Representações sociais do cuidado em saúde de pessoas em situação de rua * Social representations of health care by homeless people Representaciones sociales del cuidado sanitario de personas en situación de calle

Objective: Identify and analyze the structure and content of the social representations of homeless people in relation to health care. Method: Qualitative study, based on the structural approach of the Theory of Social Representations, conducted with homeless people, linked to two institutional shelters. To produce the data, the free-association test was used. The resulting data was processed by two software and analyzed according to the theory above. Results: Seventy-two people participated in the study. The set of evocations from the four-quadrant chart refers to individual, social and cultural actions. The terms ‘doctor’, ‘taking care of yourself ’ and ‘eating’ composed the central core of the representation, indicating image-related and functional dimensions of the object investigated. The word cloud confirmed the centrality of the terms. Conclusion: The investigated group represents health care as a dynamic action, linked to the person and context, and is anchored in elements of the hygienist conception. DESCRIPTORS Homeless Persons; Delivery of Health Care; Self Care; Public Health Nursing; Primary Care Nursing.


INTRODUCTION
Care is intrinsic to the human condition.Although the term is frequently used in discussions about comprehensiveness and humanization of health practices, its definition is still imprecise due to the complexity inherent to it.In general, care can be understood as the interaction between two or more people for the purpose of alleviating suffering and achieving wellness, mediated by knowledge focused on this end (1) .It is often carried out through normative actions reduced to procedures, prescriptions and regulations, to the detriment of a type of care that values the life projects of the other (1)(2) .
The perspective of care as a daily construction in interactions that involve relationships of power makes the person the main focus (3) .Such a perspective broadens the understanding of different ways of caring and the various factors that influence practices.Consequently, it helps diminish the barrier that separates professionals and researchers from users.Therefore, care is linked to social and cultural issues, and may differ from person to person in distinct contexts.Thus, it is pertinent to the present study, especially for its connection with homeless people.
The number of homeless or street people is rising in Brazil and various countries, illustrating the extremes of inequality and social exclusion in the world (4) .The context of the street is where numerous people seek to be welcomed, supported and sheltered, although they are constantly subjected to unhealthy conditions and human conglomerations, as well as deprivation of food and water, exposure to climatic variations and situations of violence (4)(5) .In the street context, many get entangled with alcohol and other drugs, and are vulnerable to chronic, psychiatric and infectious diseases, such as skin conditions, lice infestations, tuberculosis and sexually transmitted diseases (6)(7) .
The specificities of life in the street, associated with the complexity of factors, renders people susceptible to various social and health problems that challenge different professionals, such as nurses, nursing technicians, physicians, social workers, dentists and oral health technicians, psychologists, community health agents, occupational therapists and social agents from diverse sectors and services in society.
According to data from the National Survey on homeless people (5) , it is common for them to go to emergency hospitals when they are sick, as well as seek to perform hygiene habits and maintain food intake.The data shows that these people adopt healthcare measures aligned with the context in which they are inserted.These aspects lead to the concept of social representations (8) which understands them as a type of knowledge that produces and determines behaviors and shows that something absent can be added and something present can be modified.
Therefore, it is important to explore the meanings attributed to health care by this segment of the population, since social representations can be reflected in practices and behaviors of the social group (8)(9) , and thus have a close relationship with Nursing and health teams.The analysis of these representations makes it possible to rethink healthcare practices, as well as implement policies to promote the access of homeless people to health services, with a decrease in the various forms of prejudice, violence and vulnerability to which they are subject.
This contextualization gave rise to the following question: How do homeless people represent health care practices?The representation of an object can reveal its multiple facets and make it possible to understand specificities of the individual and/or group in relation to the object represented.In this sense, the Theory of Social Representations, in its structural approach, focused the cognitive processes of social representations, endeavors to study the influence of social factors on thought processes through the identification and characterization of relational structures (9) .The purpose of this study was to identify and analyze the structure and content of the social representations of homeless people in relation to health care.

METHOD
This was a qualitative study and the empirical data was produced from May to August 2016.Seventy-two homeless people, registered in two institutional shelters (Unidades de Acolhimento Institucional), located in the city of Salvador, Bahia, Brazil, participated in the study.The shelters were founded in 2014 and are part of the Municipal Network of the Unified Social Welfare System, in order to provide temporary shelter and the means for people 18 years of age or older to have a place to stay, social interaction and a reference address.These two shelters can accommodate between 33 and 51 people, respectively.
The group investigated was chosen according to the following criteria: be 18 years of age or older and appear to be able to interact with the researcher.For data production, the Free-Association Test -an instrument widely used in Social Representations Theory-based studies -was used due to the possibility it provides for spontaneously capturing mental projections and implicit or latent content that may be hidden in discursive and reified content (9) .
The instrument was comprised of two sections.The first involved the data identification and health characterization of the participants.The second, the test itself, composed of the prompting phrase "taking care of your health means", where each participant was requested to state up to five words or short expressions that immediately come to mind.Then the participants chose, from among the terms cited, the one considered the most important, justifying the choice.The test was applied individually, in a reserved room, and lasted 10 minutes on average.
Two software for processing qualitative data were used: one to identify the combination of the frequencies of evoked words with the average order of evocation (10) , and the other for building a word cloud (11) .This, in turn, was used to confirm the centrality of the elements that made up the probable central core.The justifications for the terms considered most important were transcribed in their entirety and used as the basis for the four-quadrant chart, which facilitated comprehending the meanings assigned to the terms evoked.
The study was assessed and approved by the Research Ethics Committee of the School of Nursing of the Universidade Federal da Bahia (EEUFBA), under Opinion No. 1.477.800/2016.The rules and guidelines for conducting studies involving human beings were respected, in compliance with Resolution No. 466/12 of the National Health Council.In conducting the study, the confidentiality and anonymity of the homeless people were ensured − through using the letter P, in reference to participant, followed by the number in order of occurrence − as well as their privacy and freedom to participate or not in the study, and to withdraw at any time.

RESULTS
In the group that was studied (72 people), most were women (50), predominantly 21 to 31 years of age (34), in conjugal relationships (47), black in terms of race/color (60), belonged to a religion (50), reported not having completed elementary school and were informally employed (44).As for length of time being homeless, a period of less than five years was the most common (34).In relation to health conditions, most reported not having any comorbidities (40), but among those who did the most prevalent ones were: hypertension (5), syphilis (3), HIV-seropositivity (4) and renal lithiasis (3).Most said they use health services (71), primarily in hospitals (52).In terms of health needs, they said they went to health units for prevention and orientation (40), medical treatment (38), tests (28) and to get medication (27).Most reported having used some type of psychoactive substance in their lives (62), the most prevalent being alcohol (54), followed by marijuana (48).
The analysis of the corpus revealed that, in response to the stimulus "taking care of your health means", the investigated group evoked 327 words, of which 47 were distinct.The minimum frequency was 5 and any terms with a lower frequency were excluded from the composition.The average frequency was 15 and the average order of evocation was 2.9.The necessary processing calculations were done through the software itself, based on Zipf 's Law (12) , which enabled expressing the content and structure of the social representation, as shown in Chart 1.
Chart 1 -Four-quadrant chart in reference to the stimulus "taking care of your health means" -Salvador, BA, Brazil, 2017.

Elements from the central core
Frequency ≥ 15 Average Order of Evocations < 2.9

Elements from the 1 st periphery
Frequency ≥ 15 Average Order of Evocations > 2.9

Element
Freq.The upper left-hand quadrant, called the central core, contains the terms which obtained a higher frequency and lower average order of evocation.In the present study, the central core was comprised of the term "doctor", which had a higher frequency and was the most readily evoked.This is confirmed by the justifications of the participants for this term: The doctor will look at you, consult with you and see what you need (P 11).

(...) The doctor knows more (P 32).
He'll do all the tests, see whether your pressure is high or low and check how you're doing (P 45).
The other terms that made up the central core were: "taking care of yourself ", and "eating", which is an intersubjective and functional dimension.The justifications for these terms, when defined as being more important, underscored the fact that health care involves a personal commitment, prioritizing on health and nutrition, as illustrated in the following excerpts: If we don't take care of our bodies, who will?First, you have to take care of yourself and have self-esteem to be healthy (P 22).
Women need to take care of themselves and take preventive measures, always go to the doctor and take care of their intimate parts, right?Apply vaginal cream.In my first pregnancy, I didn't www.ee.usp.br/reeuspSocial representations of health care by homeless people Rev Esc Enferm USP • 2018;52:e03314 even know how to apply vaginal cream.My mother-in-law taught me (P 52).

Try to go to the doctor, eat healthy food. No one can live without food (P 58).
Drugs are not healthy, alcohol is not healthy.You have to eat healthy things that give your body energy (P 68).
In the upper right-hand quadrant, also called the first periphery, are found the most important peripheral elements of the representation, since they had the highest frequencies, even though they had been evoked later on (9) , and include the terms 'taking preventive measures', 'hygiene' and 'happiness'.In the hierarchization process, 'taking preventive measures' was referred to 17 times in the justifications, demonstrating the importance of the maintenance of hygienic care for the group studied: In order not to harm yourself or others (P 5).
Through hygiene, you do not contract bacteria, which avoids having to go to the doctor or taking medication (P 4).

If you don't keep yourself clean, you're susceptible to catching a disease (P 14).
The term 'happiness' introduces an affective and subjective dimension in relation to the object investigated.Five of the participants indicated and justified this term as being the most relevant, as shown in the following narratives: Happiness is when the body and mind are in equilibrium, and health is also balanced (P 8).
Happiness is the ultimate goal of life.Your achievements in life don't matter if you're not happy.They're not worth anything (P 9).

When you're happy, it's much easier to work things out in life.
It's much easier to solve things.I think that happiness comes first in everything (P 26).
The lower right-hand quadrant, called the second periphery, contains the least frequent and most belatedly evoked elements, which have pertinence in the representational field due to their significant participation in reference to daily practices (9) .This quadrant was composed of six terms: 'physical activity', 'test', 'treat', 'beauty', 'healthy' and 'body', as illustrated in the following segments: Checkups are important for avoiding diseases.What's important in life is health, peace and freedom (P 17).

When I engage in physical activity, I feel very good (...) lighter, and my breathing improves (P 19).
If we don't take care of our bodies, who will?First, you have to take care of yourself and have self-esteem to be healthy (P 10).

If you don't treat the disease, how is it going to be cured? (P 24).
You have to take preventive measures against disease, have greater joy (P 60).
In the lower left-hand quadrant, technically referred to as the contrast zone, the elements are low in frequency and readily evoked by the participants (9) .It is composed of seven terms: 'good', 'medication', 'important', 'life', 'sickness', 'responsibility' and 'love'.These aspects reinforce the elements arranged in the central core.Ten participants assigned greater importance to the terms: When you have self-esteem, you generally take care of your health (P 12).

If you don't get treated, you aren't living. Without health, you won't live for a long time (P 16).
Because love is what drives everything; I am love, an insurmountable love; I believe in this love, immeasurable, free of charge, in simplicity (P 71).
In the word cloud (Figure 1), which randomly groups and organizes the terms taking frequency into account, it can be seen that the word 'doctor' appeared the most in the corpus (36), followed by the term 'taking preventive measures' (31) and 'taking care of yourself ' (30), as well as the terms 'hygiene' (27) and 'eating' (22).

DISCUSSION
The set of words prompted by the stimulus "taking care of your health means" and its distribution in the four-quadrant chart reveals that the social investigation of the group was anchored in habits and actions disseminated over the years by the biomedical model and permeated with specificities inherent to the context in which these individuals are inserted.
The conception that health care has evolved from strictly healing and individualized techniques to comprehensive and collective practices (13) appears to be reflected in the terms contained in the central and peripheral system of the four-quadrant chart.In general, the terms embody technical  aspects related to the treatment and cure of diseases, with intersubjective and attitudinal elements that reveal the involvement of the person in the healthcare process.
According to the principles in the structural approach of the Social Representations Theory (9) , the words arranged in the upper left-hand quadrant characterize the possible central core of the representation, since they were evoked more readily and due to their high frequency.It is worth noting that the central core is the most stable part of the social representation, with fewer possibilities of change.In this study, the elements that composed it were: 'doctor', 'taking care of yourself ' and 'eating'.Although the participants referred to a concept of care still rooted in the biomedical model, in which physicians play a central role, they indicated co-responsibility based on self-care, i.e., care which depends on the person.
As expected, the holding of power and knowledge to prescribe tests and drugs for treating and curing diseases was attributed to physicians.This conception may explain the fact that the 'doctor' element had a higher frequency and was the one most readily evoked by the group.The other terms from the central core, 'taking care of yourself ' and 'eating', as well as the others that made up the four-quadrant chart, confirm the idea of the person as the main care focus and its daily construction (3) .
In the peripheral system, there are various terms related to the group's understanding of an expanded definition of the concept of health and, consequently, of health care.The first periphery -upper right-hand quadrant -consists of elements which, due to their importance, often reinforce the central elements (9) .In this study, the terms 'taking preventive measures', 'hygiene' and 'happiness' implicate the person in the healthcare process and have attitudinal dimensions related to practices or actions that permeate caring for one's own health.In the group investigated, prevention is a daily task that is not only limited to measures against catching diseases, but also encompasses protection against situations of violence (14) and injuries that can damage physical and mental health.Such situations are linked to the reality of the context in which they are inserted (14)(15) .
As expected, the main synonyms of hygiene are 'healthy' and 'fragrance'.The conditions of homeless people, associated with dirt and poor hygiene, are factors that prevent and/or hinder access to health services and increase social exclusion.In Brazil, the hygienic mentality was propagated between the second half of the 1940s until the mid-1960s, to address commercial issues of the industrial era.The production and commercialization of new and varied products related to health and hygiene were widely covered by the press, disseminating a new modern and healthy way to live (16) .This production and commercialization of new products and their dissemination in the media is still the case today, and imposes upon the society a concept of hygiene associated with aromatic products, while at the same time condemning the natural smells of the human body.
The presence of the term 'happiness' refers to a subjective dimension of the social representation of the investigated group in relation to health care.Although many intellectuals have devoted themselves to the study of happiness, there is no still consensus as to what this feeling is.Feelings of happiness are unique to each person and may be individually or collectively associated with physical, social, affective or other factors.Satisfaction with one's health is an extremely important feeling for increasing the likelihood a person will say they are happy (17) .This satisfaction does not depend on social relationships, but on people's feelings toward themselves, since their health may be affected by a sickness, but they are nevertheless happy.A feeling of satisfaction is very important for people to claim they are happy.
It is possible to have a life that is not based on prescriptive happiness, i.e., a life whose objects of desire break away from historically and socially established criteria, for example: graduation, success at work, marriage, family (17)(18) .From this perspective, wanderers, migrants, homeless people and individuals living in diverse cultural contexts will not view themselves as disadvantaged within the broader narrative on happiness (18) .As strange as it might seem, being homeless may also be a form of feeling happy, distant from socially formatted contexts and that constitute an element that triggers/ generates a disease cycle.The street often becomes a place of refuge, liberation and for establishing new relationships.
The elements that make up the second periphery − lower right-hand quadrant − formed by words less readily and frequently evoked, had a lower significance or importance for the group examined (9) .In this study, 'physical activity', 'test', 'treat', 'beauty', 'healthy' and 'body' also had characteristics with a positive connotation for the object represented, in an attitudinal and image-related dimension.These terms are complementary and indicate that taking care of one's health helps ensure better quality of life, guided by the biomedical model, in an intimate association with the term 'doctor', found in the central core.This association reveals a more pragmatic and procedural need for this care (12) .
The terms 'physical activity', 'beauty' and 'body' complement each other and disclose an image-related dimension of the social representation of the object investigated.These terms also denote positive aspects in relation to health care and the involvement of the individual.Physical activity was inherent to the daily lives of the participants, in their attempts to find ways to maintain hygiene habits and obtain food and an adequate place to sleep and rest.However, the appearance of this term in the second periphery may be rooted in the idea that has been propagated that engaging in physical activities helps maintain a healthy life, beauty and the body, and prevents health problems (19) .
It is clear that, for the social group, health is related to the body and beauty, regardless of the location where they are.It is worth noting that beauty is relative, despite standards socially disseminated by the media.In any case, the concern about beauty and one's body involves actions focused on the complex process of health care, revealing the implication of self-care.
The set of words that make up the contrast zone -lower left-hand quadrant -contains elements that obtained a low frequency and average order of evocation, but were considered important for the group that was investigated (9) .The set of words that comprise the contrast zone are: 'good', 'medication', 'important', 'life', 'sickness', 'responsibility' and 'love', and also point to an image-related, intersubjective and functional dimension of the representation.Some terms make reference to the biomedical model, but promote the individual's involvement in health care and love as an element of this care.A predominance of terms with a positive connotation was also noted (good, important, life, responsibility, love).The term 'important' refers to the symbolic value associated with the object and indicates involvement in the development of control strategies and responsibility for one's personal health.
The 'love' element deals with an affective dimension and is associated with the term 'happiness', placed in the second periphery, reinforcing the expanded concept of health.This term denotes that care involves the participants' need for self-esteem, in order to take better care of themselves and others.The social representation also fulfills a function in relation to familiarity with the group, and the affective dimension is presented on the basis of this transit, supported by individual and collective memory and by daily experiences and situations (20) .
According to the principles of the structural approach of the theory, the peripheral system is linked to daily reality, encompasses elements of transition and is responsible for updating the central core (9) .This dynamicity promotes transformation of the social reality and helps modify behaviors, conducts and actions related to their health as homeless people.
With respect to the word cloud, the terms more emphatically expressed are represented by the expressions 'doctor', 'taking preventive measures', 'taking care of yourself ', 'hygiene' and 'eating', where two of the terms belong to the first periphery of the four-quadrant chart.This, therefore, illustrates the centrality of the terms in the central core and reinforces how the rules of medical knowledge are important for the group that was studied and, at the same time, shares and appropriates knowledge based on expanded health care, using notions of prevention and promotion of complications, as well as individual practices for taking care of health.

CONCLUSION
In studying the social representations of a group of homeless people in relation to health care, the centrality of cultural elements in regard to health and specificities in the daily lives of the investigated group were noted and that warrant being considered in professional care practices.The predominance of the term 'doctor' in the central core reflects the idea of health care linked to diagnosis, treatment and, at times, cure of a certain disease and, at the same time, reveals one of the problems faced by homeless people, which is access to health services.
The set of evoked words represents health care as a daily construction, rooted in actions for meeting basic human needs established by the context of the street.Co-responsibility for health care is inherent to this context.The terms evoked reveal aspects of the image-related, cultural and biological dimensions of health care.
The data produced cannot be generalized due to the limitation of the group studied and the dynamicity of social representations.Its originality and unprecedented nature permit reflection on the formulation of professional practices aligned with the needs and realities of homeless people, in addition to indicating the need for further studies on the topic.In this sense, it is believed that the data can be used in initiatives to train health professionals, especially nurses, in order to reduce conflicts in the care provided and decrease health complications in the homeless population.

Figure 1 -
Figure 1 -Word cloud in reference to the stimulus "taking care of yourself means" -Salvador, BA, Brazil, 2017.