Health and Self-Care from the Perspective of Institutionalized Adolescents

Saúde e Autocuidado na Perspectiva de Adolescentes Institucionalizadas

La Salud y el Autocuidado desde la Perspectiva de Adolescentes Institucionalizadas

Abstract

The health of institutionalized adolescents is permeated by peculiarities that are influenced by the different contexts in which they develop. This study aimed to understand the conceptions about health and self-care elaborated by adolescents under protective measures of institutional shelter, in the light of the Bioecological model. This is a qualitative and exploratory study, based on the Bioecological Theory. Fourteen adolescent girls participated in the study. Based on the ecological insertion methodology, data were collected from a field diary, medical records, a questionnaire, and semi-structured interviews, subjected to thematic content analysis. A plurality of understandings about health and self-care was verified, which are more associated with the institutional experience than with family life and evidenced a lack of actions that support healthcare habits and autonomy of adolescents within the family unit.

Keywords:
institutionalization; family relations; self care skills; women - health and hygiene; adolescent development

Resumo

A saúde da adolescente institucionalizada é permeada por peculiaridades que são influenciadas pelos diferentes contextos em que se desenvolve. Este estudo teve como objetivo compreender as concepções sobre saúde e autocuidado com a saúde elaboradas por adolescentes em medida protetiva de acolhimento institucional, à luz do modelo Bioecológico. Estudo qualitativo e exploratório, embasado na Teoria Bioecológica. Participaram 14 adolescentes do sexo feminino. A partir da inserção ecológica os dados foram coletados por diário de campo, prontuário, questionário e entrevistas semiestruturadas, submetidas à análise temática do conteúdo. Verificou-se uma pluralidade de compreensões sobre saúde e autocuidado, que estão mais associadas à vivência institucional do que à convivência familiar e evidenciaram carência de ações que apoiem os hábitos de cuidados com a saúde e a autonomia das adolescentes dentro do núcleo familiar.

Palavras-chave:
institucionalização; relações familiares; habilidades para autocuidado; mulheres - higiene e saúde; desenvolvimento do adolescente

Resumen

La salud de la adolescente institucionalizada tiene peculiaridades que están influenciadas por los diferentes contextos en los que se desarrollan. Este estudio tuvo como objetivo comprender las concepciones sobre la salud y el autocuidado de la salud elaboradas por las adolescentes en medidas de protección del acogimiento institucional, a la luz del modelo Bioecológico. Este es un estudio cualitativo y exploratorio, basado en la Teoría Bioecológica. Participaron 14 adolescentes mujeres. A partir de la inserción ecológica, los datos fueron recolectados mediante diario de campo, fichas médicas, cuestionario y entrevistas semiestructuradas, sometidas a análisis de contenido temático. Se verificó una pluralidad de comprensiones sobre la salud y el autocuidado, que están más asociadas a la experiencia institucional que a la vida familiar y mostraron una falta de acciones que apoyen los hábitos de cuidado de la salud y la autonomía de las adolescentes dentro del núcleo familiar.

Palabras clave:
institucionalización; relaciones familiares; habilidades para el autocuidado; mujeres - higiene y salud; desarrollo del adolescente

Institutional shelters are a temporary and exceptional protective measure, not involving deprivation of liberty. They are considered when the rights of children and adolescents are violated or threatened and all other means of protection are exhausted, as they involve the removal from family life. In this case, the institutional shelter performs the function of protecting, caring, and is often the only reference for support and provision of care (Lei Nº. 8.069, 1990).

According to the National Council of Justice, in 2020, about 34,157 children and adolescents lived in 3,259 institutional shelters in Brazil. Of the total, approximately 50.8% were boys and 49.2% were girls (National Council of Justice, 2020). In a study conducted at institutional shelters in the city of Recife, state of Pernambuco (PE), Brazil (Acioli, Barreira, Lima, Assis, & Lima, 2019), the authors verified that among institutionalized individuals, 45.9% were girls and, with the exception of abandonment, the reasons for institutionalization greatly differ between sexes, and among the reasons for the inclusion of girls, the one with the highest rate is domestic and/or sexual violence, a result that corroborates other studies (Acioli et al., 2019; Macedo et al., 2020; Santos et al., 2017).

In chronological terms, the World Health Organization (WHO) considers adolescence a period that ranges from 10 to 19 years of age. Adolescence is an evolutionary stage unique to human beings, considered one of the crucial moments in the individual’s development.

In addition to changes inherent in adolescence itself, the trajectory of the institutionalized adolescent is marked by significant changes, ranging from living together and leaving the family environment to the new insertion in the institutional shelter. Adolescents need to establish new relationships in different environments, such as: institutional shelter, school, peers inside and outside the shelter, school teachers, shelter professionals, and professionals from the institutions that compose the support network. The fragility or scarcity of healthy interactions in these environments may constitute a threat to their development. (Diniz, Assis, & Souza, 2018).

Regarding health, adolescent girls in institutional care show peculiarities, mainly because of their dual vulnerability: gender discrimination and the specific nature of the situation of institutionalized individuals (Sousa, Silva, Ferreira, & Ferreira, 2018). In this sense, adolescents must be seen as subjects with needs influenced by their history of violation of rights and the different contexts in which they develop (Furlan & Lima, 2021).

Conversely, there is a scarcity of national and international studies that address the health and development of institutionalized adolescents receiving protective measures. Thus, the purpose of this study is to especially contribute to the reduction of an important gap in studies on institutionalized adolescents, from the perspective of different contexts; and the impact of the relationships established within these environments on the process of growth and healthy development.

To perform this study, we chose the Bioecological Theory of Human Development (BTHD) proposed by Bronfenbrenner, considered by Eriksson, Ghazinour and Hammarström (2018) to be one of the most influential contributors to ecological thinking in research on health. The BTHD allows the understanding of human development in all its multiplicity, observing the reciprocal interaction between the person and their different contexts over time (Bronfenbrenner, 2011). Based on its premises, ecologically looking to institutionalized adolescent girls means apprehending ‘developing individuals’ and establish a relationship with this development ‘in context’ (Bronfenbrenner, 2011).

The BTHD seeks to represent the dynamics in which relationships and interactions between developing individuals and their environment take place, based on the analysis of four interrelated nuclei, called the PPCT Model: the Person, the Process, the Context, and the Time.

The model provided knowledge of how a person (adolescent) goes through experiences and establishes process relationships in their different developmental contexts over a specific period of time (Bronfenbrenner, 2011). According to Bronfenbrenner (2011), interactions in the immediate environment are referred to as proximal processes and are considered the primary mechanisms of development. The author defined developmental contexts according to four environmental levels: microsystem, mesosystem, exosystem, and macrosystem.

Still according to Bronfenbrenner, whenever an individual in an environment pays attention to the activities and actions of another person, or participates in them, there is a relationship. The presence of a relationship in both directions constitutes what the author classifies as a dyad.

Taking this into consideration, in this study we aimed to understand the conceptions about health and self-care developed by adolescents receiving protective measures under institutional care, in the light of the Bioecological model.

Method

This is an exploratory and descriptive research with a qualitative and interdisciplinary approach based on the proposal of Ecological Insertion. According to Creswell (2010), the qualitative method allows researchers to use diversified research approaches and strategies to understand the meanings that individuals attribute to lived experiences. In this sense, the choice for a qualitative approach is in line with the basis of the BTHD, the theory that underlies this study, and which supports the conduct of research on subjects in their natural development environments.

When observing the institutionalized adolescents, the BTHD elucidates how the contextual characteristics and relationships established within the different ecological environments in which adolescents develop, such as nuclear family, extended family, schools, institutional shelters, and the street, can influence and affect the way in which institutionalized adolescents deal with their health. When moving through different contexts, adolescents experience ecological transitions that signify moments of changes in positions, activities, relationships, and roles (Bronfenbrenner, 2011).

The choice for Ecological Insertion was made in response to the researchers’ need for a theoretical and methodological framework based on the BTHD, which would allow the researcher responsible for collecting data the insertion into the environment to be studied, and the development of a real perspective on the various interactions that compose the context in which the object of study is inserted (Koller, Paludo, & Morais, 2019).

The study scenario consisted of two institutional shelters that integrate the high-complexity services of the Unified Social Assistance System (SUAS). The institutions serve children and adolescents of both sexes, aged 0 to 18 years, and are located in the Metropolitan Region of the city of Recife (PE), Brazil (Ministério do Desenvolvimento Social e Combate à Fome, 2009).

Participants

The research participants were 14 adolescent girls, aged between 10 and 14 years, who were receiving protective measures under the institutional shelter modality and who agreed to participate in the research. This number represents the total number of adolescents, aged 10 to 14 years, who were under protective measures in the two surveyed institutions. The exclusion criterion was: adolescent with a length of institutionalization less than 30 days at the time of the interview.

Instruments

Based on the ecological insertion methodology, the following instruments were used: field diary; medical records; own questionnaire prepared by the researchers to compile data from medical records; and semi-structured interviews with prior script.

Procedure

Data collection. For data collection, the methodological strategy of Ecological Insertion was employed, with gradual introduction of researchers into the environments that constitute the subject’s natural contexts of life. The field diary was used from the time of entry into the research field to the completion of data collection, and the situations and facts about everyday life in institutions and among adolescent girls were recorded. To characterize adolescents and their families, data were collected based on the medical records and the Individual Plan of Care (IPC). The characterization of the adolescents included: the different reasons for and length of institutional care; education and vaccination status. Regarding families, the following stand out: family composition and the parents’ occupation.

Semi-structured interviews were individually conducted, recorded using a voice recorder, with the participants’ consent, with an average duration of 40 minutes, focusing on the specific language of adolescents regarding the concept of health and self-care.

The combination of these different data collection techniques sought to cover as much information as possible from the field and the study participants, providing information that allowed the results to be Ecologically Validated. To this end, months in the research field were necessary. It began with weekly visits in June 2018, which lasted until the end of the interviews and the gradual departure from the field in January 2019.

After each interview, the statements were transcribed in full, without grammatical corrections, seeking to preserve the semantic nuances of the interviewees.

Data analysis. The process of inserting, organizing, and analyzing the data was based on the BTHD principles that underlie the study. For the analysis of the interviews, the content analysis technique was chosen, in the thematic modality, and three stages were established, namely: pre-analysis, investigation of the material, and treatment and interpretation of the obtained results (Bardin, 2016).

Ethical Considerations

The study was approved by the Research Ethics Committee of Universidade de Pernambuco (UPE) under Opinion No. 2.265.027 and CAAE No. 73416917.1.0000.5207, respecting all ethical care with research involving human beings, in accordance with the provisions of Resolution 466/12 of the National Health Council. In addition, to preserve secrecy, participants were identified with letters of the alphabet followed by their age at the time of the interview. For example: A13, B11, C13, D14, E12, F14, G11.

Results and Discussion

Fourteen interviews were conducted without any withdrawal, which demonstrates the effectiveness of the proximal processes established during ecological insertion. As for the characterization of adolescent girls, different reasons for institutional care were identified in the medical records and in IPC, the following being more frequent: neglect in the family; the guardians were dependent on psychoactive substances; adolescents subject to labor exploitation, begging, and homelessness; domestic sexual violence; and lack of material resources. Among these, lack of material resources was identified in all the family groups surveyed.

With regard to the length of institutional care, we observed that half of the adolescents remained in institutions for a period ranging from 01 year to 04 years or more. Almost all of the adolescent girls were falling behind in school and over half did not have a vaccine card when they entered the institutional shelter.

Regarding family composition and income, we found that: most families are large, only 03 family groups had a maternal figure in their composition and, mostly, the parents or guardians had no occupation or had a low-status occupation. The surveyed institutions intend to serve up to a limit of 20 children and adolescents. However, during the data collection period, they operated with more than the capacity recommended by law, a situation also verified in studies that evaluated institutional shelters in the city of Recife and showed that 41.6% of them worked with the number of institutionalized individuals above the stipulated capacity (Acioli, Barreira, Lima, Lima, & Assis, 2018).

This characterization is appropriate considering that the knowledge of some elements of these scenarios and actors contributes to the process of analyzing and discussing the results.

Thematic Analysis

From the thematic analysis of the semi-structured interviews, three areas of meaning emerged: In search of a health concept; How I learned to take care of myself; How I take care of myself. Subsequently, the respective categories were identified, according to Table 1. All categories were exemplified by some of the adolescents’ statements.

Table 1
Thematic nuclei with categories extracted from the content analysis of interviews conducted with institutionalized adolescent girls - Recife, PE, Brazil, 2019

Thematic Nucleus	Categories
In search of a health concept	Hygiene
	Eating practices
	Absence of illness and sense of well-being
How I learned to take care of myself	I learned on my own
	They taught me that way
How I take care of myself	Protection
	Risky behavior

Theme: In Search of a Health Concept

Knowing the conceptions of health and the sense of being healthy among adolescents, within the different microsystems that permeate the participants’ life trajectory, is necessary as a challenge and exercise to understand and uncover health practices.

For the analysis of health conceptions, the bioecological model was chosen, a theoretical perspective from which constructs-such as hygiene, eating practices, well-being, and other categories that emerged-are recognized as the product of a fusion of experiences that show the multiple facets of the physical and social environments in which institutionalized adolescents lived (family environment) and live (institutional shelter environment), as well as reflecting the patterns of behavior and health care that are present in the family and in the shelter as specific contexts of development.

Hygiene

When asked about what does it mean to be healthy, some adolescents reported the idea of hygiene, associating health with body hygiene, oral hygiene, and individual use of utensils, such as clothes and towels, as demonstrated in the adolescent’s statement “To be healthy, I brush my teeth, take a shower, then change clothes, there are girls here at the shelter who wear the same clothes, I’m not like that.” (D14).

The idea of health is also associated with that of personal hygiene and, secondly, with the way they dress themselves: “... taking a long bath, not taking a brush from another girl, I separate my things, ‘cause I’m disgusted to take things from others, the aunties always say that everyone should use what is theirs.” (L14).

Adolescent girls not only consider themselves healthy because they judge themselves to be clean based on an established routine of basic body hygiene, but also because they adopt a perspective compared to other institutionalized girls. We can perceive discourses concerning institutional experience, associated with practices and routines related to the institutional shelter: “The aunties always say that everyone should use what is theirs.” (L14).

Based on the statements of the adolescents and the data collected from the medical records and the field diary, we can infer the presence of fragility in education and care within the family microsystem, which are demonstrated by the precarious and/or nonexistent stimuli that these girls were given by their parents during family life. However, the family is expected to be able to provide care, protection, an environment conducive to learning and the construction of identity, and to establish ties between its members (Sousa, Silva, et al., 2018; Zappe & Dell’Aglio, 2016).

Eating practices

Adolescents also linked health to food, especially concerning the access to three daily meals; an access often denied to families living in extreme poverty.

Being healthy? I don’t know, I feel like I’m in the healthiest shelter here. It’s just that there’s a lot of food here and it isn’t like at my mom’s house. Here we eat in the morning, afternoon, and evening, it wasn’t like that at my mom’s, we didn’t eat like that! (F14).

Conversely, they also related health to the idea of ‘being fat’ and to the abundant supply of food: “... eating vegetables, fruits, being fat, being fat, being fat!” (A13). This statement corroborates the socioeconomic situation of the families from which adolescent girls come from, most of them in situations of extreme poverty. We observed that the girls’ concept of health was also influenced by the family microsystem from which they came: marked by the lack of material resources capable of providing adequate nutrition and associated with family neglect.

A poor diet may not only generate consequences related to the growth and development of these adolescent girls, but also entails uncertainty regarding their own survival. In addition to the organic aspect of nutrition, eating behavior has an undeniable emotional burden, and this dimension encompasses the relationship of respect and care, in addition to providing a feeling of affection and protection (Rothes & Cunha, 2016).

Absence of illness and sense of well-being

The health-disease dichotomy emerged in the adolescents’ statements. Being healthy is related both to the absence of illness and to well-being, and includes satisfaction with life, felt or intended happiness, the sense of feeling loved, of freedom, and of leisure: “Being healthy is feeling healthy, I feel healthy, I feel fine. I have no illnesses, I don’t get ill easily.” (L14); “To be healthy is not to be sick, you’re not complaining, you’re not moaning, you’re in good health, happy, you’re able to eat, to play, to go out, to have fun.” (M14); “I feel healthy ‘cause every month my mom comes visit me.” (I11); “Being healthy is having love in your heart.” (E12).

These statements highlight a variety of health conceptions, ranging from the idea of health as the absence of illness to an expanded view of health as a sense of well-being and affection, including the clear relationship between being healthy and maternal presence. In this sense, by adding the idea of well-being, the feeling of happiness, adolescent girls introduced an affective and subjective dimension to the concept of health. Perception of health is related to the affection of family members, demonstrated by visits during the period of stay at the institutional shelter.

We can perceive that there are affective dimensions that interfere with the conception of health and the development of institutionalized adolescents, as evidenced by the study conducted by Teixeira and Spiller (2018), according to which, for institutionalized adolescents, the sense of family belonging is linked to the affection they received during institutional care or within their family of origin.

There is also an association between health and leisure, in reference to routine activities such as playing and having fun. We can observe that, when carrying out leisure activities, within the shelter or in the institution’s routine activities, adolescent girls establish emotional relationships with their peers and with the context that surrounds them, contributing to the improvement of well-being and health.

Theme: How I learned to take care of myself

According to the Bioecological model, the parent-child relationship is considered a proximal process that interacts with different aspects of the context, the person, and the time, resulting in different outcomes in the development of children and adolescents. According to Assis, Moreira and Fornasier (2021), children receive many influences from the proximal processes, which are determined by the characteristics of the person and the environment. Hence, the proximal processes can be understood as the engine or driving force of child social development.

Therefore, if the proximal processes are fragile, relationships and connections are precarious. Adolescents probably received few stimuli, which may constitute a risk to a healthy development (Bronfenbrenner, 2011).

I learned on my own

When asked how they cared for themselves, the adolescents said that knew what they had learned at the shelter, a situation that shows the deficit in health and hygiene guidelines within the family unit: “Nobody was taking care of my things, I was the one doing it. I don’t know why she [grandmother] didn’t take care of me!” (G11); “Nobody actually, nobody taught me anything, I didn’t know much about this health stuff.” (N13).

I don’t know... I don’t remember being taught anything. Here at the shelter, the aunties keep telling us to take care of ourselves and be hygienic. At home I used to take a shower only when I needed to and I’d stay that way without combing my hair, but here, they want me to take a shower every day! (B11).

According to the statements, we can observe that the adolescents’ family microsystem is permeated by different issues, including the failure of guardians to provide the essential conditions for healthy development and situations of neglect and abandonment. This reality therefore demonstrates the opposite of what is socially and legally expected from the role played by families, which would be to provide a healthy development, access to basic needs-such as food, housing, care necessary for health, education, and school-, but there is omission on the part of the family or guardian concerning one or more aspects for their children and adolescents (Acioli et al., 2019; Rothes & Cunha, 2016).

From Latin negligentia, “neglect” means inattention, carelessness, not conferring something its due value; it is about abandonment and the lack or scarcity of care. According to data from the medical records and the IPC, most of the adolescents had experienced unsuccessful family reintegration processes, or multiple measures of institutional care. This may mean a negligent and inappropriate family environment for healthy growth and development. The data from this study are consistent with the study conducted by Paiva, Moreira and Lima (2019), which points to the main reasons for the new institutionalization of institutionalized children and adolescents: family neglect, followed by abandonment, and the chemical dependency of parents or guardians.

Among the different reasons for institutionalizing adolescent girls, it should be noted that negligence is a public health issue affecting many families in society. Furthermore, there are issues of national scope and in the family context that go beyond the theme and reinforce the need for critical reflection regarding the attribution of a family as negligent or neglected (Mata, Silveira, & Deslandes, 2017). However, when dealing with adolescents in a situation of institutional shelter, we must take into account that adolescent girls had one or more rights violated and, for this reason, were removed from their families.

They taught me that way

The family microsystem is part of the first context in which a child begins to interact, having a significant influence on their development. Conflicted family contexts can be harmful, while other microsystems - such as schools and health services - can be promoters of development.

The statements of some interviewees indicate that habits associated with hygiene and health were learned from their families, but the institutional shelter and school also emerge as spaces for learning what should have been taught by the family: “Since I was little my mother taught me how to bathe and brush my teeth.” (J13); “It was at the shelter, it was only there, and I only had a lecture by a dentist, they said people should brush their teeth properly after eating” (A13); “At school, I learned about these diseases, the diseases that men have when they don’t use condoms, and other diseases too.” (O13); “At school, with the science teacher. She explained about girls and boys, she explained how girls menstruate” (F14).

The statements showed that there are gaps in actions that promote healthcare habits and individual autonomy within the family unit, as only 02 of the 14 study participants referred to learning it in the family environment.

The reports show that the dyadic relationships established within the family microsystem of these adolescents did not favor the adoption of healthy habits, and that other microsystems, such as schools or even institutional shelters, played this role.

In the learning process, the presence of others is paramount; however, relationships must be permeated by affectivity. The other may be represented by different agents, from the maternal or father figure within the family unit or the figure of the teacher within the school environment (Sousa, Ramos, & Sousa, 2018). In the case of institutionalized adolescents, these “agents” extend to the educators and the technical staff that work in the shelters, which portrays the clear reference that adolescent girls make to habits acquired at the shelter or the school. From an ecological point of view, the shelter represents, for institutionalized adolescents, the immediate environment surrounding them, the central microsystem (Bronfenbrenner, 2011), and must be recognized in its differential context of development.

Theme: How I take care of myself

The categories of analysis based on the adolescents’ statements allow us to understand their experiences and how they influence their daily lives and the way in which they care for themselves or should care for themselves.

According to Bronfenbrenner (2011), in order to promote individual development, there must be: effectiveness in the proximal processes and the establishment of interpersonal relationships with reciprocity. From this perspective, Bronfenbrenner believes that the quality of development will be strongly influenced by relational capacity and the affections that predominate in it.

Protection

The answers to the question about what they should do to be healthy, that is, about the prevention of health issues, mostly repeated guidelines received at school or institutional shelter, making it unclear, however, what are the actual health behaviors in relation to self-care: “I mean, it’s always good when you’re going to have sex... to just feel comfortable with it, when doing it, use a condom, take pills, and be careful ‘cause of the diseases.” (L14); “It’s important to use a condom to prevent diseases that, if a man has it, he passes on to the woman and, if a woman has it, she passes on to the man.” (O13); “We can only have sexual intercourse when we’re ready and even so with a condom so as not to cause diseases such as: AIDS, HIV. So they also talked about preventive medication, injection.” (M14); “Don’t use drugs, don’t smoke cigarettes, don’t drink, and that’s it.” (A13).

We can observe that adolescent girls have knowledge related to the prevention of sexually transmitted diseases, prevention of pregnancy, and the use of condoms. Although the statements about prevention indicate the strong presence of discourses from this perspective, it is noteworthy that in none of them the interviewees mentioned to be following prevention practices. A study conducted by Lisboa and Lerner (2017) shows results that corroborate these findings. The authors observed that access to information about a particular risk is insufficient for the adoption of healthy behaviors by adolescents.

It should be noted that the family microsystem was negligent in relation to health and education for the vast majority of the institutionalized adolescents. Nevertheless, the data transcend the family microsystem, involving the health service, the school, the local government, and the State as some of the elements that compose the ecological system, which did not guarantee the fundamental conditions for promoting the adolescents’ health, safety, and education.

Risky Behavior

Regarding risky behavior, the statements of the interviewees were associated with the exposure and/or use of tobacco and alcohol, especially in the family environment, in which the use of alcohol and other drugs permeates the daily lives of these individuals, being part of the contexts in which they develop with the learning of risky behaviors: “I’ve already drunk, I’ve smoked, I’ve done drugs, yeah, and I’ve even taken medicine, I’ve taken a lot of it! [self-harm]” (A13); “There’s one thing, I smoke and drink.” (G11); “My mother and father are undergoing treatment [for alcoholism], but my mom still drinks a lot, I’ve drunk a few times.” (I11); “... when I have sex with boys we don’t use a condom! I don’t think I’ve ever used it!”. (D14).

These excerpts, associated with observations from the field diary and data from the medical records, demonstrate that these girls had contact with substances such as tobacco and alcohol in their own family unit. Half of the study participants had as one of the reasons for their institutionalization the fact that parents or guardians were drug addicts or alcoholics. It is worth emphasizing that we are dealing with girls aged 10 to 14 years, who present risky behavior such as the use of tobacco, alcohol, and other drugs in addition to sexual activity. Studies show that factors significantly associated with the adoption of risky behaviors among adolescents are: intrafamilial and extrafamilial violence, having close friends or family members who use drugs (Zappe, & Dell’Aglio, 2016). The family may act as a protective or risk factor for drug use during adolescence, depending on how it plays its role (Zappe & Dapper, 2017).

Comparing these data with the characteristics of the family microsystem, we noticed that the families from which the adolescents participating in this study came from had unhealthy interactions, situations of neglect, abandonment, and violence that prove to be risk factors for health-related behaviors.

The present study aimed to understand the conceptions about health and self-care developed by institutionalized adolescents receiving protective measures in the light of the Bioecological model. Based on the collected data, the study participants came from large families with the absence of one of the guardians, with parents with low level of education and limited financial resources, ranging from poverty to extreme poverty. The reasons for institutional care that co-occurred were family negligence, drug addiction or alcoholism on the part of parents or guardians, child labor exploitation or begging, and homelessness. Adolescents also have a history of falling behind or absenteeism from school, experimentation of tobacco within the family unit. Half of the adolescent girls in the survey had already experienced institutional care in other institutions with unsuccessful attempts of reintegration into their family of origin or into a surrogate family.

The study allowed identifying thematic nuclei that guided the analysis of the interviewees’ statements: in search of a health concept; how I learned to take care of myself; how I take care of myself, and their respective categories. By these nuclei, we concluded that the health and self-care knowledge expressed by the adolescents was more associated with those based on the experience at the institutional shelter, which were part of the institutional routine, or associated with the classes and content available in the school environment, than with those apprehended in the family environment with parents or guardians. It was also possible to apprehend the concept of health as a synonym for well-being and happiness. Thus, the fragility in the interactions of adolescents with their different contexts may negatively influence health-related behaviors.

We observed that the relationship between institutionalized adolescents and self-care both changes and can be transformed by the interaction with different contexts: the family, the institution, and the school. This is because the definition of self-care transcends mere biological construction, being a multidetermined process, influenced by factors related to the individual’s coexistence and the social context in which they live. In this study, the BTHD allowed us to broaden our view beyond the representations of health expressed by the adolescents. This theory allowed us to investigate, from the perspective of adolescent girls, the various contexts in which they develop, in addition to understanding how they integrate and perceive the relationships and experiences relevant to the production of their health in the different microsystems, modifying and at the same time being transformed and influenced by it.

Therefore, it is necessary to promote intervention studies on health and self-care, which demonstrate the changes in the health conditions of this population based on the intervention considering the scarcity of current studies, in such a way that adolescent care policies can be implemented.

The limitation of this study, despite the different collection instruments used, was the limited capacity of adolescents to make statements related to their young age and the condition of institutionalization.

For research that adopts the Ecological Insertion methodology, the moment of leaving the field may be considered the greatest challenge, so that it is not felt by the participants as abandonment, especially when it comes to institutionalized adolescents.

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• 2
  Article derived from the master’s thesis of the first author under the supervision of the second author, defended in 2019 in the Graduate Program in Adolescent Medicine of Universidade de Pernambuco.

Edited by

Associate editor: Susana Maria Gonçalves Coimbra.

Publication Dates

• Publication in this collection
  15 May 2023
• Date of issue
  2023

History

• Received
  13 May 2022
• Reviewed
  07 Aug 2022
• Accepted
  01 Sept 2022