Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 2 - Apr/Jun - 2018

Original Article Imprimir 

Páginas 39 a 48

Association between Adolescent Pregnancy and the Social Responsibility Index in the State of Minas Gerais, Brazil

Asociación entre embarazo adolescente y el Índice Minero de Responsabilidad Social en el Estado de Minas Gerais, Brasil

Associação entre gravidez adolescente e o Índice Mineiro de Responsabilidade Social no Estado de Minas Gerais, Brasil

Autores: Daiane Leite da Roza1; Maria de Fátima Rodrigues Pereira de Pina2; Carla Maria Teixeira de Oliveira3; Edson Zangiacomi Martinez4

1. Post-Doctoral fellow of the Postgraduate Program in Community Health - Department of Social Medicine - São Paulo University. Doctor and Master of Science at the Ribeirão Preto Medical College, São Paulo University. Ribeirão Preto, SP, Brazil
2. Doctor in Biomedical Engineering (2001) at the Rio de Janeiro Federal University. Researcher at the Health Information Laboratory of the Institute of Communication, Scientific and Technological Information in Health - Oswaldo Cruz Foundation - ICICT/FIOCRUZ. Rio de Janeiro, RJ, Brazil
3. Doctor in Public Health by the Medicine College of the Porto University. Researcher - i3S - Institute for Inovation and Research in Health, Porto University. Porto, Portugal
4. Doctor in Medical Sciences (Tocogynecology) by the Campinas State University (UNICAMP). Campinas, SP, Brazil. Master in Statistics by the Federal University of São Carlos/SP, Brazil. Associate Professor (livre lecturer) of the São Paulo University (USP/Ribeirão Preto). Ribeirão Preto, SP, Brazil

Edson Zangiacomi Martinez
Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo
Av. Bandeirantes nº 3900, Monte Alegre
Ribeirão Preto, SP, Brasil. CEP: 14049-900

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How to cite this article

Keywords: Adolescent, pregnancy in adolescence, ecological studies, residence characteristics.
Palabra Clave: Adolescente, embarazo en la adolescencia, estudios ecológicos, distribución espacial de la población.
Descritores: Adolescente, gravidez na adolescência, estudos ecológicos, distribuição espacial da população.

OBJECTIVE: Study the relationship between adolescent pregnancy rates and the State Social Responsibility Index in Minas Gerais State.
METHODS: Was conducted an ecological study based on registers of live births from adolescent mothers, which were obtained from the Live Births Information System (SINASC). The Minas Gerais State Social Responsibility Index (MGSSRI) and its dimensions were used as co-variables. The statistical analysis was based on a Bayesian space-time regression model.
RESULTS: There was a reduction in the adolescent pregnancy rates over the years. With regard to the study period, deep differences were observed between the northern and southern regions of the state. In the most developed regions of the State as well as in with significant structural and socio-economic deficiencies, there is an inverse relationship between public administration social responsibility, measured by MGSSRI, and reduction in the adolescent pregnancy rates.
CONCLUSION: This finding is an evidence that pregnancy during adolescence cannot be studied without considering the geographical and socio-economic contexts in which these adolescents are inserted.

OBJETIVO: Estudiar la relación entre las tasas de embarazo en la adolescencia y el Índice Minero de Responsabilidad Social en Minas Gerais.
MÉTODOS: Se realizó un estudio ecológico basado en los registros de nacidos vivos de madres adolescentes, obtenidos por el Sistema de Información sobre Nacidos vivos (SINASC). Se utilizó como co-variable el Índice Minero de Responsabilidad Social (IMRS) y sus dimensiones. El análisis estadístico se basó en un modelo de regresión Bayesiano con estructura espacio-temporal.
RESULTADOS: Se observó una reducción de las tasas de embarazo en la adolescencia a lo largo de los años. Para todo el período estudiado hay profundas diferencias entre las regiones Norte y Sur del Estado. Tanto en las regiones más desarrolladas del Estado como en aquellas marcadas por significativas deficiencias estructurales y socioeconómicas, existe una relación inversa entre la responsabilidad social en la gestión pública, medida por el IMRS, y la reducción de las tasas de embarazo en la adolescencia.
CONCLUSIÓN: Este hallazgo evidencia que el embarazo en la adolescencia no puede ser estudiado sin considerar el contexto geográfico y socioeconómico en que estas jóvenes están insertas.

OBJETIVO: Estudar a relação entre as taxas de gravidez na adolescência e o Índice Mineiro de Responsabilidade Social em Minas Gerais.
MÉTODOS: Foi realizado um estudo ecológico com base nos registros de nascidos vivos de mães adolescentes, obtidos pelo Sistema de Informações sobre Nascidos Vivos (SINASC). Foi utilizado como covariável o Índice Mineiro de Responsabilidade Social (IMRS) e suas dimensões. A análise estatística baseou-se em um modelo de regressão Bayesiano com estrutura espaço-temporal.
RESULTADOS: Verificou-se uma redução das taxas de gravidez na adolescência ao longo dos anos. Para todo o período estudado há profundas diferenças entre as regiões Norte e Sul do Estado. Tanto nas regiões mais desenvolvidas do Estado quanto naquelas marcadas por significativas deficiências estruturais e socioeconômicas, existe uma relação inversa entre a responsabilidade social na gestão pública, mensurada pelo IMRS, e a redução das taxas de gravidez na adolescência.
CONCLUSÃO: Este achado evidencia que a gravidez na adolescência não pode ser estudada sem considerar o contexto geográfico e socioeconômico em que essas jovens estão inseridas.


Adolescence is a phase marked by the transition between childhood and adult life. Beyond a biological process, adolescence encompasses psychosocial aspects, it is a period in which cognitive development and personality structure, marked by bodily changes resulting from hormonal action, are accelerated in both boys and girls.1 At this stage, the individual tends not to perceive their vulnerability, doesn´t recognize the behaviors that involve personal risks, thus failing to use means that can protect them. It is in this context that unexpected and sometimes unwanted pregnancies become a relevant problem both from a social and a health point of view.2,3 Several studies highlight the causes and consequences of an early pregnancy, including social, economic, educational and behavioral aspects.4,5 Children of adolescent mothers are more likely to be born preterm, with low weight for gestational age,6,7 iron deficiency anemia and cephalopelvic disproportion, in addition to presenting, more frequently, nutritional complications and infectious diseases.8 Studies indicate that obstetric complications result mainly from the incomplete development of the pelvis and uterus ossicles.9 In addition, adolescent pregnancy has been associated with school dropout,10 and its recurrence is more frequent in young offspring of the school or in an inadequate school year.11 The exclusion of pregnant adolescents from the school environment pot the cycle of perpetuating poverty, since these young women will have difficult access to opportunities for skilled work and improvements in their social condition.12

According to the Demographic Census conducted by the Brazilian Institute of Geography and Statistics (IBGE) in 1991, 32.5% of births of primigestas mothers were concentrated in pregnant women aged between 10 and 19 years. In 2000, this percentage was higher than 38%. According to data from the Live Birth Information System (SINASC), between 2010 and 2013, an increase of approximately 3.5% in live births of adolescent mothers aged 10 to 14 years was recorded in Brazil. Some studies have described that the vulnerability of these younger adolescents is due to the early onset of sexual activity and because they come from poor families and victims of physical and sexual abuse.13,14

Adolescent pregnancy has been shown to be a serious public health problem, but it isn´t a lack of information on the part of adolescents, some studies15 conclude that adolescents show a high knowledge regarding the existence of contraceptive methods. Thus, it is believed that the conditions of the environment in which they are exposed are one of the factors that lead them to an early pregnancy. Therefore, the present study proposes to size the geographic distribution of pregnancy in adolescence in a unit of the Brazilian Federation, using a Bayesian model of temporal-space analysis that allows describing the possible associations between the phenomenon and social responsibility indicators of the areas that make up this space.


An ecological study was carried out, a model that considers people in the context of diverse environments or ecological systems in which they reside: family, relationships, neighborhood, community and institutions such as school and workplace. This model is based on the premise that individuals can´t be studied without considering the various ecological systems in which they live.16

The state of Minas Gerais has about 20 million inhabitants, being the second most populous in Brazil and the fourth largest in territorial extension. It is composed of 853 municipalities, 66 micro-regions and 12 mesoregions, as shown in figure 1. It is the Federative Unit of Brazil with the largest number of municipalities, where it presents marked characteristics of social and economic inequalities when comparing different regions, being the Central and Strongly affected by natural and structural conditions17.

Figure 1. Map of the state of Minas Gerais describing the 66 micro-regions and 12 mesoregions analyzed in the present study.

In order to characterize the state of Minas Gerais according to the number of live births of adolescent mothers, data from the Information System on Live Births (SINASC) of the Ministry of Health (DATASUS) were used, considering the total number of live births in each state of Minas Gerais in the period 2000 to 2010, and the number of live births whose mother was 10 to 19 years old, in the respective micro-regions. The percentage of teenage pregnancy was calculated according to the division between the live births of mothers aged 10 to 19 years and the total number of live births.

As an independent variable, the Minas Gerais Social Responsibility Index (IMRS) was used for the year 2000. The IMRS was created with the objective of obtaining a quantitative indicator of social responsibility in the public management of the 853 municipalities of Minas Gerais, the João Pinheiro Foundation responsible for its construction. The index has as a principle the policies, plans, programs, projects and actions implemented by the municipal administration that ensure the population's access to education, health, social assistance, public security, income and employment, sanitation and housing, environment, culture and sports . Together with a public finance indicator, these items make up the ten dimensions of the IMRS. Each of these dimensions is transformed into indices varying from 0 to 1, the "general" IMRS being given by a weighted average between the indices of the ten dimensions. The data are available on the João Pinheiro Foundation website. To obtain indicators for each micro-region, since the IMRS is available for each municipality, a weighted average was used for the respective population sizes.

This study was submitted and approved by the Local Research Ethics Committee (Process no. HCRP-10157/2011).

Statistical analysis

A conditional spatiotemporal Bayesian model (CAR) 18 was used, in which: Yij denotes the count of births of adolescent mothers, Nij denotes the total number of live births and θij denotes the rate of teenage pregnancies, i represents each micro-region and every year of the analyzed series. The statistical model considers that Yij is a random variable that follows a binomial distribution with probability of success θij in Nij independent tests (Nij known), where i=1,...,66 micro-regions e j=1,...,11 years (j=1 denotes the year 2000, j=2 denotes the year 2001, and so on). A logit bonding function was assumed between adolescent pregnancy rates θij and an observation xi of the independent variable X (the "general" IMRS or each of its dimensions), written in the form

logitoθij = a0j + di + wij + bj (xi-m)

where: m is the arithmetic mean of the observations of X, a0j and bj are fixed effects, di are spatial effects associated with the i-th micro-region and wij are the respective temporal effects. In the Bayesian analysis, each di is assumed to assume an a priori spatial distribution with a CAR structure, which allows the correlations between the near areas in space to be larger. The estimation of the parameters of the model was based on a stochastic simulation based on MCMC (Markov Chain Monte Carlo) methods, using the module GeoBUGS19 of the program WinBUGS. It was assumed that the wij effects follow a priori a normal multivariate distribution with vector of means equal to zero and variance matrix described by Branscum et al.,20 which assigns greater covariance between successive times, which guarantees a longitudinal structure for the data . It was considered that the other a priori distributions aren´t informative and, among them, independent. Using the MCMC method, 30,000 samples were generated for each parameter of interest, and the first 1,000 samples were discarded to avoid any effect of the (burn-in samples). The DIC21 criterion was used for the comparison of models, such that models with lower DIC values are those with the best fit to the data.


Among the pregnancies with live births that occurred in the state of Minas Gerais in 2000 and 2010, 20.49% and 16.82%, respectively, were adolescents. It can be seen in Figure 2 that rates tend to decrease throughout the years in a large part of the micro-regions. The maps presented in figure 2 were the result of the adjustment of the Bayesian space-time model, considering the IMRS as covariate. During the whole period, the deep differences between the rates observed in the North and South regions of the state prevailed, with the lowest rates tending to be concentrated in the South.

Figure 2. Adjusted rates of adolescent pregnancy analyzed in the present study.

The lowest rates refer, coincidentally, to the regions with larger population size and greater development, such as Belo Horizonte, Divinópolis, Itaguara and Conselheiro Lafaiete. In the north of the state, the highest rates of teenage pregnancy are concentrated, where the micro-regions of Pirapora, Frutal, Grão Mogol, Unaí and Paracatu stand out. The Pirapora micro-region stands out for having the highest rates in all the years of the series.

The largest reductions in the percentages of adolescent pregnancies for the period were observed in the micro-regions of Uberlândia, from 24% in 2000 to 16% in 2010, and Mantena, which decreased from 27% to 19%. On the other hand, the micro-regions of Conceição do Mato, Guanhães and Andrelândia had their teenage pregnancy rates increased from 17% to 21%, from 18% to 21%, and from 18% to 19%, respectively. The micro-regions of Januária, Grão Mogol, Diamantina, Pedra Azul, Curvelo, Itabira, Peçanha and Santa Rita do Sapucaí didn´t change their percentages.

Alternatively, a model without the inclusion of spatial effects (DIC=6703) was also adjusted, but the DIC value obtained from the model including these effects was lower (DIC=6513). This shows that rates of teenage pregnancy aren´t randomly distributed among the different micro-regions of the state, but there is some significant spatial effect.

Table 1 describes the average rates of adolescent pregnancy according to the "general" IMRS (from 0.3 to 0.5, from 0.5 to 0.6, and from 0.6 to 0.8), and the ratios between rates, with their respective Bayesian credibility intervals (95% CIr). Intervals that don´t include value 1 indicate significant associations with adolescent pregnancy rates (indicated with "*" asterisks in Table 1). For all years of the study period, there was an inverse relationship between adolescent pregnancy rates and IMRS values.

Space-time models were adjusted considering each of the ten dimensions of the IMRS. Table 2 shows the association between the dimensions of education, income and employment, and health, and adolescent pregnancy rates, in the years 2000, 2005 and 2010. Although these models consider all the years of the series, only the results related to these three years were described in the table, for parsimony. Table 2 showed higher rates of adolescent pregnancy in municipalities with lower levels of social responsibility related to these dimensions. Other models, considering the other dimensions of social responsibility, showed significant associations between the respective indices and adolescent pregnancy rates (results not shown).


As it is known that the North and Northeast regions of Minas Gerais have lower levels of development than those found in the southern region of the State (Figure 2), it is observed that these deep asymmetries have some effect on the phenomenon of adolescent pregnancy. The northeast of the state includes the mesoregion of the Jequitinhonha Valley, described in the literature as the poorest and least developed state17.

The micro-region of Pirapora, located in the north of the state, presented the highest percentages of adolescent pregnancies throughout the period. Other prominent micro-regions with the highest percentages are Frutal and Ituiutaba, both belonging to the Triângulo Mineiro/Alto do Paranaíba mesoregion and to the micro-regions of Jequitinhonha and the Mucuri Valley. The micro-regions where the highest percentages of adolescent pregnancies were observed were those that presented the lowest values of the "general" IMRS (Table 1) and their dimensions (Table 2). In the adjustment of the spatial-temporal model considering the "general" IMRS as a covariate, the micro-regions of Montes Claros and Salinas had a marked improvement at the end of the series in the year 2010. In all dimensions of the IMRS, the lowest percentages were observed in the metropolitan region of Belo Horizonte, a region characterized by cities with larger populations, greater supply and employment opportunities, better educational opportunities and more leisure and sports options.

The present study was based on an ecological model, in which the social phenomenon of teenage pregnancy is treated collectively, while the majority of studies published in the literature6,22,23 used as sample units women residing in specific regions. The major limitation of ecological studies is that they are liable to ecological bias or fallacy, such that an observed association between groups of individuals doesn´t necessarily mean that the same association occurs at the level of individuals. In the present study, another important limitation is that micro-regions with larger population sizes, such as the Belo Horizonte micro-region, may have a rather heterogeneous spatial distribution of their social indicators, which isn´t characterized in the model used, which describes each micro- uniform.

However, the results found were similar to those observed in studies that considered pregnant women as sample units6,22,23 and in similar ecological studies, such as the study conducted by Nogueira et al.5 on the analysis of the spatial distribution of adolescent pregnancy in the municipality of Belo Horizon. These authors evidenced the presence of conglomerates with high proportions of adolescent mothers in association with the worst socioeconomic conditions. Martinez et al.24 carried out an ecological study with spatial analysis on teenage pregnancy and socioeconomic characteristics of the municipalities of the state of São Paulo, showing that the occurrence of early pregnancy is higher in municipalities with lower per capita gross domestic product, human development and higher proportion of poverty. Martins et al.9 conducted an ecological study with spatial analysis for the micro-regions of health in the state of Mato Grosso do Sul and verified that the fecundity in adolescent women is higher in the micro-regions with worse indicators of schooling and socioeconomic development.

The Bayesian model used here proved to be efficient in estimating the adjusted rates, with the spatial structure and the neighborhood matrix adopted being adequate for the data, since when incorporated into the models, the DIC values presented a large reduction. The results obtained evidenced a strong spatial dependence on adolescent pregnancy rates among the municipalities of Minas Gerais, which suggests that the neighborhood structure plays a fundamental role for its understanding of economic and social indicators.

As another potential limitation of the present study, it was considered that the completeness of SINASC information may not be homogenous throughout the state of Minas Gerais, as in other Brazilian states.25 A study26 that evaluated SINASC in 132 municipalities of Minas Gerais in 2010 showed that the system was not adequately implemented in most of the municipalities evaluated, highlighting the insufficiency of qualified professionals, unsatisfactory collection and filling of the Declaration of Live Births, underutilization of data and poor disclosure of information.

On the other hand, although these limitations may have important effects on the findings of this study, it can be concluded that teenage pregnancy transcends the biological scope. For example, evidence was found that low levels of public safety, one of the dimensions of the IMRS, are associated with higher rates of pregnancy in adolescence. A global study27 with adolescents aged 15-19 years living in disadvantaged urban areas of five different cities (Baltimore-USA, Johannesburg-South Africa, Ibadan-Nigeria, New Delhi-India, and Shanghai-China) found a pattern similar. This study showed that the chances of a teenager getting pregnant are greater in violent neighborhoods and where the fear of being assaulted or assaulted is great. In addition, the study by Copping et al.28 supports the argument that the perception of violence, sexual precocity and teenage pregnancy are related to environmental conditions.


The present study showed a relationship between social responsibility in public management as measured by the IMRS and the reduction of pregnancy rates in adolescence. This finding contributes to the consensus that teenage pregnancy can´t be studied without considering the geographical and socioeconomic context in which these young women are inserted, so that, to a greater extent, public investments that allow the population access to multiple sectors, such as education, environment, culture and leisure, must always be understood as essential for health promotion.


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