# RESUMO

## Objetivo

Conhecer os fatores geradores das rupturas das redes sociais de suporte, identificar o cotidiano e os projetos de vida de pessoas em situação de rua.

## Método

Estudo etnográfico desenvolvido entre 2012 e 2013 em Ribeirão Preto-SP, Brasil. Quinze pessoas participaram do estudo. A coleta de dados foi realizada através de entrevistas de histórias de vida filmadas e de diário de campo. A análise foi realizada com base no referencial da Teoria da Ação Comunicativa de Habermas.

Os resultados mostraram que iniquidades estão presentes há gerações passadas nas famílias e que o cotidiano é marcado por violência e morte, pobreza e exclusão, rupturas das redes sociais e isolamento, uso de álcool e outras drogas e doenças socialmente determinadas.

## Conclusão

A situação de rua decorre de múltiplos fatores que se apresentam na organização social brasileira e de determinantes sociais que condicionam a vida e a saúde das pessoas em situação de rua.

# RESUMEN

## Objetivo

Conocer los factores generadores de las rupturas de las redes sociales de soporte, identificar su cotidiano y sus proyectos de vida de personas sin hogar.

## Método

Estudio etnográfico hecho entre 2012 y 2013 en Ribeirão Preto - SP, Brasil. Los participantes fueron quince personas sin hogar. La recolección de datos se realizó a través de entrevistas de historias de vida filmadas y diario de campo. El análisis de datos se realizó con base en el referencial de la Teoría de la Acción Comunicativa de Habermas.

Los resultados mostraron que las iniquidades están presentes durante generaciones en las familias y que el cotidiano está marcado por violencia y muerte, pobreza y exclusión, rupturas y aislamiento, uso de drogas y otras enfermedades socialmente determinadas.

## Conclusión

Personas sin hogar derivan de varios factores que se presentan en la sociedad brasileña y que determinantes sociales condicionan la vida y la salud de las personas sin hogar.

Pobreza; Vulnerabilidad social; Inequidad social; Determinantes sociales de la salud; Investigación cualitativa

# ABSTRACT

## Objective

To discover the generators of disruptions in social support networks and identify the everyday life and projects of life of homeless people.

## Method

Ethnographic study conducted between 2012 and 2013 in Ribeirão Preto -SP, Brazil. The participants were fifteen homeless people. Data were collected through video-recorded interviews addressing histories of life and a field diary. Data analysis was based on Habermas’ Theory of Communicative Action.

## Results

Results revealed that the participants’ families have faced inequalities for many generations and that everyday life is marked by violence and death, poverty and exclusion, disrupted social networks, loneliness, alcohol and drug consumption, and other socially determined diseases.

## Conclusion

The situation of living on the streets stems from several factors present in the organization of the Brazilian society and social determinants condition the life and health of homeless people.

Poverty; Social vulnerability; Social inequity; Social determinants of health; Qualitative research

# INTRODUCTION

The phenomenon of the homeless population has affected various countries worldwide. This problem is compounded of multi determinants, among which poor or total disruption of formal labor relations and ruptures in family and community ties. These factors lead to a loss of family and community support; to a loss of one’s worker identity; and to the need to survive without a shelter, i.e., subhuman survival condition11. Adorno RCF. Atenção à saúde, direitos e o diagnóstico como ameaça: políticas públicas e as populações em situação de rua. Etnográfica. 2011;15(3):543-67.-22. Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al.. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95..

The social vulnerability of people and groups accrues from a welfare crisis, the globalization of the economy, and the neoliberal orientation of economic policies, which are important factors leading to the exclusion of many individuals in the world population33. Sapir A. Globalization and the reform of European social models. J Common Mark Stud. 2006;44(2):369-90..

In Brazil, the phenomenon originated in the industrialization process that took place from 1930 to 1980, replacing the model of accumulation of agriculture exports in the country44. Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua: Aprendendo a contar: Pesquisa nacional sobre população em situação de rua. Brasília (DF): Ministério do Desenvolvimento Social e Combate à Fome, Secretaria de Avaliação e Gestão da Informação; 2009.. Note that historical-social causes are at the root of the reproduction of populations facing extreme poverty in Brazil, marked by social, economic and political inequality, an aspect that compromises democratization of society55. Freitas M, Mecena EH. Vulnerabilidade de crianças que nascem e crescem nas periferias metropolitanas: notícias do Brasil. Rev Latinoam Cienc Soc Niñez Juv. 2012;10(1):195-203..

A census study conducted in 71 Brazilian cities identified 31,922 homeless adults, most of whom are men living on the streets during the productive period of their lives, presenting high levels of social vulnerability associated with precarious income-generation activities. Most of these individuals are males (82%) and more than half (53%) are in economic productive age, between 25 and 44 years old. The reasons they present for living on the streets include alcohol and drug consumption (35.5%), unemployment (29.8%), and family disagreements (29.1%). This population gains a low income and most (52.6%) make between R$20.00 and R$ 80.00 a week44. Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua: Aprendendo a contar: Pesquisa nacional sobre população em situação de rua. Brasília (DF): Ministério do Desenvolvimento Social e Combate à Fome, Secretaria de Avaliação e Gestão da Informação; 2009..

Even though homeless individuals can access care and establish a social network among those in the same condition, in addition to people who provide occasional aid, in a way, this population floats in the social fabric and populates its interstices without, however, having a designated and recognized place. They are frequently involved in situations of violence and death, do not have access to decent living conditions, and live in extreme poverty, deprived of rights and basic survival structures66. Botti NCL, Castro CG, Silva MF, Silva AK, Oliveira LC, Castro ACO, et al. Prevalência de depressão entre homens adultos em situação de rua em Belo Horizonte. J Bras Psiquiatr. 2010;59(1):10-6..

Among social groups facing poverty and presenting high levels of social vulnerability, a homeless situation currently tends to be established during adolescence and youth77. Souza RRS, Oliveira JF, Chagas MCG, Carvalho ESS. Gender, violence and being homeless: the experience of women and high risk drug use. Rev Gaúcha Enferm. 2016 set;37(3):e59876. doi: http://dx.doi.org/10.1590/1983-1447.2016.03.59876.
http://dx.doi.org/10.1590/1983-1447.2016...
.

Homeless individuals historically travel through social imagination, through different visions and attributions, ranging from images of an urban sufferer to figures that are at the margins of society. From a complementary perspective, public care policies directed to this social segment are permeated by normative conceptions and stigmatization, based on uncertain connections among actors from various sectors, who traditionally act based on tutelage and repression, such as those in the social welfare and public security spheres, the latter remaining linked to a militarized intervention logic in Brazil. At the same time, this logic is propagated to sectors responsible for the implementation of policies, so that actions are based on the individualization of the problem, generalizing a moral interpretation that these individuals are to blame for the situation they find themselves in, leading these groups to face even greater social discrimination11. Adorno RCF. Atenção à saúde, direitos e o diagnóstico como ameaça: políticas públicas e as populações em situação de rua. Etnográfica. 2011;15(3):543-67..

To better understand the everyday life of this population, a survey was conducted with the general objective of identifying, through the histories of life of homeless individuals, the factors that disrupted their social support networks (family, community, education and work); and the social, cultural, historical, economic, and political context in which ruptures took place; in addition to the context of their everyday life on the streets and their projects of life.

# METHOD

## Study design

This ethnographic study used the following instruments to collect data: video-recorded interviews addressing histories of life and a field diary88. Nakamura, E. O método etnográfico em pesquisas na área da saúde: uma reflexão antropológica. Saúde Soc. 2011;20(1):95-103..

## Study setting and context

The study setting and context were urban areas inhabited by homeless individuals, such as squares, viaducts and streets in Ribeirão Preto. This city has 658,059 inhabitants and is located in the Northwest of the state of São Paulo, Brazil. The Gini coefficient of Ribeirão Preto, which measures social inequality, is 0.45, in which 1 is the worst number and 0 is the best. The incidence of poverty, measured by the Brazilian Institute of Geography and Statistics (IBGE), is 11.75%, the lower limit of the incidence of poverty is 8.16%, the upper limit is 15.35%, while the incidence of subjective poverty is 8.75%. In 2000, the participation of the 20% richest population in the city’s total income was 61.1%, 21 times higher than the income of the poorest 20%, which was 3.0%. In 1991, the participation of the poorest 20% was 4.0%, that is, from the beginning of the 1990s up to 2000, social inequality increased in the city99. Instituto Brasileiro de Geografia e Estatística [Internet]. Brasília (DF): IBGE; 2010. [citado 2010 nov 29]. Disponível em: http://seriesestatisticas.ibge.gov.br/.
http://seriesestatisticas.ibge.gov.br/...
.

The study was conducted by the Undergraduate Program in Occupational Therapy at the Medical School, University of São Paulo at Ribeirão Preto (OT-FMRP-USP) and received the support of CREAS-POP-RP [Reference Center and Social Welfare Specialized in Homeless Individuals].

CREAS-POP-RP, linked the City Department of Social Welfare of Ribeirão Preto, is a social assistance facility specialized in care provided to homeless individuals and seeks to meet the guidelines of the National Policy of Social Welfare, integrating the services of SUAS [Single System of Social Welfare], recommended for cities with more than 250,000 inhabitants1010. Presidência da República (BR). Decreto Nº 7.179, de 20 de maio de 2010. Institui o Plano Integrado de Enfrentamento ao Crack e outras drogas. Cria o seu Comitê Gestor e dá outras providências. Diário Oficial da União [da] República Federativa do Brasil. 2010 maio 21;147(96 Seção 1):43..

## Study participants

Fifteen (15) homeless people living in the city of Ribeirão Preto at the time of data collection participated in the study. Inclusion criteria were: being an individual who was inhabiting and performing activities of daily living in the urban public areas of the city, regardless of gender, race or any other individual characteristic.

The participants were not previously selected, rather, they were randomly recruited by the research team, who became directly immersed in public spaces frequented by homeless individuals. Hence, the individuals were directly approached on the streets and invited to participate in the study. They received clarification regarding the study, its objectives, methods and ethical procedures.

## Data collection

Data were collected by the team, which was immersed in the context under study and coexisted with the participants for periods of the day. Those who provided their consent were interviewed and filmed. The interviews were held in places that, in the context and circumstances, are considered to be the natural environment of these individuals, in agreement with the ethnographic method1111. Bauer MW, Gaskel G. Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes; 2002..

Open interviews collecting histories of life were recorded and filmed. A video documentary was produced after the field research was conducted, the purpose of which was to encourage discussions in the society by presenting it in social assistance, health, cultural and educational facilities in the city of Ribeirão Preto, São Paulo, Brazil.

An interview script was previously developed to aid in the production of the video-documentary, in order to gain easy access to the information that corresponded to the study’s general objectives, namely: identify, through histories of life, the ruptures that led the individuals to become homeless, that is, rupture of family ties, education and work connections, as well as to identify their everyday life on the streets, and projects of life. The development of the script took into account the biographic sequence of people who share similar cultural backgrounds. Hence, the following axes composed the script: 1) family history and biography; 2) experience with Education/schooling; 3) ruptures of family ties; 4) occupational experience and ruptures; 5) everyday life; and 6) projects of life.

The research team was composed of the researcher who coordinated the study, one doctoral student in public health and camera operator, an occupational therapist and laboratory technician of the OT Program at FMRP-USP, and two undergraduate students in the undergraduate program in OT at FMRP-USP who were carrying out scientific initiation research. The coordinator, doctoral student and the OT performed the interviews, the shooting, and field diary, while the remainder of the team was responsible for the photographic production and compilation of the field diary.

## Data analysis

Habermas’ theoretical-philosophical framework, based on his Theory of Communicative Action, was used in the discursive content analysis and visual analysis of the reports.

The key for an interpretative-dialectical exercise is language, because it permits accessing human rationality, impregnated with dominating influence from institutions. It allows for an interpretative analysis of reports based on their historicization and perception that reports are always contextualized and inserted in the cultural, historical, political, normative, and inter-subjective universe in which they are validated, and also reflect contradictions that historical-cultural time impose on them1212. Habermas J. Consciência moral e agir comunicativo. Rio de Janeiro: Tempo Brasileiro; 1989.-1313. Habermas J. Political communication in media society: does democracy still enjoy an epistemic dimension? the impact of normative theory on empirical research. Communication Theory. 2006;16:411-26..

The following stages were implemented in data analysis:

1. After data collection, the video-recorded reports were organized and stored in a database to be coded afterwards;

2. In the second stage, the research team repeatedly watched all the reports and compared with texts contained in the field diary. Information concerning the narratives of interviews that were selected from the analysis of films were triangulated with the reports contained in the field diary;

3. After comparing the filmed reports and field diary, parts of the film that refer to each of the six thematic categories were extracted. These thematic categories composed the interview script (family history and biography; experience with Education/schooling; ruptures in family ties; occupational experiences and rupture; everyday life; and projects of life);

4. These film excerpts were analyzed once more in light of the philosophical framework of the Theory Communicative Action. The individuals’ narratives were delineated according to discursive patterns. These discursive patterns were related to historical-cultural analyses of the Brazilian political, economic and historical context.

The documentary ExcluSOS, a 45-minute feature film, was produced.

## Ethical Procedures

According to Resolution 466/12, National Council of Health, this study was submitted to and approved by the Institutional Review Board at the Medical School, University of São Paulo at Ribeirão Preto (CAAE: No. 08745212.3.0000.5414).

Free and informed consent forms together with use of voice and image consent forms were read to the participants, who signed the documents.

# RESULTS

Fifteen homeless individuals, both sexes, aged between 18 and 64 years old, living in Ribeirão Preto at the time of data collection, were interviewed. Most individuals were born in other states and cities, only two were born in Ribeirão Preto; the most predominant states were Pernambuco and Minas Gerais.

The results are presented below according to the thematic categories previously described.

## Family history and biography

The family of the participants had been inserted in a social segment of extreme poverty for many generations, performing low-income jobs, living in areas of social vulnerability, and facing economic hardship and cultural, social and health problems.

I was born in Orlândia...and...my birth was a cause of many intrigues between my mother and father… when I was 11 years old, I was abused by my father […] I turned 11 years old and…since then my life never worked out again… then I had a quarrel with my mother, my mother fought with me and I left home afterwards, I’m on the streets ever since (Naiara).

My father died because of drinking, my uncle died because of drinking, everyone in my family died because of drinking, only my mother is alive [...] I drink since I was 7 years old...I’ll be 49... I drink since I was 7 to this day (Wilson).

## Experience in Education/schooling

The participants had a low level of education; primary school was when they abandoned school. They reported that other family members, such as grandparents and parents, were illiterate and their siblings also abandoned primary school.

I’m a hick, I’m from the countryside… I don’t have good reading skills to study anything… nothing. I was raised washing pig shit, feeding the ox, cutting grass for the ox, and pulling the hoe… I don’t know how to read, I read very little… I can’t read much (Benverlânio).

I used to go to school, more to mess up than to study, you know.., I made friends there, you know… my buds… people started getting along, kids, so we’d go smoke marijuana, cigarettes… there were times we didn’t even attend classes anymore, we’d skip classes just to hang around, went to school just to fight (José Marcos)

## Rupture of family ties

All the reports revealed that family ties went through processes of intense rupture. The older participants mentioned the early death of their parents and siblings in addition to family disagreements. The younger participants reported that family members were still alive but no ties would connect them, ruptures took place during childhood or adolescence, and they experienced the frequent absence of parents. Among the causes of such absence of parents are: abandonment due to an affective-loving attachment with a new partner and the fact parents were confined in prisons. Other factors were also listed as triggers of family disruption: poverty and famine within families, sexual abuse, and physical and moral violence committed by adults and the problematic use of psychoactive substances.

The things is that I separated from the woman [...] it wasn’t working anymore, so she took her way and I took mine, she lives her life and I live mine, I have five children with her…Will I kill her, for what? Because of children? I won’t (Wilson).

It was the death of the family, you know, father, mother, my sister [...] they all died you know, the family [...] my family is all gone in Vila Tibério to tell you the truth (Otávio).

My family is almost all evangelical, so I went to church for a while, you know… But I used drugs there and I got ashamed in front of my family, my mom, my dad, and the pastors from the church, you know… So I decided to leave, so I left and never went back (Telma).

## Experiences and ruptures in the world of work

The interviewees reported some low-income activities, only two had been factory workers. Those older than 40 years reported formal occupations (factory worker, construction worker, wall painter), however the youngest (between 18 and 30 years old) reported never having a formal job. The activities through which individuals in this age group make money include: drug trafficking, trash recycling, begging.

I have experience as a brick mason, carpenter, and plumber… I’m a construction worker (Otávio).

I’ve already worked as a warehouse assistant, administrative assistant, I’ve worked as hodman, I’ve worked in many things [...] when I decided to leave everything, I worked as a street vendor, I had already lost my job [...] cachaça (sugarcane brandy) was responsible for me losing my job, my decent life, the opportunity to be someone in life, so we have to say that cachaça is also a drug [...] (Luiz Carlos).

I worked as a mason assistant, I was very good, excellent… but today I can barely work with construction [...] some time ago I worked with this job of delivering flyers, it’s good, it calms the mind a little [...] you spend sometime with people [...] then I went to pick up cardboard, bottles, wow, lots of bottles (to recycle) (Gladison).

I never more worked in my life, my life is just taking care of cars on the streets (in exchange for some money), that’s it… I have no documents, my only document is God, I don’t have any document at all (Wilson).

## Daily life on the streets

The daily life on the streets is an experience marked by poverty, violence, linked with crime, prejudice, impotence, loneliness and despair. The individuals reported situations in which they were robbed, raped, attacked, became involved in fights and disputes for objects or territory, experience generalized prejudice and violence on the part of the society and most are continually involved with psychoactive substances. They also report that early death occurs and the main causes include: murder, tuberculosis and sexually transmitted diseases, especially HIV, hepatitis B and C. While these diseases are contracted on the streets, they are mainly aggravated by living on the streets.

You don’t have where to laundry your clothing on the streets, sometimes, I’ve seen it myself, people go beg on people’s doors and are cursed, humiliated […] you don’t have a bathroom, you don’t have a place to eat, living on the streets is difficult [...] (Telma).

You think that it’s easy to live this life? it’s not easy, I didn’t want this life for me… look what happened to me, look (Vilma).

Guys sometimes abuse girls on the streets [...] some have already tried to abuse me, you know, so I’m afraid (Telma).

It’s hard, if you’re on the streets, you may die or kill, you know… you’re sleeping somewhere and you don’t even see it, someone can hurt you, set you on fire… wow, life is crazy, horrible (Gladison)

The bad thing is nightfall, you seek a place to rest your mind, look to one side and it’s all misery, people wanting to rob your old slipper, your backpack… as asshole just like us, has nothing just like us, but wants to take from you what is yours, if he doesn’t take your life as well [...] (Luiz Carlos).

## Projects of life

Three interviewees presented a project of life in which they include a desire for having a work and housing. Three, however, reported that they would most likely die, while another three considered they would probably die if they did not change their living conditions. The remaining individuals presented ambiguous projects of life, in which there was a desire for change, however, there was also incisive content referring to hopelessness and disbelief in the alternatives offered by health services and social welfare assistance.

I want to go back to studies, because my enrollment is still valid, there are only two days I missed classes, and having a place to sleep, to take a shower, so I can get back to school and get my job back (Nayara).

I’ll see if I can buy a piece of land for me, I’ve sold what I had, I have to buy it again… or a house from Cohab [popular housing company] (Otávio).

I want to get a job, I want to have my own little house, I think of good things, though I don’t think about forming a family, I don’t want to have kids […] go to the store and get things I like and having the weekend to go out, and have fun… not where there’s beer… fun like going to an ice cream store, having pizza with guarana (Brazilian soda), drink lots of soda, this kind of stuff… going to a disco (Roseli).

I don’t know, I think that if I don’t quit drugs, I’ll go to hell, will end up in a coffin, I can’t stop it, nor me or my brother… if I tell you I’ll stop someday, it’s difficult (Gladison).

My life is over, I don’t want to live anymore, I really don’t (Vilma).

There is no future, I’m only waiting for death...is there any other way out? (Luiz Carlos).

## Comparison with the field diary

These data were also verified through the field diary, which focused on the contexts and environments where the interviews took place. Therefore, similar data were found: large contingent of migrants, low educational level, informal and low-income activities, family history of poverty, poor family ties, daily violence, and feelings of hopelessness toward life.

There was, however, a theme that predominated in all the reports: all the interviewees attributed their condition of living on the streets exclusively to the use of alcohol and other drugs. Even though all reports show social vulnerability, inequalities and exclusion, which appear associated with their family history for many generations, their condition of extreme poverty is only associated with the use of psychoactive substances, never with social determinants historically produced by the Brazilian society.

# DISCUSSION

Histories of life showed that social vulnerability and exclusion are preponderant in family histories from past generations to the present. The participants come from families and communities marked by illiteracy or low educational level, low-income jobs, and low social capital, with the presence of social ties marked by violence determining sociability. They also frequently report school was abandoned to assume informal low-income jobs as an immediate way to combat poverty. This is a context observed in other regions around the world22. Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al.. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95.,1414. O’Campo P, Kirst M, Schaefer-McDaniel N, Firestone M, Scott A, Mcshane K. Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence. J Urban Health. 2009;86(6):965-89.-1515. Sarmiento JMH, Correa N, Correa M, Franco JG, Alvarez M, Ramirez C. Tuberculosis among homeless population from Medellín, Colombia: associated mental disorders and socio-demographic characteristics. J Immigr Minor Health. 2013;15(4):693-9..

From the participants’ perspective, this reality is not associated to their exclusion to life on the streets though. Rather, their homeless condition is only associated with the use of alcohol and other drugs. This discourse is also recurrent among social workers and healthcare providers, including those providing mental health care, and in the media1616. Silva AB, Pinho LB, Olschowsky A, Siniak DS, Nunes CK. Caring for crack users: strategies and work practices in the territory. Rev Gaúcha Enferm. 2016;37(esp):e68447. doi: http://dx.doi.org/10.1590/1983-1447.2016.esp.68447.
http://dx.doi.org/10.1590/1983-1447.2016...
.

Nonetheless, when we make an intersection of these individuals’ self-perception with their histories of life, a contradiction emerges, which is their history of vulnerability and poverty, reported by these participants and confirmed by studies conducted in other countries, which has pushed this social segment out of equal life standards for many generations1717. Irestig R, Burstrom K, Wessel M, Lynoe N. How are homeless people treated in the healthcare system and other societal institutions? study of their experiences and trust. Scand J Public Health. 2010;38(3):225-31..

At this point, an important question emerges: why do the homeless people interviewed in this study completely appropriate of the discourse disseminated by the media, and by those in the health field and social welfare, a discourse that their condition is merely linked to alcohol and drug consumption, rather than associating their condition to the poverty that predominantly appears in their family histories? There are obviously many factors that explain such appropriation by social groups oppressed by the discourse of dominant social classes: low education and exclusion from the field of education, ideological reproduction of dominant discourses and social representations, among others. Therefore, another question implied in the previous question emerges: why does the discourse of the media, healthcare workers and social workers, among others reduce the social issue, of significant complexity, to the use of alcohol and other drugs, and consequently reduce it to a medical issue? In this conception, homeless people are seen as people who are not able to interrupt the use of alcohol and illegal substances. It confirms what other studies have shown in regard to this conception that prevails among those working in the care delivered to this population, that is, problems are individualized and the homeless situation is not contextualized and linked to socioeconomic, historical, political and cultural determinants, which are at the root of a society that produces social inequalities11. Adorno RCF. Atenção à saúde, direitos e o diagnóstico como ameaça: políticas públicas e as populações em situação de rua. Etnográfica. 2011;15(3):543-67..

We understand that the consensus achieved around the idea that the exclusion of these individuals living on the streets is uniquely caused by the abusive use of psychoactive substances, addressing it only from a clinical-psychiatric perspective, originated from a cultural reproduction, based on a distorted communication process concerning social representations, including prejudices disseminated by the media and ideological interests. This interpretation of reality, besides revealing an appropriation process on the part of medical institutions of issues of social, political, and economical nature and addressing them from a clinical perspective, does not take into account profound factors and aspects rooted in the social, cultural and historical formation of the Brazilian society1616. Silva AB, Pinho LB, Olschowsky A, Siniak DS, Nunes CK. Caring for crack users: strategies and work practices in the territory. Rev Gaúcha Enferm. 2016;37(esp):e68447. doi: http://dx.doi.org/10.1590/1983-1447.2016.esp.68447.
http://dx.doi.org/10.1590/1983-1447.2016...
,1818. Rayburn RL, Pals H, Wright JD. Death, drugs, and disaster: mortality among New Orleans’ homeless. Care Manag J. 2012;13(1):8-18..

The Brazilian society is still marked by a characteristic inherited from its socio-political slave-owing organization that lasted until the 19th century, which, through a culture of naturalization of poverty, remains indifferent to social inequalities, seeing immense inequalities in social relations as natural features of dysfunctional and unfit individuals. This ‘naturalization’ of inequality is a cultural product based on an excluding social agreement that does not recognize full citizen rights as being universal. There is an unequal exercise of citizenship, in which the society passively authorizes the frequent violation of the rights of people and groups, while dominant social sectors oppose or resist social policies1919. Accorsi A, Scarparo H, Guareschi P. A naturalização da pobreza: reflexões sobre a formação do pensamento social. Psicol Soc. 2012;24(3):536-46.. This proposition corroborates an observation, even of other studies, regarding a tendency to impute the causes of the situation they face to individuals. That is, the situation is seen through a moral and individualizing prism, without contextualizing social determinants, among others11. Adorno RCF. Atenção à saúde, direitos e o diagnóstico como ameaça: políticas públicas e as populações em situação de rua. Etnográfica. 2011;15(3):543-67..

From this perspective, the intention is not to minimize the use of psychoactive substances, the prevalence of which is extremely important among those living on the streets, but we understand that merely seeing this phenomenon as the single trigger of extreme poverty and the situation of living on the streets is to dangerously reduce the problem and disregard social, political, and economic factors, which are also important factors at the root of the problem, as these are factors that generate and reproduce poverty and social inequalities in Brazil, as well as disregard the prevalence of other health problems previously mentioned.

The abusive use of psychoactive substance is a social and public health problem, and, similar to other common infirmities affecting homeless individuals in Brazil, it is classified under Social Determinants of Health (SDH). The abusive use of psychoactive substances is produced within the dimension of social inequalities that mark the vulnerability of the poorest stratum of the population2020. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. As origens políticas das iniquidades em saúde: perspectivas de mudança. Rio de Janeiro: Fiocruz; 2014. The Lancet - Comissão da Universidade de Oslo sobre Governança Global em Saúde., i.e., social, economic, cultural, ethnic/racial, psychological and behavioral factors, which influence the occurrence of health problems and risk factors in the population and determine unequal access to health services and other services compared to other social groups. Such factors are at the base of social experiences and health experiences of those living on the streets.

The population represented in this study is a historical reflection of an accumulation of social problems, whose health issues are marked by social determinants with the strong presence of inequalities such as: lack of housing, education, work and income, social exclusion, lack of social and community networks, and restricted access to services, whether health care services and/or social welfare services1919. Accorsi A, Scarparo H, Guareschi P. A naturalização da pobreza: reflexões sobre a formação do pensamento social. Psicol Soc. 2012;24(3):536-46.-2020. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. As origens políticas das iniquidades em saúde: perspectivas de mudança. Rio de Janeiro: Fiocruz; 2014. The Lancet - Comissão da Universidade de Oslo sobre Governança Global em Saúde..

From this perspective, it is believed that life on the streets was strongly influenced by the course of life of these individuals, considering the fact they were born in very poor families, without education, performing disqualified jobs, and without a strong social network; families, who, according to their histories, have faced for many decades a living condition marked by high levels of social inequalities. Hence, the interviewed individuals are living on the streets and facing extreme poverty, life conditions that were produced in the context they were raised in: born in families historically experiencing social vulnerability, in very poor communities, with social ties marked by violence, broken social support networks, participating in activities linked to the organized crime since adolescence, and keeping activities from which they obtain income that are linked to drug trafficking. These factors are, among other things, social determinants that lead to their expulsion to life on the streets and the social vulnerability they face.

# CONCLUSIONS

This study shows that a context of social vulnerability, inequalities, poverty and exclusion have marked the family members of this study’s participants for many generations. The situation of living on the streets stems from political, economic, cultural and social factors present at the root of the Brazilian society. Social determinants condition one’s life and health and the factors that directly lead to a situation of living on the streets are multidimensional and complex and cannot be reduced to a single causal factor.

The combination of two theoretical frameworks, ethnography and Habermas’ hermeneutics, was very productive, because ethnography provided the tools to describe data based on the individuals’ self-perception and Habermas’ philosophical framework provided the tools to interpret the reports, connecting them to the images presented in the film, that is, taking into account how these the participants think, what they think, and why they think in a certain way. The interviewees provided certain explanations for the factors that led them to become homeless and, from a hermeneutic perspective, we contextualize their reports in cultural and historical terms, obtaining a broad and comprehensive understanding of the phenomenon under study.

The use of video recording was also a resource very appropriate to collect data in this study. It is a resource frequently used in ethnographic studies to capture information from the individuals’ symbolic universe, which is revealed by facial and body expressions, and it was also very productive as an instrument of systematic direct and indirect observation of a complex situation. The object of study could be observed many times, which permitted capturing nuances from the environment, from individual and group behaviors, non-verbal language, as well as the sequence and time in which events took place. Additionally, these aspects were essential, not only as data in themselves, but to support the interpretation of data.

# References

• 1
Adorno RCF. Atenção à saúde, direitos e o diagnóstico como ameaça: políticas públicas e as populações em situação de rua. Etnográfica. 2011;15(3):543-67.
• 2
Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al.. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-95.
• 3
Sapir A. Globalization and the reform of European social models. J Common Mark Stud. 2006;44(2):369-90.
• 4
Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua: Aprendendo a contar: Pesquisa nacional sobre população em situação de rua. Brasília (DF): Ministério do Desenvolvimento Social e Combate à Fome, Secretaria de Avaliação e Gestão da Informação; 2009.
• 5
Freitas M, Mecena EH. Vulnerabilidade de crianças que nascem e crescem nas periferias metropolitanas: notícias do Brasil. Rev Latinoam Cienc Soc Niñez Juv. 2012;10(1):195-203.
• 6
Botti NCL, Castro CG, Silva MF, Silva AK, Oliveira LC, Castro ACO, et al. Prevalência de depressão entre homens adultos em situação de rua em Belo Horizonte. J Bras Psiquiatr. 2010;59(1):10-6.
• 7
Souza RRS, Oliveira JF, Chagas MCG, Carvalho ESS. Gender, violence and being homeless: the experience of women and high risk drug use. Rev Gaúcha Enferm. 2016 set;37(3):e59876. doi: http://dx.doi.org/10.1590/1983-1447.2016.03.59876
» http://dx.doi.org/10.1590/1983-1447.2016.03.59876
• 8
Nakamura, E. O método etnográfico em pesquisas na área da saúde: uma reflexão antropológica. Saúde Soc. 2011;20(1):95-103.
• 9
Instituto Brasileiro de Geografia e Estatística [Internet]. Brasília (DF): IBGE; 2010. [citado 2010 nov 29]. Disponível em: http://seriesestatisticas.ibge.gov.br/
» http://seriesestatisticas.ibge.gov.br/
• 10
Presidência da República (BR). Decreto Nº 7.179, de 20 de maio de 2010. Institui o Plano Integrado de Enfrentamento ao Crack e outras drogas. Cria o seu Comitê Gestor e dá outras providências. Diário Oficial da União [da] República Federativa do Brasil. 2010 maio 21;147(96 Seção 1):43.
• 11
Bauer MW, Gaskel G. Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes; 2002.
• 12
Habermas J. Consciência moral e agir comunicativo. Rio de Janeiro: Tempo Brasileiro; 1989.
• 13
Habermas J. Political communication in media society: does democracy still enjoy an epistemic dimension? the impact of normative theory on empirical research. Communication Theory. 2006;16:411-26.
• 14
O’Campo P, Kirst M, Schaefer-McDaniel N, Firestone M, Scott A, Mcshane K. Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence. J Urban Health. 2009;86(6):965-89.
• 15
Sarmiento JMH, Correa N, Correa M, Franco JG, Alvarez M, Ramirez C. Tuberculosis among homeless population from Medellín, Colombia: associated mental disorders and socio-demographic characteristics. J Immigr Minor Health. 2013;15(4):693-9.
• 16
Silva AB, Pinho LB, Olschowsky A, Siniak DS, Nunes CK. Caring for crack users: strategies and work practices in the territory. Rev Gaúcha Enferm. 2016;37(esp):e68447. doi: http://dx.doi.org/10.1590/1983-1447.2016.esp.68447
» http://dx.doi.org/10.1590/1983-1447.2016.esp.68447
• 17
Irestig R, Burstrom K, Wessel M, Lynoe N. How are homeless people treated in the healthcare system and other societal institutions? study of their experiences and trust. Scand J Public Health. 2010;38(3):225-31.
• 18
Rayburn RL, Pals H, Wright JD. Death, drugs, and disaster: mortality among New Orleans’ homeless. Care Manag J. 2012;13(1):8-18.
• 19
Accorsi A, Scarparo H, Guareschi P. A naturalização da pobreza: reflexões sobre a formação do pensamento social. Psicol Soc. 2012;24(3):536-46.
• 20
Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. As origens políticas das iniquidades em saúde: perspectivas de mudança. Rio de Janeiro: Fiocruz; 2014. The Lancet - Comissão da Universidade de Oslo sobre Governança Global em Saúde.

# Publication Dates

• Publication in this collection
2016