THE TERRITORY AND ITS REPERCUSSIONS IN THE LIFE OF A TEENAGER: CHALLENGES FOR A COMPREHENSIVE CAREABSTRACT
Objective: To understand the territory and its repercussions on the comprehensive care of adolescents in the context of Primary Health Care.
Method: This qualitative research was conducted through semi-structured interviews with 24 primary healthcare professionals in 12 inland municipalities of Rio Grande do Sul, Brazil. Data were collected from June to December 2021, subjected to inductive thematic analysis, and interpreted based on the theoretical frameworks of Freirean integrality and autonomy.
Results: The existential territory of adolescents is marked by social differences, vulnerabilities, and cultural issues that influence access to health, education, rights, citizenship, and the planning of their life projects. Family and the relationships built within them have an impact on teenagers’ lives. The impact of social problems on the family unit can negatively influence health, while strengthening the family structure is a protective factor. Teenage pregnancy often emerges as a planned activity among adolescent girls, linked to social advancement.
Conclusion: Understanding the impact of territory on the comprehensive care of adolescents within the context of Primary Health Care allows for a broader perspective on the possibilities of care for this group, based on the importance of developing their autonomy from a Freirean perspective.
DESCRIPTORS:
Adolescent; Sociocultural territory; Comprehensive healthcare; Primary Health Care; Nursing
RESUMO
Objetivo: compreender o território e suas repercussões na integralidade do cuidado ao adolescente no contexto da Atenção Primária à Saúde.
Método: pesquisa qualitativa realizada por meio de entrevistas semiestruturadas com 24 profissionais de saúde da Atenção Primária à Saúde em 12 municípios do interior do Rio Grande do Sul, Brasil. Os dados foram produzidos de junho a dezembro de 2021, submetidos à análise temática indutiva e interpretados com base nos referenciais teóricos da integralidade e da autonomia freireana.
Resultados: o território existencial dos adolescentes é marcado por diferenças sociais, vulnerabilidades e questões culturais que influenciam no acesso à saúde, à educação, aos direitos, à cidadania e no planejamento de seus projetos de vida. A família e as relações construídas repercutem na vida dos adolescentes. O reflexo de problemas sociais no eixo familiar pode influenciar negativamente na sua saúde, enquanto o fortalecimento da estrutura familiar é fator protetivo. A gravidez na adolescência emerge de maneira planejada pelas adolescentes, vinculada à ascensão social.
Conclusão: a compreensão das repercussões do território na integralidade do cuidado ao adolescente no contexto da Atenção Primária à Saúde, possibilita uma ampliação do olhar sobre as possibilidades de cuidado a este grupo a partir da importância do desenvolvimento de sua autonomia na perspectiva freireana.
DESCRITORES:
Adolescente; Território sociocultural; Integralidade em saúde; Atenção primária à saúde; Enfermagem
RESUMEN
Objetivo: Comprender el territorio y sus repercusiones en la integralidad del cuidado de los adolescentes en el contexto de la Atención Primaria de Salud.
Método: Esta investigación cualitativa se llevó a cabo mediante entrevistas semiestructuradas con 24 profesionales de atención primaria de salud en 12 municipios del interior de Rio Grande do Sul, Brasil. Los datos se recogieron entre junio y diciembre de 2021, se sometieron a un análisis temático inductivo y se interpretaron basándose en los marcos teóricos de la integralidad y la autonomía freireanas.
Resultados: El territorio existencial de los adolescentes está marcado por diferencias sociales, vulnerabilidades y cuestiones culturales que influyen en el acceso a la salud, la educación, los derechos, la ciudadanía y la planificación de sus proyectos de vida. La familia y las relaciones que se construyen influyen en la vida de los adolescentes. El impacto de los problemas sociales en la unidad familiar puede influir negativamente en la salud, mientras que el fortalecimiento de la estructura familiar es un factor protector. El embarazo adolescente suele surgir como una actividad planificada entre las chicas adolescentes, vinculada al progreso social.
Conclusión: Comprender el impacto del territorio en la atención integral de los adolescentes en el contexto de la Atención Primaria de Salud permite una perspectiva más amplia sobre las posibilidades de atención para este grupo, basándose en la importancia de desarrollar su autonomía desde una perspectiva freireana.
DESCRIPTORES:
Adolescente; Territorio sociocultural; Integralidad en salud; Atención primaria de salud; Enfermería
INTRODUCTION
Caring for adolescents challenges healthcare professionals to develop a broader model of care that considers them beyond biological aspects and respects the unique characteristics of the generational stage they are experiencing. To do this, it is necessary to understand the adolescent's existential territory, which means to consider their history, living conditions, and peculiarities according to the context in which they are inserted1. The existential territory transcends the spatial aspect; it is permeated by interactions, that is, it refers to encounters and their dynamism, the experiences, dialogues, and relationships occurring in the community2.
In adolescents’ daily lives, daily activities are marked by social relationships and the resources available in the area. It should be highlighted that social inequalities and vulnerabilities in the Brazilian context point to heterogeneity in the construction of these young people's life projects, since vulnerabilities such as poverty, violence, difficulties in the family context, and cultural aspects can be significant barriers to the consolidation of comprehensive care3. Furthermore, barriers related to gender and access to education can represent obstacles to a more integrated approach to the context and unique characteristics of adolescents seeking health services4.
Furthermore, these disparities result in poor access to health services for adolescents. Therefore, in planning actions for the care of adolescents, it is essential that health professionals seek to engage in discussions about adolescence as a generational category and strive to understand the determinants of the health-disease process, the potential for strengthening, and the weaknesses that guide meaningful interventions for comprehensive care5.
This comprehensiveness is characterized by the ability to broadly understand people's needs and to assess whether the care provided is appropriate to their particular context. It is based on intersubjective relationships and dialogue, with encounters occurring between healthcare professionals and these individuals, since it is from this encounter that the needs for actions in healthcare services can be identified6. Advocating for comprehensive healthcare practices means maintaining that health actions should be aligned and adjusted to the specific conditions of each case7.
The role of Primary Health Care (PHC) is reinforced as the first level of the Health Care Network (RAS), that is, it is the “gateway” for embracing adolescents. The structural elements of PHC are highlighted, referred to as essential attributes, such as first-contact access, longitudinality, comprehensiveness, and coordination, and derived attributes, with family and community orientation and cultural competence as important tools for this care.
As a guiding principle of the study, the aim was to delve deeper into the essential attribute of comprehensiveness and to consider the territory for its consolidation8. Comprehensiveness is one of the pillars in the consolidation of the Brazilian Public Health System (SUS), which presupposes health actions that consider the biopsychosocial aspects of the individual in the health-disease process8. Furthermore, it seeks to reorient practices through the creation of bonds, acceptance, and autonomy of the individual, which values the subjectivities inherent in healthcare work and the needs of adolescents as starting points for any intervention5. In this context, in 2007 the Ministry of Health created the document “Comprehensive Health of Adolescents and Young People,” which provides guidelines for the organization of health services, expands adolescents' access to primary health care, and reinforces that young people receive comprehensive, effective, and participatory care, with privacy and confidentiality, thus promoting a stronger connection between adolescents and health services9.
Comprehensiveness can be understood from various angles, which are not mutually exclusive, but highlight different aspects of the same issue. It is an articulation between health promotion, prevention, and recovery through actions that are structured in the same space, with the constitution of knowledge and actions that complement each other. Of particular note is the decisive role of managers who organize health services and establish connections that foster comprehensiveness across the different levels of complexity and competencies within a network8.
Another theoretical framework used was Paulo Freire's perspective on autonomy, encompassing concepts such as dialogue, education, conscientization, and the subject’s autonomy10. The commitment to caring for adolescents involves recognizing educational processes as instruments to foster personal development, based on reflection on the problems faced, highlighting, in this direction, dialogue and reflection on the reality experienced.
For a person to become autonomous, they have to acquire a critical view of the world and its history. The education acquired is essential for a person to achieve autonomy, since the individual learns throughout life, based on their intersubjectivity and established relationships10.
The emancipation of human beings in their healthcare involves a liberating dimension and critical thinking, which allows for the transformation of social reality. Autonomy has to be valued in the caregiving process, by practicing a collaborative approach with others, encouraging responsibility for their care, and enabling them to “be more” in a Freirean perspective10,11. “Being more” in this perspective means not being the object, but rather the subject of one's own history through reflection, because the adolescent is a relational being who is in the world and with the world12.
Therefore, the practice of the health team in primary health care can contribute to the adolescent's autonomy in their health care, given their proximity to the population and their primary role, further strengthened by points of care in the territory, such as the school environment5. Against this background, in 2007 the Program Health at School (Programa Saúde na Escola, PSE) was established, which was an important public health policy that has guided the integration of the health and education sectors, marking a milestone in the appropriation of the school as a space for health promotion13. In 2010, the National Guidelines for Comprehensive Healthcare for Adolescents and Young People in the Promotion, Protection, and Recovery of Health were implemented as a way to integrate the health and education sectors, focusing on a comprehensive approach attentive to the specific needs of adolescents14.
Thus, this study is in line with the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030), promoted by the World Health Organization and associated with the Sustainable Development Goals, which aims to provide adolescents with access to their rights to health, well-being, education, and full and equal participation in society, preparing them to reach their full potential as adults, through more flexible and accessible health services for adolescents15,16.
Furthermore, the relevance of this study is justified as there is a gap in scientific literature directed at adolescents, which consists mostly of publications focused on biological aspects and with a view that predominantly sees this group as a phase in the developmental cycle. It becomes essential to include themes that align with their health needs and the changes in the contemporary world, and that require a focus on the social determinants of health in the population, since these have a strong impact on adolescents’ physical, cognitive, emotional, and social development17,18.
Based on this, the research question was: what is the impact of the territory where adolescents live on their lives and health? The goal is to understand the territory and its repercussions on the comprehensive care of adolescents within the context of Primary Health Care.
METHOD
This is a qualitative study based on the theoretical frameworks of comprehensiveness and autonomy by Paulo Freire8,12 for data interpretation. Data was collected through semi-structured interviews, which allowed for an in-depth conversation between the researcher and the interviewee. The script was based on a question guide, which was tested with nurses from the research group, working in primary health care, as a pilot test. The aim of this approach was not to limit the participant's freedom of expression, so that their contributions would be considered in a way that would contribute to a deeper understanding of the object of the study19. For guidance and methodological rigor, the Consolidated Criteria For Reporting Qualitative Research (COREQ)20 was applied for the preparation of this report.
The study was conducted in public primary health care units in a health region in inland cities of Rio Grande do Sul, Brazil. The health region is composed of 12 municipalities. Of the total number of municipalities, seven have a population of less than 10,000 inhabitants (58.3%), two between 10,000 and 20,000 (16.7%), two between 20,000 and 50,000 (16.7%), and one above 50,000 inhabitants (8.3%), most of which are small and medium-sized municipalities with around 200,000 inhabitants21.
The selection criteria for participants were being healthcare professionals belonging to the primary care team in the study area. They were selected through contact with the municipal coordinators of PHC, who indicated two professional categories that worked with the adolescent population to be invited to participate in the study. Considering the health region selected for the study (comprising 12 municipalities), two health professionals from each municipality were interviewed, totaling 24 participants. The PHC coordinator indicated healthcare professionals who were most active in carrying out actions directed at the adolescent population in their area of operation. Data collection involved one dentist, one nursing technician, two community health workers, three doctors, four psychologists, and thirteen nurses. It is noteworthy that, out of the 24 people interviewed, 13 recommendations were nurses. This finding reinforces the role of nurses in the care of adolescents in Family Health and Primary Care Teams, as well as their close relationship with this population. It should be noted that most of the participants were not known to the researcher.
The data collection period was from June to December 2021. A phone call was made to invite the participant and provide details about the study, followed by scheduling an in-person or remote session. The 24 interviews with healthcare professionals were conducted by one of the authors, a nurse and doctoral student with experience in this type of approach. Two interviews were conducted in person and 22 remotely, as the period coincided with the restrictions imposed by the COVID-19 pandemic.
The questions that guided the interviews were as follows: How is it for you to work with adolescents?; Did your professional training cover topics related to adolescent care?; Do adolescents seek care at the health unit?; If so, how often? In which situations?; What are the adolescents’ health needs in your area?; What actions are being developed specifically for adolescents?; Do you perceive any difficulties in caring for adolescents in your area of care?; What strategies are or could be used to approach and care for adolescents?; Do you perceive any need for change in the way adolescents are cared for?
The duration of each interview varied between 40 and 50 minutes. The in-person interviews were conducted in a specific room at the health unit where they worked. For the others, online meeting times were scheduled via the Google Meet® platform. The interviews were recorded for later transcription and analysis of the data produced. The number of participants was not determined a priori. However, during data collection, after including two participants from each municipality, the interviews were concluded because the researchers considered the empirical material sufficient for understanding the phenomenon under study19.
The data produced were subjected to inductive thematic analysis22. Initially, participants became familiar with the topics through exhaustive reading of the interviews, from which the most recurrent and polysemous themes were identified. Subsequently, an analytical synoptic chart was developed, organized with a color-coded system, highlighting the fragments of speech and themes that were inductively originated. Therefore, the themes were linked to the territory and its repercussions on the adolescent's life, leading to discussions of social and economic aspects, life plans, family context, and teenage pregnancy.
Anonymity was guaranteed through the use of codes: (ACS = community health agent, ENF = nurse, MED = doctor, TecENF = nursing technician, DENT = dentist, PSICO = psychologist) and number according to the scheduling of the interviews. It is important to note that no artificial intelligence tools were used in the creation of this article.
RESULTS
In their reports, healthcare professionals acknowledge that the context in which adolescents live has vulnerabilities related to social and economic aspects:
Some live in extreme poverty and struggle with self-esteem because their clothing is simpler. [...] Others say they'll never get a girlfriend because they're poor or can't afford one (ACS1).
In my own area it's different. I have a very vulnerable area, due to social inequality, where people have economic difficulties, and then I have another population of teenagers who have a more structured life, with rules, routines, and established families. [...] what worries me most are the vulnerable teenagers; I notice they face more problems. And now, due to the pandemic, it has ended up affecting all social classes (ENF2).
The vast majority of teenagers attend school, but we see quite a few teenagers who finish elementary school and then stop going to school. The municipality has a fairly extensive agricultural area. When they reach 14 or 15 years old, they no longer go to school and stay at home helping their parents. They also drop out of school due to poverty, to work both in the city and in the countryside (TecENF5).
[...] I have those who are more socially vulnerable, more needy, and have less access to leisure activities, experiencing hardship within their families, and then there are others who have better conditions, access to the internet and a better cell phone, a more structured family (ENF6).
Extreme poverty is present in the areas covered by primary health care teams. The community health worker reports issues related to adolescents’ self-esteem, as they feel inferior because they live in poverty. They associate the clothing worn and economic difficulties with the impossibility of having a relationship.
Within the same territory, one observes the existence of families with distinct social conditions: while some adolescents experience difficulties caused by their economic situation and the social vulnerabilities to which they are exposed, others have greater economic stability and resources such as internet and cell phones, as well as greater family structure and support. The nurse emphasizes the concern for the most vulnerable adolescents, given that they face more difficulties in their daily lives.
Poverty also influences adolescents’ formal education since, due to the barriers they encounter, they drop out of school to work in the city or with their families in the countryside. The municipalities in the selected Health Region mostly have an economic history linked to agriculture. Moreover, because this region is located in a vast rural area, many teenagers live and work in the countryside.
In this regard, more vulnerable areas may be associated with greater barriers to access to health, education, and basic life rights, also impacting their self-esteem. Furthermore, focusing on the health of adolescents living in rural areas, encompassing situations such as early and informal work, school dropout, and emotional problems related to self-esteem, denotes a need for special attention from primary health care teams.
Consequently, when considering comprehensive care in health planning, the actions developed need to be more consistent with reality to reduce local inequities, with special attention to the specific needs of adolescents living in rural areas. The vulnerabilities present can influence the adolescent's autonomy and their discernment in decision-making, since unfavorable aspects can represent limits to their potential growth and development.
The results demonstrated the professionals' perception of the perspectives of adolescents living in the PHC area: their future, entry into the job market, and access to opportunities.
It's very distressing for them. In September, we did an activity related to Suicide Prevention Month (September), and we made a time capsule, bringing poster boards with information about their dreams. Then some of them wrote that they wanted to travel abroad. And other teenagers say, “But you just wanted to, didn't you? You're going to end up here planting tobacco.” (MED9).
Most teenagers here are from rural areas and they don't have access to extracurricular activities outside of school; there are very few options available. This limits their ability to engage in different activities (ENF10).
A cultural issue. Ultimately, they start dating very young, move in together very young, then they start a family very young, and often the future perspective I see in these girls is to find a husband, someone, get married and have children, and then... (ENF13).
The life project is geared more towards affective relationships and family formation than the parental guidance we received; so here it's not about studying first, it's about studying as long as possible (PSICO15).
We realize that teenagers don't have many options here; it's either work or farming [...] I think it also has something to do with family ties and the continuity of agricultural culture (ENF22).
Healthcare professionals seek to encourage adolescents’ life projects, asking them about their dreams and what they aspire to for the future. There are difficulties in exploring these issues due to cultural aspects of the territory; adolescents work in the informal sector and in the countryside, and in addition, there is a high rate of dropping out of school.
Among the teenagers themselves, there may be some barrier to seeking new paths due to the weight of economic difficulties. Furthermore, in the area where they live, there are few attractive activities for the public, as well as opportunities for improvement in agricultural work, a common practice in the region studied.
Poor access to education, as well as early school dropout rates, negatively impacts the development of critical awareness in adolescents and their perspective on their life plans within their community. Working in the field, while maintaining family farming practices, can be a strategy to expand the activities developed in this setting, providing opportunities for professional development and continued education.
Fragility in the family structure and lack of support for adolescents were highlighted in the interviews:
Sometimes the problems are within the family itself, including parents who take little responsibility for their children's health (DENT3).
Lots of violence between parents, drug use, mothers and fathers who are users, taking it out on their children (ENF4).
Family conflicts. These are family matters. A family that is already dysfunctional, parents who fight a lot, a father who is an alcoholic. Either the mother and the father, and then there's this conflict between the couple that interferes in the teenager's life (PSICO16).
[...] a father who beat the mother at home, both physically and verbally. And it was interesting that the teenager brought [...] I thought that was normal (ENF20).
It was a father and son arriving, a father aged 30/32/34 arriving with his 16-year-old son, and the two of them smoke crack together. So, in all cases of drug use, every single one, the father either beat the mother, or the father was an alcoholic, or the mother was a drug user or a prostitute. There's always something in the parents; it's very rare that there isn't something within the family that triggered that in the child (MED24).
The family environment, the relationships built, and the support network available to adolescents are all aspects influencing their lives. The impact of social problems, such as unemployed parents, domestic violence, and the use of alcohol and other drugs, negatively affects the environment in which adolescents grow and develop.
The vulnerabilities present in their living environment have an effect on the adolescent experience, as they grow up in a space permeated by violence, illicit drugs, and constant worries. Furthermore, the lack of dialogue with the family, coupled with stigmas and prejudices, restricts communication and the relationship between parents and children, with the family not being recognized as a reference point for the adolescent's protection.
Comprehensive care requires overcoming the existence of different points of attention within a given territory and understanding how adolescents live and relate to each other, as well as the challenges they face in their daily lives, such as violence, drug use, and interfamily conflicts. All of this has to be addressed in healthcare practices.
The cultural issues associated with teenage pregnancy in the region were also highlighted in the professionals' statements:
[...] I believe it's a cultural issue; for a teenager to gain independence, leave their parents' home, develop self-esteem, and establish their identity, they stop being “so-and-so” and start being “someone's mother,” a form of empowerment (ENF7).
The whole issue of family ties, family structure, better relationships, professional development-you don't see much of that-the question of aspiring to a particular profession. We see many pregnant women say that it's planned because it's part of their culture. It's their wish. Some very young couples come with their parents, and they say they've been living together since they were 14; these are very different realities. To them it seems comfortable, it's normal. Today a young woman came here with 4 children, expecting her fifth, and she was very happy. When you delve into the situation, she's unemployed, and this worries me (ENF8).
The biggest problem for the young people, and the reason why the women were pregnant, was the fragile family relationships they had at home. So, what happens? the boy and the girl couldn't establish strong emotional family bonds; they didn't receive affection from their father, they didn't receive affection from their mother, and this weakness in fraternal love was something they tried to compensate for in their relationships (MED24).
Teenage pregnancy is planned by some teenage girls. The status of being a mother is a way for the teenage girl to seek her identity within the community in which she lives, with the possibility of social advancement. The quest for independence, with the departure from the parental home, is achieved when one begins to bring a life into the world and becomes responsible for it.
There are many teenage couples who move in together at age 14, with the knowledge of their parents. The nurse reports that this is seen as something normal and comfortable for the family. The reported situation regarding women expecting their fifth child, unemployment, and lack of reproductive planning, is a cause for concern for primary health care teams. The questioning of social recognition and the meaning of pregnancy for adolescents needs to be considered when addressing them, given the strong cultural component, since this construct has significant temporal roots and, for change and awareness, it is essential to consider the reflection-action-reflection process.
Fragility in family ties leads to the search for new relationships to compensate for the weakness of maternal and paternal emotional bonds, which often triggers early pregnancy during adolescence. The lack of affection, care, and dialogue within the family leads adolescents to seek new relationships to fill the void left by their family.
DISCUSSION
The daily lives of teenagers are permeated by situations of poverty, reinforcing the vulnerable condition they experience. It becomes essential to look at the consequences beyond individual purchasing power, reflecting on access to basic needs, such as health, and to dignified living conditions23. It is understood that health needs vary according to the specific characteristics of the users, and, for care to be based on a comprehensive perspective, it is essential to diagnose the life situation of adolescents and reorient health practices upon identifying inequalities that have to be minimized5. Therefore, one must pay attention to the specific characteristics of individuals, and this is achieved through professional knowledge, intersubjective relationships, and dialogue6.
Starfield, in presenting the structuring axes for work in PHC, affirms the need to consider community orientation as a derived attribute, since knowing the needs of adolescents involves recognizing their territory8. The vulnerabilities revealed in the study should be considered in the healthcare team's planning. When healthcare services provide attention to singularities, they create a path to more meaningfully and effectively addressing the needs of adolescents, that is, addressing them from a holistic perspective.
Therefore, health initiatives have to contribute, in particular, to the lifestyles and habits of individuals, families, and communities, to improve the determinants and conditioning factors of the health-disease process, thus impacting the quality of life of the population. This approach, based on comprehensiveness, requires investments that unfold into actions, especially educational ones, which involve a wide range of social institutions, either governmental or otherwise, particularly schools, clubs, associations, and other sectors that extend beyond the health sector23.
Education as a practice for freedom needs to consider man’s ontological vocation, his concrete reality, presented in Paulo Freire's first core concept, since man has spatio-temporal roots, making it essential to understand the place where man lives, that is, the context and the moment. For education to be effective, a dialectical relationship with the individual's social context is essential11.
In this context, PHC is a potential field for the production of care, since it is closer to people and the place where they live. In addition, it allows for shared care between the user and the multidisciplinary team, based on an expanded, person-centered clinical approach, with a focus on the family and the community8. Furthermore, it allows for understanding and considering the specific context of each person, developing attentive listening skills on the part of all healthcare professionals, with possible negotiations regarding the dynamics of the service, so that each person can receive individualized care according to their needs6.
When considering the territory in which the adolescent lives and shares experiences, the concept is broadened to include existential territory. It is “a living environment that is always subject to modifications, deviations, and recreations of itself, since it is constituted of the relation to other territories in motion.” More than a spatial delimitation, an existential territory is a spatio-temporal location. It is defined by a spatial location that is configured in time; in other words, it is a territory in process over time24.
Regarding adolescents' life project, they plan and dream about adult life and its achievements, constituting a process of emancipation and construction of personal identity. However, unfavorable scenarios, with difficulty accessing essential goods, can be significant barriers to achieving desired dreams25.
In this context, social vulnerability can be seen as a disadvantaged position regarding the rights that should be guaranteed for certain populations. When adolescents experience fear, insecurity, and vulnerability, it is crucial to reflect on the impact of these events on their growth and development, as well as on their adult lives, considering that their paths are marked by unfavorable events and situations26.
The literature suggests that emotional factors, such as self-esteem and the adolescent's identification with the environment in which they grow up, as well as demotivation within the family to continue their studies, hinder the adolescents' life project. This constitutes a risk factor for school dropout during this period of life27, as mentioned by the participants in this study.
A study conducted in Brazil shows that school dropout among teenagers is associated with several factors, including early entry into the labor market, social inequalities, family conditions, financial difficulties, and teenage pregnancy. It should be noted that 41.7% of school dropouts occur due to the need to work, especially in the final years of elementary school. Data from Rio Grande do Sul, from 2023, revealed that 49,000 young people between the ages of 14 and 18 were out of school without having finished high school, with lack of resources for transportation appearing as one of the main reasons, especially among young black people, who make up the majority of those who interrupt their studies in the state. Furthermore, it is observed that women represent almost twice as many young people who are neither studying nor working compared to men28.
It is noteworthy that, in Rio Grande do Sul, the indicator for monitoring the number of live births to adolescent mothers shows high proportions in some health regions and municipal areas with greater socioeconomic vulnerability. Also, in 2023, 314 births were registered to girls between 10 and 14 years old, according to the Live Birth Information System - SINASC-RS, indicating that almost every day a child or very young adolescent becomes a mother in the state29.
According to the Freirean theory, the interaction of man with his environment, with human beings influencing and being influenced by it, leads to reflection on the unfavorable situations reported by health professionals regarding the reality of adolescents in the territory. The importance of considering the scenario experienced by adolescents is reinforced, given that the influence of the environment on them constitutes a dialectical movement that proposes an understanding of their concrete reality, the awareness of this context, and the transition to a critical awareness in which they become committed to change11.
Considering the individual as a product of social and historical construction, this cannot be disregarded in the planning of their future25. Therefore, man strives to be the subject of his own history, aiming at overcoming the barriers produced by material, economic, social, political, cultural, and ideological conditions. The transformation from naive consciousness to critical consciousness involves dialogue and dynamism, and is key to enabling changes in reality10.
Family history and cultural background are reflected in adolescents' choices, as well as in the (im)possibilities arising from the limitations of their environment and the experiences they perceive within their family context. In this sense, the family can be a source of adversity or protection. Therefore, understanding family dynamics and relationships is critical to comprehensive adolescent care30.
In addition, violence and drug use within the family context are detrimental to health. The impact of adolescent exposure to violent acts is a major risk factor for physical and mental health disorders, since the family is the one who should be protecting adolescents. In this regard, parental education and mutual respect are strategies to be implemented to reduce vulnerabilities experienced within the family unit31.
Domestic violence is indicated as a risk factor for drug use and risky behavior among adolescents32. Experiences of violence within the family environment break the adolescent's bond with their family, alienating them and contributing to social disorders and exposing adolescents to greater vulnerabilities32.
From an educational perspective and through horizontal dialogue with young people, healthcare professionals can use tools to stimulate the development of adolescents' life project, based on intersectoral partnerships. This is a responsibility shared by the community, family, and the adolescent themselves. The challenge is to make the dialogue engaging for the audience, which requires understanding the individual's strengths and weaknesses so that the support and care planning are tailored to the adolescent's context and make sense to them33.
Neglectful parenting has negative consequences in children's lives, which can lead to mental health disorders, alcohol and drug use, impaired school performance, and dysfunction in future relationships. Therefore, recognizing an adolescent who is in a situation of parental vulnerability can lead to the provision of more specific care, which presupposes a comprehensive approach, since intersectoral actions can be developed to strengthen the restoration of adolescents’ bonds, trust, and autonomy34.
Family orientation, an attribute listed by Starfield8, underscores the importance of considering the family context for care in PHC. This is because punitive and authoritarian communication between teenagers and their families, coupled with unstable family dynamics, can be a threat to the young person's health.
An adolescent's understanding of their autonomy and the ability to manage their own life is essential for their emancipation. The ability to make decisions and self-determination are strongly linked to one's family background. In this circumstance, working with adolescents and their families presupposes a care that moves towards comprehensiveness33.
Family structure, coupled with cultural issues perpetuated in the territory, influence the decision to become pregnant during adolescence. This is part of family dynamics and is understood as a life project, often planned by teenagers35. Teenage motherhood occurs in a heterogeneous manner, being more common in groups with more vulnerable economic situations, which also impacts lower levels of education. It is known that early pregnancy, between the ages of 12 and 16, is more concerning, since the risks associated with prenatal care, childbirth, and the newborn period are higher compared to other age groups2 6. There is also the transgenerational inheritance of inequalities, that is, the history of teenage pregnancy repeating itself within the same family cycle36.
Another topic discussed by the professionals relates to the adolescents’ life project, which is influenced by family and local culture. It encompasses knowledge, skills, and competencies that enable them to build and rebuild their life projects autonomously, as well as learn to cope with unforeseen events, uncertainties, and changes37.
In light of the Freirean theory, it is understood that the adolescent needs to be considered a subject in this process; the social environment and culture in which they are immersed are a sum of experiences that impact their life projection11. In this context, the adolescent may experience a state of oppression, in which the adult acts as a normative figure by underestimating the adolescent's potential, ignoring the importance of this phase for identity formation, and dismissing their desires and perspectives, thus regulating their future paths38.
The life project constitutes an educational practice, of a longitudinal nature, that has to stimulate critical thinking, reflection, and the individual’s emancipation. In this regard, it is essential to recognize existing vulnerabilities to foster the conception of public policies that strengthen protective factors for adolescent development and minimize risk factors. Therefore, the school stands out as one of the spaces for building mechanisms to protect adolescents and strengthen their autonomy, considering criticism and normative approaches38.
From this perspective, the school is a potential space for addressing life planning and reproductive acts. It is important to encourage young people to reflect on their future, on what they aspire to for the coming years of their lives, to guide them towards greater critical thinking in the face of the situations they experience35. From Freire's perspective, the process of transformation towards liberation is linked to reflection, requiring the overcoming of an oppressive condition through health practices that increase adolescents’ autonomy and empowerment12.
Thus, adolescents’ empowerment constitutes a critical-reflective act and stems from their intersubjectivity and the appreciation of behavioral and cultural factors. Identifying these elements presupposes a dialogue that fosters critical awareness in the individual and promotes greater engagement in life transformations from the perspective of “being more”12. When conducting educational activities with the public, healthcare professionals must be guided by an ethical commitment to leading emancipatory and liberating practices, so that they can contribute to the formation of critical individuals capable of creating change in themselves and in the environment in which they live5.
Therefore, comprehensive care for adolescents cannot be fragmented; it involves an intersectoral approach and is not limited to the responsibility of social and health policies, but encompasses various representations involving public authorities, the family, the community, and civil society as a whole. Intersectorality cannot be seen as a mere act of referral; the coordination of care5 involves shared responsibility and longitudinal monitoring11.
Accordingly, from the community's perspective, as one of the actors in the emancipation of adolescents, in Starfield's view8, community orientation stands out as a derived attribute in PHC. Therefore, for the development of protective practices for adolescents, it is essential to create spaces for greater interaction with the community, which need to emerge within the context of the local reality39.
In light of the results, it is recommended to implement ongoing educational strategies in schools that encourage life projects and critical reflection on adolescents' reproductive choices, with the active participation of health professionals through practices based on dialogue and adolescent autonomy. Likewise, care must be comprehensive and intersectoral, involving health, education, family, and community, aiming to create spaces for interaction that promote the personal and social development of this population.
One limitation is that the study was conducted in a specific region of Brazil, which may restrict the application of the results to other social, cultural, and economic realities. Along with it, as an implication of this study, it is suggested that further research be conducted in different school contexts to analyze the impact of the environment on the autonomy and empowerment of adolescents, to broaden the understanding of intersectorality in the comprehensive care of young people.
CONCLUSION
The existential territory of adolescents, where they live and interact, is permeated by social differences, vulnerabilities, and cultural issues that influence access to health, education, rights, and citizenship. Understanding the repercussions of this territory on the comprehensive care of adolescents within the context of primary health care has broadened the perspective on the possibilities of care for this group, based on the importance of developing their autonomy from a Freirean perspective.
Also, adolescents’ life project from this perspective, recognizing their needs, is one of the cornerstones for strengthening the comprehensiveness of adolescent care in PHC. Initiatives that promote the adolescent's life project should be included in care planning to minimize barriers present in the community.
It is believed that comprehensive care presupposes considering the family unit, since, in the home context, the adolescent can find safety or, in some situations, vulnerabilities that indicate the need to be attentive to situations of violence and the use of alcohol and other drugs. Therefore, shared care with the RAS has to be coordinated to ensure the adolescents’ protection.
Also highlighted is the potential of the PSE to strengthen ties between health teams and the school community, promoting greater access for adolescents to qualified health information, increased family participation and involvement in the actions developed, and the consolidation of intersectoral partnerships that contribute to comprehensive care.
Similarly, social projects are strategies that improve the quality of care for adolescents, through collaboration between different sectors, as well as companies and non-governmental organizations, and contribute to their empowerment from caregiving. Moreover, the school is an important partner for connecting adolescents with the health unit, as it serves as a space to publicize the actions being carried out and to address topics of interest to young people according to their needs.
This way, the importance of providing feedback on the findings of this study to municipal and regional administrations is highlighted, to improve care by paying attention to the needs of the territory studied, and to implement more effective practices to guarantee comprehensive care for adolescents. One limitation of the study is the interpretation of the results, which should be considered appropriate for the population studied. It is suggested that further studies be conducted in other contexts to understand this phenomenon from the perspective of adolescents.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the thesis - Integrality in adolescent care in primary health care, presented to the Graduate Program in Nursing, Universidade Federal de Santa Maria, in 2023.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Santa Maria, opinion no. 4,827,966, Certificate of Presentation for Ethical Review 47386521.8.0000.5346.
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TRANSLATED BY
Denise Costa Rodrigues.
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DATA AVAILABILITY
The entire dataset supporting the results of this study is available upon request from the corresponding author Francielle Brum dos Santos de Siqueira. The dataset is not publicly available because it contains information that compromises the privacy of the study participants.
The entire dataset supporting the results of this study is available upon request from the corresponding author Francielle Brum dos Santos de Siqueira. The dataset is not publicly available because it contains information that compromises the privacy of the study participants.
