A abordagem sobre a saúde no Exame Nacional do Ensino Médio (ENEM): tendências e perspectivas no período 2019-2024Abstract
This study aimed to analyze how health was addressed in the Brazilian National High School Examination between 2019 and 2024. Exploratory documentary research was conducted, combining an analysis of examination descriptors (year, theme, and knowledge area) with content analysis of the questions. A total of 59 health-related questions were identified, showing relatively consistent presence throughout the study period, except in 2020 and 2021, when the number of such questions declined. In the context of the COVID-19 pandemic, this reduction was particularly evident in questions related to vaccination, a recurring theme in other years, and may be interpreted in light of the rise of vaccine denialism in Brazil. The most frequent thematic categories were physical activity and body practices, vaccination, and mental health. The Languages knowledge area contained the largest number of health-related questions, primarily because of the inclusion of Physical Education. Overall, health was approached predominantly from a sociocultural and historical perspective, reflecting an interdisciplinary treatment of the content.
Keywords
health education; national high school exam; analysis of test questions; evaluation of basic education
Resumo
O objetivo deste estudo foi analisar a abordagem sobre a saúde nas questões do Exame Nacional do Ensino Médio (ENEM) entre 2019 e 2024. Realizou-se uma pesquisa documental, de caráter exploratório, que articulou a análise dos descritores da prova (ano, tema e área de conhecimento) à Análise de Conteúdo das questões. Identificaram-se 59 questões relacionadas à saúde, com relativa prevalência ao longo do período, à exceção de 2020 e 2021, quando se observou redução desses assuntos. No contexto da pandemia de COVID-19, essa diminuição incidiu especialmente sobre questões relacionadas à vacinação — tema recorrente nos demais anos —, podendo ser analisada à luz do avanço negacionista no país. As categorias temáticas mais frequentes foram atividade física e práticas corporais, vacinação e saúde mental. A área de Linguagens concentrou o maior número de questões, especialmente em função da disciplina Educação Física. Predominou a categoria sociocultural e histórica da saúde, com tratamento interdisciplinar dos conteúdos.
Keywords
health education; national high school exam; analysis of test questions; evaluation of basic education
Introduction
Since 2009, the Brazilian National High School Examination (Enem) has served as Brazil’s primary standardized assessment for higher education admission. Originally introduced in 1998, however, its primary purpose was to evaluate the academic performance of students completing basic education (Inep, 2021). Currently, the examination comprises 180 multiple-choice questions administered over two days and is organized into four knowledge areas: Languages, Codes and Their Technologies; Natural Sciences and Their Technologies; Human Sciences and Their Technologies; and Mathematics and Their Technologies. In addition, candidates are required to write an argumentative essay based on a contemporary social issue.
Students' Enem scores may be used to gain admission to public universities through the Unified Selection System (Sisu), to compete for scholarships at private higher education institutions through the University for All Program (ProUni), or to apply for student loans through the Student Financing Fund (Fies). Enem scores are also accepted by Portuguese higher education institutions that maintain cooperation agreements with the Anísio Teixeira National Institute for Educational Studies and Research (Inep), the federal agency responsible for administering the examination (Inep, 2021).
A recurring concern regarding the Enem is the importance attributed to the knowledge required for the examination. As a nationwide assessment, it is expected to cover content common to Brazil’s basic education system that is socially relevant and shaped by educational policy (Dias; Pinto, 2019). The questions must be carefully designed and aligned with the skills and competencies expected of high school students (Silveira; Barbosa; Silva, 2015). In addition, the argumentative essay requires students to construct a persuasive argument and propose an intervention addressing the issue presented in the prompt texts (Oliveira et al., 2021).
In this context, the content covered by the Exam questions, as well as the essay prompts, constitutes an important source of guidance for students preparing to take the Enem. Schools also use the examination as a reference when adapting their curricula, helping to define the topics addressed and discussed in the classroom. Among the recurring themes featured on the Enem is health, a cross-cutting theme in Brazilian basic education (Brasil, 1997, 2018).
The political and pedagogical recognition of health as a universal right, achieved through public mobilization and participation during the Brazilian Health Reform movement, which encompasses housing conditions, income, education, the environment, leisure, and nutrition (Brasil, 1997; Report..., 1986), for example, should guide critical-social education in schools (Malacarne; Rocha, 2024). It is closely aligned with the perspective of health education, understood as a political and pedagogical process through which individuals come to understand how individual and collective factors shape access to health services and exercise their rights whenever necessary (Falkenberg et al., 2014; Palma, 2020). However, recent studies have shown that health education has historically emphasized individual, behavioral, and hygienist approaches rooted in the biomedical sciences (Lourenço; Zômpero, 2025; Mantovani; Maldonado; Freire, 2021).
Every year, millions of adolescents, young adults, adults, and older adults take the Enem. Data from the Anísio Teixeira National Institute for Educational Studies and Research (Inep, 2024) indicate that, over the six years from 2019 to 2024, the number of registered candidates reached 5.142 million in 2019, 6.152 million in 2020, 3.444 million in 2021, 3.548 million in 2022, 4.018 million in 2023, and 4.325 million in 2024. Although absenteeism has been substantial, exceeded 50% in 2020, during the peak of the COVID-19 pandemic, the Exam nonetheless engages millions of people with its questions and the issues they raise.
In this context, health must be addressed in the examination from a collective and historical perspective that supports citizenship education and is connected to the lived realities of its participants. Examining how health has been addressed in the Enem provides valuable evidence to help educators, education systems, and policymakers to identify gaps and opportunities in health education. This will ensure that school curricula respond to the contemporary challenges facing Brazilian society.
With this in mind, this study analyzed how health was addressed in the Brazilian National High School Examination (Enem) questions between 2019 and 2024.
Methodology
Study design
This exploratory, qualitative study was based on a documentary analysis of the Brazilian National High School Examination (Enem), administered from 2019 to 2024. This methodological approach was appropriate because it enabled the mapping, systematization, and critical examination of how Health was addressed in the Exam questions. This approach supported hypothesis generation and a deeper understanding of the phenomenon under investigation (Gil, 2002). A qualitative approach was essential to interpreting the meanings attributed to health in the exam questions, considering their thematic content and the social, political, cultural, and educational contexts in which the Exam is situated (Godoy, 1995).
Data collection procedures
The documentary analysis focused on materials that “[…] have not yet undergone analytical treatment or that can still be reworked in accordance with the research objectives” (Gil, 2002, p. 45, our translation). Furthermore, the analysis of data from a documentary study may involve selecting specific segments of the material or the selection of the content for the researcher to analyze (Sá-Silva; Almeida; Guindani, 2009).
To ensure consistency across the dataset, the analysis was limited to the blue test booklet1 of the Enem administered between 2019 and 2024. In 2020, in response to the COVID-19 pandemic, the Enem was offered in both paper-based and digital formats. The digital edition was excluded from the analysis because of its low number of registered candidates and the high absenteeism rate (71.3%). The paper-based examination administered that year was retained. The exam booklets were obtained from the official website of the Anísio Teixeira National Institute for Educational Studies and Research (Inep, 2026).
Since each Enem edition consists of 180 questions, all of the questions from the examinations between 2019 and 2024 were first reviewed in their entirety first. Subsequently, the Microsoft Windows search function (Ctrl+F) was used to search for the Portuguese terms saúde (health), doença (disease), and enfermidade (illness), as well as their English and Spanish equivalents, because the Languages section includes questions in other languages. Questions were then selected if they addressed health or referred to it explicitly within social, political, economic, biological, or other contexts.
Two independent researchers conducted the search and selection of the exam materials. Whenever there was disagreement about including a particular question in the analysis, the researchers discussed it to reach a consensus. If disagreement persisted, a third researcher was consulted.
Data analysis and presentation
The selected questions were organized in a spreadsheet (Microsoft Excel, Version 2021), recording the year, question number, theme, area of knowledge, primary and interdisciplinary subject areas, approach to health, and the context of each question. This process ensured traceability and supported the initial organization of the corpus.
The data were analyzed using Bardin (2011)’s Content Analysis, following three stages: pre-analysis, exploration of the material, and treatment, inference, and interpretation of the data. During the pre-analysis stage, the questions were first examined using a floating reading approach. Terms from the Enem Reference Matrix (Inep, 2020) were extracted and coded as recording units, and their respective contexts were coded as context units. This procedure identified how health was framed within the examination and the areas of knowledge in which it appeared. Each question was assigned an identification code in the format Q/year (e.g., Q001/2019 refers to Question 1 from the 2019 examination).
During the material exploration stage, thematic units corresponding to the primary focus of each question were identified, and the analytical categories were developed inductively from the corpus. These categories were not mutually exclusive; as a single question could address more than one theme. In such cases, the predominant theme was recorded. The frequencies and distributions of the categories were presented in tables, a word cloud (Mentimeter), and graphs organized by area of knowledge.
During the treatment, inference, and interpretation stage, the questions were further classified according to their approach to health: (a) biomedical and mathematical, when the answer required mathematical calculations or biological and chemical analyses, and (b) sociocultural and historical, when the answer required an understanding of the social, historical, or cultural processes that influence health. For questions combining both approaches, classification was based on the primary cognitive demand. We recorded the question number, year, main theme, and content for each question, which allowed us to identify patterns and trends in the treatment of health across the Enem during the study period.
Results and discussion
Health in the Enem reference matrix
The Enem Reference Matrix, available on the Inep (2020) website, outlines the content expected of students preparing for the exam. The document specifies the skills (H) and competencies required to answer questions in the exam's different subject areas.
Within this framework, competency refers to the application of knowledge through concepts and procedures, along with practical, cognitive, and socio-emotional skills, as well as the attitudes and values necessary to addressing real-world situations. These competencies are intended to promote social transformation and contribute to a more equitable society while fostering environmental stewardship (Brasil, 2018).
Table 1 summarizes the areas of knowledge in which health-related content is included in the Enem Reference Matrix.
Health is present in seven sections of the Enem Reference Matrix, six of which fall under Natural Sciences and Their Technologies. Therefore, of all the areas of knowledge, the Natural Sciences and Their Technologies section would be expected to have the most questions about health. This may be partly explained by the inclusion of Biology in this area of knowledge or by the historically hegemonic biomedical emphasis and orientation in Brazilian curricula (Sousa; Guimarães; Amantes, 2019).
However, the unequal distribution of health-related content within the Reference Matrix’s areas of knowledge conflicts with and contradicts the pedagogical mandates established by the National Curricular Parameters2 (Brasil, 1997) and the National Common Curricular Base3 (BNCC) (Brasil, 2018). Although these documents have limitations and have been subject to criticism, they define health as a cross-cutting theme across school subjects, meaning that it can be addressed in all areas of knowledge.
Conversely, there is no guidance identifying Humanities and their Technologies or Mathematics and their Technologies as areas of knowledge capable of addressing health education. This supports the argument of Sousa, Guimarães, and Amantes (2019) and Mantovani, Maldonado, and Freire (2021) that curriculum guidelines and governmental institutions promote and reinforce a predominantly biological perspective on the relationship between education and health.
Furthermore, the emphasis placed on Natural Sciences weakens health as a theme within the National Common Curricular Base, where it lost its status as a cross-cutting theme and became a fragmented and technical competency (Sousa; Guimarães; Amantes, 2019). According to Venturi and Mohr (2021), silencing sociopolitical dimensions in favor of a biological perspective limits students’ critical and civic education. Thus, the Reference Matrix crystallizes a reductionist bio-discourse that overlooks health as a field of inquiry within the Human Sciences, hindering efforts to overcome the predominant medical-hygienist model in curricula.
The approach to health in the Enem essay section
During the analyzed period, the 2020 edition of the Enem included health-related content in its essay section. That year, the prompt for the argumentative essay was The stigma associated with mental illness in Brazilian society. It was accompanied by three motivational texts addressing mental health (Oliveira et al., 2021). Text 1 reflected on the relationship between mental health and mental illness, emphasizing that mental health extends beyond the absence of mental disorders. Text 2 further discussed mental disorders further, particularly how the internet and social media contribute to the idealization of perfect lives. Finally, Text 3, was an image-based campaign containing relevant information about depression, which has been referred to by the World Health Organization (2022) as the “disease of the century”.
This approach is consistent with Amarante’s (2007) perspective, which conceptualizes mental health as a complex and multidimensional social process. According to the author, understanding this topic requires moving beyond the biomedical model and diagnosis-centered logic, instead focusing on individual empowerment and on the sociocultural factors that influence psychological well-being. Addressing the stigmas associated with mental illness while considering mental health and its determinants, cannot be achieved through a restricted perspective that confines the topic to specific fields of knowledge. Furthermore, when considering students’ experiences with mental health issues, educational institutions must address these topics critically and supportively, while avoiding the premature medicalization of school behaviors.
However, when examining the Enem Reference Matrix or national documents that guide health education in schools, such as the National Common Core Curriculum (BNCC) (Brasil, 2018) and its Contemporary Cross-Curricular Themes4 (Brasil, 2019), mental health is not explicitly addressed.
Allocation of time for multiple-choice questions
Between 2019 and 2024, a total of 59 health-related, multiple-choice questions were identified. These questions addressed health in different contexts and for different purposes. Figure 1 presents how these questions were distributed over time during the examined period.
Based on these data, the number of health-related questions appears to have remained relatively stable from 2019 to 2024, with at least ten such questions included in each exam edition. However, two years stand out from this pattern: in 2020, there was a marked decrease in the number of health-related questions, followed by an even greater decline in 2021. Notably, these years coincided with the COVID-19 pandemic, the greatest public health crisis in recent history. Despite the pandemic’s social and educational relevance, no questions specifically addressing it appeared on the exam.
In 2020, the first year of the COVID-19 pandemic, the world became increasingly engaged in health-related discussions, with vaccination emerging as one of the most debated topics. Brazil began administering the vaccine on January 17, 2021, under widespread public pressure on the federal government (Brasil, 2023). Substantial vaccination uptake was, however, part of the population continued, and continues, to follow the guidance of the administration at the time, led by Jair Bolsonaro, which administration was characterized by the delegitimization of scientific knowledge and the explicit adoption of a denialist stance (Gomes; Zamora, 2024).
The political and institutional context of that period makes it possible to us analyze how the government in coordination with the Ministry of Education and the Ministry of Health, was associated with the reduction of health-related questions, particularly those in the 2020 and 2021 editions of the Enem, particularly those addressing vaccines and public health, in the 2020 and 2021 editions of the Enem. In the other analyzed years (2019, 2022, 2023, and 2024), these themes were recurrent, with questions explicitly emphasizing the importance of vaccines, public health, and population health. This pattern was not observed in 2020 and 2021, as discussed further below.
This scenario is associated with the erosion of health education in the school curriculum promoted by recent educational counter-reforms. Venturi and Mohr (2021) argue that the BNCC silences health education by restricting it to individual self-care practices, representing a pedagogical setback of approximately 50 years, as it returns to conceptions that predate the 1971 National Education Guidelines and Framework Law (LDB). These curricular orientations have repercussions for large-scale assessments, such as the Enem, which tend to be guided by such educational policies. In this sense, the reduction in questions addressing public health and vaccination in 2020 and 2021 can also be understood as an expression of this broader political-curricular movement.
The 2024 edition of the exam included a question specifically addressing the topic of COVID-19 vaccine. The current federal administration’s adoption of a more progressive and science-oriented approach to health policy may lead one to the interpretation that attention to this topic was intentionally diverted in 2020 and 2021 to avoid promoting reflection, criticism, and confrontation of the ideas advanced by public authorities who disseminated misinformation and anti-vaccine statements (Gomes; Zamora, 2024).
Distribution of multiple-choice questions by knowledge area
Figure 2 shows the subject areas into which the ENEM is divided and how the health-related questions were distributed among these groups.
The Languages, Codes, and their Technologies area accounts for the largest number of health-related questions. This is partially explained by the presence of physical education in this field of study. More broadly, it reinforces the importance of addressing health from a social and collective perspective in schools. This encompasses issues such as social struggles, sanitation, social equity, society, and citizenship (Malacarne; Rocha, 2024). Although Natural Sciences and Their Technologies encompass the largest number of health-related skills and competencies in the Enem Reference Matrix5 (Inep, 2020), it accounted for the second-highest number of questions (n = 17).
Although they are less frequently represented, the areas of Human Sciences and Their Technologies and Mathematics and Their Technologies also include health-related questions. The presence of health topics across all subject areas highlights their cross-cutting nature, which is consistent with the Enem's stated commitment to interdisciplinarity in its assessment framework.
Thematic categories in the multiple-choice questions
Table 2 presents the thematic categories represented in the 59 health-related questions included in the last six editions of the Enem.
Physical activity, exercise, body practices, and health constituted the largest thematic category of questions, encompassing cross-cutting health topics traditionally associated with Physical Education. It is important to note that these topics are assessed from a humanities and social sciences perspectives. Consequently, students are required to demonstrate a broad and critical understanding of issues such as mental health in sports, the social determinants of leisure-time physical activity and sedentary lifestyles and income distribution in physical activities and body practices. These topics still appear to be underexplored in Physical Education classes, given the tendency to adopt a simplistic biomedical approach when teaching the relationship between physical exercise and health (Malacarne; Rocha, 2024; Palma, 2020).
Marques et al. (2022) observed that, between 2009 and 2017, Physical Education appeared on the Enem in ways that emphasized interdisciplinary connections and everyday situations, reflecting the subject's multidisciplinary nature. Consistent with the broader perspective adopted in the area of Languages, Codes, and Their Technologies, Physical Education questions require students to demonstrate broad contextual understanding of the topics addressed. Therefore, traditional approaches to teaching Physical Education that are based on medical-hygienist conceptions are insufficient for addressing the complexity of human relationships with body practices, sports, and physical exercise (Palma, 2020).
Thus, whether in relation to health or other curricular content, vaccination emerged as the second most prevalent theme, appearing every year, except in 2020 and 2021. The absence is concerning because adolescents, the primary Enem demographic, typically have lower vaccination coverage (Viegas et al., 2019), despite facing biopsychosocial changes and vulnerabilities that underscore the need for immunization. Therefore, providing students with scientifically grounded vaccine information is therefore essential. For example, question Q126/2024 addresses the mechanism of COVID-19 vaccines by requiring students to identify how viral proteins trigger antibody production. Although this question is biologically focused, it illustrates how exam items can effectively bridge scientific knowledge with pressing public health issues, such as immunization inequalities (Viegas et al., 2019). In the context of vaccination, it is important to recognize that vaccines have been the targeted by disinformation campaigns in Brazil, even in the post-pandemic period. Brazil, a country historically recognized for the success of its national immunization programs, has recently experienced a decline in vaccination coverage that has been partly attributed to the dissemination of misinformation about vaccines. As a consequence, outbreaks of vaccine-preventable diseases, such as measles, have emerged (Brasil, 2023).
Mental health was the third most frequent thematic category identified during the period analyzed. This area encompasses a range of mental illnesses and psychological disorders, such as depression, which is recognized as a major contemporary public health problem worldwide (World Health Organization, 2022). In addition, common mental health issues are highly prevalent among university students, particularly during the transition to higher education. These issues are often associated with intense academic demands, a lack of motivation to study, and dissatisfaction with academic performance (Barros; Peixoto, 2022). Question Q009/2024, for example, presents a news report addressing depression, stress, and anxiety attacks among athletes; it requires students to recognize that factors such as constant pressure to perform and media exposure may negatively affect mental health (alternative E). These challenges are not limited to sports contexts and can also be observed in academic and workplace settings.
Figure 3 presents the graphical distribution of the thematic categories identified in the health-related Enem questions. The larger a category appears, the more frequently it was represented in the exam.
Biomedical/Mathematical and Sociocultural/Historical approaches in health-related questions
The questions were classified into two groups based on the thematic analysis of the health-related content: those involving biomedical and mathematical knowledge (n = 25) and those focused on sociocultural and historical knowledge (n = 34), as illustrated in table 3.
Evidently, biomedical approaches tend to focus on, and require students to engage with, more restricted conceptions of health. It is important to emphasize that there is nothing inherently problematic about teaching and learning about health from these perspectives. However, problems arise when the social dimension of the health-disease process is neglected, that is, when the ways in which social and historical living conditions influence biological parameters and shape people's vulnerabilities are overlooked (Nespoli, 2016).
Although some topics are highly relevant to public health, such as auditory health, health clinics, and medications, the questions tend to prioritize the resolution of discipline-specific problems, particularly those associated with mathematics and chemistry. In these cases, health-related content is predominantly used as a backdrop for assessing technical and cognitive competencies, with limited connection to its broader social and public health contexts. Question Q164/2024 exemplifies this tendency by invoking the theme of health clinics without substantively exploring their role in the organization of healthcare services or providing essential services to the population. The discussion is restricted to the instrumental logic of the proposed solution. This indicates a thematic appropriation that limits the analytical potential of these topics in broader social debates on health.
In dialogue with this discussion, Lourenço and Zômpero (2025), in their analysis of the 2021 textbooks approved under Brazil's National Textbook Program for the Natural Sciences, identified two main approaches to health education: behavioral and reflective. After analyzing 56 activities included in these materials, the authors found a predominance of the behavioral approach, which is grounded in the biological aspects of diseases and health risks and emphasizes the adoption of healthy habits and behaviors. They argue that the way health education is presented in these textbooks does not promote citizenship education and is inconsistent with the contemporary goals of science education.
Similarly, Stadler, Gonçalves, and Silva (2017), in their analysis of Enem questions in the Natural Sciences from 2009 to 2014 found that, contrary to the exam’s official principles of interdisciplinarity and contextualization, the questions predominantly reflected disciplinary and poorly integrated approaches. The authors argue that this pattern mirrors recurring practices in everyday school settings where is often taught in an isolated and fragmented manner with limited interdisciplinary integration. The similarity between the structure of the assessment items and classroom practices suggests a structural misalignment between the exam’s normative discourse and its implementation, which directly affects how content is taught and learned.
According to Lenoir (1988), interdisciplinary practices involve the articulation of two or more disciplines and their respective bodies of knowledge through contextualized educational activities that promote dialogue among different areas of knowledge. The purpose of these activities is the dissemination of knowledge and the development of socially critical individuals. This approach is strongly encouraged by the National Curriculum Parameters (Brasil, 1997) and the National Common Core Curriculum (Brasil, 2018), given that health is conceived as a cross-cutting theme across school subjects.
On the other hand, the group of questions comprising the analytical category based on sociocultural and historical knowledge seems more explicitly to contemplate the interdisciplinarity of the content surrounding this theme. The themes themselves and the contexts in which they are placed demonstrate broader reflections that are necessary for understanding the social determinants of health.
This perspective can be observed in question Q66/2019, which situates the creation of the Brazilian Unified Health System (Sistema Único de Saúde — SUS) and highlights its significance as one of the most important public policies implemented in Brazil during the 20th century. Building on students' knowledge of public health and their interpretation of the information provided, the question asks them to identify the universalist and egalitarian principles underlying the system. Likewise, question Q37/2020 addresses the broadened concept of health presented in the final report of the 8th National Health Conference (Brasil, 1986), a pivotal event in the Brazilian Health Reform movement, establishing the SUS through extensive social participation. Based on this framework, students must understand that health is shaped by social organizations.
The 2023 edition of the exam revisited the concept of health and its application across different fields and areas. Question Q42 addresses bodily practices and physical activities in various domains, such as leisure, domestic activities, work, and commuting, as they relate to the social classes of the Brazilian population. From an intersectional perspective, the question reveals that Black individuals, adults over 60, individuals earning up to four minimum wages, and those living in areas without public leisure spaces are among the most physically inactive social groups. Based on these data, students are asked to recognize that social inequality is the central factor associated with leisure-time physical inactivity in Brazil (identified as correct answer E). Malacarne and Rocha (2024) argue that although the Enem assesses physical activity from a broader perspective, its teaching in schools continues to follow a hegemonic logic centered on biological and sports-oriented parameters.
According to a broader conception of health, health education in basic education cannot be dissociated from the social determinants of health since these dimensions permeate students’ daily lives and experiences (Malacarne; Rocha, 2024). Reflecting on these issues, and on their implications for access to health services contributes to a critical, meaningful, and concrete understanding of health and its social dimensions.
In 2024, the most recent year included in this analysis, the focus was on another health-related issue: menstrual hygiene. The question addressed women's access to sanitary pads, particularly among school-aged girls, and examined the consequences of not having these products, such as school absenteeism. Students must therefore understand the impact of menstrual poverty on women's lives. In Brazil, for, example, approximately 60 million people menstruate, yet about 15 million lack access to adequate menstrual hygiene products, according to data from the United Nations Children's Fund (UNICEF) indicates that about (Galvão, 2023). Within schools, approximately 321,000 girls lack access to adequate bathroom facilities. This situation, combined with inadequate facilities, directly affects school attendance among this population.
Although the term women is used by the Enem to refer to all people who menstruate, Galvão (2023) argues that menstrual poverty affects a broad population, including cisgender girls and women, transgender boys and men, and non-binary individuals. This socioeconomic, public health, and infrastructure-related issue particularly affects individuals experiencing homelessness, refugees, and those deprived of liberty. Using inexpensive alternatives, such as newspapers, toilet paper, or breadcrumbs, to absorb menstrual blood can lead to serious physical and mental health issues (Galvão, 2023).
In this context, including this topic in the Enem relates directly to students' experiences, everyday lives, knowledge, and social realities. This gives discussions of health greater meaning and relevance. However, an analysis of the question reveals that it does not incorporate references to recently implemented public policies. For example, it fails to mention the federal Menstrual Dignity program, which was launched in 2024 following extensive public debate. This program provides free sanitary pads to socially vulnerable individuals aged 10 to 49. This omission limits the informational scope of the question, framing menstrual poverty as an individual issue rather than an expression of structural inequalities and institutional responses.
The same applies to questions concerning mental health, such as Q37/2022 and Q46/2021, which discuss the connection between working conditions and health. According to Amarante (2007), social and historical experiences and dynamics are inextricably linked to health. Along with biological determinants, these factors provide a more contextualized and coherent explanation of health-related phenomena. In light of the analyzed questions, it is evident that approaching health from social and historical perspectives in more than half of the 59 questions examined represents a shift in emphasis away from the hegemonic biomedical approaches traditionally associated with the teaching of this subject. Furthermore, the exam demonstrates a tendency to address emerging issues in collective health, although this debate was notably absent during crucial moments of the COVID-19 pandemic, reinforcing the thesis that political contexts exert influence over educational processes (Saviani, 2020).
However, these results are at odds with the guidelines and provisions for health education in Brazilian basic education. Content related to the right to health and public health policies remains scarce in textbooks (Lourenço; Zômpero, 2025) and current legislation, such as the BNCC, demonstrating the need to broaden the conception of health promoted in formal education (Sousa; Guimarães; Amantes, 2019).
Finally, we argue that teaching, discussing, and reflecting on health — especially the rights, duties, and achievements of the population — should not be a utilitarian activity aimed at the Enem and university entrance exams. Instead, health education should empower students and individuals to develop the autonomy and emancipation necessary to participate in and advocate for decisions impacting individual and collective health (Palma, 2020). Furthermore, as Venturi and Mohr (2021) assert, health education must transcend normative approaches and assume a central role in constructing scientific knowledge, fostering autonomy, and promoting citizenship education.
Final remarks
This study analyzed, through a documentary review of Enem examinations administered between 2019 and 2024, how health is addressed in the exam’s questions. The analysis revealed that the reference framework tends to prioritize the biological dimensions of health over a broader social understanding of the phenomenon. During the period under investigation, 59 questions explicitly related to health were identified. However, a significant reduction in this number was observed in 2020 and 2021, the first years of the COVID-19 pandemic, when no questions addressed vaccination or public health, amid widespread scientific denialism in the country.
The most recurring themes were physical activity and bodily practices, vaccination, and mental health. These themes predominated in the area of Languages, Codes, and their Technologies, largely due to the inclusion of Physical Education, followed by Natural Sciences and their Technologies, which remains characterized by more discipline-specific approaches. Although over half of the analyzed questions reflect sociocultural and historical perspectives on health, these approaches have yet to be more fully incorporated into basic education’s guiding documents and everyday pedagogical practices in schools.
In this sense, the analysis of health in the Enem indicates that the exam is not limited to assessing knowledge but also contributes to the production of meanings regarding what is considered legitimate school content in Brazilian basic education. The reduced presence of central public health themes during critical historical moments highlights the Enem’s role as a political-curricular instrument whose limitations cannot be resolved with technical adjustments alone but rather demand broader pedagogical and epistemological reflections. Thus, this study reaffirms the need to strengthen interdisciplinary and socially situated approaches to health in the curriculum and large-scale assessments to contribute to scientific, critical, and civic education.
Data Availability Statement
All data supporting the research findings are included in the text of this article.
1
2
3
4
5
References
- AMARANTE, P. Saúde mental e atenção psicossocial Rio de Janeiro: Editora Fiocruz, 2007.
- BARDIN, L. Análise de conteúdo São Paulo: Edições 70, 2011.
-
BARROS, R. N.; PEIXOTO, A. L. A. Integração ao ensino superior e saúde mental: um estudo em uma universidade pública federal brasileira. Avaliação: revista da avaliação da educação superior, Campinas, v. 27, n. 3, p. 609-631, 2022. DOI: https://doi.org/10.1590/S1414-40772022000300012
» https://doi.org/10.1590/S1414-40772022000300012 -
BRASIL. Ministério da Educação. Base nacional comum curricular: educação é a base. Brasília, DF: MEC, [2018]. Retrieved June 25, 2026, from: https://basenacionalcomum.mec.gov.br/
» https://basenacionalcomum.mec.gov.br/ -
BRASIL. Ministério da Educação. Parâmetros curriculares nacionais: saúde. Brasília, DF: MEC, 1997. Retrieved June 25, 2026, from: https://tinyurl.com/5hbptyxv
» https://tinyurl.com/5hbptyxv -
BRASIL. Ministério da Educação. Temas contemporâneos transversais na BNCC Brasília, DF: MEC, 2019. Retrieved June 25, 2026, from: https://tinyurl.com/mr4a2crk
» https://tinyurl.com/mr4a2crk - BRASIL. Secretaria de Comunicação Social. Luta contra a desinformação: a ciência por trás das vacinas. Brasília, DF: SECOM, 23 nov. 2023.
-
DIAS, É.; PINTO, F. C. F. Educação e sociedade. Ensaio: avaliação e políticas públicas em educação, Rio de Janeiro, v. 27, n. 104, p. 449-454, 2019. DOI: https://doi.org/10.1590/S0104-40362019002701041
» https://doi.org/10.1590/S0104-40362019002701041 -
FALKENBERG, M. B.; MENDES, T. P. L.; MORAES, E. P.; SOUZA, E. M. Educação em saúde e educação na saúde: conceitos e implicações para a saúde coletiva. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 3, p. 847-852, 2014. DOI: https://doi.org/10.1590/1413-81232014193.01572013
» https://doi.org/10.1590/1413-81232014193.01572013 -
GALVÃO, J. Novas políticas públicas precisam de um olhar abrangente para solucionar a pobreza menstrual. Jornal da USP, Ribeirão Preto, 14 jul. 2023. Retrieved June 25, 2026, from: https://tinyurl.com/y8ve3zjb
» https://tinyurl.com/y8ve3zjb - GIL, A. C. Como classificar as pesquisas? In: GIL, A. C. Como elaborar projetos de pesquisa 4. ed. São Paulo: Atlas, 2002. p. 41-56.
- GODOY, A. S. Pesquisa qualitativa: tipos fundamentais. Revista de Administração de Empresas, São Paulo, v. 35, n. 3, p. 20-29, 1995.
-
GOMES, S. R.; ZAMORA, M. H. Negacionismo: definições, confusões epistêmicas e implicações éticas. Ciência & Educação, Bauru, v. 30, p. e24008, 2024. DOI: https://doi.org/10.1590/1516-731320240008
» https://doi.org/10.1590/1516-731320240008 -
INEP. Enem 2023: resultados. Brasília, DF: INEP, 2024. Retrieved July 25, 2026, from: https://tinyurl.com/2thzhxdt
» https://tinyurl.com/2thzhxdt -
INEP. Exame nacional do ensino médio Brasília, DF: INEP, 2021. Retrieved July 25, 2026, from: https://tinyurl.com/2e7t2rxn
» https://tinyurl.com/2e7t2rxn -
INEP. Matriz de referência Enem [Brasília, DF: INEP, 2020]. Retrieved July 25, 2026, from: https://tinyurl.com/9us26n52
» https://tinyurl.com/9us26n52 -
INEP. Provas e gabaritos Brasília, DF: INEP, [2026]. Retrieved July 25, 2026, from: https://tinyurl.com/zpcbs99d
» https://tinyurl.com/zpcbs99d - LENOIR, Y. Didática e interdisciplinaridade: uma complementaridade necessária e incontrolável. In: FAZENDA, I. C. A. Didática e interdisciplinaridade Campinas: Papirus, 1998.
-
LOURENÇO, V. F; ZÔMPERO, A. F. Tendências da educação em saúde em atividades presentes em livros didáticos da área de ciências da natureza e suas tecnologias. Ciência & Educação, Bauru, v. 31, p. 1–15, 2025. DOI: https://doi.org/10.1590/1516-731320250050
» https://doi.org/10.1590/1516-731320250050 - MALACARNE, J. A. D.; ROCHA, M. B. Ensino da saúde na cidade do Rio de Janeiro: percepções de professores de educação física na educação básica. Revista Cocar, Belém, v. 21, n. 39, p. 1-20, 2024.
-
MANTOVANI, T. V. L.; MALDONADO, D. T.; FREIRE, E. D. S. A relação entre saúde e educação física escolar: uma revisão integrativa. Movimento, Porto Alegre, v. 27, p. e27008, fev. 2021. DOI: https://doi.org/10.22456/1982-8918.106792
» https://doi.org/10.22456/1982-8918.106792 -
MARQUES, R.; GAMA, J. C. F.; OLIVEIRA JUNIOR, G. L.; FERREIRA NETO, A.; SANTOS, W. A educação física no ensino médio e os exames estandardizados: uma análise das questões do Enem. Movimento, Porto Alegre, v. 27, n. 1, e27076, p. 1-21, 2021. DOI: https://doi.org/10.22456/1982-8918.113585
» https://doi.org/10.22456/1982-8918.113585 -
NESPOLI, G. Da educação sanitária à educação popular em saúde. In: BORNSTEIN, V. J.; ALENCAR, A.; LEANDRO, B. B. S.; MATIELO, E.; NESPOLI, G.; GOLDSCHMIDT, I. L.; PINTO, J. M. C. et al (org.). Curso de aperfeiçoamento em educação popular em saúde: textos de apoio. Rio de Janeiro: EPSJV, 2016. p. 47-51. Retrieved June 25, 2026, from: https://tinyurl.com/yc5m72ds
» https://tinyurl.com/yc5m72ds - OLIVEIRA, A. R.; DIAS, A. C. E.; CARVALHO, A. P. M. A.; MAIA, D. G.; HENRIQUES, F. E. S.; RODRIGUES, M. C. J. P. C. Redação do ENEM: o que é? como se faz? Ouro Branco: Instituto Federal de Minas Gerais, 2021.
-
PALMA, A. Saúde na educação física escolar: diálogos e possibilidades a partir do conceito ampliado de saúde. Temas em Educação Física Escolar, Rio de Janeiro, v. 5, n. 2, p. 5-15, 2020. DOI: https://doi.org/10.33025/tefe.v5i2.3025
» https://doi.org/10.33025/tefe.v5i2.3025 -
RELATÓRIO final da 8.ª conferência nacional de saúde. In: CONFERÊNCIA NACIONAL DE SAÚDE, 8., 1986, Brasília, DF. Anais [...]. Brasília, DF: Centro de Documentação do Ministério da Saúde, 1986. p. 381-389. Retrieved June 25, 2026, from: https://tinyurl.com/y2s3szny
» https://tinyurl.com/y2s3szny -
SÁ-SILVA, J. R.; ALMEIDA, C.D.; GUINDANI, J.F. Pesquisa documental: pistas teóricas e metodológicas. Revista Brasileira de História & Ciências Sociais, Rio Grande, v. 1, n. 1, p. 1-15, jul. 2009. DOI: https://doi.org/10.63595/rbhcs.v1i1.10351
» https://doi.org/10.63595/rbhcs.v1i1.10351 -
SAVIANI, D. Políticas educacionais em tempos de golpe: retrocessos e formas de resistência. Roteiro, Joaçaba, v. 45, p. 1-18, 2020. DOI: https://doi.org/10.18593/r.v45i0.21512
» https://doi.org/10.18593/r.v45i0.21512 -
SILVEIRA, F. L.; BARBOSA, M. C. B.; SILVA, R. Exame nacional do ensino médio (ENEM): uma análise crítica. Revista Brasileira de Ensino de Física, São Paulo, v. 37, n. 1, p. 1101-1105, 2015. DOI: https://doi.org/10.1590/S1806-11173710001
» https://doi.org/10.1590/S1806-11173710001 - SOUSA, M. C.; GUIMARÃES, A. P. M.; AMANTES, A. A saúde nos documentos curriculares oficiais para o ensino de ciências: da lei de diretrizes e bases da educação à base nacional comum curricular. Revista Brasileira de Pesquisa em Educação em Ciências, Belo Horizonte, v. 19, p. 129-153, 2019.
-
STADLER, J. P.; HUSSEIN, F. R. G. S. O perfil das questões de ciências naturais do novo Enem: interdisciplinaridade ou contextualização? Ciência & Educação, Bauru, v. 23, n. 2, p. 391–402, 2017. DOI: https://doi.org/10.1590/1516-731320170020007
» https://doi.org/10.1590/1516-731320170020007 -
VENTURI, T.; MOHR, A. Panorama e análise de períodos e abordagens da educação em saúde no contexto escolar brasileiro. Ensaio: pesquisa em educação em ciências, Belo Horizonte, v. 23, e33376, 2021. DOI: https://doi.org/10.1590/1983-21172021230121
» https://doi.org/10.1590/1983-21172021230121 -
VIEGAS, S. M.; SAMPAIO, F. C.; OLIVEIRA, P. P.; LANZA, F. M. A vacinação e o saber do adolescente: educação em saúde e ações para a imunoprevenção. Ciência & Saúde Coletiva, Rio de Janeiro, v. 24, n. 2, p. 351–360, fev. 2019. DOI: https://doi.org/10.1590/1413-81232018242.30812016
» https://doi.org/10.1590/1413-81232018242.30812016 -
VIEIRA, L. Governo federal lança campanha de orientação sobre programa de distribuição gratuita de absorventes. Dignidade Menstrual, Brasília, DF, 15 jan. 2025. Retrieved June 25, 2026, from: https://tinyurl.com/mr42vcve
» https://tinyurl.com/mr42vcve -
WORLD HEALTH ORGANIZATION. World mental health report: transforming mental health for all. Geneva: WHO, 2022. Retrieved June 25, 2026, from: https://tinyurl.com/3xzrs6yy
» https://tinyurl.com/3xzrs6yy
Source: Prepared by the authors.
Source: Prepared by the authors.
*The thematic categories are the same as those presented in 
