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St udy ext r act ed fr om Doct or al Disser t at ion. Financial Suppor t pr ovided by CAPES/ CNPQ. CAPES Aw ar d of Disser t at ion 2005 - Honorable Ment ion; 2 Dent ist , PhD in Nur sing, e- m ail: alfm @t er r a.com .br ; 3 Nur se, PhD in Nur sing Philosophy, Full Pr ofessor. Sant a Cat ar ina Feder al Univ er sidade, Br azil, e- m ail:
alacoque@new sit e.com .br
D isponible e n ca st e lla no/ D isponíve l e m língua por t ugue sa SciELO Br a sil w w w .scie lo.br / r la e
I NVESTI GATI NG ORAL HEALTHCARE I N THE ELDERLY USI NG GROUNDED THEORY
1Ana Lúcia Fer r eir a de Mello2
Alacoqu e Lor en zin i Er dm an n3
Mello ALF, Er d m an n AL. I nv est ig at in g or al h ealt h car e in t h e eld er ly u sin g g r ou n d ed t h eor y. Rev Lat in o- am
En fer m agem 2 0 0 7 set em br o- ou t u br o; 1 5 ( 5 ) : 9 2 2 - 8 .
The pr esent ar t icle aim ed t o descr ibe t he foundat ions and adequacy of t he Gr ounded Theor y ( GT) t o
t he const r uct ion of t he subst ant iv e t heor y on t he phenom enon of or al healt h car e of inst it ut ionalized elder ly people. GT is a m et hodology t hat allow s for m ulat ing or der ly abst r act ions fr om t he r eal life dat a. Thr ough t his
r efer ent ial is possible t o elabor at e a r elev ant and funct ional t heor y in or der t o under st and t he m eaning of t he elder ly or al healt h car e pr act ices. GT allow ed an ex t ensiv e and r ich pr oduct ion of infor m at ion codes subm it t ed
t o a p r ocess of Com p ar at iv e An aly sis. Th e im m er sion in t h e act or s’ su b j ect iv e an d p r iv at e v iew , t h r ou g h int er view s per for m ed w it h t he par t icipant s, allow ed by t he open and flexible char act er of t he m et hod, per m it t ed
t h e f or m u lat ion of com pr eh en siv e an aly sis cat egor ies. Th e t ex t dem on st r at es t h e v alidit y of t h is alt er n at iv e
m et hodology t o t he scient ific inv est igat ion of t his com plex phenom enon.
DESCRI PTORS: aged; em pat hy ; or al healt h
I NVESTI GANDO EL CUI DADO A LA SALUD BUCAL DE ANCI ANOS UTI LI ZANDO LA TEORÍ A
BASADA EN LOS DATOS
El pr esent e ar t ículo obj et iva descr ibir las fundaciones y adecuabilidad de la Teor ía Basada en los Dat os
( TFD) en la const r ucción de una t eor ía subst ant iv a acer ca del fenóm eno del cuidado a la salud bucodent al de los ancianos inst it ucionalizados. La TFD es una m et odología que per m it e for m ular abst r acciones or denadas a
p ar t ir d e los d at os d e la v id a r eal. Ut ilizan d o ese r ef er en cial, es p osib le elab or ar u n a t eor ía r elev an t e y funcional par a la com pr ensión del significado de las pr áct icas de cuidado a la salud bucodent al del anciano. La
TFD hizo posible una pr oducción ex t ensa y r ica de códigos infor m acionales som et idos a un pr oceso de Análisis Com par at iv o. Esa inm er sión en la v isión subj et iv a y par t icular de los act or es, a t r av és de las ent r ev ist as con
los p ar t icip an t es, y p r op iciad a p or el car áct er ab ier t o y f lex ib le d el m ét od o, cr eó las con d icion es p ar a la
for m ulación am plias cat egor ías de análisis. El ar t ículo dem uest r a la validad de la aplicación de est a m et odología alt er nat iv a par a la inv est igación cient ífica de est e fenóm eno com plej o.
DESCRI PTORES: anciano; em pat ía; salud bucal
I NVESTI GANDO O CUI DADO À SAÚDE BUCAL DE I DOSOS UTI LI ZANDO A TEORI A
FUNDAMENTADA NOS DADOS
O pr esent e ar t igo t em por obj et ivo descr ever os fundam ent os e adequabilidade da Teor ia Fundam ent ada n os Dados ( TFD) n a con st r u ção de t eor ia su bst an t iv a sobr e o f en ôm en o do cu idado com a saú de bu cal de
idosos inst it ucionalizados. A TFD é m et odologia que per m it e for m ular abst r ações or denadas a par t ir dos dados r ecolhidos da v ida r eal. Segundo esse r efer encial, é possív el elabor ar um a t eor ia r elev ant e e funcional par a a
com pr eensão do significado das pr át icas de cuidado com a saúde bucal do idoso. A TFD possibilit ou pr odução ex t ensa e r ica de códigos infor m acionais subm et idos a um pr ocesso de Análise Com par at iv a. Essa im er são na
v isão subj et iv a e par t icular dos at or es env olv idos, por m eio das ent r ev ist as r ealizadas com os par t icipant es e
pr opiciada pelo car át er aber t o e flex ív el do m ét odo, cr iou condições par a for m ulação de cat egor ias de análise abr an gen t es. O t ex t o dem on st r a a v alidade da aplicação dessa m et odologia alt er n at iv a par a a in v est igação
cien t íf ica desse f en ôm en o com plex o.
ORAL HEALTHCARE I N THE ELDERLY AS AN
OBJECT OF STUDY
W
o r l d w i d e d e m o g r a p h i c d a t a s h o w a cont inuous expansion of t he rat io of elderly people int h e g lob al p op u lat ion( 1 ). How ev er, su ch ex p an sion , w hen associat ed t o t he process of living, is not alw ays
accom p an ied b y g ain s in h ealt h( 2 - 3 ). Th at b ecom es ev ident w hen t he or al condit ion of elder ly Br azilians
is analy zed( 4).
Or al healt hcar e, by it self int r insic t o car e in
bot h t he indiv idual and collect iv e spher es, im plies a
dynam ic and cont inuous pr ocess of hum an living and
it s con seq u en t ial, r esp on sib le d ecision - m ak in g an d
act ions t hat are focused on pr om ot ing or al healt hcar e,
aim ing t o prot ect life. Hence, oral healt hcare is a daily
const r uct t hat m oves beyond t he pr esent space- t im e,
assu m in g a t h or ou gh v iew of t h e h u m an bein g an d
h o w i t r e l a t e s t o o t h e r b e i n g s , s o c i e t y a n d t h e
en v ir on m en t .
Appr opr iat e or al healt hcar e has not r eceiv ed
sufficient at t ent ion w hen it com es t o long- t er m car e
facilit ies for t he elderly, w here flagrant om issions have
been obser v ed( 5 ).
Th e i n s t i t u t i o n a l i z a t i o n o f t h e e l d e r l y
est ab lish es a com p lex w eb of social an d econ om ic
r elat ion s( 6 ). At t h e v er y least , t h e f ollow in g play er s t ake par t in t his w eb: t he elder ly and t heir fam ily; t he
public, pr iv at e or t hir d- sect or inst it ut ion w her e t hey
r esid e; t h e p r of ession als w h o w or k t h er e an d w h o
are, or should be, available at all t im es; t he st at e and
a l so t h e g o v e r n m e n t , t h e f o r m e r b e ca u se o f i t s
cor r esp on d in g social f u n ct ion an d t h e lat t er d u e t o
t h e p o l i c i e s a n d a c t i o n s t h a t a r e d e v i s e d a n d
im p lem en t ed .
The incr easing, disor der ed inst it ut ionalizat ion
pr ocess, as a pr oduct of st r uct ur al changes in fam ily
r e l a t i o n sh i p s( 7 ), g e n e r a t e s a co m p l e x sce n a r i o o f int er act ions bet w een subj ect s and or ganizat ions, w it h
m a r k e d e f f e c t s o n o r a l h e a l t h c a r e . M o r e o v e r,
especially in t he area of oral healt hcare for t he elderly,
r esear ch an d st u d i es ar e st i l l i n ci p i en t an d r at h er
cir cu m scr ip t iv e.
Th e pr ocess of epist em ological con st r u ct ion
of oral healt hcare in t he elderly as a t heoret ical body
m u st co n si d e r m u l t i d i sci p l i n a r i t y a n d e n co u r a g e
c o m p r e h e n s i v e , t h o r o u g h d e n t i s t r y p r a x i s . Th e
m u l t i d i sci p l i n a r i t y o f t h e r e se a r ch t o p i c a i m s t o
surpass, t hus, t he barrier of isolat ed act ions in dent ist ry
an d ot h er h ealt h ar eas, an d ev iden ces t h e n eed t o
addr ess t he social and hum an cont ex t of t he elder ly
in it s m any int er faces.
Th u s , t h i s a r t i c l e a i m s t o d e s c r i b e t h e
fundam ent als and adequacy of t he const r uct ion of a
subst ant ial t heor y about or al healt hcar e pr act ices for
in st it u t ion alized elder ly pat ien t s, dev eloped t h r ou gh
Gr ou n ded Th eor y ( GT) .
H a v i n g o r a l h e a l t h c a r e p r a c t i c e s
cir cu m scr ib ed in t o a scen ar io of h u m an in t er act ion
as it s obj ect of st udy, GT br ings t o light subst ant ial
k n ow ledge t h at h ad been v eiled in su ch a scen ar io.
Th e r e f o r e , u n d e r s t a n d i n g t h e m e a n i n g o f o r a l
h ea l t h ca r e i n t h e el d er l y l i v i n g i n l o n g - t er m ca r e
f a c i l i t i e s w a s c o n s i d e r e d p e r t i n e n t , c o n s i d e r i n g
per spect iv es of liv ing and aging in good healt h. This
under st anding per m it s t he elabor at ion of a subst ant ial
t heor y about t he phenom enon t hat com pr ehends t he
pract ices of oral healt hcare in t he elderly, in a cont ext
of long- t er m car e facilit ies, in it s m any dim ensions:
i n d i v i d u a l , p r o f e ssi o n a l , i n st i t u t i o n a l a n d p u b l i c/
g ov er n m en t al.
Th e u n d e r s t a n d i n g o f t h i s p h e n o m e n o n ,
b ased on t h e in t er act ion am on g t h ese d im en sion s,
an d p ar t icu lar ly in t h e sp h er e of t h e r elat ion sh ip s
est ablished ar ound t hese inst it ut ions, m ight w ar r ant
t h e ( r e ) c o n s t r u c t i o n o f h e a l t h c a r e p r a c t i c e s ,
consider ing per spect iv es of liv ing and aging in good
h ealt h .
GROUNDED THEORY - A METHODOLOGI CAL
POSSI BI LI TY
The choice of t he r esear ch m et hod basically
depends on t he nat ur e of t he pr oblem t hat is being
i n v e s t i g a t e d . Th e c h a r a c t e r i s t i c s o f t h e s t u d y
p h e n o m e n o n , b y t h e m s e l v e s , s e t l i m i t s t o t h e
r esear ch er.
Th e o r a l h e a l t h ca r e si t u a t i o n o f t h e
inst it ut ionalized elderly is precarious, and t he am ount
of st udies t hat m easur e and analy ze t he condit ion of
oral healt hcare in t he elderly const ant ly increases. These
are scient ifically relevant art icles, built on quant it at ive
bases. However, it seem s t hat quant it at ive st udies cannot
r ev eal t he m ult iple and differ ent sides, i.e.: a bet t er
a n d m o r e co m p r e h e n si v e u n d e r st a n d i n g o f w h a t
happens, appr oaching t he com plex it y of t he r esult ing
relat ionships; obt aining dat a on how oral healt hcare and
t he people involved develop, enabling t hese people t o
people’s experiences, t he needs t hat com e int o being,
t h e f e e l i n g s t h a t su r f a ce , a n d i n v e st i g a t i n g o r a l
healt hcare using everyt hing t hat is report ed and lived
in t hese long- t erm care facilit ies for t he elderly.
The phenom enon under st udy fit s bet t er int o
a qualit at ive st udy, w it h findings t hat could har dly be
obt ained by st at ist ical pr ocedur es or ot her m eans of
q u a n t i f i c a t i o n( 8 ). H e n c e , q u a l i t a t i v e r e s e a r c h t e ch n i q u e s w e r e a p p l i e d f o r d a t a co l l e ct i o n a n d
an aly sis. Th e q u alit at iv e an aly sis cor r esp on d s t o a
non- m at hem at ical pr ocess of int er pr et at ion, w hich is
p er f or m ed t o d iscov er an d elab or at e con cep t s an d
r elat ions bet w een t he r aw dat a and t o ar r ange t hem
int o a t heor et ical fr am ew or k . This pr ocedur e r equir es
a t h eor et ical an d m et h odological basis f ou n d in t h e
so- called Gr ounded Theor y, or GT.
GT i s a m e t h o d o l o g y t h a t p e r m i t s t h e
form ulat ion of abst ract ions, engineered from t he dat a
co l l ect ed i n r ea l l i f e si t u a t i o n s. Acco r d i n g t o t h i s
m et hodological r efer ence, it w as possible t o com e up
with a substantial, relevant and functional theory in view
of t he concer ns t hat m ov ed t he aut hor s t ow ar ds t he
understanding of the m eaning of oral healthcare practices
in the elderly, focusing on living and aging in good health.
Thus, t he field w or k consist ed of an or der ly
ex cu r sion t h at u sed academ ic r esear ch appr oach es,
capable of cont ribut ing t o t he const ruct ion of scient ific
k n ow ledge, w h ose per spect iv e an d select ed m et h od
hav e not been t hor oughly ex plor ed as of y et .
The research obj ect present ed herein denot es
a st r u ct u r e, p eo p l e, p r a ct i ces, a p r o cess a n d t h e
consequences derived from all of t hem . Alt hough t hey
m a y a l l v a r y, a r e l a t i o n o f c o n s t a n c y a n d t h e
phenom enon, as a whole, shows a capacit y t o develop
cont inually. The GT m et hod is a sufficient ly broad and
well-adj ust ed plat form t o accom m odat e t his reality. The
ack now ledgm ent of t he com plex it y and v ar iabilit y of
t he phenom ena t hat m ak e up or al healt hcar e in t he
elderly, as well as t he belief t hat t he subj ect s play an
act iv e r ole in t he face of t he pr oblem sit uat ions, ar e
sufficient as a base for t he em erging knowledge of t he
r ealit y r epor t ed by t h e su bj ect s t h em selv es an d by
t he m eanings t hey at t ribut e t o t he phenom enon.
TH E RESEARCH PROCESS I N GROUN D ED
THEORY
Th e Gr ou n d ed Th eor y m et h od olog y, or GT,
w as cr eat ed by Am er ican sociologist s, based on t he
or der ly for m at ion of a t heor y fr om dat a found t hr ough
social sur v ey ing( 9- 10). I t is an effor t t o br ing w hat is concr et e t o a degr ee of abst r act ion.
Th e o r i zi n g o n t h e f i e l d o f So ci o l o g y i s a
st r at egy t o deal w it h r esear ch dat a, pr oviding m et hods
o f c o n c e p t u a l i z a t i o n t o d e s c r i b e o r e x p l a i n a
p h e n o m e n o n( 9 ). Th e t h e o r y m u st cl e a r l y e x p l a i n cat egor ies and hypot heses, in a w ay t hat t hey can be
v er if ied in p r esen t an d f u t u r e st u d ies. Mor eov er, it
m u st be u n der st an dable, h av e pr act ical applicat ion s
and be capable of m odificat ion as new dat a ar e found.
GT is inspir ed on t he pr inciple t hat r ealit y is flow ing,
w hile ideas ar e last ing. Findings ar e soon for got t en,
but not ideas( 10).
Com par at iv e An aly sis is t h e m et h odological
st r u ct u r e u sed t o discov er a t h eor y based on dat a.
Theor y is em phasized as a pr ocess, as a cont inually
d ev elop in g en t it y, an d n ot as a p er f ect an d st at ic
pr oduct( 9).
The elem ent s of t he t heor y gener at ed t hr ough
Com par at iv e Analy sis and t he r esear cher ’ t heor et ical
sen sit iv it y ar e p r im ar ily cat eg or ies, an d also t h eir
con cep t u al p r op er t ies, f ollow ed b y h y p ot h eses an d
g en er alized r elat ion s b et w een t h ese cat eg or ies an d
pr oper t ies( 9 ).
GT has offer ed an im por t ant cont r ibut ion t o
m at er ialize r esear ch under less- ex plor ed angles, and
has been m ainly applied t o pr elim inar y, ex planat or y
and descr ipt ive st udies( 1). Due t o t he fact t hat t heor y is based on dat a, it is expect ed t hat aw ar eness of t he
phenom ena incr eases and pr ovides a significant guide
for act ion( 8). I t is also believed t hat a t heor y built on r esear ch dat a w ould be m or e successful t han t heories
l o g i c a l l y d e d u c t e d f r o m p r e v i o u s l y e l a b o r a t e d
in qu ir ies( 9 ).
GT does not need an epist em ological base t o
j ust ify it s usage. I t is a com pr ehensive m et hod, based
o n a n i n d i ca t i v e - co n ce p t m o d e l , w h i ch m a y u se
sev er al t h eor et ical per spect iv es, pr ov ided t h at t h ey
a r e p e r t i n e n t t o t h e t o p i c u n d e r st u d y. GT i s a n
induct iv e m et hod, w hich m ay be used w it h any k ind
of dat abase, and it is gener ic enough t o be used by
any r esear cher in his or her field( 12).
Nev er t h eless, t h e in depen den ce f r om t h ese
e l e m e n t s i n t e r m s o f b u i l d i n g a t h e o r e t i c a l /
m et hodological r efer ence should be appoint ed. GT is
not link ed t o any t heor et ical fr am ew or k or school of
t hought t hat lim it s t he possibilit y of t he em er gence of
REPORT OF A GT RESEARCH ON ORAL
H EALT H CARE I N I N STI TU TI O N ALI Z ED
ELDERLY
Th e r esear ch ex am ple descr ibed h er e, u sin g
GT, w a s p e r f o r m e d w i t h a g r o u p o f f o u r p r i v a t e ,
pr ofit an d n on - pr of it lon g- t er m car e f acilit ies f or t h e
e l d e r l y. Th e d a t a co l l e ct e d a n d t h e co n co m i t a n t ,
su cce ssi v e a n a l y se s g u i d e d b o t h t h e n u m b e r o f
par t icipan t s in each gr ou p an d t h e in clu sion of n ew
g r o u p s o f su b j ect s n ecessar y f o r t h e co n st r u ct i o n
of t h e t h eor y.
Pr ev ious k now ledge of t he pr oblem and t he
phenom enon t o be st udied has helped t o ident ify t he
f ollow in g st ar t in g gr ou ps: Elder ly r esiden t s of lon
g-t er m car e facilig-t ies, car egiv er s em ploy ed in long- g-t er m
car e facilit ies for t he elder ly ( Nur sing pr ofessionals) ,
dir ect or s of lon g- t er m car e f acilit ies f or t h e elder ly.
B e s i d e s , a c c o r d i n g t o t h e G T m e t h o d o l o g y o f
t heor et ical sam pling cr it er ia, ot her gr oups w er e also
in clu d ed in t h e st u d y : d en t al su r g eon s f r om p u b lic
h ealt h ser v ices, d ir ect or s of p u b lic h ealt h ( on t h e
st at e an d cit y lev els) , m em b er s of eld er ly d ef en se
en t it ies.
I t is im p or t an t t o p oin t ou t t h at GT is n ot
ab ou t col l ect i n g as m an y d at a as p ossi b l e f r om a
p a r t i c u l a r g r o u p , b u t c o l l e c t i n g d a t a a b o u t t h e
c a t e g o r y , a i m i n g t o g e n e r a t e p r o p e r t i e s a n d
h y p o t h eses, an d t h u s d et er m i n i n g t h e d ep t h o f a
sam ple( 9). By ident ify ing gaps not cov er ed by t heor y, t h e r esear ch er w ill seek n ew sou r ces or p laces t o
collect dat a or n ew st y les of in t er v iew in g, dir ect in g
t h e qu est ion s on t h e em er gin g t opics of in t er est t o
com plet e t h e st u dy. Th u s, w h en GT is applied, it is
difficult t o pr edict how m any gr oups w ill t ak e par t in
t h e st u dy. Wh ile t h e r esear ch er is im m er sed in t h e
ch allen g e of d esig n in g a t h eor y, sev er al g r ou p s or
si t u a t i o n s m a y b e co m e i n v o l v e d i n t h e r e se a r ch .
How ev er, t h er e com es a t im e w h en cr it er ia n eed t o
be defined t o j udge w hen t he sam ple is sufficient for
t hat t heor et ical point . This j udgm ent cr it er ion is called
t h eor et ical sat u r at ion( 9 ).
At t he end of t he r esear ch pr ocess, t he gr oup
of int erview ees consist ed of ninet een people, fourt een
of w hom w er e w om en: Thr ee elder ly subj ect s liv ing
in long- t er m car e facilit ies; six Nur sing pr ofessionals,
b e i n g t h r e e n u r se s a n d t h r e e n u r si n g a i d s; f o u r
d ir ect or s of lon g - t er m car e f acilit ies; t h r ee d en t al
sur geons fr om t he public healt h ser v ice; t hr ee public
a d m i n i st r a t o r s, o n e o f w h i ch a l so r ep r esen t ed a n
elder ly defen se en t it y.
I n GT, t he dat a collect ion st age ov er laps w it h
t h e an aly sis st age, i. e., bot h h appen con com it an t ly.
Th e d a t a co l l e ct i o n w a s p e r f o r m e d b y m e a n s o f
int erview s w it h init ial quest ions t hat aim ed t o answ er
t he init ial r esear ch quest ion: How do t he r elat ions of
oral healt hcare happen, according t o t he int erview ees?
Which pr act ices do t hey r epor t or show ? What is t he
significance of t hese pr act ices? These quest ions w er e
alt er ed accor ding t o t he gr oups of subj ect s and t heir
int eract ion w it h t he t opic under st udy. The int erview s
const it ut ed an exercise in list ening t o t he part icipant s’
d iscou r se.
Th e p r o cess o f d at a an al y si s st ar t ed w i t h
coding. Coding is t he gener al t er m used t o t r ansfor m
dat a int o concept s. A code t r ansfor m s pat t er ns fr om
a gr oup of em pir ical m ar ker s int o dat a cont ent s. Fr om
t he hy pot het ical r elat ions bet w een concept ual codes
( t h eir cat eg or ies an d p r op er t ies) or ig in at ed in t h e
d at a, an ab st r act ion of t h eor et ical n at u r e is b u ilt ,
back ed by dat a( 13).
The pr ocess begins w it h open coding, w her e
t he researcher m ust st ep in w it h as few prej udices as
possible, and k eep an open m ind t o each and ev er y
signal t he dat a m ight point out . The r esear cher st ar t s
t o analy ze t he dat a in ever y possible w ay, scanning
t he t ext line- by- line and t r ying t o ident ify subst ant ial
codes. Open coding aim s t o gener at e cat egor ies and
t h e i r p r o p e r t i e s f r o m a c a r e f u l a n a l y s i s o f t h e
con st it u en t in ciden t s of t h e dat a. I t is an an aly t ical
p r ocess w h er e con cep t s, t h eir p r op er t ies an d t h eir
dim en sion s ar e iden t if ied. Pr oper t ies ar e gen er al or
specific charact erist ics or at t ribut es of a cat egory and
d im en sion s r ep r esen t t h e p lacem en t of a p r op er t y
w it hin a r anking( 8).
Th e t ex t of t h e in t er v iew s w as t h or ou g h ly
a n a l y ze d , p h r a se - b y - p h r a se , a n d e v e r y so o f t e n
w or d - b y - w or d . Wh en t h e t ex t w as r ead , q u est ion s
w er e ask ed: Do t hese dat a r efer t o t he st udy ? What
d oes t h is in cid en t sh ow ? Wh at is h ap p en in g ? Wh at
did t he par t icipant m ean?
The ar r angem ent of t he codes w as per for m ed
a c c o r d i n g t o t h e i r p r o p e r t i e s , s i m i l a r i t i e s a n d
dif f er en ces, at lev els t h at r epr esen t t h e dim en sion s
t hey belong t o. I nit ially, t he codes w ere grouped int o
c o m p o n e n t s ; c o m p o n e n t s w e r e g r o u p e d i n t o
su bcat egor ies an d su bcat egor ies w er e gr ou ped in t o
To r efine t he em er ging cat egor ies t hat w er e
st r ict ly r elat ed t o t he phenom enon under st udy, t he
pr ocess of open coding had t o be delim it ed. The
so-called select iv e coding for ces t he r esear cher t o code
only t he event s t hat relat e significant ly t o t he cent ral
cat egor y, so t hat t he t heor y can be dev ised( 10). The p r o c e s s o f d e l i m i t i n g o c c u r r e d a t t w o l e v e l s :
t heoret ical and cat egorical. Adj ust m ent s, m odificat ions
o f l o g i ca l o r d e r, e l a b o r a t i o n o f p r o p e r t y d e t a i l s,
elim inat ion of ir r elev ant pr oper t ies and int egr at ion of
pr oper t ies w er e all per f or m ed. At t h e sam e t im e, a
pr ocess of r educt ion w as per for m ed, since t her e w as
a cer t ain d eg r ee of u n if or m it y am on g t h e or ig in al
cat egor ies, w h ich per m it t ed t h e con st r u ct ion of t h e
t h eor y w it h a sm aller n u m b er of con cep t s. At t h e
second lev el of delim it at ion, it w as also decided t hat
a r e d u c t i o n i n t h e l i s t o f t h e c o m p o n e n t s a n d
subcat egor ies w as necessar y t o finish dat a collect ion
and coding.
Th e i n t e r a ct i o n b e t w e e n su b st a n t i a l a n d
t h e o r e t i ca l co d e s i s w h a t ch a r a ct e r i ze s GT a s a n
a n a l y t i c - i n d u c t i v e r e s e a r c h m e t h o d( 1 2 ). W h e n t h eor et ical cod in g est ab lish es n ew con n ect ion s an d
t r a n s f o r m s t h e m i n t o r e l e v a n t i d e a s , i t a l s o
d et er m in es t h e or ig in al ch ar act er of t h e t h eor y( 1 0 ). The t heor et ical codes w er e select ed as t hey em er ged
f r o m t h e d a t a a n d w e r e co n si d e r e d r e l e v a n t a n d
u sef u l t o in t eg r at e t h e com p on en t s, su b cat eg or ies
an d cat eg or ies; an d con seq u en t ly, t o elab or at e t h e
t h e o r y.
Epist em ological fu n dam en t als fr om differ en t
f i el d s o f k n o w l ed g e w er e ap p l i ed , an d t h e u se o f
t heor et ical r efer ences fr om Sy m bolic I nt er act ionism ,
Th eor y of Com plex it y, Healt h Pr om ot ion an d Bet t er
Pr act ices w as also n ecessar y.
An ot h er st ep in t h e p r ocess of g en er at in g
t h e t h e o r y i s t h e p r o d u c t i o n o f w r i t t e n
m em o r an d u m s. Th ese ar e t h e r eg i st r i es o f i d eas,
t h r o u g h w r i t t e n r e c o r d s , a b o u t c o d e s a n d t h e i r
r el a t i o n s, t a k i n g co n cep t s t h a t su r f a ced f r o m t h e
p r o ce ss o f d a t a a n a l y si s t o t h e h i g h e st l e v e l o f
ab st r act ion( 1 0 ).
W h e n t h e r e s e a r c h e r e l a b o r a t e s
m e m o r a n d u m s , h e o r s h e r a i s e s t h e d a t a t o
con cep t u al lev els, d ev elop s t h e p r op er t ies of each
cat eg or y, elab or at es hy p ot h eses ab ou t con n ect ion s
b et w een cat eg or ies an d t h eir p r op er t ies, b eg in s t o
in t egr at e t h ese con n ect ion s in cat egor y gr ou ps an d
r elat es t h e em er g in g t h eor y w it h ot h er p ot en t ially
r e l e v a n t t h e o r i e s( 1 0 ). Th e m e m o r a n d u m s i n t h e d e scr i b e d r e se a r ch h a d b e e n p r o d u ce d si n ce t h e
ear ly st ag es, alon g t h e d at a collect ion an d cod in g
p r o c e s s . Co n s i d e r i n g t h a t t h e y a r e a c a c h e o f
a n a l y t i c i d e a s t h a t c a n b e g r o u p e d , o r d e r e d ,
classified an d r et r iev ed( 8 ), t h e sy st em at ic pr odu ct ion of m em or an d u m s m ak es it easier t o ar t icu lat e t h e
t h e o r y. I f t h e co d e s co n ce p t u a l i ze t h e d a t a , t h e
m em o r a n d u m s r ev ea l a n d co n n ect t h e p r o p er t i es
of t h e su b st an t ial cod es t h r ou g h t h eor et ical cod es.
Once t heor et ical sat ur at ion of t he cat egor ies
w a s r e a ch e d , p r o ce sse s o f r e v i si o n , so r t i n g a n d
i n t e g r a t i o n o f t h e m e m o r a n d u m s r e l a t e d t o t h e
c a t e g o r i e s f o l l o w e d . W h i l e t h e c o n t e n t o f t h e
m em orandum s const it ut e t he base of GT, t heir sor t ing
i s t h e k e y t o e l a b o r a t e t h e t h e o r y f o r a t e x t u a l
pr esen t at ion( 1 0 ).
The final st age of t he pr ocess of gener at ing
a subst ant ial t heor y, befor e w r it ing, is int egrat ion: t he
cum ulat ive ar r angem ent ( or ar t iculat ion) of t he t heor y
com p on en t s( 1 3 ). Th e cat eg or ies an d p r op er t ies ar e so r t e d b y si m i l a r i t y, co n n e ct i o n s a n d co n ce p t u a l
ar r an gem en t . I n t egr at ion is cen t er ed on t h e sor t in g
of t he m em or andum s( 10).
I n GT, t e x t s p u b l i s h e d i n l i t e r a t u r e a r e
c o n s i d e r e d t o b e a n o t h e r s o u r c e o f d a t a t h e
r esear ch er can access an d in t egr at e in t o t h e t h eor y
t h r o u g h t h e Co m p a r a t i v e An a l y si s m e t h o d( 1 4 ). A b r oad lit er at u r e r ev iew w as t h en p er f or m ed as t h e
s t u d y t o o k p l a c e , a i m i n g t o c o m p l y w i t h t h e
r eq u ir em en t s of t h e an aly ses of t h e d at a f r om t h e
i n t e r v i e w s . T h e l i t e r a t u r e a l s o h e l p e d i n t h e
elab or at ion of h y p ot h eses, d elim it in g p r op er t ies of
cat eg or ies, an d in t h e d ef in it ion of t h e t h eor et ical
co d e s.
The descr ipt ion of t hese em er ging cat egor ies,
as a w h ole an d in t h eir in t er r elat ion s, r ev ealed t h e
cat egor y t hat w as cent r al t o all t he ot her s: “ Pr om ot ing
or al healt hcar e of t he elder ly in t he cont ex t of
long-t er m car e f acililong-t ies”. Th is calong-t egor y m along-t ch es w h along-t is
d e f i n e d a s t h e B a s i c S o c i a l Pr o c e s s , e s p e c i a l l y
b e ca u se i t i s f u l l y ca p a b l e t o r e g a r d a ct i o n a n d
m a n i f e s t i n g t h e r e l a t i o n s a m o n g t h e m u l t i p l e
cat egor ies of analy sis( 1 2 ).
Th e ce n t r a l ca t e g o r y i n co r p o r a t e d se v e n
o t h e r c a t e g o r i e s t h a t d e f i n e d t h e s t r u c t u r e s ,
pr oper t ies and dim ensions of t he phenom enon. These
cat eg or ies, en d og en ou s t o t h e d at a, ar e p r esen t ed
Th e t h e o r e t i ca l m o d e l f o r m u l a t e d a n d i t s
con st it u en t elem en t s ar e r epr esen t ed by t h e sev en
i n t e r r e l a t e d a n a l y t i ca l ca t e g o r i e s a n d t h e ce n t r a l
cat egory. Two process st ages are ident ified, which, from
a n e v o l v i n g p e r s p e c t i v e , c o n s t i t u t e t w o d i s t i n c t
m om ent s of t he phenom enon. The pr om ot ion of or al
healt hcare of t he elderly residing in inst it ut ions cont ains
a st age t hat represent s t he st at e of apat hy in t he face
of t he cont radict ions in t he healt hcare process and it s
m alignant consequences for t he oral healt hcare of t his
group. This st age seem s t o correspond t o t he sit uat ion
t hat prevails in a large share of t he local Brazilian realit y,
w h ich m ay b e v er if ied f r om t h e p er sp ect iv e of t h e
t heor et ical analy sis m odel, by it self a pr oduct of t his
r esear ch. The second st age, consider ed qualit at iv ely
su p e r i o r, d e r i v e s f r o m t h e f i r st st a g e b e ca u se i t
m aint ains t he or iginal cont r adict ions. This new st age
in cor p or at es at t it u d es of con t in u ou s im p r ov em en t ,
elaborat ed on t op of t he cont radict ory elem ent s of t he
preceding st age. Such elem ent s are neit her discarded
nor dism issed, but confront ed, driven by t he desire t o
ov er com e cont r adict ions and push bot h let har gy and
in act ion aw ay, t h r ou gh t h e adopt ion of n ew act ion
-awareness, t ranslat ed as t he im plem ent at ion of bet t er
h ealt h car e pr act ices.
The result ing t heoret ical m odel t o address t he
process of oral healt hcare prom ot ion in t he elderly living
in inst it ut ions, using GT, is charact erized by variabilit y
and diffusion. The st ruct uring bases of t he t heoret ical
m o d e l w e r e d e si g n e d a s q u e st i o n s/ i n q u i r i e s a n d
su p p or t each an d ev er y cat eg or y of an aly sis. Th ey
ar e a guide t o st ep int o t he w or ld of or al healt hcar e
dir ect ed t o elder ly pat ient s liv ing in inst it ut ions, and
t hey also cont ribut e t o t he building and orient at ion of
st udies about oral healt hcare of t he elderly. Therefore,
t he use of GT has dem onst rat ed, in t his research, t he
validit y of it s applicat ion as a scient ific m et hod capable
of accom m odat ing such a com plex phenom enon.
FI NAL CONSI DERATI ONS
By st u d y i n g o r a l h e a l t h ca r e , t h e p r e se n t
r esear ch, alt hough select ing only one of it s aspect s,
st em s f r om t h e p r em ise t h at h u m an lif e is car in g .
Th u s , c a r i n g a s c o n c e r n f o r l i f e i r r a d i a t e s a n d
sim ult aneously int egrat es it self t o every discipline t hat
const it ut es t he healt h ar ea, and est ablishes a st r ong
bond w it h t he envir onm ent . I n a syst em ic view , w her e
m ult iple elem ent s int er act t o gener at e a r esult , or al
h e a l t h ca r e i s u n d e r st o o d a s o n e o f t h e e sse n t i a l
com p on en t s of t h e h ealt h car e sy st em , in it s m an y
d i m e n s i o n s . S u c h d i m e n s i o n s - i n d i v i d u a l ,
pr ofession al, in st it u t ion al an d polit ical- or gan izat ion al
- ar e not st at ionar y. Quit e t he opposit e: t her e is an
i n t e n s e , c o m p l e x i n t e r c h a n g e o f r e c i p r o c a l a n d
in t er depen den t r elat ion s.
A closer look at t h ese in t er act ion s allow ed
for t he ack now ledgm ent of t he significance t hat t he
p r act ices of or al h ealt h car e d ir ect ed t o t h e eld er ly Figur e 1 - pr om ot ing or al healt h car e in t he elder ly in t he cont ex t of r et ir em ent hom es: cent r al cat egor y and
su b cat eg or ies
Attributing significance to oral healthcare
Determining the oral healthcare conditions
Oral healthcare and the aging process
Revealing the interactions established in oral healthcare of
the elderly
Managing oral healthcare in a long-term care facility for the elderly
Inserting the oral healthcare of the elderly in a political-organizational dimension
Discerning the possibility of better practices in the oral healthcare of the elderly
liv in g in in st it u t ion s p oses t o t h e p lay er s in v olv ed .
This has only been possible w it h t he t ot al and careful
ad op t ion of t h e ch osen m et h od olog y. GT p er m it t ed
an ex t en si v e an d r i ch p r o d u ct i o n o f i n f o r m at i o n al
co d e s f r o m t h e d a t a co l l e ct e d , w h i ch w e r e t h e n
su b m it t ed t o a p er m an en t p r ocess of com p ar at iv e
a n a l y s i s . Th i s i m m e r s i o n i n t o a s u b j e c t i v e a n d
i n d i v i d u al p er sp ect i v e o f t h e i n v o l v ed p l ay er s, b y
m ean s of in t er v iew s w it h t h e r esear ch p ar t icip an t s
and t he r esear cher ’s t heor et ical sensit iv it y, and also
p r ov id ed b y t h e f lex ib le an d op en ch ar act er ist ic of
t he m et hod, has cr eat ed t he adequat e cir cum st ances
t o for m ulat e sufficient ly br oad analy sis cat egor ies.
Th e p h e n o m e n o n o f t h e o r a l h e a l t h c a r e
pr om ot ion pr ocess in t he elder ly liv ing in inst it ut ions
can be ex am in ed in t h e con t ex t of t h e con st r u ct ed
t h eor et ical m odel. I n t h is sen se, t h e m odel h as t h e
following propert ies: it can be applied in ot her t im e or
space cir cum st ances of oral healt hcar e in t he elder ly,
since it show s an adequat e lev el of abst r act ion; it is
capable of adapt ing t o condit ions of v ar iabilit y of t he
“ or al h ealt h car e” ph en om en on , posin g n o r isk t o it s
ar chit ect ur e; it is capable t o r eceiv e t he m ov em ent s
of t r an sf or m at ion of t h e pr ocess; it adm it s ch an ge,
t hrough t he incorporat ion of new t heoret ical elem ent s,
aim in g t o im pr ov e it self, an d it s applicat ion in du ces
crit ical reflect ion about t he prom ot ion of oral healt hcare
for t he elderly living in long- t erm care inst it ut ions.
Th e s t u d y r e a c h e s i t s e n d b y a i m i n g t o
cont ribut e t o t he adopt ion of appropriat e oral healt hcare
pr act ices dir ect ed t ow ar ds a h ealt h y agin g pr ocess.
Living wit h t he com plexit y of t he sit uat ion- problem in
t he lit t le- big world of long- t erm care inst it ut ions clearly
shows, t o t hose who are sensit ive and have a sense of
civ ilit y, t h e social v alu e an d u r gen cy of r esear ch in
t his ar ea. The pr oduct ion of k now ledge t hat not only
co n t r i b u t e s t o t h e a ca d e m i c d e v e l o p m e n t o f t h e
disciplin es an d f ields of st u dy in v olv ed, bu t also t o
p r o v i d e g r o u n d w o r k f o r r e l e v a n t s o c i a l a c t i o n s ,
including gov er nm ent al r esponsibilit y.
REFERENCES
1 . Un i t e d Na t i o n s Po p u l a t i o n D i v i si o n . W o r l d p o p u l a t i o n pr ospect s: t he 2002 r evision. [ cit ed 2004 Mar ch 5] Available f r om : URL: h t t p: / / w w w . u n . or g/ esa/ popu lat ion / pu blicat ion s/ w p p 2 0 0 2 / W PP2 0 0 2 - H I GH LI GH TS r e v 1 . PD F
2 . Fer n an d es MGM. Av aliação d a cap acid ad e f u n cion al em idosos. Nu r sin g 1 9 9 9 j u n h o; 2 ( 1 3 ) : 2 6 - 9 .
3. Hofecker G. The physiology and pat hophysiology of ageing. I n t Den t J 1 9 8 3 Sept em ber ; 3 3 ( 3 ) : 2 5 1 - 6 1 .
4 . Co l u ssi CF, Fr e i t a s SFT. Asp e ct o s e p i d e m i o l ó g i co s d a saú d e b u cal d o i d o so n o Br asi l . Cad Saú d e Pú b l i ca 2 0 0 2 ou t u b r o; 1 8 ( 5 ) : 1 3 1 3 - 2 0 .
5 . Me l l o ALSF. Cu i d a d o à sa ú d e b u ca l p r o v i d o a i d o so s r esiden t es em in st it u ições ger iát r icas de pequ en o por t e em Po r t o Al e g r e - RS: a r e t ó r i ca , a p r á t i ca e o s r e su l t a d o s. [ disser t ação] Por t o Alegr e ( RS) : Facu ldade de Odon t ologia/ UFRGS; 2 0 0 1 .
6. Yam am ot o A, Diogo MJD. O idoso e as inst it uições asilar es do m unicípio de Cam pinas. Rev Lat ino- am Enfer m agem 2002 set em b r o- ou t u b r o; 1 0 ( 5 ) : 6 6 0 - 6 .
7. Vieir a EB. I nst it uições ger iát r icas: av anço ou r et r ocesso? Rio de Janeir o ( RJ) : Rev int er ; 2003.
8. St r auss A, Cor bin J. Bases de la inv est igación qualit at iv a: t é c n i c a s y p r o c e d i m i e n t o s p a r a d e s a r r o l l a r l a t e o r i a fundam ent ada. Medelín: Ed. Univ er sidad de Ant ioquia; 2002. 9. Glaser BG, St r auss AL. The discover y of gr ounded t heor y: st r a t e g i e s f o r q u a l i t a t i v e r e se a r ch . Ne w Yo r k : Al d i n e d e Gr u y t er ; 1 9 6 7 .
1 0 . Glaser BG. Th eor et ical sen sit iv it y. Ch icag o: Sociolog y Pr e ss; 1 9 7 8 .
1 1 . Ch en it z WC, Sw an son JM. Fr om p r act ice t o g r ou n d ed t h eor y. Men lo Par k : Ad d ison - Wesley ; 1 9 8 6 .
1 2 . Glaser B. Gr ou n d ed t h eor y p er sp ect iv e I I I : t h eor et ical cod in g . Ch icag o: Sociolog y Pr ess; 2 0 0 5 .
1 3 . St r au ss AL. Qu alit at iv e an aly ses f or social scien t ist s. Cam b r id g e: Cam b r id g e Un iv er sit y Pr ess; 1 9 8 7 .
14. Glaser B, Holt on J. Rem odeling gr ounded t heor y. Gr ounded Th eor y Rev 2 0 0 4 Nov em ber ; 4 ( 1 ) : 1 - 2 4 .
