Meaning of Health Alterations in Children Living in the Streets1 Significado de alteraciones en la salud de niños en situación de calle

| INTRODUCTION: The research was conducted in Medellín, Colombia. OBJECTIVE: The work sought to understand the meaning of diseases and their treatment for homeless children. METHODOLOGY: Ethnographic and qualitative research. Thirty interviews were carried out to homeless children and a field diary was kept. RESULTS: Diseases were classified as those caused by God and diseases or injuries caused by men; the latter can be prevented, but the first one cannot. Diseases caused by men can be severe, if they pose the risk of death and require hospital treatment; serious, when they jeopardize freedom; and mild, when they do not place at risk their independence and are treated through self-medication or culturally determined treatment. Diseases mean experience and injuries mean revenge, courage, and shame. CONCLUSION: Homeless children build the meaning of diseases from their experience, in relation to death and freedom.


Introduction
This work stems from the concept of children presented by UNICEF (2019), which considers them up to 18 years of age and includes both girls and boys. Thus, homeless children are those < 18 years of age who appropriate the street settings and build it socially to survive therein and raise their families.
The situations they go through due to their living conditions that imply seeking daily sustenance, such as not having a place where they can sleep and rest; being subjected to temperature changes and rain; not having a way to protect themselves; eating spoiled food; getting money by selling their bodies; ingesting psychoactive substances excessively and being in contact with different people, exposes to accidents or enduring trauma and diseases, like those of sexual transmission, gastrointestinal, neurological, and respiratory, Instituto Colombiano de Bienestar Familiar (2014).
The review of works on access to health services and the meanings the homeless assign to health and disease found that the vast majority of these refer to the population in general, but few focused specifically on homeless children.
Concerning health alterations, Akman et al. (1999) propose as principal motives for consultation in the city of Buenos Aire's intoxications, trauma, dermatological conditions, sexually transmitted and respiratory diseases. Pasamonik (2009) identifies children's health problems attending a comprehensive center for childhood and adolescence with skin diseases first, childbirth-puerperium pregnancy, infectious diseases, and lastly, trauma. Furthermore, besides the aforementioned, Forselledo (2001) raises due to diseases growth retardation and mental alterations due to stress associated with economic hardship. Finally, Giraldo, Forero and Aristizábal (2020) identified that homeless children receive and exert violence and, consequently, suffer lesions; in addition, it is considered that the diseases and wounds of homeless children are a relevant public health problem.
This work presents the experiences and meanings homeless children assign to disease and lesions, situations they denominate as health alterations.
Hence, this work sought to understand the meaning health alterations have for homeless children and how they treat them. The work used qualitative research with an ethnographic approach with participation by homeless children to respond to the research objective, which permitted greater involvement in the process and ensured greater rigor in the research.

Social and Scientific Relevance
Due to the social, political, and economic conditions endured in the country, this population is on the rise. Therefore, this group is considered vulnerable, especially in health aspects, due to diseases and injuries. From the cultural point of view, this allows us to get closer to how they handle certain diseases and injuries, which permits learning from them, and when caring for them, keep in mind their cultural point of view. Hence, this study sought to understand the health alterations and, thus, provide elements that facilitate institutions and government entities working with this population to approach the children and serve to construct programs and policies in favor of improving their health.

Methodology
Given that the work sought to know the experiences of homeless children, regarding the diseases and injuries they suffer in their daily lives and try to comprehend the meanings of those experiences, it became necessary to select a type of study that would permit comprehension; which would be flexible; which would provide a broad and total view of the phenomenon; which would not judge the thoughts or behaviors of the participants; and, finally, which would work with non-quantifiable data. Therefore, due to said reasons, qualitative research was selected as the type of study.
Upon deciding the type of study, it was necessary to select an approach that would respond to the specific needs of the research, like understanding the meanings that support the behaviors of the homeless children; being aware that the presence of the researchers in the environment of these individuals provokes reactions in them; understanding the sense children give to their actions; and, finally, managing to approach their culture, represented in their experiences and meanings, from their vision (emic approach) and opting for the ethnographic approach and within such, adopting the concept of culture given by Clifford Geertz, which understands it as "a set of meanings constructed socially" (Geertz, 2003).

Techniques
The study participants have applied 30 interviews whose questions were aimed at knowing the experiences about alterations in health, expressed in their behaviors and the meanings given, both to those experiences and diseases and injuries. In the application of the interviews, with a prior request for acceptance by the participants, two interviewers intervened, where one of them conducted the interview. When this was finished, the second interviewer asked the participant questions the first interviewer had omitted and those that could explain some situations reported by the interviewee or delve into some valuable aspects for the research. After that, the second interviewer made contributions to the first aspects that could be improved or kept in mind in subsequent interviews.
Each researcher kept a field diary, which described their perceptions, fears, anguish, meetings with the people that observed, methodological reflections about the research process, and activities carried out. These notes were useful during the information analysis process.

Population
The study participants were children with life experience on the streets, living in the center of the city of Medellín, Colombia, and with whom work had been conducted for several years. Children who had suffered at any moment during their time in the streets some disease or injury and who voluntarily accepted to participate in the research. The work was supported by the culture and health line of research, with the participation of individuals with life experience in the streets; they accompanied some of the outings, through which it was possible to meet other children with whom the first contacts were made, explaining to them the nature of the research and inviting them to participate in it.

Information analysis
It should be noted that the research group includes representatives from the studied community and provides them with research elements, especially in that related to the techniques to collect information and analysis so that they can participate actively. This work and previous works involved homeless children in the analysis process. It was found that they have great sensitivity to identify the codes and construct the pertinent categories, besides correcting the etic vision of the researchers concerning the information obtained.
The analysis process followed the following steps: the interviews were transcribed, being careful to respect the language used by the participants; then, each of the interviews was read individually, where the researchers wrote general comments, which were later shared in the group meeting in which the interview was again read and therein identified possible codes to after that, in later meetings, construct categories, besides elaborating maps, which aided in the visualization of the categories and in drafting the article.

Rigor criteria
According to Castillo and Vásquez (2003), the rigor criteria in qualitative research are credibility, auditability or confirmability, transferability or applicability, and validity and reliability. Each of these criteria was considered in the research. Participants were included in the research group to achieve credibility, with whom prior contact was established for several months to ensure that the information they furnished was truthful; the results were also discussed with the children, who gave the endorsement so that the information could be presented to the community through spoken and written means. Special care was taken to make a faithful transcription of the interviews to ensure auditability or confirmability and conserve the recordings. Applicability is up to those who read the research, whether it can be applied or not.
To achieve reliability and validity, congruence was sought between the research question and the elements used in the method. The study made sure the participants were representative of the group of homeless children and saturation of the selected categories.

Ethical aspects
The study kept in mind the principle of respect, a source of recognition of the autonomy of those participating; during the research, no remuneration of any kind was offered, and the interviews were conducted in the places and times in which the children felt most comfortable. They were told of the study's intention, and it was made clear that they could withdraw from the study at any moment they so desire. During the socialization of the findings, the information was handled with reliability criteria; personal data were not revealed to guarantee the anonymity of the participants.
This study is adjusted to international norms on ethics in human research. It kept in mind aspects established in Resolution 008430 of 1993 by the Colombian Ministry of Health; according to article 11, the research is classified as low risk (1993), and the researchers have no conflict of interest with the theme.

Context
In the city of Medellín, children run the streets in small groups; they have abandoned their homes to start their lives on the streets, where they get organized into "parches -cliques" in which they share and support each other mutually. Thus, they convert the street into their home in which they live situations, such as economic difficulties, violence, "caciqueo" (actions of dominance and aggression against them), sex abuse, the start of consumption of psychoactive substances, and rejection from people who frequent the streets, like pedestrians, street and stationary vendors, and control agencies, such as the police.
One of the first sectors where the children arrive in the center of the city, given its conditions since it has hotels and residences where they can "hang out" (sell their body) and sleep; places to get food, "camellarstruggle" (work), use drugs, have fun and meet their needs, such as calming hunger, bathing, sheltering from heat and cold. In the city, they set up certain spaces they identify as their own. One of the most frequented is the metro viaduct, dedicated to odd jobs or using drugs. This zone also has many street vendors who offer second-hand goods, like tools, home appliances, clothing, shoes, dolls, cell phones, magazines, and old books. Likewise, it is possible to see fruit and vegetable vendors on makeshift carts or those who sell coffee in baby carriages that have been conditioned for this purpose. Also, at the entrances to the hotels, girls and adolescents are waiting for clients to sell their bodies; generally, they are watched closely by those who, in exchange for protection, receive a part of what the clients pay them.
All these experiences on the street expose them to problems and fights with others; besides, the conditions in which they live alter their health and cause infectious diseases due to not taking care of their bodies.

Findings
Health alterations are everyday experiences in all people. Traditionally, medicine, especially epidemiology, has classified them into chronic and acute diseases, according to the time of duration and into severe, serious, and mild, according to the damage they cause in the organism and the organs they affect. Injuries, according to the compromise to the skin and other structures, are denominated simple, complex, penetrating, and not penetrating.
Homeless children live experiences characteristic of the environment within which are the health alterations that can be physical or mental. Health alterations are classified into two forms that have to do with the conception they have of them, according to the experiences lived: those caused by God (Supreme being) and those caused by man.

Yes, my dear God, things of my dear God
The first have no cure and cannot be prevented, like the case of cancer, besides being considered severe. However, these diseases do not cause rejection from their street companions or "parceros -members of the clique," with whom they live daily.
These are God's doing, that is nature, because everybody has cancer, but in some it develops faster than in others According to the children, health alterations "caused by man" are injuries of any type and diseases, like those of sexual transmission acquired due to having intercourse with infected people and which could be the very "parceros" or "parceras" or due to contact with the clients in the case of girls who "hang out," that is, sell their bodies.
Those of sexual transmission, the famous one, the one they call gonorrhea.
Also, diseases produced due to lack of food or eating too many sweets, being in contact with spoiled food, contaminated elements, or sick individuals, and due to the untimely suspension of psychoactive substances or their excessive consumption.

I got too many overdose attacks because I snorted too much coke (cocaine)
The children include, within the conception of injuries, the blows they can receive from their parceros and the traffic accidents (being run over by an automobile), even if their skin is not broken or cause loss of blood, stabs and puncture wounds caused by other homeless children or by "culebras" (people to whom they owe something or who owe something), the blows caused by the fights or fights between the companions of the group (parceros).

That "pelaita" (girl) was very aggressive and we had a fight and she stabbed me -almost killed me
They also are hit by passersby or any other person and from the police who dominate them or "caciquea" and obligate them to do certain things, abusively, generally of sexual nature, which they (boys and girls) refuse to do, and that is why they are punished through physical aggression or by getting locked up in police stations.
They were beating me too hard, I felt sad knowing that they (the police) were going to leave all bruised, beaten and that I would be in pain.
The children classify the health alterations caused by man into severe, serious, and mild. To reach this classification, they use criteria that -to a certain extent -differ from those used by medicine and epidemiology, which involve activities characteristic of their way of life.
Diseases, by being in the street, survival habits always bear risk ahead

Severe alterations
Diseases considered severe require immediate care in a health institution and, if not cared for, may cause death. These include convulsions attributed to uncontrolled and excessive psychoactive substances, like cocaine and heroin, and sexually transmitted diseases in the advanced phase of AIDS.
She had many attacks due to overdose, because she snorted a lot of coke, we had to take her to the hospital.
To be told you have AIDS, you will die of AIDS.
Injuries are severe when they compromise organs or are large and deep and also require care in a health institution.
When you go to the hospital, it has to be for something very severe and are losing too much blood or have a very large stab wound and a very big injury, something great to end up in the hospital.
In severe alterations, children use the hospital as a last resort, which they consider the place where you go to be saved or die. On few occasions do children go on their own to the hospital, most are taken there by their parceros or by staff from protection institutions. For many of the children going to hospitals implies having to deal with bad treatment, being discriminated against, or, if injured, getting infected when their injuries are manipulated.

Serious alterations
These alter their mood and do not let them perform diverse daily life activities, like walking, running, working ("camellar"), eating, stealing, seeking amusement, sharing with their parceros, among others.

My body was no capable of walking, running, or being happy.
This restriction in the freedom of movement is related to an injury that does not cause internal damage and which may or may not be penetrating, but causes much pain; also, with the use of psychoactive substances, which cause discomfort; a sexually transmitted disease in the initial phase; abundant intake of sweets, which cause intense headache and stomachache; not eating enough food, which according to them produces "anemia due to malnutrition"; drug withdrawal that generates emotional suffering, depression, and fatigue; besides respiratory and gastrointestinal infections, which do not let them move.

Sometimes I get pain here in the stomach, or when I don't feel well, it gives me the chills, so I can't get up.
Regarding the limitations in movement that hinder their performing their daily activities, homeless children seek the aid of a pharmacist, a physician or of support entities to be treated and recover their freedom; they also gather money to have access to consultation in health institutions; however, said access is limited because they have to show certain documents they generally do not have. Also, due to the bad treatment they receive, sometimes they prefer not to go to said services.

Mild alterations
The homeless children denominate as mild alterations in which they can continue with their daily lives normally when activities and daily life are not interrupted by any disability or indisposition that hinders their movement. Mild diseases, then, are all the infectious processes, like colds, mild pain, and gastrointestinal diseases in their initial phase.
It is something mild, not so severe.
The ways homeless children manage the mild disease are self-care and rest where they live until the discomfort passes, and they feel totally normal; they do not attend a hospital unit, given that diseases in this phase do not require additional support, only personal care.

Stay there in the room very still, and it starts healing
With colds and things like that, with a pill, you try to self-medicate Homeless children define mild injuries as those that are not penetrating and do not affect any organ severely and which are called punctures, which do not require medical care, only personal care, to have an adequate healing process and avoid their infection. For this, they use home remedies offered by their parceros or fellow street dwellers who have already gone through these same processes and are a good practice to keep the wounds in a good state of disinfection and healing. These practices include using cigarette or marihuana ash, peroxide, and Good disinfection with Rey soap (blue bar of laundry soap).

Every night I applied lemon with Rey soap and scrubbed the wound well until it healed
When suffering any injury, they prefer to cover it to avoid onlookers and being judged by their companions or parceros.
I clean it up, apply alcohol, water, I don't let anyone see that.
The children report not going to hospitals for two reasons; the first is that these are not injuries that can jeopardize their lives or restrict freedom and prefer to treat them by themselves; the second is that in hospitals, they are interrogated, are not well received and state that the sutures made there end up "ugly" and can get infected.
You should see how the skin was left all gathered up incredibly disfigured; she was left quite badly, which occurs a lot with homeless children.
In treating mild health alterations, diseases, and injuries, the fundamental for the homeless children in their own care or that of their closest companions and not using hospital units. You medicate yourself in the street, self-medicate

Feelings
The children feel stigmatized and rejected by their parceros or companions when they contract diseases like AIDS because this disease is infected easily, causes death, and has no cure. Forms of stigmatization are represented in rejection, not seeking the company of those affected by AIDS, not sharing food, not getting close to avoid being touched by them, and not agreeing to have sex.
What's more, because of the stigma created by the disease itself, of AIDS Homeless children express fear of acquiring sexually transmitted diseases, given that such limit their interactions with others, cause pain, and become severe diseases.

That I do fear a lot, the sexually transmitted diseases
Severe injuries make the children angry, given that they see that their bodies are no longer the same.

Meanings
For the homeless children, health alterations mean experience; experiences make them take preventive measures in the future, like avoiding mismanagement in the use of psychoactive substances or alcohol and contact with people who mean risk.

Since I went through that, I got to experience
Given that the injuries have additionally marked their bodies and spirit, they learn to defend themselves and not go through the same place where they have been injured.

You learn that you can't walk through there at certain hours.
Experience makes them avoid "culebras," set themselves up in places where they feel safer, not fighting with other street dwellers or with those with whom they share the center of town, like street vendors, police, convivires (private surveillance and security cooperative groups created by legislative decree 356 of 1994), and maintaining with them adequate dialogues and interpersonal relations.

Convivires are something like the police, but more violent
Severe and serious injuries mean vengeance, making them confront the people who injured them and collect that debt.
You stay with that vengeance, so you will hit them at any moment because you have that vengeance.
Scars mean bravery and a motive for pride when these are caused in any part of the body other than the face.

I got a stab wound when fighting. It is how I was left, cool because it is like a label you carry
Wounds are a source of discomfort and shame when they are done to the face and, therefore, in fights, this is the part of the body they protect the most.

I do not accept to be done that, not there, my face is the best, for me it is the best, because my body I don't, they
can stab me... in the body ... not the face.

Prevention
Prevention is established according to the experiences and meanings constructed in the street.
It is clear to the participants that to avoid diseases caused by man, they must undertake actions, like caring for their bodies, which implies eating well, exercising, and staying clean.
I do lots of exercises, eat everything, salads, that helps keep good health.
They also recommend keeping distance from people who have any type of infection, controlling food intake, and the use of psychoactive substances.
What do I do to care for myself? Get away from those people.
One way of preventing infection of sexually transmitted diseases is to wear a condom and detect them on time (diagnose them), prior to engaging in the sexual relationship and, for such, they apply different techniques, which they consider effective in which they employ elements, like marihuana ash, lemon juice, and beer. If there is a reaction, they conclude that the person is infected and avoid the sexual relation.
For women, you apply lemon juice to the vagina, and if they show some discomfort, it is concluded that they have a sexually transmitted disease.
For men, you pour beer or lemon on the penis, and you notice it with their startled reaction.
If I am going to have sexual relations, I will always wear a condom.
The way to prevent convulsions is by controlling the use of psychoactive substances.
I use to have attacks hardly; It was due to the same less use of drugs.
The homeless children affirm that preventing diseases is to manage affection and feelings because the stress generated by life on the street facilitates and worsens diseases.
Sometimes I make the mistake of getting too tense, getting too stressed out; these are situations that cause too much anguish, too much helplessness. I am trying to manage my affections, my feelings.
In case of the injuries, infection prevention is achieved by avoiding contact with those who can contaminate them and who do not belong to the world of the homeless, and if they are going to cure the injury, they demand that the person who is going to cure them to wash their hands well; under no circumstance do they accept to have their injuries washed or disinfected, given that they think that such can get infected. In practice, the researchers have proven this when treating the injuries, and it has been found that when these are not washed, not only do they not get infected; rather, these heal faster.

Discussion
The classification criteria of the homeless children concerning diseases, injuries, and treatment do not coincide with the criteria of classical epidemiology.
For authors, like Orozco (2020), the precarious conditions in which homeless children live cause them diseases, like venereal disease, tuberculosis, AIDS, and hepatitis. Our study coincides with this author; however, the children do not report suffering diseases like tuberculosis and hepatitis in this study. Orozco (2020) suggests, like that found in this work, that the causes of the injuries are related to interactions with each other, other street dwellers, and public forces. The same is stated by Monsalve, Arcila, Suescún and Cardona (2016), but adding accidents as a cause of injuries, principally due to automotive vehicles.
Our work agrees with Forero, Giraldo, Valencia, Hurtado and Montoya (2007), with regards to the fear the children report about AIDS because it generates rejection from others, and with Morais (2005), who states that the study on homeless children found that they manifest fear of AIDS, given that it is a disease without a cure and which kills. However, AIDS is not a common disease in this population, given that measures are taken to avoid it. The Maya Paya Kimsa organization also found that children do not like to get contact diseases; the same was found in this study, where the participants report avoiding people who could infect them.
According to Sontag (2003), diseases like AIDS and cancer are considered mysterious and generate prejudice, phobia, and fear. Therefore, we coincide with the author because the children fear contracting AIDS. After all, it causes rejection from their companions and takes them to death. Goffman (2006) proposes that the term stigma refers to the sickness itself and not to bodily manifestations; it is rather "a deeply discrediting attribute" (p.13). Thus, for example, when acquiring AIDS, homeless children are stigmatized by the connotations of the disease: not having a cure, being lethal, and is easily transmitted. The same occurs when they attend health institutions in which bad treatment and prejudice do not refer to the health problem they have at that moment, as to their condition as homeless children, and obstacles emerge against their care. In this regard, Morais (2005) states: "Street dwellers are discriminated against in hospitals, and if they do not have legal documents, it is difficult for them to be admitted." Our work coincides with Abadíe (2009) in that children adapt to the Street conditions and, due to this, have a higher pain threshold and do not acquire characteristic diseases of children, and although the management of their injuries is not conventional, these heal easily and do not get infected. Grime, denominated by the children as "the dirt," represents a protection factor that avoids infections. In the study by Monsalve-Escudero, this grime must remain on the skin but cannot enter the wound because the infection is produced. This study differs in that grime represents a protective barrier, and it does not matter if it is on the skin or in the wound.
The research findings regarding the classification and treatment of diseases and injuries are related to that postulated by Menéndez (1994), who considers that one of the ways of resolving physical and emotional ailments is through the self-care performed according to the culture and alternatives available.
According to Oliveira (2011), self-care is related to individuals' capacity to define their own conduct and take place with the interaction and sociocultural determinants. The same occurs with that found in this study because children, considering themselves free, act autonomously and make decisions about their diseases from what they have learned in the interactions they establish in the streets.
The concept of the hospital as the place to die coincides with that proposed by Ariés (1984), for whom it is reserved for the severely ill and it is the place for normal death.
The results from this study coincide with Monsalve-Escudero (2016), who states that children avoid going to hospitals because they consider these as places where they are rejected and stigmatized, both by the health staff and by other patients, besides the hygiene measures taken in hospitals to care for injuries are harmful, given that they increase the risk of infection.

Conclusions
Children define health alterations as diseases and injuries.
Children classify health alterations as severe, which leads to death; serious, which restricts freedom; and mild, which permits continuing with their daily lives.
There are health alterations caused by God and by man, the first is not preventable, and those caused by man are preventable.
Severe alterations must be treated in the hospital and generally end in deaths.
Serious alterations restrict freedom, and they must seek others to help them.
Mild alterations do not restrict freedom and are treated with self-care.
A fundamental condition for their wounds not to get infected is to avoid any antiseptic procedure while doing so in the people who will care for them.
Stigmatization, especially in health institutions (hospitals), is quite strong with this population.
Health alterations for homeless children mean experience.
Wounds for homeless children mean vengeance, bravery, or shame.

Recommendations
The recommendations from this work are supported in two visions: those of the homeless children and those of the researchers.
For the homeless children, it is fundamental that not only in the health services but in their daily lives, the people caring for them understand that they are human beings and, hence, should not be discriminated against or rejected. In the case of health institutions, the children propose that the health staff be trained to understand them, and for such, they propose that students from different health areas be taken to the streets to interact with the people who live in them and to learn of their situation.
From the vision of the researchers, it is suggested that people from the health area and researchers in general conduct research on diseases and injuries know the types of diseases and injuries and the different ways of management used by the children so that, in turn, those seeing them in the consultations understand, not only how they conceive them, but the ways they manage them.
Design proposals aimed at supporting homeless children in preventing the diseases discussed in this article and caring for the injuries produced by living on the streets.
Additionally, enhance psychosocial, comprehensive care oriented at health promotion.