect topics are bullying and cyberbullying. These are important issues for health professionals, due to its prevalence and potential health harms to adolescents, since cyberbullying has a prevalence of up to 35.4%, and victims present more emotional and psychosomatic problems, social difficulties, moderate to severe depressive symptoms, substance use and suicide ideation and attempts (27) .
Other studies point out the increased risk of self-harm, suicidal behavior (28) and depression in adolescent victims of cyberbullying, highlighting the need for prevention and management actions (29) .
Complementarily, the use and misuse of digital technologies occupies ranks second among content that should be taught. Excessive use of digital technologies is associated with decreased well-being, with adolescents being the most vulnerable group (30) .
Smartphone addiction and overuse has been shown to be a concerning factor due to its effects on adolescent health, such as decreased hours of sleep, neck pain and mental disorders. Moreover, excessive use of social networks has been associated with decreased self-esteem and body satisfaction, elevated risk of cyberbullying, increased exposure to pornographic material and risky sexual behaviors (31) .
Youth and partner violence are issues yet to be addressed. In 2018, one in four adolescent girls aged 15-19 who were married or in a relationship experienced partner violence (1) .
Despite the high prevalence of adolescents who experience some type of violence (sexual, physical, psychological or institutional), the issue is often silenced and made invisible due to the reproduction of social gender norms (32) . It is worrying that this group has few support networks and do not consider health professionals as a support source (33) .
Combating violence against adolescents requires professionals, to create a support and protection network (34)(35) , considering, among other things, the impact of the COVID-19 pandemic on the prevalence of violence (35) .
Another topic of interest is teenage parenthood.
Adolescent parents disproportionately come from single-parent families and low parental socioeconomic status. As a result, children of adolescent parents are at increased risk for prematurity, low birth weight, and psychological disorders (36)(37) .
From a clinical perspective, issues such as delayed or precocious puberty can also trigger emotional and psychosocial disorders; thus, timely treatment and support for adolescents and families are necessary (38) .
Gender identity and sexual orientation are also topics related to possible physchological distress. Adolescents victims of intolerance to gender identity and sexual orientation are at increased risk of lack of opportunities, dropping out, loss of family ties and suicidal behavior (39) .
Young people have specific health needs and sometimes face barriers in accessing health services, health promotion and wellness actions (40) .
Given the problems outlined above, school nursing should be adopted to expand health knowledge and health-promoting behaviors is advocated (41) , expecially for vulnerable population with lower scores in health knowledge (42) .
School nurses can support this population by establishing an effective bond, listening carefully to their feelings and health needs, intervening early and continuously, in collaboration with the family, school and health services, based on comprehensive care (43) . Studies show that, from the perspective of the educational system, school nurses contribute to improve health, reduce absenteeism and improve student performance (44) . Hence, WHO supports the creation of school-based health centers as an important community resource to address the health needs of adolescents and increase their participation in health services (45) .

Limitation
Self-evaluation, when used isolated, does not provide insight into other perspectives or indicators for evaluating teaching programs. However, the high participation rate of nursing schools and the results presented here are important indicators of nursing education in some Latin America countries.

Implications for knowledge advancement
The results indicated limitations in terms of teaching capacity to train nurses, thus indicating the need to invest in the continuous education of nurses and faculty regarding pedagogical updating and adolescent health.