Adolescent health in the Brazilian federal school system: a metasynthesis

The institutions of the federal educational network have their own health team and, therefore, have the possibility of developing multiple strategies for the implementation of School Health Program actions. This study aimed to systematize and synthesize the scientific production developed by workers from the federal educational network on adolescent health in the school environment. This is a qualitative meta-synthesis carried out from searches on the Virtual Health Library, Brazilian Digital Library of Theses and Dissertations, and Google. Content analysis was used for data analysis. The sample consisted of 15 publications and 4 thematic units emerged: pedagogical integration of health education in federal institutes; conception of adolescence and adolescent health in the school environment in federal institutes; perspectives of health work in federal institutes with adolescents; and facilities and difficulties in the development of adolescent health in the school environment in federal institutes. It was found that the scientific production on the subject is still incipient. Even in federal institutes, it is necessary to advance in the methodology of activities and in the topics of health education developed. It is necessary to stimulate youth protagonism, transcending the hygienist and fragmented aspects of school health.


Introduction
In Brazil, School Health (SE) was conceived, starting in the 1850s, anchored in a hygienist logic of inspection and disease control.Over time, it developed itself based on the precepts of the health surveillance model, and is currently regulated by the School Health Program (PSE), which originated in 2007 1,2 .It stands out for articulating common axes between health and education, fundamentally aiming at promoting health and a culture of peace, contributing to the constitution of conditions for the integral formation of students, favoring the construction of a social care system, with a focus on promoting citizenship and human rights, in addition to strengthening the fight against health vulnerabilities that may compromise full school development, among other aspects 3 .
Designed within the perspective of health promotion in partnership with the Family Health Strategy, the PSE involves the work of the multidisciplinary team in the Family Health Units of the municipalities, working in partnership with the schools in their territories.It should be noted that the school, in general, presents itself as a place with high permeability to address relevant topics for the Health Promotion (HP) of children, adolescents and young people.Thus, taking advantage of the contact interfaces between health and education allows the targeting of activities aimed at a specific audience, of a certain age group, whose adoption of healthy practices will contribute to the maintenance of good health in adult life.
Although there is the prospect that HP initiatives are part of the school curriculum, specific actions by the health services of the territories within the schools are still observed, addressing issues related to the preventive/ biomedical logic.In this scenario, attention is drawn to the development of SE activities within the federal education network, in which student health care services have been established within the school itself with its own and specific health team.Created in 2008, the Federal Network of Education, Science and Technology currently comprises 38 Federal Institutes of Education, Science and Technology (IF); two Federal Centers for Technological Education (CEFET); 22 Technical Schools linked to Federal Universities, Colégio Pedro II and Universidade Tecnológica do Paraná (UTFPR), totaling more than 600 teaching units distributed throughout the country 4 .
In 2010, with the creation of the National Student Assistance Policy with the objective of contributing to the permanence and success of students in school, the institutions of the Federal Education Network started to have health professionals to work in SE 5 .
The health team of the institutions of the federal network is composed of different professionals, nurses, doctors, dentists, nutritionists, psychologists and social workers.The composition of the multiprofessional health team varies between institutions according to the professionals available in each teaching unit, whose positions are filled through public service exams.
These professionals, integrating the nucleus of the exclusive student assistance of the federal network, have the possibility of developing multiple strategies aimed at the implementation of the PSE.In the meantime, it is highlighted the possibility of mapping the issues of greatest interest to the adolescent community, with the purpose of acting directly by promoting HP actions and prevention of diseases and aggravations in a perennial way within the school, in addition to the direct monitoring of the health of students' for the time they are linked to the institutions, helping to mitigate health vulnerabilities that interfere with learning, success and permanence.
It is considered that, given the social function and national scope of the federal network, knowing the experience of the development of health actions, in these spaces, can provide subsidies for the improvement of the PSE, especially in the context of adolescent health, given the peculiarities and specific transformations of this phase 6 ; above all, considering that the adolescent population corresponds to a significant number of students enrolled in the federal education network.In 2020, the federal network had more than 1 million students enrolled, of which 257,099 belonged to Elementary School II, High School, or Technical Course Integrated to High School, according to data from the Nilo Peçanha platform 7 .
Considering the potential of the health work developed within the federal network, it becomes fruitful to carry out a meta-synthesis of the qualitative productions developed by health professionals in the last 14 years, bringing to the surface its significant potential for contributions to the area of adolescent health at the SE interface, contributing to the sedimentation of the scientific production on the subject, developed in this scope, allowing its applicability in other educational institutions and bringing visibility to the health work developed within the federal education network in Brazil.
This work aims to answer the following question: what does the qualitative scientific production produced by health professionals reveal about adolescent health in the school environment in the Federal Network of Education, Science and Technology?
In this way, it is intended to systematize and synthesize the scientific production developed by workers from the federal education network on the topic of adolescent health in the school environment.

Material and methods
This is a qualitative meta-synthesis, which was developed by a team of six researchers, authors of this article, health professionals involved with the SE theme, four of them working directly in adolescent SE in the federal education network.
The metasynthesis was developed following five steps: 1) data selection; 2) description of the phenomena; 3) data integration; 4) analysis of primary data; and 5) new interpretations.
The first two stages of metasynthesis were established from the elaboration of the research protocol that was registered and published in the Open Science Framework platform (DOI: 10.17605/OSF.IO/AUQGT).
After the elaboration of the protocol was completed, searches were carried out in Brazilian databases and in the gray literature to identify relevant materials to answer the research question.The main search portal chosen was the Virtual Health Library (VHL), which integrates Latin American databases with qualitative peer-reviewed studies, relevant to finding the evidence sought, such as Latin American and Caribbean Literature on Health Sciences (LILACS), the Nursing Database (BDENF), the Virtual Library on Adolescent Health (ADOLEC) and others, which make it possible to find studies on SE in the federal education network in Brazil in Portuguese, English or Spanish.The combination of descriptors used is shown in tables 1 and 2.
Table 2. Use of descriptors integrating health in the school environment, student assistance and federal institutes
To complement the findings, the search terms were adapted to search for gray literature productions, encompassing the four main terms of this research: "school health", "adolescent health", "student assistance" and "federal institute".These summarized main descriptors were used to search the Brazilian Digital Library of Theses and Dissertations (BDTD) and Google®.
Studies published between January 2009 (month following the creation of the federal education network) and January 2022, in selected Latin American databases, were included, considering the interest in the Brazilian reality, in peer review, in qualitative methodology and in the theme: adolescent health in the school environment within the federal education network.Publications from the gray literature, that comprised dissertations from stricto sensu graduate courses and book chapters published in titles on adolescent health, school health or student assistance were also included.Protocols, comments, technical notes and therapeutic guidelines were excluded from the metasynthesis.
The selection of material included in the review was carried out in three main steps after the search for studies: selection by title, selection by abstract and selection after reading the material in full.At all stages of selection, the group of researchers discussed the inclusions and exclusions made.In case of doubt, a researcher could be requested to make the final decision.
The searches performed returned 305 publications; and, after removing the duplicates, the material was selected according to figure 1, including 15 publications (4 articles, 6 dissertations, 5 book chapters).
In the last step, the material that had a compatible methodology was submitted to quality assessment using the Consolidated Criteria for Reporting Qualitative Research (Coreq) checklist.The quality assessment was performed independently by 4 authors, being selected 14 strategic items of relevance within the Coreq (items 7, 9-12, 14, 16, 17, 25,  26, 29-32).If necessary, discrepancies between authors would be submitted to a fifth review by a senior researcher.
For the analysis of the material, the content analysis of Bardin8 was used, following the steps of pre-analysis, exploration of the material and treatment of the results.The categories found in the material exploration phase were defined in group meetings between the researchers.The interpretation of the results was conceived in a reflexive and critical way, based on the experience of the researchers in the work in adolescent health within the federal network.The production of the data synthesis was based on the data extraction form built with the support of Excel®, in which the researchers entered information related to the publication, including the authors' profession, institutional affiliation, place of study and information about sample and study results.
As this is a type of review, submission to a Research Ethics Committee was waived; however, all ethical and authorial aspects were respected.This research received no funding of any kind.

Results
After selecting the content, we reached the amount of 15 publications (4 articles, 6 dissertations, 5 book chapters).Most authors were linked to the IF, they were technicaladministrative personnel (22), with the largest professional category being nurses ( 6), followed by professors (4) in the areas of physical education (2), biology (1) and languages (1).Also noteworthy is the participation of 4 students in the production of 2 studies.As for gender, there was a predominance of female authors (36) as opposed to male authors (7).
Most publications were carried out from IFs located in the Northeast region (7), with a smaller number of studies carried out in the North (1) and Central-West regions (no records).Most studies were published in dissertation format, and only one dissertation was found to have a related article published.As for the methodological designs of the included studies, 14 were qualitative studies, and 1 was a qualitative-quantitative study.There is a high number of experience reports (7), which limits the application of the Coreq quality checklist, so that the checklist was applied only to products from field research.In studies in which the quality checklist was applied, a medium to low score ranging from 14 to 24 was observed.
As for the research participants, there is a greater number of studies aimed at the student public, with some studies approaching students, but without quantifying them, indicating the approach of the study in number of classes or groups per grade of High School.At least five studies include the category of professionals (149), ranging from technical-administrative staff directly involved in student assistance to teaching staff linked to teaching.
Based on the content analysis of the productions, it was possible to compose four thematic units: 1) pedagogical integration of health education in federal institutes, which addresses the relevance of incorporating adolescent health themes into the curriculum of subjects; 2) conception of adolescence and adolescent health in federal institutes, which highlights how these two concepts are understood by professionals and assisted adolescents; 3) perspectives of health work with adolescents in federal institutes, which discusses how the understanding of the concepts of adolescence and adolescent health operate in care practice; and, finally, 4) facilities and difficulties in the development of adolescent health in the school environment in federal institutes, which presents the challenges involved in the implementation of actions in the field of adolescent health in federal educational institutions.

Discussion
The fact that the nursing category was more representative in the authorship of publications may indicate a greater link between the area and the study of adolescent health within the school environment.When observing the link between professors, there is a greater participation of professors from subjects closer to the health area, such as biology and physical education.In addition, the participation of students in the production of two studies demonstrates the consideration of the awareness of the adolescent public by their peers, encompassing the active role of the student during health education activities, but still in few studies.The types of publications found also reiterate the potential that the topic of adolescent health in the school environment has as a field of research.However, the low conversion in publications (dissertations and book chapters) in the scientific article format limits the dissemination of the findings made by the researches.A significant number of productions in experience report format shows that investment in research in this area is still incipient or little stimulated, still in IF, in which there are exclusive teams to develop work related to adolescent health in the school environment.
Geographical inequalities in the production of research on adolescent health in the federal education network, in turn, may reflect not only the stimulus generated by institutions in the development of studies in this area, but also the availability of openings in research notices for the technical-administrative category and the opening for publications in the area of health/student assistance.It may also be a reflection of institutional policies for the absence of civil servants for stricto sensu postgraduate studies, which may limit or enhance the development of research on adolescent health in the school environment.
These questions are points of reference for further theoretical deepening and investment in research within the area of adolescent health in the school environment, with emphasis on the federal education network that has specific services and foster devices.
Regarding the systematized categories, the main findings are presented below.

Pedagogical integration of health education in federal institutes
Education in SE represents a strategic opportunity for HP and prevention of risks and injuries.In most schools, the curriculum does not include this topic as part of the pedagogical project of the courses offered.When the topic is addressed by teachers, they usually touch on a superficial level as part of a specific subject in the basic curriculum.Some institutions that have health professionals present in the workforce usually develop health promotion activities in an extracurricular way, seeking adherence strategies using various pedagogical tools 13 .
In the study carried out by Bezerra 13 , it was highlighted that student assistance professionals have doubts about the implementation of the integrated curriculum proposal.Based on the participants' responses, it was observed that they do not perceive interdisciplinarity being prioritized or worked directly with the integrated curriculum, that the concepts and actions for some subjects are still worked independently and without dialogue with the integrated curriculum.This study also highlights, in the speech of professionals, that the health practices developed by them lack space in the institution, both for their execution in an integrated way with other public-servants and for their involvement in school contents.
Differing from this, some professors believe that the proposal is present in the integrated curriculum, due to the presence of health issues in transversal themes and the provision in the legal documents of the courses.The students interviewed in this study, on the other hand, have a splitted opinion: half understand the SE actions as part of curricular activities, and the other part as extracurricular activities, only as occasional health actions 13 .
Souza 14 highlights that working on the integrated curriculum requires effort and commitment from the people involved.There is a need to link with the proposal.Santos and Oliveira 22 highlight the importance of student assistance as a social right, in federal public institutions, and HP actions as a broad, effective strategy that values the integrality of the subject.In addition to offering psychosocial, pedagogical and health support, they help students to remain and succeed in the integrated courses offered, even when affected by health vulnerabilities.
These actions, in addition to bringing students closer to the health service, collaborate to expand and understand the role of professionals involved in the school context.By developing these activities at school in a participatory way, adolescents are provided with a space for protagonism both in the construction of knowledge and in the formation of a conscious and critical individual.Thus, an action that allows collaborating for the emancipation of health care and autonomy of individuals is highlighted 22 .
Corroborating this idea, Oliveira et al. 23 emphasize that, when effectively applied, the health promotion intervention fulfills its objective through the construction of knowledge centered on interactivity, in a climate of mutual respect and affection.It also provokes reflections on broad and complex themes, which really contribute to the formation of the individual, without ending the discussion or covering all its aspects, but meaning something for the teenager, in addition to information.
Bezerra 13 argues that, when analyzing the Pedagogical Project of High School Technical Courses (PPC), the topic of health education and healthy eating is approached tangentially in some subjects that had a related theme.It suggests the need to qualify teachers so that they can act in health promotion actions, as well as train them to address content on this topic that is not always correlated to their area of training.
Although some themes related to education in SE are not yet part of the school curriculum of educational institutions, including federal institutions, it is essential to encourage interdisciplinarity with teachers and pedagogical coordination for the insertion of transversal themes in the Political-Pedagogical Project (PPP) of the institutions' courses 13 .

Conception of adolescence and adolescent health in federal institutes
Studies indicate that there are different conceptions about what it means to be an adolescent and what is involved in caring for the health of adolescents.Brolini 10 , in his study with professionals linked to student assistance, found that there is a need to guide professionals who work in the area, observing that many linked the health education actions promoted to adolescents as a passive entity, opting for teaching-learning methodologies focused on the transmission of information.
The students, in turn, in discussions about adolescence, demonstrated the difficulty of reconciling the condition of being a teenager-patient and health in the school environment.They expressed the importance of the health services model within the IF.They demonstrated feelings of trust provided by the service, whether in the reception or in the follow-up, considering the characteristic changes of the adolescence phase.In parallel to this, they also showed concern about the precarious conditions of hygiene in the environment, low nutritional quality of school meals and possible health impacts 11 .Thus, they demonstrated an ambiguous position within the school space: while they feel cared for by the services offered (position of patients), they actively reflect on the environmental health conditions offered to them in public education.
From this perspective, it is beneficial to understand the students' impressions about the health service developed within the IF in order to equip professionals in the construction of a work proposal with an emphasis on health protection, prevention and promotion.The studies developed by Faial 11 and by Faial et al. 17 , when bringing the perspective of the adolescent student public, observed the need for improvements in health services to provide humanized assistance: attending to the institution's three operating shifts; expand the team of professionals; carry out interdisciplinary actions, with emphasis on mental health; adopt pedagogical practices in health.Such adjustments involve the need to provide inputs and adequate infrastructure for the practice of SE and professional training.
Health education, humanized care and the participation of the school community and society are the foundations for boosting SE.Furthermore, the contribution of health lies in the capacity for integrated and articulated action, of a critical and reflective nature, educating adolescents for the characteristic challenges of this phase 11, 17 .Nevertheless, the exercise of an ES linked to hygienist practices and the biomedical assistance model is still observed, strengthening the fragmentation of individuals, opposing the ideal of comprehensive health care.
In this sense, it is important to highlight the importance that SE practices, within the IF or not, must assume the main role of the adolescent in his health 17 .To this end, it is necessary to formulate and implement training projects that promote the improvement of educational practices aimed at health education for professionals working in the area of student assistance, especially with regard to thematic diversity and the curriculum integration 10 .

Perspectives of health work with adolescents in federal institutes
The way in which professionals work in health education aimed at the adolescent public is related to their professional training.With regard to health professionals who work in student health (within student assistance services), most of them do not have specific training in SE and are selected from public tenders that require generalist training.
In the reflection carried out by Faria, Araújo and Oliveira 19 , the professionals describe that training to work with adolescents was a blind spot in their technical training.This required the development of their own strategies and the completion of the study autonomously to deal with a heterogeneous population and with well-defined individual/group particularities.In this sense, they put the starting point for the transposition of these formative gaps: welcoming, active listening and collateral in relations with the adolescent public; the skills that can be learned with the adolescent public during the consultations carried out within the health services of federal institutions.
This aspect also slips in the teachers category.In the IF, not only the propaedeutic subjects but also the technical subjects are part of the high school curriculum, and this has a positive impact on the potential for the integration of SE to the high school curriculum due to the thematic diversity of the subjects.Ancini 9 highlights that there is interest on the part of professors in contributing to an integrated curriculum that favors integral human formation and that addresses health issues, but recognizes that there is a need for support from the health technical staff in addressing some themes, as there was an expression of interest only in some specific areas (biology, chemistry, mathematics, veterinary medicine and physical education).
Barreto Filho and Valente 16 present similar results in their study on interdisciplinary work and obesity prevention at school.The research carried out with physical education teachers finds that, despite recognizing the relevance of the discipline as an ally in the prevention of obesity, teachers in the area do not direct their educational practice towards this preventive application, pointing out that they did not feel supported for the development of interdisciplinary practices.
The displacement of the school from a space of academic/technical training only to a space of instrumentalization for life choices, comprehensive training and protection of the adolescent public involves the need to overcome fixed conceptions about adolescent health; demanding, also, a work management that privileges creativity in its execution, detaching itself from fixed ideas of knowledge transmission and learning hierarchy deriving from banking education and the training limitations of professionals 10 .
This also permeates the need to break with the hygienist character linked to work in ES 21 , either by choosing the topics discussed, or by the assistance provided within the services in IF, which reflect the biomedical model 11,17, 23 , as well as the need to establish partnerships that articulate teaching, pedagogical practice and adolescent health care 9, 16 .

Facilities and difficulties in the development of adolescent health in the school environment in federal institutes
SE actions have faced, for their implementation, multiple weaknesses and challenges throughout history 2 .Such challenges permeate the conceptions of practices, still of a strong hygienist character, the predominance of biomedical approaches and the fragmentation of actions.
Within the scope of the federal network, studies corroborate this perspective, showing strengths and weaknesses during the development of SE actions.In this sense, the experience reports included in this study indicate that the challenges result from the high curricular workload of students and the deficiencies of financial and material resources to carry out the activities.The reduced time for activities and the fragility in the integration between health and education hamper the development of intersectoral actions 15,20, 24 .
Sakai 21 is in line with this understanding and highlights the challenge of building a critical and meaningful health education, by establishing a service that listens to students during the COVID-19 pandemic and has variable adherence among the students themselves.Thus, Oliveira et al. 23 emphasize that health actions should enable students to play a leading role in the construction of knowledge and critical, conscious and reflective training.Furthermore, they argue that, in SE actions, interdisciplinarity, the integration of knowledge and the playful and participatory methodology are tools that collaborate to promote self-care in adolescence.
Despite the weaknesses to be overcome, the studies reveal positive perspectives.Santos and Oliveira 22 show a beneficial association between student assistance actions, including health interventions, and the permanence of pregnant adolescent students in school, which contradicts the statistics related to teenage pregnancy and school dropout.While Costa et al. 18 , in their work on the topic of hygiene with incoming adolescent students, also indicate the relevance of approaching the theme to contribute to the prevention of diseases and promotion of the integration of adolescents.Therefore, the potency of the actions can be seen, with beneficial repercussions on the health of adolescents in the school environment.
The productions converge on the need to encourage the use of participatory methodology as a guide to actions.It is inferred, therefore, that the experience reports produced in the context of the federal network reveal possible paths: dialogue and reflection, transcending the simple transmission of information.
Contrary to other findings, which signaled the inexistence of collective planning of health actions, limiting them to isolated and disjointed initiatives 24 , studies point to the planning of actions to be carried out by multiprofessional health teams in the IF, but still restricted to these professionals, with low articulation with the integrated curriculum and with teachers.
Thus, in spite of difficulties, the potential of the actions is significant, requiring the engagement of professionals and managers in order to make health activities viable (in the financial, structural and training areas), and thus favoring autonomy and integral formation, placing the adolescent at the center of the health care process.In this context, it is relevant to broadly strengthen health actions, to the detriment of specific, fragmented actions with a hygienist profile, valuing subjects as transformers of their reality and their sociocultural context.

Study summary
The thematic units present the way in which the exercise of health is carried out in the IF.Overcoming predominantly hygienist molds, historical parts of the SE, presents itself as its structural challenge.Achieving a work focused on HP in the school environment is in line with the paradigm shift proposed in the PSE and which is more in tune with the perspectives brought by the Unified Health System 2 , promoting integrality and citizenship in health care.
In the IF scenario, with the presence of the health team in the institutes themselves, it is expected that some alignments can be better carried out, given the greater possibility of integration between the health team and the school environment.It is observed, however, that this proposal of adolescent health as an intertwined curricular axis, overcoming the merely biological view of adolescence and adolescent health, assuming an integral and integrated health perspective and assimilating the issues that cross the school environment, still encounters obstacles.
Clearly, there are efforts aimed at the adoption of health practices that value curricular integration and the protagonism of the adolescent public, but, even in these spaces, there are still difficulties in implementing an agenda of curricular decisions and situated practices, with collective decisions that add adolescents as active agents in the processes.The thematic units found in this study demonstrate that seeking a health practice at school focused on PS is challenging, especially in relation to operationalization, the formation of a collective agenda and the mobilization of different actors for this practice 25 .
In this way, the searches reinforce the importance of integration and collective work between faculty, health professionals and students to carry out actions that develop health in these spaces, understanding students as an integral and participatory part of this process, in order to achieve the integrality of these subjects.It is important for health education to reinforce its own concept by producing critical reflections on social determinants, contexts of violence, situations of risk and contagion, the search for well-being, sexual and reproductive rights, among other topics.
The construction of spaces that provide health, with guarantees of hygiene, food and leisure is also reinforced.Adolescents' HP at school constitutes an instrument for the construction of broader debates that also integrate other domains of daily life: mental health, family life, combating violence, labor market perspectives, social mobility, participation in public and political life; fundamental for the development and emancipation of adolescents within a conscious and citizen education.
As a limitation of this study, the pulverizing of the themes dealt with in the publications is presented, leaving little room for other meanings and explanations on each theme to gain importance.

Conclusions
From the analysis of qualitative studies on adolescent health in the school environment, developed within the IF, it is observed that, despite having its own health teams, it is necessary to strengthen and encourage youth protagonism.Pointed out as desirable, in the studies, perhaps, the leading role fades in the realization of a vision of health linked to hygienist practices and in the exercise of health education through the transmission of knowledge.
It is evident the need to invest in training curricula that understand the health issues added to teaching within the school, as well as the professional training of technical health personnel and teachers, who work in the IF and who effectively demonstrate little experience in the development of pedagogical practices aimed at teenagers.
The workload of disciplines, the investment in interdisciplinarity and the engagement of SE themes in the IF are still difficulties.There is a need to develop empirical studies on the contributions of health education within the context of technical and technological training and its relationship with encouraging the adoption of a healthy lifestyle, autonomy to exercise their health rights, individual and collective emancipation and the development of citizenship -and in the deepening of health issues focused on mental health, for adolescents with specific needs and those in serious social vulnerability, especially in contexts of racial and gender violence.

Collaborators
Carvalho EL (0000-0002-1145-9306)* contributed to the conception and design of the research, data collection, data analysis and interpretation, writing of the manuscript, critical review of the text, final approval of the text and integrity of the results presented.Jesus LA (0000-0002-4471-6057)* and Paz OS (0000-0002-1126-0620)* contributed to data collection, data analysis and interpretation, manuscript writing, final approval of the text and integrity of the results presented.Santos JO (0000-0001-8687-6430)* contributed to the analysis and interpretation of data, writing of the manuscript, final approval of the text and integrity of the results presented.Vieira GN (0000-0002-7393-3958)* and Neves RF (0000-0002-3889-560X)* contributed to data interpretation, manuscript writing, critical review of the text, final approval of the text and integrity of the results presented.s

Table 1 .
Use of descriptors integrating adolescent health, health in the school environment and federal institutes

Table 3 .
Summary of results