VULNERABILITY OF ADOLESCENTS TO SEXUALLY TRANSMISSIBLE DISEASES IN PRIMARY CARE VULNERABILIDADE DE ADOLESCENTES ÀS DOENÇAS SEXUALMENTE TRANSMISSÍVEIS NA ATENÇÃO PRIMÁRIA VULNERABILIDAD DE ADOLESCENTES A LAS ENFERMEDADES SEXUALMENTE TRANSMISIBLES EN LA ATENCIÓN PRIMARIA

Objective: to identify the vulnerability situations adolescents are in relation to Sexually Transmitted Diseases in Primary Health Care. Method: this is a bibliographical, descriptive, integrative review type search of articles in the MEDLINE, BDENF and LILACS databases, in the period from January 2011 to December 2015. For this purpose, the following descriptors were used: adolescent, sexually transmitted diseases and primary health care, all with associations applying the “AND” in Portuguese, English and Spanish languages. The instrument adapted from the Ursi 2006 study was used to select the articles, which allowed outlining the main information. Results: there were 12 articles analyzed after applying the criteria. The results identified the following themes: socioeconomic conditions, early onset of sexual activity, lack of condom use, gender differences and difficulty of communication and access to Primary Health Care services. Conclusion: it was observed that adolescents need to be sensitized on the circumstances that lead to Sexually Transmitted Diseases, through partnerships with health services and social spaces in the community. Descriptors: Adolescent; Sexually Transmitted Diseases; Primary Health Care; Sexuality; Condoms; Gender Identity. RESUMO Objetivo: identificar as situações de vulnerabilidade em que os adolescentes se encontram em relação às Doenças Sexualmente Transmissíveis na Atenção Primária à Saúde. Método: estudo bibliográfico, descritivo, tipo revisão integrativa com busca de artigos nas bases de dados MEDLINE, BDENF e LILACS, no período de janeiro de 2011 a dezembro de 2015. Para tanto, utilizou-se os descritores: adolescente, doenças sexualmente transmissíveis e atenção primária à saúde, todos com associações aplicando-se o “AND” nos idiomas português, inglês e espanhol, além disso, para a seleção dos artigos, foi utilizado o instrumento adaptado do estudo de Ursi 2006, o qual permitiu esquematizar as principais informações. Resultados: foram analisados 12 artigos após aplicação dos critérios. Os resultados identificaram as seguintes temáticas: condições socioeconômicas; início precoce da atividade sexual; falta do uso do preservativo; diferença de gêneros; e dificuldade de comunicação e acesso aos serviços de Atenção Primária à Saúde. Conclusão: observou-se que os adolescentes necessitam ser sensibilizados sobre as circunstâncias que acarretam às Doenças Sexualmente Transmissíveis por meio de parcerias com os serviços de saúde e espaços sociais na comunidade. Descritores: Adolescente; Doenças Sexualmente Transmissíveis; Atenção Primária à Saúde; Sexualidade; Preservativos; Identidade de Gênero. RESUMEN Objetivo: identificar las situaciones de vulnerabilidad en que los adolescentes se encuentran en relación a las Enfermedades Sexualmente Transmisibles en la Atención Primaria a la Salud. Método: estudio bibliográfico, descriptivo, tipo revisión integradora con búsqueda de artículos en las bases de datos MEDLINE, BDENF y LILACS, en el período de enero de 2011 a diciembre de 2015. Para eso, se utilizaron los descriptores: adolescente, enfermedades sexualmente transmisibles y atención primaria a la salud, todos con asociaciones aplicándose “AND” en los idiomas portugués, inglés y español, además de eso, para la selección de los artículos fue utilizado el instrumento adaptado del estudio de Ursi 2006, el cual permitió esquematizar las principales informaciones. Resultados: fueron analizados 12 artículos después de la aplicación de los criterios. Los resultados identificaron las siguientes temáticas: condiciones socioeconómicas, inicio precoz de la actividad sexual, falta del uso del preservativo, diferencia de géneros y dificultad de comunicación y acceso a los servicios de Atención Primaria a la Salud. Conclusión: se observó que los adolescentes necesitan ser sensibilizados sobre las circunstancias que acarretan las Enfermedades Sexualmente Transmisibles, por medio de la asociación con los servicios de salud y espacios sociales en la comunidad. Descriptores: Adolescente; Enfermedades de Transmisión Sexual; Atención Primaria de Salud; Sexualidad; Condones; Identidad de Género. 1Master ́s degree student, Master's Program in Nursing – Level of Master's Degree Academic, Federal University of Bahia/UFBA. Salvador (BA), Brazil. E-mail: patricia_sdoli@yahoo.com ORCID iD: http://orcid.org/0000-0001-8441-8022; 2Ph.D., Federal University of Sergipe/UFS. Aracaju (SE), Brazil. E-mail: acfabud@uol.com.br ORCID iD: http://orcid.org/0000-0003-1885-2992; 3Ph.D., Federal University of Sergipe/UFS. Aracaju (SE), Brazil. E-mail: anadorcas@hotmail.com ORCID iD: http://orcid.org/0000-0002-4709-1013; 4Ph.D., Federal University of Sergipe/UFS. Aracaju (SE), Brazil. E-mail: antoniobalves@gmail.com ORCID iD: http://orcid.org/0000-0002-8647-8050; 5Obstetric Nurse, Federal University of Sergipe/UFS. Aracaju (SE), Brazil. E-mail: kaellyne@yahoo.com.br ORCID iD: http://orcid.org/0000-0002-3655-959X INTEGRATIVE REVIEW ARTICLE Oliveira PS de, Abud ACF, Inagaki ADM et al. Vulnerability of adolescents to sexually... English/Portuguese J Nurs UFPE on line., Recife, 12(3):753-62, Mar., 2018 754 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i3a24120p753-762-2018 Adolescence is a period of physical and organic transformation, associated with the perception of sexual and occupational identity and comprises the age group of 10 to 19 years old. This phase involves intense biopsychosocial changes, especially those related to sexual maturation, the search for adult identity and autonomy in front of parents. Regarding sexuality, the adolescent is influenced by personal and family beliefs and values, as well as by moral norms and social taboos. Currently, the number of adolescents with early coitarche is increasing, resulting in greater vulnerability to Sexually Transmissible Diseases (STDs), which constitute a serious public health problem. STDs are transmitted through sexual contact, blood route, vertical transmission, and breastfeeding, with adolescence being the main sexual transmission, being the main etiological agent viruses, bacteria, fungi, and protozoa. According to the (WHO), more of one million people get STDs in the world daily, with a focus on low-income countries. In Brazil, most STDs have affected the population of young people and adolescents, especially syphilis in pregnant women, Human Papillomavirus (HPV) and Human Immunodeficiency Virus (HIV). Such diseases could be prevented with the use of condoms. More recently, the possibility of sexual transmission by the Zika virus has been proven and its consequences are still poorly understood. Situations of violence, family disruption, exposure to risks and failures or incongruity in the use of condoms that associated with adolescence contribute to the onset of STDs. These situations are important because they define some common vulnerability in this period of life.4 The vulnerability is understood as a dynamic process formed by the interaction of the elements that constitute it, such as age, race, ethnicity, poverty, education level, social support and the presence of health problems. Thus, it is a process that encompasses not only the individual character but also the collective characteristics and it is equivalent to the different forms that the individual or group deals with the healthdisease process comprising its social, cultural and political conditions. It should be emphasized that Primary Health Care (PHC) should take important actions to reduce vulnerability to STDs. PHC represents the first level of care and it has the role of developing and articulating health promotion actions with intra-sectoral and intersectoral networks, such as family members, youth leadership, schools and churches to promote an approximation of the adolescent with the service health. Therefore, this study is justified because adolescents constitute a population vulnerable to STDs and PHC should favor a rapprochement with these adolescents, ensuring activities of prevention and health promotion. ● To identify the vulnerability situations in which adolescents are regarding Sexually Transmitted Diseases in Primary Health Care. This is a bibliographical, descriptive study, integrative review type, which expresses importance in the health area as it synthesizes the differently available research on a certain subject and guides the practice based on scientific knowledge. It is composed of six stages distributed as follows: definition of the guiding question, search of material in the literature, data collection, critical analysis of the studies, discussion of the results and presentation of the integrative review. For the development of this research, the following guiding question was elaborated: what are the vulnerability situations in which adolescents are regarding in relation to Sexually Transmitted Diseases in Primary Health Care? The following descriptors with associations were applied with “AND” in Portuguese, English and Spanish respectively: “adolescente” AND “doenças sexualmente transmissíveis” AND “atenção primária à saúde”; “adolescent” AND “sexually transmitted diseases” AND “primary health care”; “adolescente” AND “enfermedades de transmisión sexual” AND “atención primaria de salud”.The search for primary studies was carried out in the databases: Online System of Search and Analysis of Medical Literature (MEDLINE), Nursing Database (BDENF) and Latin American and Caribbean Literature in Health Sciences (LILACS). For the refinement of the sample, primary articles that dealt with the subject in the languages described above, human research, with abstracts available online and in full text, published between January 2011 and December 2015 were used as inclusion criteria. Duplicate articles and review articles were excluded from the research. INTRODUCTION

] This phase involves intense biopsychosocial changes, especially those related to sexual maturation, the search for adult identity and autonomy in front of parents.
Regarding sexuality, the adolescent is influenced by personal and family beliefs and values, as well as by moral norms and social taboos. 3Currently, the number of adolescents with early coitarche is increasing, resulting in greater vulnerability to Sexually Transmissible Diseases (STDs), which constitute a serious public health problem. 4TDs are transmitted through sexual contact, blood route, vertical transmission, and breastfeeding, with adolescence being the main sexual transmission, being the main etiological agent viruses, bacteria, fungi, and protozoa. 4According to the (WHO), more of one million people get STDs in the world daily, with a focus on low-income countries. 57][8] Such diseases could be prevented with the use of condoms. 6More recently, the possibility of sexual transmission by the Zika virus has been proven and its consequences are still poorly understood. 9ituations of violence, family disruption, exposure to risks and failures or incongruity in the use of condoms that associated with adolescence contribute to the onset of STDs.These situations are important because they define some common vulnerability in this period of life.4 The vulnerability is understood as a dynamic process formed by the interaction of the elements that constitute it, such as age, race, ethnicity, poverty, education level, social support and the presence of health problems.Thus, it is a process that encompasses not only the individual character but also the collective characteristics and it is equivalent to the different forms that the individual or group deals with the healthdisease process comprising its social, cultural and political conditions. 10 It should be emphasized that Primary Health Care (PHC) should take important actions to reduce vulnerability to STDs.PHC represents the first level of care and it has the role of developing and articulating health promotion actions with intra-sectoral and intersectoral networks, such as family members, youth leadership, schools and churches to promote an approximation of the adolescent with the service health. 11herefore, this study is justified because adolescents constitute a population vulnerable to STDs and PHC should favor a rapprochement with these adolescents, ensuring activities of prevention and health promotion.
• To identify the vulnerability situations in which adolescents are regarding Sexually Transmitted Diseases in Primary Health Care.This is a bibliographical, descriptive study, integrative review type, which expresses importance in the health area as it synthesizes the differently available research on a certain subject and guides the practice based on scientific knowledge.It is composed of six stages distributed as follows: definition of the guiding question, search of material in the literature, data collection, critical analysis of the studies, discussion of the results and presentation of the integrative review. 12or the development of this research, the following guiding question was elaborated: what are the vulnerability situations in which adolescents are regarding in relation to Sexually Transmitted Diseases in Primary Health Care?
The following descriptors with associations were applied with "AND" in Portuguese, English and Spanish respectively: "adolescente" AND "doenças sexualmente transmissíveis" AND "atenção primária à saúde"; "adolescent" AND "sexually transmitted diseases" AND "primary health care"; "adolescente" AND "enfermedades de transmisión sexual" AND "atención primaria de salud".The search for primary studies was carried out in the databases: Online System of Search and Analysis of Medical Literature (MEDLINE), Nursing Database (BDENF) and Latin American and Caribbean Literature in Health Sciences (LILACS).The articles were searched in October 2016.The instrument adapted from Ursi´s study (2006) was used to select the articles, which allowed outlining the main information on the vulnerability situations of adolescents regarding STDs and they can be prevented in primary care, besides the characteristics of the articles such as objectives, sample, study variables, method of analysis, main results and level of evidence (LE). 13e evidence is divided into six levels: the first level is the results from the meta-analysis of multiple controlled and randomized clinical trials; the second level is the evidence resulting from individual studies with an experimental design; the third level is the findings from quasi-experimental studies; the fourth level is the evidence from descriptive or qualitative studies; the fifth level is the case or experience reports and the sixth, corresponds to evidence based on expert opinions. 12e data were analyzed and the results presented through descriptive statistics, allowing the reader to check the applicability and the possibility of replicating using the same methodological path.

INTRODUCTION
In the LILACS database, there were 20 articles found with the descriptors in Portuguese and six with the descriptors in Spanish.Of them, only eight articles were selected after applying the inclusion and exclusion criteria.
In the MEDLINE, there were 76 articles found with descriptors only in English, using four articles with the exclusion of the others by repetition and for not attending the theme.In the BDENF, three articles were found, which two articles were eliminated by repetition and one article for not referring to the research theme.
Thus, 12 articles were analyzed, according to Table 1, which met the inclusion criteria.In terms of methodology, eight (67%) studies had a quantitative approach, two (17%) had a qualitative approach, one (8%) had a quantityqualitative approach and one (8%) had a report experience.For better analysis and presentation of the results, the articles were grouped by category according to the research object.This grouping enabled to identify the vulnerability situations of adolescents assisted in PHC, according to Figure 1.

 Socioeconomic conditions
STDs are pathologies in adolescents, especially those with low socioeconomic status.The income and level of education of the family, as well as the place of residence of the adolescents, are recurrent characteristics that serve as indicators of vulnerability to STD/AIDS.
5][16][17][18][19][20][21][22][23][24][25] Also, there are additional situations such as structural, family and sexual violence, involvement with drugs, sexual promiscuity, and cultural issues that expose young people to STD/AIDS. 16,24he social environment where adolescents live, whether in the home or at school, tends to influence their behavior and sometimes leads to situations that compromise their health.A study carried out with community health agents, in a social environment permeated by tourists, showed that adolescents are exposed to the conditions of sexual exploitation and the need to value the body.This reveals that local social and cultural aspects contribute to STDs in adolescents. 17ost of the articles deal with adolescents with low social conditions, although some articles address students from private schools belonging to the white race, with high education level and adequate housing conditions. 16,25] Therefore, the authors suggest that disinformation about condom use is often linked to social issues. 7,28Socioeconomic status may interfere with the quality and quantity of information about sexuality, health care, the importance of contraception and access to health services, as well as the early start of the first sexual intercourse. 1

 Early onset of sexual activity
The early onset of sexual activity was pointed out by the studies selected as a situation that causes vulnerability to STDs. 19,25dolescents have begun their sexual life before 13 years old, evidenced in a study in which about 80% of the adolescents declared onset of sexual activity before that age. 28nother study carried out with 1,015 young people identified that 42.6% had had the first sexual intercourse.Of them, 55.4% occurred before the age of 15 years old. 29Also, on the age of cohabitation, this tends to approach the age of the menarche and is distant from 18 years old, more precisely before 15 years old. 30s adolescents and young people initiate sexual activity earlier and acquire some STDs, they become prone to HIV/AIDS infection.A study carried out in Cuba reveals a high number of STDs among the population aged 15-25 years old.
In Brazil, the incidence and prevalence of HIV/AIDS has increased in the 15-24 age group, with new cases growing in the North and Northeast regions, 8 corroborating data released by the United Nations Children's Fund ( UNICEF), which states that an average of 29 adolescents between 15 and 19 are infected with HIV every hour and AIDS represents the second cause of death for young people aged 10 to 19 in the world. 31Faced with this, authors bring the importance of adopting preventive measures against HIV/AIDS for the population of adolescents. 14,19] HPV can be transmitted with the early onset of sexual activity and may be manifested in adolescents through the progression of low-grade lesions, making them prone to develop cancer of the cervix.This fact was evidenced in a study carried out with adolescents between 12 and 18 years old, which identified that most of the epithelial lesions were squamous or glandular cells and of low grade. 28,30Lack of condom use On the other hand, a study carried out with 25 adolescents in a municipality of Ceará revealed that there is no lack of knowledge but an incorrect use of the condom linked to social, cultural and affective factors. 32lso, adolescents use other contraceptive methods and do not associate with condoms.This is reinforced when pregnancy is placed as the central axis of concern of young people even knowing the consequences of an unprotected relationship. 18,20,24In this sense, it is possible to observe that there is greater concern about avoiding pregnancy and neglects the prevention of pregnancy.] Regarding the frequency of condom use, it can be observed that most adolescents stated that they used it only during their first sexual intercourse.This fact is reaffirmed in the study done with school adolescents, in the public network of the city of Rio Grande do Norte, where 56.60% of the respondents reported having used the condom during the first sexual intercourse, but in the last six months, this percentage decreases to 26.42%. 35he lack of condom use by adolescents is based on the following justifications: unexpected situations (relationships with partners, lack of confidence in partner), or thoughts that sexual relationships with only women are incapable of causing any STD. 16,18,20According to a qualitative study conducted with adolescents, trust is due to intimate and affective ties developed by the couple, and sexual pleasure is compromised by the use of condoms. 32n spite of so many barriers to condom use, it is still the most frequently used method by many adolescents, followed by the English/Portuguese J Nurs UFPE on line., Recife, 12(3):753-62, Mar., 2018 758 contraceptive pill. 16,18,20,25These methods are corroborated by as the most popular among adolescents. 32

 Gender differences
Society participates in the formation of people´s thoughts about diverse contexts, an example of which is in the strong condition of privilege of men.Research from this review revealed that adolescents do not feel vulnerable to unprotected sexual practices with their partners. 19,25] Gender relationships are understood by perceptions of differences established through a hierarchical way of thinking in male universes and female specificities. 38As a result, adolescents have shifted responsibility for prevention to girls and understand that they are vulnerable to STDs because of unstable sexual relationships of their partners.For some adolescents, using condoms is a symbol of infidelity and mistrust. 25or adolescents, marital relationships, marriage, courtship or fixed partnership symbolize security and attribute non-use of condoms to the trust established in the partner. 19,25For some authors, it reflects the female submission to the masculine will that puts adolescents in a lower position for negotiation. 26,32,35This condition can lead to restricted communication with the partner about healthy sexual behaviors and exposes adolescents to early pregnancy and STD/HIV. 19,22,24ogether with this reality, adolescents perceive in marital life, the possibility of living in an environment far from the situations of intra-family, psychological and sexual violence that are exposed. 27Marital relationships can be seen as an object of protection for many adolescents.
The female population represents a group of society with innumerable situations of vulnerability, explained by the power relationships established by the male universe over women.This truth is emphasized when black women are associated with situations of violence. 267] This condition is evidenced by studies that state that black women are more predisposed to HIV/AIDS infections due to the strong feminization, pauperization and heterosexualization of this infection. 39

 Difficulty in information and access to PHC services
Regarding the information, PHC services are rarely sought by adolescents for information on STD prevention.The selected articles identified that STD information is obtained with friends, parents or relatives and, finally, teachers and health services. 14,17,20Also, the media such as television/radio, newspapers or magazines and, mainly, the internet has provided knowledge about STD/AIDS for many adolescents. 35ealth professionals seldom use the local setting that adolescents are inserted to address conditions of vulnerability. 17Thus, adolescents need to be understood as people in their totality, with their histories, their experiences and their sexual experiences. 292] Health professionals can make the most enjoyable environment and understand the real needs of adolescents, as well as the importance of mediating knowledge regarding STD/AIDS. 35esearch also reveals that girls sought health care more than boys.Communication about contraceptive methods, sexuality, STDs are issues that cause embarrassment to health professionals, such a situation has a higher proportion when information needs to be offered to male adolescents. 19-20Also, it is worth mentioning that the male universe has a resistance in seeking health services or professionals and many boys believe they have resistance to STDs. 364 To this end, it is necessary to identify the population of adolescents in the PHC service and their characteristics in the healthcare process to implement effective health promotion/prevention policies. 40 view of the studies presented, it can be seen that the situations of vulnerability found among adolescents in PHC services are related to socioeconomic conditions, the onset of early sexual activity, the lack of condom use, gender differences and the difficulty of communication and access to primary health care services.Poor level of education and poor housing conditions imply the lack of information about the correct use of condoms and the increasingly early onset of sexual activity among adolescents.Associated with these issues, male hegemony puts women in a position of submission and does not give them the right to choose about condom use.In this perspective, health professionals have limitations in the approach to STDs and often do not use other social spaces in which adolescents are inserted, such as churches and schools to ensure approximation with the health service.

CONCLUSION
Adolescents are knowledgeable about the ways of STD prevention, but there is a lack of awareness of the vulnerability and awareness of the damage caused by these diseases.Besides to health professionals, family members, educators, and other social groups are fundamental structures for the transformation in the way of thinking and acting of adolescents who initiate their sexual life in a casual way, based on uncertainty and without responsibility.
It is necessary to reorient PHC services so professionals and managers perceive that political, social, cultural and economic issues permeate the situations of vulnerability that adolescents are exposed in relation to STDs.Consequently, re-significances will be given on racial and gender issues to build a society freed from prejudice and stigma.
Adolescent health needs to be taken as a priority for PHC services, which often limit their actions to the care of hypertensive, diabetic, children, and women, but do not seek to assist these individuals who are vulnerable to STDs.Understanding health indicators, the real needs of this population and extrapolating the walls of services are fundamental steps to develop effective actions that meet reality.

Figure 1 .
Figure 1.Diagram of vulnerability situations that interfere with the occurrence of STD in adolescents.Aracaju (SE), Brazil, 2016.

Table 1 .
Description of articles analyzed according to the database, authors of articles, level of evidence, journal (year) and considerations, Aracaju, SE, Brazil, 2016.