The vulnerabilities in childhood and adolescence and the Brazilian public policy intervention

Objective: To review and discuss childhood and adolescence vulnerabilities, as well as Brazilian public policies of intervention. Data sources: A narrative review was performed, considering studies published between 1990 and 2012, found in the Virtual Health Library databases (Biblioteca Virtual em Saúde – BVS). A combination of the following descriptors was used in the search strategy: “Adolescent Health”, “Child Health”, “Health Public Politics” and “Vulnerability”. In addition, Brazilian official documents, the Statute of the Child and the Adolescent, Guardianship Council, Bolsa Família and Saúde na Escola Programs were evaluated. Data synthesis: The results were divided into five categories of analysis: Vulnerability of Children and Adolescents in Brazil, Public Politics of Intervention to Risk Factors in Childhood and Adolescence, the Statute of the Child and the Adolescent and Guardianship Council, Bolsa Família Program and Saúde na Escola Program. The studies show that children and adolescents are vulnerable to environmental and social situations. Vulnerabilities are exhibited in daily violence within families and schools, which results in the premature entrance of children and adolescents in the work environment Endereço para correspondência: Franciele Fagundes Fonseca Rua João Paulo I, 525 – Amazonas CEP 39401-225 – Montes Claros/MG E-mail: franciele.fagundes13@gmail.com Conflito de interesse: nada a declarar Recebido em: 3/7/2012 Aprovado em: 17/12/2012


Introduction
The World Health Organization (WHO) defines adolescence as the period from 10 to 20 incomplete years.The Statute of the Child and Adolescent (SCA -Brazil, 1990), however, defines this phase as the period from 12 to 18 years old.Thus, there is no consensus on the precise age that determines the level of complete development to the performance of activities related to childhood and adolescence (1) .
Adolescence is a period characterized by important discoveries and emotional instability, during which the personality is embodied.This phase cannot be reduced to a simple age range, because it represents the transformation into adulthood and, therefore, a phase of making biological, social, and especially psychological decisions for all life (2) .Adolescents are in a continuous search for their own personality, can manifest extreme behaviors, and at certain times, can be negligent regarding their own health care (3) .
The definition of vulnerability refers to the concept of fragility and dependence, which is related to the situation of children and adolescents, especially those with low socioeconomic status.Due to the fragility and dependence on adults, adolescents are influenced by their physical and social environment.In certain situations, such vulnerability can affect their health, even in the absence of disease, but with repercussions on the psychological, social or mental state (4) of children and adolescents.
This article is justified by the importance that the health professionals become acquainted with the vulnerabilities and risk factors that threaten children and adolescents, a problem of global dimensions.Therefore, we aimed to identify, in the literature, the vulnerabilities of childhood and adolescence and contrast them with the public policies adopted to deal with the major risks.

Method
We conducted a non-systematic review of the literature, based on the documentary analysis of the Brazilian government public policies to address the risks of childhood and adolescence, both inherent to this phase and those linked to environmental and social situations.We analyzed the following documents: the Statute of the Child and Adolescent (Brazil, 1990), the Creation of Guardianship Councils (Brazil,  1990), the Family Grant Program (Brazil, 2003) and the School Health Program (Brazil, 2007).The official documents were read in full and the issues related to the vulnerabilities in childhood and adolescence were selected for discussion.We also performed an integrative literature review of articles published between 1990-2012 using the databases of the Virtual Health Library (VHL), to address the vulnerabilities in childhood and adolescence.This time frame was chosen based on the year of enactment of the SCA in Brazil.We used the combination of the following keywords: Adolescent Health, Child Health, Public Policy and Health Vulnerabilities.The selection of the articles started with the evaluation of the titles and abstracts, and when the requirements were fulfilled, the articles were read in full.Book chapters were also analyzed and used in the discussion of the results.
The results were grouped in five categories: the Vulnerabilities of Children and Adolescents in Brazil from the analysis of 10 articles; the Public Policies of Intervention for Risk Factors in Childhood and Adolescence, using the official documents; SCA and the Guardianship Council was a category that resulted from the analysis of official documents and three original articles; the Family Grant Program (FGP) resulted from the analysis of four documents published by the government and two book chapters, and finally, the category School Health Program (SCP) was the result of the analysis of four documents published by the government, one law among them, two publications of the Ministry of Education and one of the Ministry of Health.

The vulnerabilities of children and adolescents in Brazil
In 1948, the World Health Organization (WHO) defined health as a complete state of physical, psychological and social wellbeing, and not merely the absence of disease.It is observed that health is defined as quality of life, and depends on several factors, such as the social, historical, economic and environmental conditions of the individual.The state of vulnerability of many children and adolescents in Brazil contradicts this definition, since it directly affects the quality of life (5) .
There are several important components to assess the conditions of greater or lesser individual and collective social vulnerability.These components include: the access to the media and education, the availability of material resources, the autonomy to influence political decisions and the possibility of facing cultural barriers and to be free or be able to defend oneself from violent coercion (6) .
The concept of social vulnerability in Latin America is recent.It was created in order to expand the analysis of social problems, surpassing the markers of income or material possessions of the general population.The concept is linked to the conceptions of Social Welfare (7) .
In Brazil, the main vulnerabilities that affect children and adolescents are the risks related to problems such as alcoholism and conflicts between partners, which make children witnesses of aggressions and all forms of violence.Risks related to the residency place include the poor supply of public institutions and services, the lack of availability leisure spaces, relations in the neighborhood and the proximity to spots of drug trafficking.Besides all these, the risks of child labor and the exploitation of prostitution must also be highlighted.In addition, the personality and behavior of the child and adolescent make them more vulnerable to involvement with drugs, theft and teenage pregnancy.It is considered that the individual may also have a genetic trend for chemical dependency and vulnerability to the psychological and physiological effects of illicit drugs (4) .
The rates of violation of the rights of children and adolescents in Brazil are still high, although showing a downward trend.The main forms of transgression of the rights against this group are abandonment, child labor and sexual exploitation (8) .In addition, adolescence is characterized by profound changes in the life of the individuals, and the physical and psychological changes make the adolescents more vulnerable to alcohol consumption and drug abuse (9) .The alcohol consumption may be related to the need of being accepted by a particular social group.Although the Brazilian law, including the Statute of the Child and Adolescent, prohibit the sale of alcoholic beverages to underaged (10) , the alcohol consumption by adolescents in Brazil is worrying, and strongly induced by advertising strategies (11) .
The exacerbated alcohol consumption among adolescents has raised both social and health problems.The figures of the Pan American Health Organization (PAHO) show that the social and health problems related to alcohol consumption include car accidents and traffic deaths, homicides, falls, burns, drowning and suicide.These data show the magnitude of the problem to the different social layers, among them the health services, especially given the fact that 25% of all deaths of youths from 15 to 19 years are attributed to alcohol consumption (12) .
In addition to the particularities of childhood and adolescence, the reality of life on the streets poses several risk factors to these individuals, such as drug abuse, prostitution for living and lack of basic needs, and place them in a situation of extreme vulnerability.This leads to ominous consequences on health.Among them, drug addiction, sexually transmitted diseases, injuries, accidents, unplanned pregnancies and premature death resulting from suicide or homicide (13) .
In general, the vulnerabilities of children, adolescents and their families are manifested as everyday violence in the family and at school.The lack of offer of quality education, low salaries and unemployment also affect the history of life of the Brazilians, forcing them to childhood labor and / or drug trafficking (14) .

The public policy of intervention on risk factors in childhood and adolescence
The development of public actions directed to the youths in ensured by the Federal Constitution in the Article 224, which states that "the policy of attending the rights of children and adolescents will be conducted through a coordinated set of governmental and non-governmental actions of the Union, the States, the Federal District and the Municipalities".To ensure that such actions respond to the priorities, a basic requirement is to acknowledge the need of children and adolescents regarding the factors that stimulate and protect their development, such as health, education and leisure, among others (15) .
The Brazilian government has established several measures to provide better care to children and adolescents in need, who, for various reasons, are excluded from health care as defined by the WHO.Among these measures is the development of the SCA (15) , the creation of the Guardianship Councils (in municipalities) (16) and welfare programs such as the Family Grant (17) and the School Health Program (SHP) (18) .

The Statute of the Child and Adolescent and the Council Guardianship
The SCA was sanctioned in Brazil on July 13 th , 1990, by the Law No. 8069.This law is based on the total protection of children and adolescents, to guarantee them the right of protection of life and health, through the application of public social policies that allow healthy and harmonious birth and development, and worthy conditions of life (15) .
The SCA (15) defines children and adolescents as subjects of the law, and they are guaranteed full protection.Article 4 states that: It is the duty of the family, the community, the society and the government to ensure, with absolute priority, the realization of the rights to life, health, food, education, sport, leisure, professional training, culture, dignity, respect, freedom, and life in family and community.(p.9).
The SCA also states that, in cases of oppression, physical or sexual abuse by the parents or guardians, the judicial authority can remove the offender from the common residence.With respect to alcoholics and drug addicts, the protection measures are several, including the guidance, temporary support and monitoring, the inclusion in community or official programs of support to the families, children and adolescents, the offer of medical, psychological or psychiatric treatment or even the allocation of the individual in a foster family.In cases of pregnancy, the SCA provides the right to life and health and assures the care at different levels of the public health services.It is the duty of the Government to provide food to pregnant women and nursing mothers who need such support (15) .
Despite the progress obtained with the publication of the SCA and its wide discussion among the civil society and the social organizations, the SCA has been facing the opposition of various conservative representations (19) .The resistance and criticism against the guarantee of the rights of children and adolescents have cultural origin.The lack of notion of "owning" rights and of mechanisms to ensure access to these rights make it difficult to persuade the Brazilian people on the importance of the Statute of the Child and Adolescent (19) .
Nevertheless, the SCA portrays the maturity and engagement of the Brazilian society, by allowing a wider participation of non-governmental organizations (NGOs), creating forums and Councils and supporting the consolidation of social and political movements to ensure the rights of children and adolescents.In this sense, comes into operation the National Council for the Rights of Children and Adolescents (Conanda), which accounts for the integration of social and governmental representatives to favor of the execution of the SCA.Among the duties of the Conanda is the implementation of Councils in states and municipalities, and the establishment of the Councils of Law and Guardianship.The Councils of Law are deliberative, parity public organs, which are responsible for setting policy of service and control of the budget to the child, in connection with all the other policies.The Guardianship Councils, in their turn, must ensure that the measures of protection, support and guidance to children and adolescents are met (16,20) .
The Guardianship Council is a permanent, autonomous, non-jurisdictional public organ, elected by the local community to ensure the rights of children and adolescents.It operates in the municipality and has the specific function to care for each case of physical or sexual abuse, child labor, neglect or other forms of violence against children and adolescents (21) .This organ must ensure the complete state of physical, mental and social welfare, and must offer health treatment when such conditions are not met by those who need them.The duties of the Council are stated in the Article 136 of the SCA, among which must be highlighted the care and advice for parents or guardians of children and adolescents, the requirements of public health, education, welfare, labor, safety and social services and the notification to the Public Ministry any news of criminal or administrative violation against the rights guaranteed to children and adolescents (15) .One of the main roles of the Guardian Council concerns the guarantee of enrolment to school, which has been a difficulty faced by the counselors.Although the SCA states that all children have the right to education, the counselors have observed an inconsistency between the statute and the reality, indicating a mismatch between the administration of the Department of Education and the guarantee of the rights established by the SCA.The role of mediation between family and school played by the counselor depends on their own values and conceptions about education (21) .

The Family Grant Program
The Family Grant Program (FGP) established by the Federal Government develops actions in health promotion that benefits not only children and adolescents, but also needy families in Brazil.It aims to benefit the most vulnerable population, to transform the society and contribute to the achievement of citizenship.It also acts on health, aiming the improvement of the quality of life of the families, by overcoming the hunger and poverty (17,22) .
When it was created in 2003, there were already around ten million families receiving aids from prior programs (22) .In the first term of 2011, the organs of the health monitoring recorded 7.35 million families enrolled in the FGP, consisting of children under 7 years old and women 14-44 years old.Among the children, 71% accounted for 4.24 million children benefited and fully followed by the program.Among these children, 99.1% had the vaccination schedule updated.Among the pregnant women, 95.8% had complete prenatal care (23) .
Regarding the income transfer, the Curve of Incidence is the tool used to evaluate this aspect, which is characterized by the Coefficient of Incidence.The estimation of this coefficient is based on the ordering of individuals based on the net income of the transfer, whose incidence is under evaluation.The Curve of Incidence is the most appropriate approach to evaluate the performance of an executing agency in making the program to reach the poorest.The progressive transfer shows a negative Coefficient of Incidence, and the more negative this coefficient, the more focused on the poorest individuals.A negative coefficient of one (-1) indicates that the poorest person of a given population receives all the resources of a transfer, while the positive Coefficient indicates a regressive a transfer; the more positive the more focused on the rich (24) .Accordingly, the coefficient ranges from -1 to +1, and the negative value is the most desirable in a Social Program.In the FGP in 2006, the Coefficient of Incidence was -0.568.This value is similar to the indices of the latest available figures of the program Progresa / Oportunidades in Mexico (-0.56) and Chile Solidario (-0.57) offered in Chile.A social program is relevant regarding the impact on poverty and social inequality when it reaches large numbers of poor people.Thus, the focus of FGP has shown to have a similar level to the international standards (24) .A work with selected groups of women, both beneficiaries and managers of FGP in ten municipalities of the Federation, showed that the FGP had a dramatic impact on the perception of citizenship by those women holders of the benefit, and in reducing the social isolation of these same women (25) .
In Brazil, the FGP is considered of utmost importance among the social policies.Its impact on the reduction of poverty and income inequality, on higher school attendance and in ensuring that beneficiary children are not victims of child labor are well acknowledged.However, some changes to this program are needed (22) .Changes in the conception and methodological design would be necessary, as they have not occurred in the last years.Much of the attention of the Ministry of Social Development and Combat to (SDM), which is responsible for the was developed because of a small, yet important, improvement in management (22) .
A social program can only be considered able to reduce poverty and inequality if, first place, it reaches the population living in such conditions.The higher the amount of resources of the program available for this vulnerable population, the greater the focus and, consequently, the greater the impact (26) .

The School Health Program
Still aiming to protect children and adolescents, the Brazilian government instituted the School Health Program (SHP), which was developed as intersectoral policy between the Ministries of Health and Education.The SHP aims the total health care (prevention, promotion and attention) of children, adolescents and youths attending public elementary school.It is developed in schools and basic health units, with the integrated participation of health and education teams.The SHP provides medical, psychosocial, nutritional and oral health evaluations.Actions for promotion of health and disease prevention through the incentive to healthy eating, physical activities, education for sexual and reproductive health, counselling about the use of alcohol, tobacco and other drugs are also included.The actions aim to address the vulnerabilities that affect the development of children and youths enrolled in the public school system (18,27) .
The Federal Government plans that, in the four-year period starting in 2008, 26 million students will benefit from the integrated health care in the priority municipalities.Those who need glasses and hearing aids will be served with program resources.The actions in SHP are monitored by an intersectoral commission of education and health, comprised of parents, teachers and representatives of the Ministry of Health (28) .
The SHP tends to generalization as the number of participating municipalities gradually increases.The program has guaranteed the health care of schoolchildren in an inclusive manner.The health needs of the various age groups served by program are accessed in different expressions and dimensions.The SHP favors the access to health services in a resolute and good quality manner (28) .In addition, the actions of the SHP must be integrated into the political and pedagogical project of the schools.In carrying out these activities, it should consider the social and school context, as well as the local health status (29) .
It is of great importance that the clinical environment created by the health professionals (nursing, dentistry, medicine and others) corroborates the concern for the well-being of children, conveying interest, acceptance and trust.The health professional must always, at each meeting, identify changes and create an emotional bond with the users of the health services (30) .The health care for the youths cannot be separated from their families and family needs, which requires the mastery of specific theoretical information and the development of a special sensitivity to deal with this public (31) .Thus, the knowledge of public proposals for facing situations of risk is essential to the health professional, regardless of the practice setting, whether at school or in public or private health units.

Final considerations
This article has methodological limitations, especially the revision of the material available only at the Virtual Health Library to search for papers related to a subject of global nature.With respect to official documents, it is considered that other documents, such as the Brazilian Constitution of 1988, also include the subject.However, the selected documents are justified by being specifically directed to the target population of children and adolescents addressed in this study.
Despite these limitations, we can conclude that progress has been made with regard to the proposals of policy interventions to the risk problems in childhood and adolescence, but there is still a long way to go to ensure the full right to health, as assumed by the Brazilian laws.Strategies should be developed, ranging from the guidance of parents or guardians to the creation of shelters, community programs, and investments in research on the theme for the development of new proposals of intervention on the risks in childhood and adolescence.
Accordingly, the Government programs evaluated herein are complementary to each other and converge towards a common goal: to ensure the rights of children and adolescents established in SCA.Aligned with the SCA, indicators show that the FGP has increased school attendance by inhibiting child labor.When they stay in school, especially in public schools, children and adolescents have opportunities to participate in the actions of the SHP, directed to addressing the vulnerabilities that affect their development.