Theoretical and methodological framework

The Theory of Self-Care proposed by Dorothea E. Orem was used. This framework was developed from a broad analysis of the self-care deficit and encompasses a range of meanings, especially regarding quality care in Nursing⁽⁵⁾. In addition, the study used the interface with the field of Health Psychology to point out that self-care goes beyond the logic of health illness, being a sensitive result of psychological mechanisms (e.g., self-regulation) and systemic processes (e.g., support network and third-party care)^(9,10).

Type of Study

This is a qualitative and exploratory study. The COnsolidated criteria for REporting Qualitative research (COREQ)⁽¹¹⁾⁾ tool guided the structuring of this report.

Study Scenario

The study was developed in a public school in the countryside of São Paulo State. The school offered students the three grades of high school full-time. The field was selected by convenience, considering the openness and receptivity of the coordination and the previous contact of the responsible researcher (ACC) with the institution. The researcher did not maintain routine contact with the students but only sporadically upon invitation to participate in educational activities promoted by the school.

Participants

Seventeen adolescents participated in the research, 15 of whom were female, aged between 15 and 17 years, enrolled in the three grades of full-time high school. This study included students regularly enrolled and regularly attending school, as well as those who obtained parental consent to participate in the research and signed the consent form. There were 273 students enrolled in the school in 2022. Adolescents with chronic health conditions or declared illnesses were not included.

Initially, 40 students volunteered to participate, although some did not return the parent/guardian consent form, others did not return the data collection instrument, and one student had the parent/guardian consent withdrawn during data collection, totaling 23 losses.

Methodological Procedures

After initial contact with the research setting, presentation of the proposal objectives to the administration and potential participants, and dissemination among students, data collection occurred in November/December 2021 and February 2022. In the first moment of data collection, students identified as class representatives were invited to join the study. This moment coincided with the return of classroom activities in public schools in São Paulo State, Brazil. Volunteering students received the data collection instrument and possessed the material for 30 days. Afterward, the material was collected, and the researchers evaluated the adequacy of the number of days filled out by the participants. From this preliminary evaluation of the procedure used, we decided to collect data again, with a reduction in the number of days to fill out the instrument. Thus, in the second moment of data collection, all high school students were invited to join the study, and those who agreed to participate were given the data collection instrument for 15 days. During all data collection moments, the responsible researcher (ACC) monitored and stimulated the students through messages sent via the WhatsApp application.

Collecting and organizing data

Data were collected using the Personal Diary Technique. This technique is characterized by using simple, cheap, and easy-to-handle material, making it feasible to apply in populations with different socioeconomic strata and allowing the research participant rich insights into information⁽¹²⁾. It is worth noting that the personal diary technique is different from the field diary technique since, in the latter, the notes used are made by the researcher according to the purpose of the study⁽¹²⁾.

For this study, a diary was built in which the participants reported their daily activities, health care, and information they considered pertinent (emotions, feelings, personal and reflections, among others). The diaries were made up of five blocks, printed on paper, and were filled out individually. The blocks that made up the data collection instrument were: block 1 - single entry - questions about health and self-care; block 2 - daily entry - space to record daily activities performed; block 3 - daily entry - recording of physical self-care activities; block 4 - daily entry - recording of psychological and emotional self-care activities; block 5 - optional entry - spaces for recording personal reflections. The diaries contained either 15 or 30 pages (one page per day). In total, the participants filled 260 pages of the diaries manually, and 60 pages of transcription were totaled (Arial font, size 12, 1.5 line spacing).

Data Analysis

The Iramuteq software (version 0.7, alpha 2) was used to organize the transcribed material and operationalize the thematic analysis⁽¹³⁾. Six phases were operationalized for thematic analysis: 1) familiarization with the data (exhaustive reading of the material, notes, and preliminary ideas were highlighted); 2) generating the initial codes (69 codes related to semantic or latent contents were identified); 3) searching for themes; 4) reviewing the themes; 5) defining and naming of themes; 6) producing of the report that originated this article. The analysis resulted in four categories: Adolescents’ conceptions of self-care; Capacity, willingness, and behaviors for self-care; Background of self-care or its absence at the individual level; Self-care deficit and absence of family or community background. Every analysis process was independently operationalized by a researcher (ACC) under the supervision and conference of another researcher (WAO).

Ethical Aspects

The study was conducted according to national and international ethical guidelines and approved by the Pontifical Catholic University of Campinas Research Ethics Committee, whose opinion is attached to this submission. Participants were named by codes of number, age, and declared sex (e.g., Participant 1, 16 years old, female).

Conceptions of self-care

The adolescents understood self-care as a set of actions they should adopt to preserve physical and mental health. In the definitions presented by the participants, the perception of individual responsibility for self-care was evident as the main characteristic. This understanding may have been influenced by the timing of the pandemic of COVID-19, which stimulated, to some extent, individual responsibility for self-care and avoidance of illness. These aspects can be illustrated in the following fragments.

It's when you have the autonomy to care for yourself (Participant 2, 16 years old, female).

You do something for yourself, intending to have a better quality of life (Participant 4, 16 years old, male).

When you do something good for yourself, it "disconnects" you from your problems (Participant 9, 17 years old, female).

For me, self-care is everything related to your well-being, like going to the gym, eating well, staying hydrated, seeking psychological support, etc. (Participant 5, 16 years old, female).

The person should be clean, have a nice bath, and dress well (Participant 14, 16 years old, female).

In theory, self-care is knowing how to take care of yourself and control thoughts and feelings, to know what you really want, what you need, and, most importantly, what you deserve. But, in practice, I don't know how to do that (Participant 15, 17 years old, female).

We also observed that the activities of daily living and necessary adjustments in eating or physical activities were used as examples for adolescents to illustrate their understanding of self-care. Other aspects considered relevant elements for self-care were hand hygiene and wearing masks. This movement may indicate how the evocation of elements of concrete reality is still necessary to understand a construct that is essentially abstract (self-care).

Capacity, willingness, and behaviors for self-care

Some adolescents' reflections indicate the belief that it is necessary to have the ability to take care of oneself, followed by the willingness to do so and that this is achieved through action. That is, this aspect reflects their definition of self-care - very much based on empiricism and resorting to everyday habits. Thus, even for the reproduction of basic activities of daily living, such as hygiene and eating, cognitive and functional abilities, prior knowledge, experience, and well-developed awareness of oneself and the world are required. In terms of self-care, this ability would be a resource for maintaining one's health. In this sense, the following fragments illustrate the self-care behaviors listed by some of the participants.

I think it would be to do basic things, shower daily, eat regularly, without exaggeration, have leisure time, and sleep well... (Participant 2, 16 years old, female).

Talking about [the difficulties I face] it with my friends. Playing sports, eating well (I try) or drinking a lot of water (Participant 5, 16 years old, female).

Waking up early, brushing my teeth, washing my face, doing my make-up, fixing my hair (Participant 14, 16 years old, female).

However, many times, in the daily activities, there was no clear awareness about the self-care behaviors, which were automatically experienced, without a cognitive evaluation or reflective elaboration about them. Actions were activated when physically (in response to hunger, for example) or emotionally (feelings of sadness and loneliness, for instance) necessary.

For self-care behaviors to happen, we also noted that the willingness to self-care component must also be triggered. This component is based on adolescents' assessment in terms of motivation, self-regulation, and self-efficacy of their behaviors. In addition, when addressing specific symptoms or outcomes related to the COVID-19 pandemic, the perceived benefit of health care can be interpreted as a strong influence for self-care action, according to the adolescents themselves.

Background of self-care or lack thereof on an individual level

Regarding the analytical theme presented herein, a good perception of self and the moment being lived is one of the first aspects to influence the adoption of self-care behaviors at the individual level was observed. The adolescents expressed positive perceptions, including self-efficacy, self-regulation, and beliefs that self-care works.

I try to see the good side of the bad event of everyday life (sometimes even hilarious). For example, my car broke down; at least now you will walk and won't collaborate so much with pollution (Participant 7, 17 years old, female).

I seek to do something that brings me peace of mind, but I don't know if that comes into self-care (Participant 9, 17 years old, female).

In the daily entries, some activities referred to a positive perspective on life, which may have influenced adopting self-care behaviors. It is inferred that this approach to existence and the moments lived can work as a reinforcing element for self-care, contributing to the preservation of an optimistic expectation about the future and greater confidence in their ability to overcome adversity. This posture can extend throughout life. Experiences of religiosity/spirituality also appeared in this theme. Spiritual self-care is the set of practices based on spirituality in which people get involved to promote continuous personal development and well-being, aspects mentioned by adolescents.

I went to church with my mom and my boyfriend, we came home, and after dinner, I am here talking to you, 'diary' (Participant 1, 16 years old, female).

I went to school and only came back in the afternoon and went to PG, a small group for young people in my church (Participant 10, 16 years old, female).

Manifestations of negative feelings or emotions were the primary barriers, at the individual level, identified for self-care effectiveness. They often include functional, cognitive, psychological, or physiological changes. Some of the participants' notes in this direction are presented below.

Today I ate very little and junk food because of anxiety (Participant 3, 16 years old, female).

I woke up late again, had an anxiety crisis, watched fights at home, went out crying, taught classes, went to the holy supper, went to my cousin's, and went to sleep at my friend's house (Participant 7, 17 years old, female)

It was a calm day, kind of happy, but also: discouragement, worry, fear, anxiety, sadness, and remorse. I argued with my boyfriend in the early morning (Participant 15, 17 years old, female).

Today I think I was still tense from this whole situation [messages sent by classmates about school assignments], and a little sad that I didn't go to my friend's birthday and not making out with him and our classmates (Participant 17, 16 years old, female).

Self-care deficit and absence of family or community background

This theme includes social and cultural aspects that can contribute to adopting self-care behaviors from the perspective that they can be learned and reinforced positively or negatively throughout the life cycle. Nevertheless, from the adolescents' diary entries, there were aspects learned or encouraged that refer more to self-care deficit. Some adolescents revealed the perception of being devoid of some of the abovementioned attributes.

I'm not used to practicing self-care, and I think I am more about taking care of others than myself (Participant 1, 16 years old, female).

I stay in the "half phase" [practicing self-care or not]; I'm never 100%. I deal with the difficulties of everyday life by crying (Participant 6, 16 years old, female).

I try, but it's not always that I succeed. Sometimes I just try to pretend that there is no problem and then automatically occupy my mind with other things (Participant 6, 16 years old, female).

I try to care for my skin, hair, health, and well-being. But I usually don't practice because I don't feel like it. [I usually cry in my corner alone, draw to calm myself down, and try to escape problems and noise (Participant 12, 15 years old, female).

I don't know how to practice [self-care], nor where to start; I've never tried, the way I treat myself is the same since always, and I don't know how to change (Participant 15, 17 years old, female).

I often end up freaking out because I can't deal with [everyday difficulties]; other times, I try to organize myself and analyze the situation well to find the best solution for that problem (Participant 17, 16 years old, female).

Negative lifestyle habits may indicate an absence of instruction or training in self-care (family background). Considering that the participants are adolescents, the care of food and sleep routines are not regulated by parental or caregiving figures at home, as seen in the following fragments.

It was a tiring day. When my father works at home, he leaves my mother and me with our heads full because he doesn't let us be quiet for a second (Participant 1, 16 years old, female).

I went to school, and when I arrived, I helped my mother [with household activities], went to sleep, and only woke up for dinner (Participant 6, 16 years old, female).

[Today I had a lot of] Stress, me and my mother fighting (Participant 10, 16 years old, female).

I woke up at 8 o'clock [in the morning] with my parents yelling; I got up, took a shower, went to church, and returned. I had lunch, went out with A. [my boyfriend], and then got discouraged (Participant 12, 15 years old, female).

In general, the adolescents remained alone most of the time, with minimal adaptation conditions for home care, considering the quality of the environment and the relationships with family members. There were no records of examples or references to parental encouragement for eating, physical activity, or leisure behaviors.

When recording their daily routines, the adolescents also did not recognize the presence of public policies that could facilitate or help in the self-care process. This recognition did not occur even when they referred to school activities in a public educational institution. The mentions to the school referred to the volume of academic activities and meetings with friends/colleagues. Positive relationships with teachers were also mentioned, especially when adolescents needed help, although they were not appreciated as drivers for adopting self-care behaviors.