Accessibility / Report Error

Youth empowerment in health: a theoretical structure of literacy practices

Empoderamiento de los jóvenes en salud: una estructura teórica de las prácticas de alfabetización

ABSTRACT

Objective:

To develop a theoretical structure on literacy practices committed to health empowerment, based on the understanding of school adolescents and members of a Quilombola community in the State of Pernambuco, Brazil.

Method:

Interpretative analysis, based on the assumptions of the Grounded Theory and Symbolic Interactionism. For data collection, Culture Circles were conducted with 18 adolescents from October 2020 to August 2021.

Results:

The theoretical archetype is structured based on the recognition of vulnerable youth context, and the development of potential through collective relations built by dialogue, trust, shared knowledge construction, and the use of technologies.

Final considerations:

The theoretical structure on literacy practices committed to empowerment through the understanding of adolescents runs through the framework of a substantive theory that culminates in a perspective of agency and recognition of their needs.

Descriptors:
Adolescent; Health literacy; Empowerment

RESUMEN

Objetivo:

Elaborar una estructura teórica sobre prácticas de alfabetización comprometidas con el empoderamiento en salud, basada en la comprensión de los adolescentes escolares y miembros de una comunidad Quilombola, en el Estado de Pernambuco, Brasil.

Método:

Análisis interpretativo, basada en los supuestos de la Teoría Fundamentada y el Interaccionismo Simbólico. Para la recolección de datos, los Círculos culturales se llevaron a cabo con 18 adolescentes desde octubre de 2020 hasta agosto de 2021.

Resultados:

El arquetipo teórico se estructura de acuerdo con el reconocimiento del contexto juvenil en vulnerabilidad, y el desarrollo del potencial mediante relaciones colectivas construidas por el diálogo, la confianza, la construcción compartida del conocimiento y el uso de las tecnologías.

Consideraciones finales:

El marco teórico sobre las prácticas de alfabetización comprometidas con el empoderamiento a través de la comprensión de los adolescentes pasa por el marco de una teoría sustantiva que culmina en una perspectiva de protagonismo y reconocimiento de sus necesidades.

Descriptores:
Adolescente; Alfabetización en salud; Empoderamiento

RESUMO

Objetivo:

Elaborar uma estrutura teórica sobre práticas de letramento comprometidas com o empoderamento em saúde com base na compreensão de adolescentes escolares e integrantes de uma comunidade Quilombola, no Estado de Pernambuco, Brasil.

Método:

Análise interpretativa alicerçada nos pressupostos da Teoria Fundamentada nos Dados e o Interacionismo Simbólico. Para a coleta dos dados, foram realizados Círculos de Cultura com 18 adolescentes no período de outubro de 2020 a agosto de 2021.

Resultados:

O arquétipo teórico se estrutura consoante ao reconhecimento do contexto juvenil em vulnerabilidade, e o desenvolvimento do potencial pelas relações coletivas edificadas pelo diálogo, confiança, construção compartilhada do conhecimento e o uso das tecnologias.

Considerações finais:

A estrutura teórica sobre práticas de letramento comprometidas com o empoderamento pela compreensão dos adolescentes perpassa pelo arcabouço de uma teoria substantiva que culmina em uma perspectiva de protagonismo e reconhecimento de suas necessidades.

Descritores:
Adolescente; Letramento em saúde; Empoderamento

INTRODUCTION

As a complex and multidimensional construct, health literacy is an action competency with a strong focus on personal attributes while at the same time enabling individuals not only to act in the development of the ability for understanding information and make decisions, but also to critically recognize and respond to its interrelationship with social determinants of health11. Dearfield CT, Barnum AJ, Pugh-Yi RH. Adapting Paulo Freire’s pedagogy for health literacy interventions. Humanity Soc. 2017;41(2):182-208. doi: https://doi.org/10.1177/0160597616633253
https://doi.org/10.1177/0160597616633253...
,22. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. doi: https://doi.org/10.1186/s12889-017-4267-y
https://doi.org/10.1186/s12889-017-4267-...
.

Health literacy considers specificities and specific social structural actions by recognizing skills for solid decision-making, thus, promoting healthy behaviors and mitigating future health risks. In addition to meeting the different phases of life based on a cognitive and developmental perspective upon needs and the context of vulnerabilities22. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. doi: https://doi.org/10.1186/s12889-017-4267-y
https://doi.org/10.1186/s12889-017-4267-...
.

Adolescence is a phase of life in which crucial processes of physical, cognitive and emotional development occur, emerging new experiences and various concerns due to susceptibility and the expectation of greater responsibility33. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
https://doi.org/10.1093/heapro/daz041...
.

The vulnerabilities faced by quilombola adolescents are multifaceted and are linked to social and health determinants, not only inherent to their ethnic-racial conditions, but also the result of historical economic, cultural and structural inequalities44. Moraes-Partelli AN, Coelho MP, Santos SG, Santos IL, Cabral IE. Participation of adolescents from the Quilombola community in the creation of an educational game about alcohol consumption. Rev Esc Enferm USP. 2022;56:e20210402. doi: https://doi.org/10.1590/1980-220X-REEUSP-2021-0402
https://doi.org/10.1590/1980-220X-REEUSP...
.

The Culture Circle pedagogical approach, proposed by Paulo Freire, supports an empowering methodological structure for the recognition and planning of interventions to cope with problems through a process of liberating education, and can be applied to health literacy as a way of empowering adolescents to face their own oppression, that is, a means of perceiving education as empowerment in their personal and community lives11. Dearfield CT, Barnum AJ, Pugh-Yi RH. Adapting Paulo Freire’s pedagogy for health literacy interventions. Humanity Soc. 2017;41(2):182-208. doi: https://doi.org/10.1177/0160597616633253
https://doi.org/10.1177/0160597616633253...
.

The empowerment of an individual as liberation from a context of oppression is beyond cognitive abilities. From a health perspective, the objective is to improve the behavior of healthy habits and act on the social determinants of health based on a critical awareness that, in the Freirean approach, provides possibilities for decision-making in health with autonomy and safety in the exercise of an ethical stance for greater control over their lives and confronting social inequities33. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
https://doi.org/10.1093/heapro/daz041...
,55. Heidemann ITSB, Dalmolin IS, Rumor PCF, Cypriano CC, Costa MFBNA, Durand MK. Reflections on Paulo Freire’s research itinerary: contributions to health. Texto Contexto Enferm. 2017;26(4):e0680017. doi: https://doi.org/10.1590/0104-07072017000680017
https://doi.org/10.1590/0104-07072017000...
.

The engagement of adolescents in the social mediation of vulnerability through educational interventions and practices implies empowerment, that is, strengthening their voices for decision-making and changes in health behaviors, managing a political and social act of liberation from injustices imposed by the domination of socially instituted corruption that compromises access to rights and the exercise of citizenship.

Theorizing about adolescent health empowerment from the literacy perspective may contribute to engaging healthcare professionals in conscious and critical exercise of their role as health educators in the face of the vulnerabilities affecting adolescent health issues. Thus, the study aims to develop a theoretical structure on literacy practices committed to health empowerment, based on the understanding of school adolescents and members of a Quilombola community, in the State of Pernambuco, Brazil.

METHOD

This is an interpretative study with a qualitative approach based on the perspective of Strauss and Corbin66. Mairink APAR, Gradim CVC, Panobianco MS. The use of the qualitative methodology of the Grounded Theory in Nursing research. Esc Anna Nery. 2021;25(3):e20200494. doi: https://doi.org/10.1590/2177-9465-EAN-2020-0494
https://doi.org/10.1590/2177-9465-EAN-20...
of the assumptions of Grounded Theory or Theory Based on Data (GT) and Symbolic Interactionism (SI) as a theoretical framework developed inductively by a theory derived from data that generate theoretical constructs and explain action in the social context and perspectives regarding the phenomenon area77. Chun Tie Y, Birks M, Francis K. Grounded theory research: a design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. doi: https://doi.org/10.1177/2050312118822927
https://doi.org/10.1177/2050312118822927...
,88. Santos JLG, Erdmann AL, Sousa FGM, Lanzoni GMM, Melo ALSF, Leite JL. Methodological perspectives in the use of grounded theory in nursing and health research. Esc Anna Nery. 2016;20(3):e20160056. doi: https://doi.org/10.5935/1414-8145.20160056
https://doi.org/10.5935/1414-8145.201600...
.

GT enables explanations based on the understanding of actions taken by individuals or groups in response to lived social situations. It constructs experiences and meanings with participants, and the data become both products and producers of new values through a cyclical and dynamic process of deduction-induction-verification in a constant comparative analysis77. Chun Tie Y, Birks M, Francis K. Grounded theory research: a design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. doi: https://doi.org/10.1177/2050312118822927
https://doi.org/10.1177/2050312118822927...
.

To describe the substantive theory, we started with open coding, grounded in the identification of codes and their similarities that emerged during reading, with emphasis on similar phrases or expressions. This analysis allowed the generation of hypotheses and the development of memos using methodological, theoretical, and observational notes.

Subsequently, we conducted axial coding which, by grouping the data from the aforementioned coding, we could structure the subcategories and categories for understanding and theoretical awareness of the study phenomenon in a dynamic process with coherent information for selective coding. The data were analyzed with the support of the QDA Miner Liter software in its free version 2.0.9.

In this third stage of analysis, the central phenomenon was identified as Adolescents empowered with their health have a voice and know their own needs based on four processes identified in the data analysis: Development of the Identity Process: Being an Adolescent, Adolescents’ Potential Development Arises from their Life Stories and Collective Relationships; Becoming an Adolescent through (Re)Understanding the Support Network and Social Determinants; Construction of democratic and popular standpoints: Emancipatory reflections.

Considering the positivist or constructivist approaches coming from Strauss and Corbin, the authors will allow the same “confusing” interpretative license for readers to self-direct the results and discussion of the present study99. Rieger KL. Discriminating among grounded theory approaches. Nurs Inq. 2019;26(1):e12261. doi: https://doi.org/10.1111/nin.12261
https://doi.org/10.1111/nin.12261...
.

At this conceptual level, the social processes of youth empowerment in health were developed based on a substantive theory that, represented in a diagram, allowed the exploration and significant understanding of the complex properties and dimensions of the phenomenon1010. Urcia IA. Comparisons of adaptations in grounded theory and phenomenology: selecting the specific qualitative research methodology. Int J Qual Methods. 2021;20. doi: https://doi.org/10.1177/16094069211045474
https://doi.org/10.1177/1609406921104547...
,1111. Girardon-Perlini NMO, Simon BS, Lacerda MR. Grounded theory methodological aspects in Brazilian nursing thesis. Rev Bras Enferm. 2020;73(6):e20190274. doi: https://doi.org/10.1590/0034-7167-2019-0274
https://doi.org/10.1590/0034-7167-2019-0...
.

The increasing use of GT in nursing contributes to the expansion of complexities in care and management practices as well as educational ones. An approach that attributes meanings to the construct under investigation and shaped by social interactions1212. Santos JLG, Cunha KS, Adamy EK, Backes MTS, Leite JL, Sousa FGM. Análise de dados: comparação entre as diferentes perspectivas metodológicas da Teoria Fundamentada nos Dados. Rev Esc Enferm USP. 2018;52. doi: https://doi.org/10.1590/S1980-220X2017021803303
https://doi.org/10.1590/S1980-220X201702...
.

This qualitative methodological framework can unveil the social reality, and the commitment to political transformation through the dialogic characteristic of Freire’s praxis that makes visible the context in which people live55. Heidemann ITSB, Dalmolin IS, Rumor PCF, Cypriano CC, Costa MFBNA, Durand MK. Reflections on Paulo Freire’s research itinerary: contributions to health. Texto Contexto Enferm. 2017;26(4):e0680017. doi: https://doi.org/10.1590/0104-07072017000680017
https://doi.org/10.1590/0104-07072017000...
.

The reliability of the research and the quality of the results were evaluated by authors who recently published articles on GT cited in this manuscript, who were invited to judge the methodological consistency and applicability as recommended by the criteria of Corbin and Strauss1313. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing Grounded Theory. California: SAGE; 2015.: Contextualization of concepts, Logic, Depth, Variation, Creativity, Sensitivity and Evidence of memos.

Data collection was carried out through Culture Circles led by the main author, whose background is in nursing, a university professor with a master’s degree in science focused on public health and healthcare promotion, with experience in conducting the method and target audience, and training during their academic training for the doctorate in Nursing from October 2020 to August 2021, when perceptions about empowerment were evaluated based on promoting the agency of adolescents in contexts of social and health vulnerability.

The situation of social and health vulnerability verified by the IVF-ID allowed us to understand the social relationships regarding the network and social support of families as well as health conditions. The final Index is made up of social conditions of strengthening (access to durable goods, schooling, employment, and income) and wearing conditions (illiteracy, poverty). Furthermore, health conditions are addressed not only in the biological sphere, but also in access to healthcare services and self-assessment of health1414. Amendola F, Alvarenga MRM, Latorre MRDO, Oliveira MAC. Índice de vulnerabilidade a incapacidades e dependência (IVF-ID), segundo condições sociais e de saúde. Cien Saude Colet. 2017;22(6):2063-71. doi: https://doi.org/10.1590/1413-81232017226.03432016
https://doi.org/10.1590/1413-81232017226...
.

Given the current context of pandemic and the sanitary measures of social isolation, with changes in the school routine, in the face of Emergency Remote Education (ERE), the research proposed innovating the holding of Culture Circles in a virtual format, developed and recorded with the support of the Google Meet tool, a video communication service developed by the Google company, to facilitate data collection. Interaction via chat and messaging applications was also analyzed and proved to be complementary to the capture of the empirical data analyzed to support the theory to be proposed.

To this end, previous contact was established with the adolescents, mediated by teachers and members of the quilombola community through video calls and chats on messaging applications, and by scheduling virtual meetings before holding the circles to present the objectives and study methodology, reasons, and research interests. The meetings allowed to build bonds, and also the approximation with the vocabulary universe and the teaching practices that motivated the students.

The Culture Circle, a method proposed by Paulo Freire, was developed in eight stages, as defined by Monteiro and Vieira1515. Monteiro EMLM, Vieira NFC. (Re)construction of health education actions based on circles of culture: participatory experience with Family Health Program nurses in Recife-PE. Recife: EDUPE; 2008.: previous knowledge of the group; dynamics of sensitization and relaxation; problematization; theoretical foundation; theoretical-practical reflection; collective elaboration of responses; synthesis of the experiences; and evaluation of each Circle.

The culture circles were developed in five meetings, totaling ten circles, as two distinct groups of adolescents were formed, with an average duration of two hours each meeting, addressing the following generating questions: “What does it mean to be an adolescent and how is an adolescent perceived by society?”; “What is the role of adolescents in the family, school and community?”; “What do you know about vulnerabilities and citizenship?”; “How to experience health education and the role of adolescents?”; “What do you know about adolescent health empowerment?” There was no repetition of the culture circles, however, the results were returned and analyzed by the adolescents who consented to their statements.

To support the adequacy of the application of the circles remotely, as well as to value the playful, interactive and creative characteristics required to motivate the participation of adolescents, some technological resources were created, such as: podcast; comics; story-drawing; photo-language; bingo; parody; poetry; and editing a newspaper1616. Barros MBSC, Silva RGM, Silva ACC, Rocha LP, Menezes MLN, Bushatsky M, et al. Círculo de Cultura Virtual como arena promotora do empoderamento juvenil em saúde. Estud Univ. 2021;38(1):347. doi: https://doi.org/10.51359/2675-7354.2021.250280
https://doi.org/10.51359/2675-7354.2021....
.

For ethical and methodological purposes, the practice of Culture Circles was based on the number of interviews necessary and sufficient to sample saturation, so the study considered the inclusion of 6 to 12 participants1717. Guest G, Bunce A, Johnson L. How many interviews are enough? an experiment with data saturation and variability. Field Methods. 2006;18(1):59-82. doi: https://doi.org/10.1177/1525822X05279903
https://doi.org/10.1177/1525822X05279903...
.

The sampling was non-random and intentional, since the choice to work with a non-probabilistic intentional sample was based on the proposal of free and spontaneous participation of adolescents in the final sample composition. Strengthening the spontaneous and conscious participation of young people is essential for the development of Culture Circles, whose dialogical nature and awareness are relevant milestones of this method1515. Monteiro EMLM, Vieira NFC. (Re)construction of health education actions based on circles of culture: participatory experience with Family Health Program nurses in Recife-PE. Recife: EDUPE; 2008..

GT allows the researcher to perceive the saturation of the categories through data analysis, from the perspective of knowing whether the findings promoted the consistent development of the categories on the phenomenon studied, and not by the number of study participants. To achieve this, the theoretical sample occurred with hypotheses, constituted by a constant comparative method, initially conducted with 12 adolescents inserted in the context of social and health vulnerability in the age group of 10 to 18 years, students of a public school in Recife, Pernambuco and, later, with six adolescents of a Quilombola community in the rural area of Passira, Pernambuco, who presented an indicator of social or health vulnerability according to the IVF-ID.

The adolescents who did not participate in at least 75% of culture circles were excluded from the study. The research project was approved by the research ethics committee under the Certification of Presentation for Ethical Appreciation number: 33605320,4,0000,5208.

RESULTS

Even with the virtual meetings, and the possibility of scheduling flexible meetings and meetings according to the availability of the children’s parents, from the 24 who showed interest, only 18 parents and/or guardians consented to the students’ participation in the culture circles. The mean age of the participants was 14.3 years, most were female, 83.3% (15), six from non-vulnerable families, three from families under vulnerability of social conditions, and one to health conditions, considering that eight families were scored as more vulnerable, with a final mean score on the family vulnerability index to disabilities and dependence (IVF-ID) of 10.34 points.

It is observed, corresponding to the findings, how paradigms and social determinants, as well as the contribution of the support network, can interfere in the structuring of an identity process with autonomy and awareness of the vulnerable youth context. Concomitantly with this issue, the development of adolescents’ potential comes from their life stories and collective relationships built by dialogue, trust, shared construction of knowledge, school, and the use of technologies in health literacy actions.

The development of concepts of individual, collective and critical-social empowerment in the culture circles encourage emancipatory reflections through democratic and popular standpoints represented by a cyclical dynamism under the apprehension of reality. The categories are anchored in the visibility of adolescents due to their agency and criticism regarding the knowledge of their specificities (Figure 1).

The analysis used in GT allowed the central construction of an adolescent empowered with their health through agency and recognition of their own needs based on a critical-reflexive perspective on the social determinants and vulnerabilities that involve adolescents to promote autonomy through dialogue and amorousness. The turmoil of adolescents emerges as liberation from a context of oppression and overcoming inequalities, an exit from the paradigm that places this public in the status quo towards a stance of accountability to understand and transform their health choices and actions in both individual and collective dimensions.

The first category demonstrates the perception of the process of identity construction in “being an adolescent” due to inconsistencies, changes in social interactions, social paradigms that limit the potential of adolescents, and the development of an attitude of respect and acceptance of singularities and adversities.

Oscillations during the adolescence process cause physiological, psychological and social changes that interfere in interactions and perceptions of life, contributing to the structuring of a critical position as a citizen for the ethical and conscious development of the responsibilities, an individual empowerment that explores agency with decision-making power and constructs of resilience with sustainability.

Social constructions and the conservative stance focus on the adolescent’s capacity and potential development. This conception, shaped by paradigms and dogmas of the economic production model that promotes inequality and vulnerabilities, does not invest in the potential of adolescents, and considers their entire context of change as rebellion, in order to silence and repress their choices and creativity. The interference of social determinants reflects injustices and vulnerabilities, undermining the hope capable of generating personal capacities for the promotion of one’s health.

I think being an adolescent is: Being a storehouse of expectations. (E3)

Being an adolescent means having responsibility in a democracy. (E6)

[...] adolescent maturing, making decisions, and showing the power he has in society. (E10)

Some people just call us rebels because they don't understand... simply because they don't want to make the effort to understand what we're going through. (E1)

The following category, The Development of Adolescents’ Potential comes from their Life Stories and Collective Relationships, permeates health empowerment beyond self-care for collective well-being arising from self-recognition, the promotion of autonomy, and the shared knowledge construction through communicational and pedagogical processes, in addition to technological insertions. The school serves as an agent for socializing the lives of young people, a space for a culture of peace, promoting youth empowerment in health through the construction of democratic and civic attitudes.

Adolescents, when guided, helps them to have more of a voice. (E2)

Nowadays adolescents just want to know about technology. Games about adolescence and the risks at this stage would be great. (E10)

It would be very important if we, adolescents, had a stronger participation in school, where we had a voice, something we don't have anywhere! It is very rare for an adolescent to have a voice at school, in society. (E15)

The school is a democratic place, however, certain attitudes that are taken... we are left without a position on what is good or not, because it is for us, but they [School Managers] choose, they [School Managers] are the ones who have a say. (E13)

When you are with more people you feel more empowered. (E4)

With the guidance of an adult, there will be dialogue between the adolescent and the healthcare professional, and these conversations can help a lot. (E1)

Knowing to choose helps adolescents to have a sense of what is right in life. (E8)

Health empowerment permeates a perception of collectiveness that encourages adolescents and their decisions about health care. The trust established in these relationships is essential for recognizing the adolescent’s space for making demands and overcoming the context of vulnerabilities as well as transforming the way of living collectively.

In the analysis of the Becoming an Adolescent through (Re)Understanding the Support Network and Social Determinants, it is observed the development of a critical-social reflection on health social determinants:

I think that nowhere in the world does there exist social inequality... rich people are focused on getting more money, people who are poor are unfortunately poor, they need care, they need food, they need what a human being common human needs. (E6)

Adolescents are vulnerable because they do not receive much health care, food, school... (E1)

Sometimes the parents didn't have opportunities, they didn't take advantage of it, but then it affects the child because it also ends up making them not having the opportunity. (E2)

I think that the adolescent's focus is school, family, and friends, those are the most important things... (E13)

Reports on the universe of vulnerabilities of these adolescents enabled an expanded view of social determinants and inequalities with the identification of their own stories. From a perspective of critical-social empowerment, the recognition of the influences of macropolitics advances towards a perception based on the potential that can be guided by the support network, which promotes democratic and citizen positions, which contribute to the construction of youth agency, where adolescents can be participants in the construction in society.

The last category under analysis brought an understanding of reality, reflections and positions that reveal the nuances and uncertainties of the current political scenario, a recognition of the adolescents’ cultural identity. A focus aimed at liberating sectarian and austerity positions that are reflected in adolescents and limit the development of empowerment. Education then emerges as a driving force for agency and autonomy based on dialogical and emancipatory practices.

We are all equal [...] democracy without dictatorship, democracy is freedom! (E6)

Society is capitalist in Brazil... they make workers, like, work a lot more, for a reduced salary, they charge a lot of taxes... they charge a lot, this is absurd! (E1)

Politicians don't want us to become empowered people because that doesn't benefit them. (E15)

Education helps adolescents to have autonomy, study and take on a leading role. (E10)

Education makes people grow. (E18)

The culture circles allowed adolescents freedom of expression for in-depth discussions about the mode of production and economics that permeate the country’s scenario at the time of collection. The achievement of emancipation and construction of a democratic and popular project by the participating adolescents was based on shared discourses of liberation from all forms of oppression, exploitation, discrimination, and violence with the reaffirmation of the need and recognition of a culture of peace by a fairer society, more supportive and sustainable, guaranteed by the strengthening of democracy.

Figure 1 -
Model of the Substantive Theory on Educational Practices Committed to Health Empowerment based on adolescent understanding (TPEcES). Recife, Pernambuco, Brazil, 2022

DISCUSSION

The theoretical framework of public health policies already highlights the relevance of the theoretical constructs proposed by Paulo Freire since 2007 with the frameworks of Popular Education Policies, although marked by gaps in their effective application in the Brazilian reality1818. Pedrosa JIS. The National Policy of Popular Education in Health in debate: (re) knowing knowledge and struggles for the production of Collective Health. Interface. 2021;25. doi: https://doi.org/10.1590/Interface.200190
https://doi.org/10.1590/Interface.200190...
.

Freire highlights important issues that reorient the role of the educator/facilitator: Recognizing the expectations, interests and potential of students, valuing popular knowledge, developing contextualized content, fostering the intertwining between popular and scientific knowledge, encouraging active participation and autonomy in the teaching-learning process, a dialogical arena of mutual learning through the sharing of knowledge1919. Freire P. Pedagogia da autonomia. São Paulo: Paz e Terra; 2021..

Symbolic interactionism understood by the speeches and perceptions about youth empowerment in health reveals that the process of learning and developing agency through health literacy practices does not occur in isolation, nor in a singular context of vulnerabilities, but rather through interactions social activities mediated by dialogue, trust, technologies, shared construction, and school training that take place within the groups and communities in which adolescents are inserted.

Adolescents experience empowerment at an individual, collective and even critical-social level through the acquisition of a reflective perception of acquired knowledge, and decision-making to transform social injustices with the proposal of increasing self-awareness, promoting agency in the search for health care, motivating a shift in attitudes regarding risk behaviors, and overcoming exposure to vulnerable situations.

The highly generalized notions of social and health vulnerability permeate a scenario of challenges for professionals in the fields of health and education who, restricted to social incentive policies, try to develop problematizing educational activities that seek to understand the cultural context that nurtures adolescent resilience and mitigate expectations of reducing inequalities2020. Stark L, Seff I, Assezenew A, Eoomkham J, Falb K, Ssewamala FM. Effects of a social empowerment intervention on economic vulnerability for adolescent refugee girls in Ethiopia. J Adolesc Healt. 2018;62(1S):S15-S20. doi: https://doi.org/10.1016/j.jadohealth.2017.06.014
https://doi.org/10.1016/j.jadohealth.201...
.

Even upon the unique context of social and health vulnerability, in which the groups studied are inserted: socioeconomic inequality, violence, discrimination, limited access to quality education, and weak specific policies, adolescents align themselves with the theoretical framework constructed by exposing a broad, critical and problematizing vision based on their own points of view of how empowerment, whether individual, collective or critical-social, is necessary so that they can transcend and break the barriers established by society, which hinder these young people to share their knowledge and change their realities.

The development of autonomy for healthy choices boosts a sense of internal and external change that affects the adolescents’ life and the social context in which they are inserted22. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. doi: https://doi.org/10.1186/s12889-017-4267-y
https://doi.org/10.1186/s12889-017-4267-...
,2121. Nutbeam D. Health education and health promotion revisited. Health Educ J. 2019;78(6):705-9. doi: https://doi.org/10.1177/0017896918770215
https://doi.org/10.1177/0017896918770215...
,2222. Masson LN, Silva MAI, Andrade LS, Gonçalves MFC, Santos BD. A educação em saúde crítica como ferramenta para o empoderamento de adolescentes escolares frente às suas vunerabilidades em saúde. Rev Min Enferm. 2020;24:e1294. doi: http://doi.org/10.5935/1415-2762.20200023
http://doi.org/10.5935/1415-2762.2020002...
.

Analyzing the contextual environment as well as providing opportunities for dialogical participation with an active voice to understand the perspectives, and what information adolescents perceive as relevant and significant are essential for the construction of intersubjective processes, and the development of individual empowerment, and health literacy as a resource, to encourage interest and leadership in adolescents for active participation in self-care33. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
https://doi.org/10.1093/heapro/daz041...
.

Subject to social, cultural and environmental influences, adolescents are marked by intense biological and behavioral changes that put them in a weakened social position, vulnerable to oppressive relationships and lacking strong social networks that may offer support2323. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, Beamon T. The DREAMS core package of interventions: a comprehensive approach to preventing HIV among adolescent girls and young women. PLoS One. 2018;13(12):e0208167. doi: https://doi.org/10.1371/journal.pone.0208167
https://doi.org/10.1371/journal.pone.020...
.

Social support from families, caregivers, schools and communities contributes both to the awareness of adolescents and to the involvement of these social actors in ensuring emancipatory educational processes with current and long-term repercussions on individual and collective care2323. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, Beamon T. The DREAMS core package of interventions: a comprehensive approach to preventing HIV among adolescent girls and young women. PLoS One. 2018;13(12):e0208167. doi: https://doi.org/10.1371/journal.pone.0208167
https://doi.org/10.1371/journal.pone.020...
-2525. Mwilike B, Shimoda K, Oka M, Leshabari S, Shimpuku Y, Horiuchi S. A feasibility study of an educational program on obstetric danger signs among pregnant adolescents in Tanzania: a mixed-methods study. Int J Africa Nurs Sci. 2018;8:33-43. doi: https://doi.org/10.1016/j.ijans.2018.02.004
https://doi.org/10.1016/j.ijans.2018.02....
.

The school represents a privileged space in the comprehensive formation of adolescents, an opportunity for social, economic and cultural development, in addition to providing opportunities for a change in the way of reading the world in which they are inserted2626. Sahb WF, Almeida FJ. Tecnologia como direito humano: acesso, liberdade, usos e criação. Interacções. 2018;14(47):1-20. doi: https://doi.org/10.25755/int.3185
https://doi.org/10.25755/int.3185...
.

In the statements, it can be observed that school has to make sense to adolescents, who do not aim to be mere listeners in the learning process, but rather active, reflective and critical subjects, agents of the construction of a dialogical educational process which can give new meaning to the youth agency in society2222. Masson LN, Silva MAI, Andrade LS, Gonçalves MFC, Santos BD. A educação em saúde crítica como ferramenta para o empoderamento de adolescentes escolares frente às suas vunerabilidades em saúde. Rev Min Enferm. 2020;24:e1294. doi: http://doi.org/10.5935/1415-2762.20200023
http://doi.org/10.5935/1415-2762.2020002...
.

With a focus on youth empowerment in a context of vulnerability, studies conducted on the African continent with adolescent mothers and pregnant women also correlated social determinants with the achievement of empowerment when they suggest that those who have social support are more likely to have appropriate behavior for self-care and seeking healthcare services2525. Mwilike B, Shimoda K, Oka M, Leshabari S, Shimpuku Y, Horiuchi S. A feasibility study of an educational program on obstetric danger signs among pregnant adolescents in Tanzania: a mixed-methods study. Int J Africa Nurs Sci. 2018;8:33-43. doi: https://doi.org/10.1016/j.ijans.2018.02.004
https://doi.org/10.1016/j.ijans.2018.02....
,2727. Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, et al. “I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone”: adapting the Mothers2Mothers mentor mother model for adolescent mothers living with HIV in Malawi. PLoS One. 2019;14(6):e0217693. doi: https://doi.org/10.1371/journal.pone.0217693
https://doi.org/10.1371/journal.pone.021...
.

From a development perspective, health literacy can be a strong resource for building coping or resilience strategies. Therefore, it is essential to explore how adolescents perceive that they are recognized and respected in different social contexts relevant to health, such as family, community, education or even health care33. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
https://doi.org/10.1093/heapro/daz041...
.

The engagement of adolescents in the social mediation of vulnerability through educational interventions and practices implies strengthening their voices for decision-making and behavioral changes in individual and collective health.

The intervention method by virtual culture circle enabled a solid representation of health literacy for adolescents from the perspective of the empirical universe of empowerment, as well as valid and practical conceptual structures that met the specificities of the target group.

This methodological alternative favored a dialogical, creative and systematized condition through a cyclical and continuous process in a historical, social and cultural context of adolescents that involves opportunities and challenges for the process of construction/deconstruction/reconstruction of reality, allowing the production of more conscious attitudes regarding their social role in a context of vulnerabilities.

When conducted through critical and reflective dialogue, liberating education promotes the development and empowerment of skills that influence decisions on healthcare and adaptation to new circumstances in a context of social vulnerability2121. Nutbeam D. Health education and health promotion revisited. Health Educ J. 2019;78(6):705-9. doi: https://doi.org/10.1177/0017896918770215
https://doi.org/10.1177/0017896918770215...
,2222. Masson LN, Silva MAI, Andrade LS, Gonçalves MFC, Santos BD. A educação em saúde crítica como ferramenta para o empoderamento de adolescentes escolares frente às suas vunerabilidades em saúde. Rev Min Enferm. 2020;24:e1294. doi: http://doi.org/10.5935/1415-2762.20200023
http://doi.org/10.5935/1415-2762.2020002...
.

Applied to health literacy, the pedagogy of popular education empowers people to identify power dynamics in their daily relationships and become more involved in their life decisions through self-reflection. Once people become aware, they can make better health decisions and take an active role in improving their health and well-being11. Dearfield CT, Barnum AJ, Pugh-Yi RH. Adapting Paulo Freire’s pedagogy for health literacy interventions. Humanity Soc. 2017;41(2):182-208. doi: https://doi.org/10.1177/0160597616633253
https://doi.org/10.1177/0160597616633253...
.

Empowering health education interventions conducted with pregnant adolescents in Tanzania, Africa, also invite professionals to adopt a stance that makes this group visible as social subjects to promote participatory autonomy through questioning and rediscovery, fostering a critical and resilient awareness on inequalities, emerged through a process of social and transformative action2525. Mwilike B, Shimoda K, Oka M, Leshabari S, Shimpuku Y, Horiuchi S. A feasibility study of an educational program on obstetric danger signs among pregnant adolescents in Tanzania: a mixed-methods study. Int J Africa Nurs Sci. 2018;8:33-43. doi: https://doi.org/10.1016/j.ijans.2018.02.004
https://doi.org/10.1016/j.ijans.2018.02....
.

Chart 1 shows the implications for literacy practices committed to youth empowerment in health.

Chart 1 -
Implications for literacy practices committed to youth empowerment in health. Recife, Pernambuco, Brazil, 2022.

The recognition and acceptance of different and subjective interpretations of reality are considered essential requirements for democratic practices of thinking, observing and acting in a revolutionary way, and influencing the socialization of adolescents, their values and standards33. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
https://doi.org/10.1093/heapro/daz041...
.

FINAL CONSIDERATIONS

The theoretical structure on literacy practices, committed to health empowerment, based on the understanding of school adolescents and members of a Quilombola community, runs through the framework of a substantive theory intertwined by the interference of social determinants and the support network for structuring of an identity process. This can be nurtured through the experiences of adolescents in health literacy actions based on dialogic relationships, trust, use of technology and school routine.

Amid the analysis of the statements, the definitions of individual, collective and critical-social empowerment emerge in synergy for the construction of democratic and popular standpoints that culminate in a central thematic axis: Adolescents empowered with their health have a voice and know their own needs.

Despite the reflection of the context of social vulnerability that led some students to not participate regularly in the activities, the remote teaching format enabled monitoring the parents of the students who interacted with the authors as well as the creation of dialogic spaces and opportunities for valuing adolescents as competent social actors and critical citizens. The use of virtual culture circles, due to the sanitary social isolation measures, allowed an innovative experience that let to new discoveries for both researchers and adolescents, who were able to explore new educational technologies and enhance creativity even further.

Understanding the definition of youth empowerment in health from the adolescent’s perspective for health literacy actions can contribute to the planning of interventions that can boost critical assimilation by this group and develop cognitive and behavioral attributes that demystify the dialogue between professional and adolescents with authoritarianism, without horizontal relationships or valuing of popular culture and knowledge.

Acknowledgments:

To the Universidade do Minho and Universidade de Coimbra for their support and guidance in conducting the study. To UFPE for support in carrying out internationalization. To the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq). Special thanks to researchers Dr. Carolina Giordani da Silva and Dr. Ana Paula Alonso Reis Mairink for validating the results.

REFERENCES

  • 1. Dearfield CT, Barnum AJ, Pugh-Yi RH. Adapting Paulo Freire’s pedagogy for health literacy interventions. Humanity Soc. 2017;41(2):182-208. doi: https://doi.org/10.1177/0160597616633253
    » https://doi.org/10.1177/0160597616633253
  • 2. Bröder J, Okan O, Bauer U, Bruland D, Schlupp S, Bollweg TM, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. doi: https://doi.org/10.1186/s12889-017-4267-y
    » https://doi.org/10.1186/s12889-017-4267-y
  • 3. Bröder J, Okan O, Bauer U, Schlupp S, Pinheiro P. Advancing perspectives on health literacy in childhood and youth. Health Promot Int. 2020;35(3):575-85. doi: https://doi.org/10.1093/heapro/daz041
    » https://doi.org/10.1093/heapro/daz041
  • 4. Moraes-Partelli AN, Coelho MP, Santos SG, Santos IL, Cabral IE. Participation of adolescents from the Quilombola community in the creation of an educational game about alcohol consumption. Rev Esc Enferm USP. 2022;56:e20210402. doi: https://doi.org/10.1590/1980-220X-REEUSP-2021-0402
    » https://doi.org/10.1590/1980-220X-REEUSP-2021-0402
  • 5. Heidemann ITSB, Dalmolin IS, Rumor PCF, Cypriano CC, Costa MFBNA, Durand MK. Reflections on Paulo Freire’s research itinerary: contributions to health. Texto Contexto Enferm. 2017;26(4):e0680017. doi: https://doi.org/10.1590/0104-07072017000680017
    » https://doi.org/10.1590/0104-07072017000680017
  • 6. Mairink APAR, Gradim CVC, Panobianco MS. The use of the qualitative methodology of the Grounded Theory in Nursing research. Esc Anna Nery. 2021;25(3):e20200494. doi: https://doi.org/10.1590/2177-9465-EAN-2020-0494
    » https://doi.org/10.1590/2177-9465-EAN-2020-0494
  • 7. Chun Tie Y, Birks M, Francis K. Grounded theory research: a design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. doi: https://doi.org/10.1177/2050312118822927
    » https://doi.org/10.1177/2050312118822927
  • 8. Santos JLG, Erdmann AL, Sousa FGM, Lanzoni GMM, Melo ALSF, Leite JL. Methodological perspectives in the use of grounded theory in nursing and health research. Esc Anna Nery. 2016;20(3):e20160056. doi: https://doi.org/10.5935/1414-8145.20160056
    » https://doi.org/10.5935/1414-8145.20160056
  • 9. Rieger KL. Discriminating among grounded theory approaches. Nurs Inq. 2019;26(1):e12261. doi: https://doi.org/10.1111/nin.12261
    » https://doi.org/10.1111/nin.12261
  • 10. Urcia IA. Comparisons of adaptations in grounded theory and phenomenology: selecting the specific qualitative research methodology. Int J Qual Methods. 2021;20. doi: https://doi.org/10.1177/16094069211045474
    » https://doi.org/10.1177/16094069211045474
  • 11. Girardon-Perlini NMO, Simon BS, Lacerda MR. Grounded theory methodological aspects in Brazilian nursing thesis. Rev Bras Enferm. 2020;73(6):e20190274. doi: https://doi.org/10.1590/0034-7167-2019-0274
    » https://doi.org/10.1590/0034-7167-2019-0274
  • 12. Santos JLG, Cunha KS, Adamy EK, Backes MTS, Leite JL, Sousa FGM. Análise de dados: comparação entre as diferentes perspectivas metodológicas da Teoria Fundamentada nos Dados. Rev Esc Enferm USP. 2018;52. doi: https://doi.org/10.1590/S1980-220X2017021803303
    » https://doi.org/10.1590/S1980-220X2017021803303
  • 13. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing Grounded Theory. California: SAGE; 2015.
  • 14. Amendola F, Alvarenga MRM, Latorre MRDO, Oliveira MAC. Índice de vulnerabilidade a incapacidades e dependência (IVF-ID), segundo condições sociais e de saúde. Cien Saude Colet. 2017;22(6):2063-71. doi: https://doi.org/10.1590/1413-81232017226.03432016
    » https://doi.org/10.1590/1413-81232017226.03432016
  • 15. Monteiro EMLM, Vieira NFC. (Re)construction of health education actions based on circles of culture: participatory experience with Family Health Program nurses in Recife-PE. Recife: EDUPE; 2008.
  • 16. Barros MBSC, Silva RGM, Silva ACC, Rocha LP, Menezes MLN, Bushatsky M, et al. Círculo de Cultura Virtual como arena promotora do empoderamento juvenil em saúde. Estud Univ. 2021;38(1):347. doi: https://doi.org/10.51359/2675-7354.2021.250280
    » https://doi.org/10.51359/2675-7354.2021.250280
  • 17. Guest G, Bunce A, Johnson L. How many interviews are enough? an experiment with data saturation and variability. Field Methods. 2006;18(1):59-82. doi: https://doi.org/10.1177/1525822X05279903
    » https://doi.org/10.1177/1525822X05279903
  • 18. Pedrosa JIS. The National Policy of Popular Education in Health in debate: (re) knowing knowledge and struggles for the production of Collective Health. Interface. 2021;25. doi: https://doi.org/10.1590/Interface.200190
    » https://doi.org/10.1590/Interface.200190
  • 19. Freire P. Pedagogia da autonomia. São Paulo: Paz e Terra; 2021.
  • 20. Stark L, Seff I, Assezenew A, Eoomkham J, Falb K, Ssewamala FM. Effects of a social empowerment intervention on economic vulnerability for adolescent refugee girls in Ethiopia. J Adolesc Healt. 2018;62(1S):S15-S20. doi: https://doi.org/10.1016/j.jadohealth.2017.06.014
    » https://doi.org/10.1016/j.jadohealth.2017.06.014
  • 21. Nutbeam D. Health education and health promotion revisited. Health Educ J. 2019;78(6):705-9. doi: https://doi.org/10.1177/0017896918770215
    » https://doi.org/10.1177/0017896918770215
  • 22. Masson LN, Silva MAI, Andrade LS, Gonçalves MFC, Santos BD. A educação em saúde crítica como ferramenta para o empoderamento de adolescentes escolares frente às suas vunerabilidades em saúde. Rev Min Enferm. 2020;24:e1294. doi: http://doi.org/10.5935/1415-2762.20200023
    » http://doi.org/10.5935/1415-2762.20200023
  • 23. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, Beamon T. The DREAMS core package of interventions: a comprehensive approach to preventing HIV among adolescent girls and young women. PLoS One. 2018;13(12):e0208167. doi: https://doi.org/10.1371/journal.pone.0208167
    » https://doi.org/10.1371/journal.pone.0208167
  • 24. Bello TK, Pillay J. An evidence-based nutrition education programme for orphans and vulnerable children: protocol on the development of nutrition education intervention for orphans in Soweto, South Africa using mixed methods research. BMC Public Health. 2019;19(1):306. doi: https://doi.org/10.1186/s12889-019-6596-5
    » https://doi.org/10.1186/s12889-019-6596-5
  • 25. Mwilike B, Shimoda K, Oka M, Leshabari S, Shimpuku Y, Horiuchi S. A feasibility study of an educational program on obstetric danger signs among pregnant adolescents in Tanzania: a mixed-methods study. Int J Africa Nurs Sci. 2018;8:33-43. doi: https://doi.org/10.1016/j.ijans.2018.02.004
    » https://doi.org/10.1016/j.ijans.2018.02.004
  • 26. Sahb WF, Almeida FJ. Tecnologia como direito humano: acesso, liberdade, usos e criação. Interacções. 2018;14(47):1-20. doi: https://doi.org/10.25755/int.3185
    » https://doi.org/10.25755/int.3185
  • 27. Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, et al. “I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone”: adapting the Mothers2Mothers mentor mother model for adolescent mothers living with HIV in Malawi. PLoS One. 2019;14(6):e0217693. doi: https://doi.org/10.1371/journal.pone.0217693
    » https://doi.org/10.1371/journal.pone.0217693
  • Authorship contribution:

    Formal analysis: Mariana Boulitreau Siqueira Campos Barros, Estela Maria Leite Meirelles Monteiro. Conceptualization: Mariana Boulitreau Siqueira Campos Barros, Estela Maria Leite Meirelles Monteiro. Data curation: Mariana Boulitreau Siqueira Campos Barros, Estela Maria Leite Meirelles Monteiro, Marcela Martins da Silva Nascimento. Writing-original draft: Mariana Boulitreau Siqueira Campos Barros, Estela Maria Leite Meirelles Monteiro. Writing-review & editing: Helena Rafaela Vieira do Rosário, Dulce Maria Pereira Garcia Galvão. Methodology: Mariana Boulitreau Siqueira Campos Barros, Estela Maria Leite Meirelles Monteiro. Validation: Marcela Martins da Silva Nascimento.

Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

João Lucas Campos de Oliveira

Publication Dates

  • Publication in this collection
    24 Nov 2023
  • Date of issue
    2023

History

  • Received
    18 May 2022
  • Accepted
    28 June 2023
Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
E-mail: revista@enf.ufrgs.br