Beyond Self-Rated Health

Abstract

The aim of this phenomenological study was to describe the phenomenon of health as experienced by adolescent girls in Sweden. Fifteen adolescent girls were interviewed with a focus on what made them feel well in their everyday life. This study reveals that the adolescent girl’s health is a complex phenomenon interwoven with their lives. Health arises in meaningful contexts, in an adolescent girl’s relations to others as well as in her ability to manage her life. Health is shaped in their everyday life and can be understood as a mood of “being” well that involves actions and practices. The results show that it is important to meet these girls from an open approach in order to support and strengthen their health and well-being. The health of adolescent girls can be supported, and it is a challenge for professionals, particularly school nurses, who meet these girls in everyday life to improve their health.

Keywords

qualitative research parent/family high school community health/wellness elementary

Introduction

Since the late 20th century, a trend can be seen in Sweden that the percentage of teenaged girls that self-report very good health decreases with age (Danielson, 2006; National Board of Health and Welfare, 2009). Girls in the adolescence have a higher risk of poor health, than males (Cavallo et al., 2006; Currie et al., 2008). Epidemiological research has increased awareness in society about the fact that health and illness among young people are related to different factors, that is the socioeconomic situation of their family (Richter et al., 2009), the enjoyment of school and risk factors such as smoking (Schnohr, Kreiner, Rasmussen, Due, & Diderichsen, 2009), being a member of and actively participating in organizations (Zambon et al., 2010), empowerment (Jerdén, Burell, Stenlund, Weinehall, & Bergström, 2011), satisfaction with body image (Al Sabbah et al., 2009), and the degree of well-being and self-esteem of the young person (Breidablik, Meland, & Lydersen, 2008). Large-scale population-based studies have addressed problems of adolescent girls’ health. Epidemiological research on health has mainly focused on aspects of ill-health, symptoms, or risk factors. However, these studies have mainly focused on health-related problems and they are limited in their capacity to further explore adolescent girls’ health or reveal a holistic picture of what health means to girls in adolescence. There is a lack of what the decrease in self-rated good health means to adolescent girls. As far as we know, the lived dimensions of health have been neglected in health research with adolescent girls.

In this study, the phenomenon of health will be further explored, and health is highlighted with an emphasis on adolescent girls’ lived experiences. Dahlberg (2011) highlights that health is essential for the understanding of caring hence the goal of caring is health. Healey-Ogden and Austin (2011) claim that the three words health, well-being, and wellness are used interchangeably, and in nursing literature these words are commonly used. For example, World Health Organization’s definition of health says, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946). Dahlberg and Segesten (2010) purport that health is related to human existence and experiences of well-being, and they define health as “well-being” together with experiences of “being able to.” Similarly, Healey-Ogden and Austin (2011) found well-being to be inherent in life and therefore lived. Well-being was described as an ongoing journey in which well-being was experienced and lived in the movement of life (Healey-Ogden & Austin, 2011). Lipworth, Hooker, and Carter (2011) argue that health and well-being involves a state of balance in life, and to have a good life was related to balance processes. Balance was described as a powerful concept related to the view, experiences, and responses people have to their health-related circumstances. The concepts of health and well-being can be defined and described in different ways and the concepts seem to have connections with each other as well. However, the meaning of health can be hidden and the philosopher Gadamer states that people generally take their health for granted and usually do not reflect upon health in everyday life. Gadamer writes that health “does not actually present itself to us” (Gadamer, 1996, p. 107). It is not health but illness that “objectifies” itself in our embodied everyday life. Experiences of health involve our bodily being, and as Merleau-Ponty emphasizes, the body is more than just something physical. He means that one “is” one’s body. The lived body is constantly present and it is through the lived body that we gain access to the world (Merleau-Ponty, 2002). Consequently, the health of adolescent girls can never be understood as solely a physical attribute; it is an experience involving the bodily being and the everyday world of these girls. Even if some studies have focused on health, for example in epidemiological studies, little is still known about how adolescent girls experience health. The impact of health on their everyday life is relatively unexplored. Therefore, the aim of this study is to describe the phenomenon of health as experienced by adolescent girls in Sweden.

Method

The research was conducted from a reflective lifeworld approach (RLR) as described by Dahlberg, Dahlberg, and Nyström (2008) based on Husserl’s phenomenological philosophy of the lifeworld. The lifeworld was further explicated by Merleau-Ponty (2002) as a world of perception and human existence. The approach takes its starting point in human lifeworld and forms a foundation for how caring science phenomena, for example health, can be highlighted and described in depth. Central to the RLR approach is the phenomenological attitude and the approach calls attention to principles of openness and bridling. The RLR entails a critical and a reflective attitude where the researchers must critically reflect upon the entire research process. To do so, we needed to be open and responsive to the studied phenomenon, wanting to illuminate the meaning of the phenomenon as experienced by the informants. By questioning our understanding and pre-understanding, we strived to bridle and our natural attitude, thus allowing the meaning of the phenomenon to emerge and to be described. The first author has previously worked as a district nurse. The coauthors took an active part in the whole research process and are well versed in phenomenological research (Johansson & Ekebergh, 2006).

Ethical Considerations

The study was conducted in accordance with the Helsinki Declaration. In cases where the girls were under 15 years, information about the study and consent forms were sent to their guardians. Written informed consent was obtained from all informants and from the guardians of the informants who were under 15 years, in accordance with Swedish law. The study was approved by the ethics committee in Gothenburg, Sweden.

Participants

In this study, a total of 15 adolescent girls, aged 13–19 years, who were able and willing to give their consent, were interviewed. Informants were sought through an ad in three local newspapers on two occasions, resulting in one informant. The ad was then handed over to friends and colleagues who contacted adolescent girls they knew, which resulted in 15 informants. If the girls were interested, they either sent an e-mail or left their phone number to the first author through the person that gave them the ad. Each of the girls was then contacted by phone and they all showed interest in participating in the study after receiving both oral and written information about it. The number of informants was not determined beforehand. The data collection was conducted until the material was estimated to be sufficient in richness of meanings. According to the RLR approach, validity rather than the number of informants is of greater importance (Dahlberg, Dahlberg, & Nyström, 2008).

The informants all lived in western Sweden, in mid-sized and small urban communities or rural areas. Their family situations varied; some lived with both parents, some lived only with their mother, and some alternated between their mother and father. Some of the girls’ parents had a new partner. One girl lived by herself. Many of the girls also had siblings. Half of the girls were in public school, seventh to ninth grade, and the other half were in secondary school enrolled in either a theoretical or a vocational educational program. One girl had, earlier in life, lived in other countries both within and outside of Europe, and another girl had a parent with a different cultural background. All girls had Swedish as their native language. One or more girls from each of the age 13 to 19 years participated.

Dates and places for the interviews were decided by the informants. The interviews were conducted in private rooms in the informant’s home, at a youth center, in a club house, or at the university where the researcher worked. All interviews were conducted by the first author (M.L.) from March to August 2010. The interviews lasted between 30 and 80 min, with an average of 50 min, and were recorded and transcribed verbatim.

Data Collection

Phenomenological interviews were conducted in order to enable personal disclosure and expressions of the informants’ lived experiences (Dahlberg et al., 2008; Kvale, 2009). The interviews began with the question: Can you tell me about your everyday life? This was a way to initiate a dialog and to enable the researcher and informant to become acquainted. After that the interview focused on health, and the informant was asked to express lived experiences of what made them feel good in everyday life. They were encouraged to describe experiences that in some way affected their health and well-being. With the aim of being open, questions were formulated in the interviews with sensitivity to the informant and the situation. The informants were asked to expand their story, to clarify their descriptions and to give examples from everyday life. The questions were intended to encourage the informant to reflect upon their health experiences in everyday life. The informants were encouraged before the interview to think about situations where they had felt good. In some interviews, the informants had difficulties talking about their health so photo cards were used to evoke a response. When necessary, the informants were asked to browse through the photo cards, black and white cards that showed people of different ages in different situations. When the informant spotted something that evoked a feeling of being well, they were told to stop and talk about their thoughts.

Data Analysis

The phenomenological analysis is aimed to allow the emergence of varied meanings as well as the essence of the phenomenon being studied (Dahlberg et al., 2008). The aim of the analysis was to describe the essence and the constituents of the studied phenomenon. It is a challenge for lifeworld researchers to capture the “ambiguity of the lifeworld and its meaning” (Dahlberg et al., 2008, p. 238).

The process of analyzing was characterized by an intense dialogue with the text. At first the interviews were read and reread. After that the focus in the analysis was on qualitative meanings. With sensitivity to parts and the text as a whole, we searched for patterns and nuances of qualitative meanings in the transcriptions. We tried to go beyond given conditions and avoid causal explanations in order to allow the phenomenon’s meanings to emerge and become visible. The authors discussed the analysis and the descriptions of meanings regularly with each other. The discussions evolved around the text as a whole as well as its parts. In the discussions, we strived to bridle our understanding and to question our pre-understanding. We wanted to minimize any negative influence of our pre-understanding on the emerging meaning and the description of the phenomenon, as far as possible. Emerging patterns of meanings were discussed as well as how the phenomenon could be understood and described. In the analysis meanings related to each other were organized in patterns which formed the constituents. As the analysis progressed, the essence of the phenomenon emerged that was possible to describe. The essence can be understood as the invariant meaning of the phenomenon on a more general and abstract level than the constituents. The constituents describe variations and nuances of meanings of the phenomenon, and these are exemplified with quotes from the interviews. The essence of the phenomenon is presented first and binds the constituents together.

Results

Adolescent girls’ health is a complex phenomenon interwoven with their everyday lives. The essential meaning of health involves an ambiguous embodiment and, when in good health, adolescent girls are able to “dwell” in the world with others. Health arises in meaningful contexts, in an adolescent girl’s relationships with others as well as in her ability to manage her life. Health is shaped in her everyday life and can be understood as a mood of “being” well. This mood contains feelings of well-being in combination with actions and practices and is experienced when these are in balance. At the same time as life is in balance it is also in a flow, the girl has a sense of moving on with life, and this gives meaning to and a zest for life. Adolescent girls meet resistance when their health is challenged, and they seldom take the easy way out in life. Their everyday life is ambiguous; a girl’s ability to handle her health and well-being varies from jumping into the fray, fumbling along, or fighting for life.

The essential meanings can be clarified with the following constituents: The importance of togetherness, to manage and incorporate demands and expectations—a tension between inadequacy and a zest for life, an emotional roller-coaster, and to strive for balance.

The Importance of Togetherness

For the adolescent girls, meaningful contexts, such as togetherness with others, are important. Togetherness with others means having a place in life and being someone in the eyes of others. It is important for the informants that other people understand them and the girls need others to share their life with. Togetherness is experienced with those present in their everyday lives. These relations are influenced by both their own personality and the personality of others. When the girls feel togetherness this is something meaningful for them that form a basis for security and stability in everyday life.

It is not enough to simply be a member of a group such as family, friends, school, or organizations to feel togetherness. The atmosphere in the group influenced the sense of unity and togetherness, “So everyone really cares and everyone is affected by that, everyone becomes like one.” Their feelings of togetherness are related to how other people act in the group as well as the girls’ own insight into their ability to engage and interact with others. When different groups that the girls are involved in do not create a sense of togetherness, uncertainty is experienced. Such relations made them vulnerable and exposed to other members in the group, causing them to distrust others. This uncertainty and distrust made them feel alone and they do not allow others to help them when needed.

The family could be a basis for feelings of togetherness. A contrast is described in the girls’ relations with their parents. On one hand, the adolescent girl seeks her parents’ care and support. On the other hand, the girl wants to take responsibility for her own life.

You can’t imagine being without them [the parents]. It’s like, it’s often the case that you want to, go, get out of here, I want to be left alone, but then when they’re not there then you immediately know that something is missing.

When the parents show that they care, the girl feels like an important member of the family. When togetherness with the parents is experienced, this provides the girl with a sense of security and well-being. Togetherness is experienced when the parents listen and are able to be in the moment for and with the adolescent girl. For example, when doing something the parents, or parent, and the girl both are interested in, this act would tie them together and create a manifold value for the girl. When the interplay with her parents does not work out or does not support the girl, the sense of togetherness fails to arise. “It’s hard that she [mother] doesn’t understand that she is so insensitive to me.”

The mother is prominent in the girl’s everyday experiences, even if relationships with both parents are important and manifold. The mother seemed to be in the foreground and the father in the background. Even though their father is important, it is necessary that he invite his daughter to do activities together. “He told me that he booked the tickets and that only he and I were going.” If the mother is experienced as someone really close to the adolescent girl, she is supportive and trustful. If the relationship with the mother is fraught with conflict instead, she is experienced as someone who does not listen or does not respect her daughter as a valuable person. The way the mother acted could create exclusion where the adolescent girl experienced herself as being left outside. “It feels as if she [mother] doesn’t like me anymore, as if she has replaced me.”

Togetherness is also experienced in relation to siblings. Siblings symbolized a community that the adolescent girl could always return to, a togetherness that the girl often experienced as challenging when they learned from each other. “My brother brings me with him, we usually jump on the trampoline where he tries to teach me how to do a backflip.”

Feelings of belonging and togetherness are described both with family and friends. With friends these feelings are based on a long-lasting friendship with common memories. Similar experiences also eased the understanding of each other and are commonly used in conversations that create the togetherness. “She also got an F [failed] in English, so we understand each other and how, how hard it really is.”

In meaningful relationships the girls also expose themselves, and the togetherness entails both security and insecurity, at the same time. Initially, new relationships are fragile since there are few ties that bind the girls together. By spending more and more time together, trust in these relationships might be strengthened and the sense of togetherness would grow. Togetherness is about being there for each other and caring for each other, building a common understanding that gives a feeling of being important in a mutual relationship. When such a mutual and common relationship was missing, the feeling of belonging and togetherness was lost. “I think it’s really hard when you disagree with your closest friend . . . . Then it feels like you don’t have that person anymore, and that person becomes just like anyone else.”

Being on bad terms with someone close is experienced as a lost. The togetherness with that person could be disrupted for a long period of time. When losing a true friend, the girls feel deeply wounded, a feeling they easily get stuck in and cannot keep away from.

To Manage and Incorporate Demands and Expectations—A Tension Between Inadequacy and a Zest for Life

To have goals and to be able to strive toward those goals in life are important for the adolescent girl. In relation to their own goals the girls also need to manage the demands and expectations of others. They want to achieve fulfillment of their goals as well as meet the demands of others, and they strive to have control of and the ability to organize daily life. Too much scheduling risks reducing the time the girls have for spontaneous activities and may take the edge off things that can be fun and pleasurable. There is a lack of a zest for life when their daily life becomes too scheduled.

I usually make a list in my calendar where I tick off what I am supposed to do, it’s a good way of keeping track, though the more you look at it the more stressed you get . . . . And in the back of my mind I constantly feel that I need to study.

The adolescent girls are torn between fulfilling expectations and demands as they perceive their parents, leaders in leisure associations, teachers, media, and peers have on them. All together these demands and the girls’ goals need to be handled, and the girls are often scared of losing control over their own situation. What the girls really need to be are in conflict with many of the demands and expectations that others have on them. High levels of demands create a pressure, which initially may be helpful, although at a later stage, demands that are too high lead to a decrease in the ability to reach those goals and this decrease makes the girls feel inadequate. Time and space for spontaneous actions are needed. When there is no time left for fun and enjoyable activities, the pressure on the girls increases. A schedule that is too comprehensive creates “musts” and the girls lose control when the schedule must be followed slavishly.

I'm trying to organize the best I can. But, especially when everything is just hard you prefer to put it aside, and go do something with your friends, because being with friends is fun, it easily gets that way.

The shape of everyday life, for the informants, is determined by time in school. The girls cannot drop out of school. Compulsory school is a part of ordinary life whereas secondary school seems to be more of an opportunity, an opportunity to choose a direction in life that the adolescent girls want to take part of, but which is conditioned by getting passing grades in compulsory school. The meaning of school varies, and for some girls school is a possible arena to dwell in and sometimes a step towards reaching a desired future.

For me it's like building blocks. That you may need different kinds of building blocks to be able, able to build the future that you want. You just pick and choose, but then it's important, of course, that you really use time well to make good, stable building blocks.

For this girl, the demands of school are managed in a meaningful way. For other adolescent girls, school involves too many expectations which they cannot handle. When not able to manage or incorporate these demands, a feeling of being left out can occur. Life in school can then become a struggle. It may become hard to find the strength needed in this struggle. To be able to manage this struggle, the time spent in school is important. For example, teachers in school can be meaningful for the girls’ well-being.

He [the teacher] helped me to find solutions to problems I never thought would be possible, making sense of it, his help made me become more self-confident. When getting this support you are pushed to continue working and to give your all.

When the girls do not have enough strength and capacity to reach the expected threshold set for a passing performance, feelings of incapacity and failure arise. “They do not understand how hard you try and still don’t make it, can’t manage it.” Failure to meet and incorporate demands and expectations from others creates an imbalance and increases a girl’s feeling of inadequacy. These girls are in need of an open and permissible atmosphere. If others allow the girls to find their own ways and let them get to know who they are, then it becomes easier for them to handle and incorporate requirements and expectations from others. They also need support from others to be assured that they are good enough. “They might have said that, it doesn’t matter, you’ll do better next time.” When others show they care and believe in the capability of the girls, this enhances their capacity to manage everyday life. This provokes their desire to fight in order to achieve what was previously perceived as out of reach.

An Emotional Roller-Coaster

There are many ups and downs in an adolescent girl’s life, and these are experienced as an emotional roller-coaster. In these ups and downs, a girl needs peace to be able to dwell and feel content with life. The emotions of the informants rapidly change and the girls are sensitive to what they meet in everyday life. The girls search for a sense of being well. In this search, they are sensitive to what they encounter and the wide range of signals from others that call for their attention. They struggle with many dubious emotions. The girls need to handle and respond to all of this, even if they may experience tension between what they know and what they feel. The way others meet them may be in contrast to their own expectations. They sometimes feel like a game piece, without meaning to others. “Perhaps you are with a friend and then someone cooler comes along and says ‘come with me instead’ then you stand there alone and nobody cares.”

When others do not see them or take them into account, then the feeling of being valuable declines. When the girls experience that others diminish their value and their performance, it depends on to what degree they can focus their energy on processing the thoughts and transform them into something more manageable that does not affect the feeling of having a value. “After you’ve run then you might have something completely different on your mind, then it doesn’t matter what he said about my hair, I still think it is good.” They constantly strive to feel valuable both for themselves and for others.

The adolescent girl’s mood is affected by thoughts and feelings, feelings that sometimes are beyond the control of her mind and lack logic. Things that in one moment can be of great importance can in the next moment be without appreciable effect to the girl. In the lived emotional roller-coaster, their emotions sometime abruptly swing around. “Sometimes you can be in great mood, and then two minutes later your mood is really bad.” What triggered the emotional swing may be more or less known, but it seems that the lived emotional roller-coaster decreases at the end of the adolescent period for the girls. To feel well, the adolescent girls need to act out their emotions. Together with friends it is possible to share positive emotions while other emotions often are expressed within the family. When their family members are unsympathetic to them, conflicts arise. “I am angry about everything . . . . I think sometimes that I take it out a little too much on my mother.”

To get the strength needed to handle the emotional ups and downs, the girls must find places for recovery. At home, their own room is often a place that symbolizes peace, a place to dwell that allows them to be alone. The period of time that they can steer by themselves can be used to reflect upon what they have been through and the impact those experiences had on them. The time alone is a place where they can manage their feelings and earlier experiences with others. “To be alone sometimes, just thinking about anything and doing something for myself, can be wonderful sometimes, when I do that I feel relaxed.” The time they spend on their own can be perceived as rest or as loneliness. When alone they try to manage the past and dream about the future.

There are many dubious emotions, and the girls are sensitive in their mood. When getting stuck on something that affects their mood negatively they search for strength in other things, such as books, television programs, music, or animals and nature. These things might help the girls to dwell, feel peace, and to find a rhythm when everyday life feels precarious. In the outdoors, the adolescent girl can be as she is, “It is so natural, and you don’t get disturbed.” This provides respite from efforts to fit into everyday life with others. In the outdoors and in interaction with animals, the girl is given the opportunity to focus on the present. When the animals are doing well, a feeling of well-being is created in the girl. “They [horses] should have as good a situation as possible, then I feel good.” Animals do not value or judge, instead they invite to a form of togetherness which often requires activity where the girls feel needed.

Music of the genre that the girl appreciates is used to confirm feelings. Melodies and texts can speak to her. Music conveys messages and is associated with memories, causing feelings to both be calmed and be enhanced. Feelings that cause malaise can, with the help of music, be transformed into something more positive. “A song that I like incredibly much, can make my day, I can become so amazingly happy.”

To Strive for Balance

The adolescent girl is in a period of life where she tests and experiments and does not want to get stuck. To be able to dwell in life, she must dare try what she wants and what she can manage. To be able to grasp and pounce upon everyday life, the adolescent girl needs courage and anchoring. Being comfortable with herself is a key to feeling courageous. In the daily life of the adolescent girl, health appears in a life-giving mood, a mood that involves both the sensual and the visible. The things an adolescent girl encounters in everyday life create a flow of sudden movements and changes, and the way these are perceived influences the life mood and well-being of the girl.

Perhaps discussing something that is interesting or saying something in a very good way, so that you become interested, and want to listen and understand, and like, I want to learn about this, it is more fun.

To be able to dwell in life courage is required. Courage is about daring to show who “I” am. By putting words to one’s own thoughts, expectations, and goals, an insight might be provided. This insight is reached in a dialogue with themselves as well as in conversations with others. These are conversations where the informants are listened to, where they can raise awareness and perceive something about themselves. The girl’s image of herself also relates to the value that is put into words by others. The value experienced from others can create ambivalence. “It felt like the world was trying to make me appear as, as stupid, and that of course makes you feel stupid even though I know I’m not.”

Adolescence is experienced as a period of commotion in life. Challenges that test their own abilities are tempting and raise their vitality and will to develop further. Clothing and cosmetics are often used when the adolescent girl tests and experiments with how to live and balance everyday life. Clothing and cosmetics can convey both an identity with and a distinction from others. Belonging with others can be confirmed through appearance and clothes, whereas deviations allow for a unique image. “I like to, not be prettier than anyone else, but still stick out a bit so people feel that I have my own style.” The girl is conscious of her own look that she compares with and assesses against ideals. Depending on the context, the girl chooses how she wants to appear in front of others. In more secure situations she might appear more as she is and wants to be, but in unknown situations where she is valued and may be compared with others she has the desire to portray herself as good as possible. She endeavors to appear as beneficial as possible.

Through her body, the girl experiences living with her uncontrollable natural growth. “It happens whether I like it or not, you have to try to adapt to it.” The developments that occur are balanced with taking care of her body, both the visible and the invisible. The visible includes the image of herself that she shows others. Her appearance is formed by, for example, taking care of her nails and hair. The invisible includes moods and the lifestyle that the girl has chosen to live. The lifestyle of the adolescent girl is influenced by numerous factors, including what the surrounding world conveys to her which in turn arouses her own ideas about who she is and how she wants to be. Taking care of herself provides the girl with a physical foundation in daily life and pleasure, pleasure about feeling good about herself and her appearance.

To be well also involves being visible and mobile. Physical activity and movement creates opportunities to dwell in life. “When I exercise I feel very good, it, it’s a special feeling.” Physical exercise is a way for the adolescent girl to test her body’s boundaries and can also allow for development. When the implementation of a physical activity is in line with expectations, both her own and the expectations of others, her confidence in her own person becomes greater. She is strengthened by the cheerful shouts from others and also by herself when she feels that her body is with her. “Then I feel YES, it is actually possible, I can for a fact do this.” She dares to move, to take living space in possession when her courage is strengthened.

Discussion

Findings reveal that health was a complex phenomenon embedded in life and interwoven with the girls’ everyday activities. In their natural approach to life, health was experienced as something elusive and invisible to the adolescent girl. Gadamer (1996) writes that “health is silent,” meaning that when people feel good, life is lived and people are directed out toward the world. To feel good, can be viewed as a search for fulfillment of life, and health reflects the person’s whole life situation. This corresponds with Sarvimäki (2006) who argues, with an emphasis on Heidegger’s philosophy, that people describe their health as a whole.

Our study reveals that what happens in girls’ lives influences and changes their health. The way she manages life and finds meaning in it are interwoven with and tied to each adolescent girl’s individual life context and are integrated into her unique lived body. To be included in togetherness with others can add meaning and strength to the lifeworld of the girl, but other people can also be less supportive of and not meaningful for the adolescent girl’s ability to dwell in life. Todres and Galvin (2010) describe dwelling in their existential theory of well-being in a way that has similarities with our findings. This is also in agreement with Merleau-Ponty’s (2002) description of human existence as intersubjective, an existence where one is a bodily being in relation to others and the world. van Daalen-Smith (2008) claims that girls will avoid relationship disruptions to avert relational losses. Our finding reveals that a girl’s relations with others are important to her experiences of health and well-being. To be someone for someone else is necessary and this can be understood as a prerequisite for the adolescent girl to feel anchored in the world, especially for a girl who is fumbling or fighting for her life during adolescence. When the girl felt anchored it was easier for her to explore her abilities and test her own bodily boundaries in life.

This study included girls of different ages from the entire adolescent period. The findings give an overview of the complexity of those girls’ health during this period of life. Their health is complex in many ways; health was tied to and interwoven with their everyday life and health was also experienced as a state of constant change, with many ups and downs as well as with sharp contrasts. It seems as if these contrasts were less sharp and more nuanced in the latter part of the adolescent period. To our knowledge there are few qualitative studies like ours, with an openness to lived experiences of health during adolescence. Our findings are coherent and have similarities with both Dahlberg and Segesten’s (2010) definition of health and Healey-Ogden and Austins’s (2011) description of well-being. We argue that an existential view of well-being is important in relation to health issues, as well as in relation to illness. And in caring and nursing science this is highlighted in the framework of lifeworld-led health care (Dahlberg, Todres, & Galvin, 2009).

The informants felt that they were in an ongoing search for who they were and who they wanted to be. This search made them feel insecure. Healey-Ogden and Austin (2011) argue that well-being requires a personal drive to exist, and their finding points to the importance of becoming oriented to a new identity when being afflicted with, for example cancer. Even if the adolecent girls were healthy, their identity was important for their well-being and health. In the girls’ lives, there were many hindrances for their personal drive and lust for life. A girl’s mood is intertwined with her thoughts and emotions as well as her ability to act, which gives her sense of health. Experiences of health and well-being were strengthened in meaningful relationships with others at the same time as the girl experienced a mood of being well.

The results show that the informants experienced health when they were able to balance different aspects of life. To balance or be in balance is both a process and a state (Lipworth, Hooker, & Carter, 2011). In a girl’s everyday life, health was an ongoing process, where balance was intertwined with feelings of well-being, and imbalance disrupted this state and called for action and change. In addition, we could see that health must be viewed in relation to an adolescent girl’s lifeworld, a lifeworld that can be seen as both definite and indefinite (Dahlberg et al., 2008). The adolescent girl lives in a world that, in some aspects, is definite, for example her biological body, her place of birth, and her family. At the same time, there were many aspects related to the health of the adolescent girl that she could influence, for example relationships with others. Despite this, the girls many times felt that everyday life was beyond their control.

The participants in this study sometimes had difficulties finding words to express their experiences of health and what made them feel well, whereas they talked spontaneously when they did not feel well. There are similarities between the concept of health and the concept of comfort, and Morse, Bottorff, and Hutchinson (1995) describe comfort as hard to grasp while its opposite can be expressed. To use photo cards in the interviews was a way to reach the informants’ forgotten experiences. When they saw the photo cards they remembered and could disclose detailed stories. The phenomenological approach allows for the description of the richness and varied meaning of lifeworld phenomena. The meanings in this study are abstractions that can be generalized (Dahlberg et al., 2008) although with caution, because the findings are contextual.

Implications for School Nurses

This study reveals that it is important to meet these girls from an open approach in order to support and strengthen their health and well-being. The adolescent girl’s health is related to their existence, also involving parents, teachers, and school nurses. Whether the girl’s parents, teachers, or school nurses will or not, their actions and demands influence the girl’s well-being. The girls need help and support to become aware of themselves and their potential in life, in order to experience a sense of being well and to be able to dwell in the world with others that is to be healthy. Experiences of health involve striving for a state of equilibrium in which a girl can find meaning with others as well as manage her everyday life.

The data suggest that it is vital that others are there for adolescent girls and that others listen to them and are present for them. A meaningful relationship with an adolescent girl is created when she is treated with respect and feels valuable. We agree with Summach (2011) that school nurses require skills of engendering trust in developing relationships with adolescents. Caregivers must shift their focus from routines that solely highlight ill-health to seeing the girl and her needs and how to enhance her self-determination (Speraw, 2009). Berglund (2011) argues that caregivers have to leave their role as informers and be supportive in a tactful didactic approach. From such an approach, the caregiver can create an open relationship with adolescent girls with the aim of being supportive, a relationship where the girls are allowed to put words to their view of their own lives and health. The health and well-being of adolescent girls can be supported, and it is a challenge for professionals, particularly school nurses, who meet these girls to improve their health.

Conclusions

The adolescent girl needs support from those close to them and from professionals they meet in their everyday life, for example in school. They have an influence on the adolescent girls’ health, whether they are aware of it or not. Promoting health is about supporting how to manage and balance the ambiguous health and life circumstances of importance to their well-being. This study reveals knowledge necessary for school nurses when meeting these girls. The adolescent girl must be able to balance and to manage her life to feel well. Consequently, well-being and health need to be viewed in relation to an individual’s life. The complexity of health and knowledge about what it means to adolescent girls described in this study needs to be translated into practice. Further interventions are needed based on the lifeworld of these girls, involving significant others as, for example, school nurses, teachers, or parents.

Footnotes

Acknowledgments

We thank the adolescents who willingly shared their lived experiences with us and made this research possible.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Ebba Danelius stiftelse and Skaraborg-institute for research and development, Skövde, Sweden.

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