DISCUSSION
Characterization of the integration between the health and education sectors
Intersectoral action related to health and education began at the end of the 19th century with the promotion of integration between health and education practices. In Brazil, in 1971, the Law of Guidelines and Bases of Education was implemented, making it mandatory to implement health programs in the school curriculum. In 1984, based on the same law, the National School Health Program (PNSE) was created, which expressed a biological and curative ideology based on the political influences of the Military Dictatorship. Health actions in the school setting had as common characteristics the discontinuity and the lack of coordination between health and education professionals40,41.
At the end of the 20th century, with the creation of the ECA, adolescents began to be recognized as subjects of rights and to have priority in public health policies. They are understood as individuals in biopsychosocial development who require comprehensive protection. The emergence of the ECA transformed the view of offenders that society attributed to adolescents, allowing their full development by combating social exclusion42. In dialogue with the ECA, the document Care Line for Comprehensive Health Care for Children, Adolescents and Their Families in Situations of Violence: Guidance for Managers and Health Professionals guides the prioritization of adolescent health care and encourages the development of actions to prevent violence that threatens the rights consolidated to adolescents31.
In 2007, with a view to implementing actions to promote and prevent risk factors that permeate adolescence, the document Comprehensive Health for Adolescents and Young People: Guidelines for the Organization of Health Services was created, which reinforces the need for a service that is accessible to adolescents, bringing privacy and confidentiality as one of the pillars of care, which guarantees a greater connection between adolescents and services when their decisions are respected21. However, for this to happen, better professional training is necessary so that these adolescents can be kept in the network. The lack of preparation of a team to deal with the issues that permeate young people does not allow the development of effective actions due to the absence of instruments capable of changing this scenario in order to validate their real demands12,17,21.
To meet the needs of adolescents in an intersectoral manner, Decree No. 6,286 of 2007 instituted the School Health Program (PSE). This important public health policy began to guide the integration of the health and education sectors in order to guarantee comprehensive care for the school population, including adolescents16. The PSE seeks to optimize the use of available resources with the work of professionals from Primary Health Care (PHC) teams in the development of actions aligned with the demands observed by the school team or by the students themselves17,25,35. However, approaches directed at mental health, violence and racism are currently less frequent, which demonstrates the difficulty of professionals in discussing issues of a more social and humanistic nature16,43.
The Primary Care Notebook: Health at School, published in 2009, addresses the implementation of the PSE, providing important information on intersectorality. It highlights collaboration between health and school teams as fundamental not only for disease prevention, but also for promoting healthy practices among school adolescents24. However, for adolescents to understand their responsibilities in self-care and associate health with well-being, family support and the positive influence of the community are essential. These factors have a significant impact on their choices, reflected, for example, in the adoption of a healthy diet and the practice of physical activities44.
In 2011, the PSE Step by Step: Health Program at School - Weaving Paths of Intersectorality provided guidance on program management and described the components of the PSE, which range from clinical and psychosocial assessment to health promotion and prevention actions, highlighting the need to integrate these actions into the school's political-pedagogical project and to strengthen the participation of the school community27. In the same direction and with the perspective of contributing to the resolution and effectiveness of health actions, coordinated with schools, with the adolescent population aged 10 to 19 years, in 2013 the document Basic Guidelines for Comprehensive Health Care for Adolescents in Schools and Basic Health Units was published. The document points out possible paths for promoting intersectorality and details the procedures that can be carried out, such as basic health monitoring and educational actions focusing on different themes28.
The National Guidelines for Comprehensive Health Care for Adolescents and Young People in Health Promotion, Protection and Recovery, dated 2010, play an important role in seeking to promote positive integration between the health and education sectors, focusing on a comprehensive approach that is attentive to the specific needs of adolescents26. Although adolescence in general has its own particularities related to the age group, it is essential that health and education professionals are able to observe particularities and emphasize the importance of care that respects rights and singularities12,17,25.
In 2015, the PSE Manager's Handbook also emerged with the narrative of promoting school health, guiding both health and education management in the implementation of PSE actions, addressing intersectorality as an important process for health promotion. Even if the actions are carried out, planning, support from the school community, continuity and periodic assessment of emerging needs are necessary for their effectiveness33. The lack of school collaboration is due to the lack of information related to health and, consequently, to the lack of understanding about the importance of the PSE, leading to the mistaken characterization of the program as a substitute for the role of the family in adolescent health. In addition, the continuity of actions is also compromised when family support is insufficient, especially with regard to collaboration with the program, such as, for example, when refusing to authorize vaccination for adolescents45.
The 2017 National Health Promotion Policy (PNPS) highlights intersectorality as a fundamental concept for addressing social determinants of health through the articulation of public policies that target the vulnerabilities that emerge in the population with health promotion actions, promotion of sustainable development in various scenarios, including school, sharing goals and objectives, with health being the main point among all policies, with the understanding that factors related to well-being are also developed socially and economically34. In the context of school health practice, intersectoral action is essential, recognizing that the health sector alone does not cover all the possible responses for the area. Coordinated actions between the health and education sectors advance the design of actions that aim to improve health and healthy behaviors, which can be reached by the general population, and in particular, by priority groups that attend schools and, naturally, are far from health units46.
With the aim of guiding and expanding adolescents' access to PHC, the Ministry of Health developed the guide Protecting and Caring for Adolescent Health in Primary Care. The document emphasizes the need for comprehensive care that takes into account the specificities, needs and vulnerabilities of this population, including adolescents at risk, in conflict with the law, quilombolas and indigenous people. To this end, it addresses topics such as interculturality and health, socio-education, nutrition, work and sexuality, promoting autonomy and youth protagonism through the Strategy for the Integration of Management of Adolescents and their Needs (Iman)35. In this context, transposing the focus from adolescents to the adolescence category becomes a viable path. By expanding individual actions to collective actions, with participatory, aggregating, emancipatory, informative and constructive strategies, it is possible to bring the health service closer to the expectations and needs of adolescents12. The adolescent health records were created as tools for guidance and monitoring of growth and development, gathering information on physical processes in the body, the promotion of healthy habits, the vaccination schedule and sexual health. In addition, the document highlights the role of schools in guaranteeing rights and promoting the comprehensive health of adolescents over time29,30. In the perception of health professionals, the record is an effective alternative for managing care, since its illustrative and dynamic format facilitates the care of adolescents12. However, the lack of professional preparation and the low demand of young people for services interfere with the completion and verification of the document. In addition, there is some resistance on the part of parents and guardians, who interpret the illustrations on pubertal development as a possible early encouragement of sexual practices47.
The Legal Framework: Health, a right of adolescents, aims to support health professionals in the development of public policies that promote the comprehensive health of adolescents. The document addresses national and international legislation related to adolescent health, citing the ECA as a major pillar for these rights. Furthermore, it discusses several vulnerabilities that affect adolescence, such as pregnancy, exposure to the HIV virus, alcohol and drug abuse, among others22. Adolescence, in itself, is already marked by several development and growth factors, both individual and social, making this group more in need of attention. However, social inequality worsens this condition by limiting access to education, basic sanitation and decent housing. As a consequence, adolescents are more vulnerable to health problems, such as substance abuse, violence, infectious diseases and crime. In this context, intersectoral activities involving culture, health, education and social assistance are essential to break the cycle of exclusion and promote effective social policies48.
In 2024, Technical Note No. 2 addressed the National Week for the Prevention of Adolescent Pregnancy in Brazil, highlighting the importance of adolescent rights and health promotion. The document emphasizes that adolescent pregnancy is a public health problem that directly impacts the lives of girls, whether from an educational, financial or health perspective. Furthermore, it highlights the high rates of obstetric complications, such as premature rupture of membranes and premature birth, as well as the impacts on the mental health of adolescents39. Given this scenario, it is recommended that male adolescents be involved in discussions about teenage pregnancy, with the aim of promoting shared responsibility and ensuring access to adequate information. Teenage pregnancy also reflects territorial, ethnic-racial and socioeconomic inequalities, being more prevalent among adolescents from poorer regions, indigenous people, black people, mixed race people and those with low levels of education39,49.
In addition to these issues, the mental health of adolescents should also be a priority in public policies. The Mental Health Guide for adolescents aged 11 to 14 is a booklet that is part of the Integrated Educommunication Actions for the Prevention of Suicide and Self-harm project. The booklet addresses the development of emotional intelligence in adolescents, encouraging the identification and sharing of emotions, in addition to raising awareness of relevant social issues, such as bullying36.
Health promotion is a fundamental tool for expanding knowledge, encouraging self-care and strengthening the autonomy of adolescents. It can help address social determinants of health and act in mental health care, promoting integration among different sectors38,50.
Understanding the need to expand the approach to mental health in Primary Care, it is essential to take a different look at adolescents, aiming at improving care. Currently, many of the strategic mental health facilities that serve this population are still under construction51. Most Primary Health Care (PHC) services do not have specific activities for adolescents, or, when they do exist, they are specific and focused on prevention, generally related to sexuality (prevention of sexually transmitted diseases) or drug use. The development of specific actions for this population could be a key strategy to improve care and ensure greater adherence of adolescents to health services50.
Role of schools in comprehensively addressing adolescents’ health needs
Promoting mental health in schools is essential to identify symptoms of psychological distress among adolescents and provide adequate support. The discussion circle methodology is an effective tool for addressing sensitive topics, as it allows adolescents to express their feelings in a safe and comfortable way(56). Thus, mental health education in schools becomes an essential strategy for building a more welcoming and inclusive environment57.
The Activity Suggestions Guide: Health Week at School proposes activities that promote healthy behaviors and intersectoral actions between school and primary care32. Schools also play a fundamental role in building adolescents' critical and moral sense, helping them deal with adversities, including school violence, which directly impacts their performance and well-being31. Along the same lines, the Escola que Protege project emphasizes the importance of schools in preventing violence and training professionals capable of defending the rights of children and adolescents23.
FINAL CONSIDERATIONS
Integration between the health and education sectors is essential for promoting adolescent health, ensuring comprehensive care aligned with their needs. The documentary analysis demonstrated that, over the years, several regulations and public policies have been developed to strengthen this intersectoral approach, with the PSE being one of the main milestones in this articulation. However, despite advances in the formulation of guidelines and strategies, their implementation still faces structural challenges, such as fragmented actions, lack of continuity in policies, and the need for greater training of professionals involved.
Recognized as a privileged space for youth development, schools play a central role in promoting health and preventing harm. However, for this action to be effective, the school environment must be prepared to welcome and respond to adolescents' demands in a comprehensive manner. This includes expanding discussions on mental health, violence, racism, and social inequalities, topics that still encounter barriers to being addressed in PSE actions and other intersectoral initiatives. The lack of specific training for education and health professionals also limits the potential of these policies, making them, in many cases, isolated and disconnected from the reality of students.
Another point that deserves to be highlighted is the active participation of adolescents in the planning and implementation of health promotion actions. The documents indicated that the most effective actions are those that recognize the leading role of youth, allowing adolescents themselves to be agents of change in their school and community context.
Furthermore, strengthening the intersectoral relationship between health and education requires actions that go beyond the formulation of regulations, including governance strategies that guarantee the sustainability and effectiveness of these policies in practice. The advancement of this agenda depends on the valorization of joint work between health and education teams, investment in professional training and the creation of mechanisms that enable adolescents to be listened to and actively participate. Only then will it be possible to guarantee comprehensive, equitable and evidence-based care, capable of effectively responding to the demands of the adolescent population in Brazil.
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Funding and Acknowledgements:
The research did not receive funding.
Authorship criteria (authors' contributions)
Tarciso Feijó da Silva: 1. contributed substantially to the conception and/or planning of the study; 2. to obtaining, analyzing and/or interpreting the data; 3. And to the writing and/or critical review and final approval of the published version.
Juliana de Moura Rodrigues: 1. contributed substantially to the conception and/or planning of the study; 2. to obtaining, analyzing and/or interpreting the data; 3. And to the writing and/or critical review and final approval of the published version.
Bruno Santos Moreira: 1. Contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Nicolle Silva de Menezes: 1. Contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Jéssica da Cunha Campos: 1. Contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Ana Beatriz da Costa Santiago de Almeida: 1. Contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Caroline Fernandes de Oliveira: 1. Contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Luciana Alves Paixão: 1. contributes to obtaining, analyzing and/or interpreting data; 2. And to writing and/or critically reviewing and final approval of the published version.
Declaration of conflict of interest
Nothing to declare.
Scientific Editor: Ítalo Arão Pereira Ribeiro. Orcid: https://orcid.org/0000-0003-0778-1447
Rev Enferm Atual In Derme 2025;99(supl.1): e025075
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