Challenges for prevention and promotion in the 21st century

_____________________________________________________________________________________________________ *Corresponding author: E-mail: [email protected], mma[email protected]lisboa.pt; Journal of Education, Society and Behavioural Science 26(2): 1-7, 2018; Article no.JESBS.43287 ISSN: 2456-981X (Past name: British Journal of Education, Society & Behavioural Science, Past ISSN: 2278-0998) Challenges for Prevention and Promotion in the 21 st Century Margarida Gaspar de Matos 1* and Lucia Ramiro 1 1 FMH & ISAMB, School of Medicine, University of Lisbon, Portugal. Authors’ contributions This work was carried out in collaboration between both authors. Author MGM designed the study and wrote the first draft of the manuscript. Author LR reviewed the draft critically. Both authors read and approved the final manuscript. Article Information DOI: 10.9734/JESBS/2018/43287 Editor(s): (1) Dr. Chih-Wei Pai, Assistant Professor, Taipei Medical University, Taiwan. Reviewers: (1) Cihad Dundar, Ondokuz Mayis Universiy, Turkey. (2) Paweł F. Nowak, Opole University of Technology, Poland. (3) Nelly Fernández de Morgado, Universidad Simón Bolívar, Venezuela. (4) Masoud Mohammadnezhad, Fiji National University, Fiji. Complete Peer review History: http://www.sciencedomain.org/review-history/25783 Received 24 th May 2018 Accepted 30 th July 2018 Published 3 rd August 2018 ABSTRACT Prevention is now considered as a way to spread curiosity and commitment and has to do with the creation of communities where it is believed that "good things happen" and that people are part of them. Promoting people positive development, that is, promoting competence, motivation, opportunities and positive expectations is now considered the best prevention strategy, making prevention and promotion two sides of the same coin. Consequently, the approaches based on positive aspects are preferred and considered more effective in various contexts. In the field of health, this positive focus was represented in the "Model of Assets in health" which includes the mapping of resources of each community, both individually and collectively. It also aimed at the increasingly progressive participation of populations. Some aspects of the trajectory of knowledge in recent decades and their impact on interventions in Psychology, Public Health and Public Policies will be highlighted. Review Article Matos and Ramiro; JESBS, 26(2): 1-7, 2018; Article no.JESBS.43287 2 Keywords: Health promotion; prevention; child and adolescents health; public policy. 1. INTRODUCTION, Universal prevention (prevention for all) constitutes a civilizational leap, promoting the access of all people to health, well-being and quality of life, but it was then found that this measure - on its genesis so equitable, could generate by itself inequities by the fact that all populations, regardless their level of need for prevention, receive the advantages of universal interventions with the same pattern. This means that wealthier populations could benefit and profit more from universal prevention than less healthier populations. Thus, paradoxically, universal prevention measures may become potential sources of inequity, increasing the gap between the most-advantaged groups and less advantaged ones. This fact stresses the need to complement preventive interventions of a universal character with other more selective interventions in order to reach the "hidden nested" of populations with more vulnerabilities and to adjust to their characteristics and specific needs [1,2]. 2. PREVENTION AND PROMOTION The "perspective of deficit" consists of assessing people mainly on risk behaviours and problems. This perspective, which was spread till the beginning of the 21st century, has influenced public policy, research and practice, and was reflected in programmes and in service organizations, mainly focused to help people coping with their deficits and avoiding risks. Over the past two decades [3], it was recognized that interventions based mainly on risks and vulnerabilities would have a limited impact, and the approaches based on enhancing positive aspects were preferred and considered more effective [4,5,6,7]. Therefore, approaches focusing exclusively on specific behaviours (e.g., drug prevention, violence prevention, risky sexual behaviour prevention) were reduced and instead were favoured those approaches that considered people globally, not only their “single” risks but also their whole personal and social existence as well as their perception of wellbeing and quality of life. This integrated approach focuses on searching "alternatives", promoting "well-being" and enhancing “personal and social skills”, considering the person as a whole and not just reducing the person to "vulnerabilities" [8,9]. In the field of health, this positive focus was represented in the "Model of Assets in health" [5]. This model includes the mapping of resources of each community, its strengths and abilities, both individually and collectively [10], and claims an increasing participation from the target populations [1,9,11]. To summarise, two decades ago prevention focused mainly on avoiding risks and keeping people away from situations that could anyhow harm them, or their social or physical environment, while promotion was meant to increase their behavioural capacity in order to cope with life challenges with minimum harmful effects; in the last couple of decades this twofold view was challenged and Promotion and Prevention began being considered as two sides of the same coin, both necessary for personal positive development and for the enhancement of individual perception of well-being and social engagement [1,9,12]. 3. INTEGRATED MODELS OF PERSONAL POSITIVE DEVELOPMENT AND PROBLEM PREVENTION The prevention approach aims to reduce/eliminate the risk factors so that people are more able to deal with stress or challenges [13]. Yet some researchers [14] consider that both risk and protective factors coexist in individuals as well as in their various surrounding environments (family, peer group, school and community), besides most issues are determined in such a way that multiple risk factors often occur together [15]. Resilience is the result of a combination of different processes that allow a person to keep his/her assets, helping people to be competent and to avoid problematic behaviours in spite of their previous stressful experiences [16]. Processes that trigger resilience, which include situations of protection, personal characteristics, acquisition of additional resources and reassessment of situations can co-occur, since they are not mutually exclusive. Another approach emphasizes the conditions that contribute to health and well-being, suggesting that the prevention of problems is not enough [17]. The Model of the Development of Assets identifies significant factors to prevent/reduce risk behaviour, or that contribute to positive results, or even that promote resilience [4]. The model identifies 40 "assets" considered fundamental in promoting human Matos and Ramiro; JESBS, 26(2): 1-7, 2018; Article no.JESBS.43287 3 positive development [18], which are organized in two main blocks (internal and external). These authors presented the results of studies that stress the relationship between these development assets and people's well-being [19]. An alternative contemporary approach was based on the identification of five skills - 5Cs, by operationalizing the PYD-Positive Youth Development [5], through the evaluation of 5 Cs: Competence (in academic, social, emotional and vocational areas), Confidence (on who the individual is becoming – in his/her own identity), Character (related to positive values, integrity), Connection (bonds to self and others), and Care (empathy and commitment). These five areas are interactive and a healthy development of all of them is required for the PYD [20]. Later on a sixth CContribution (social involvement and social participation) emerged. During childhood and adolescence, the ability to regulate actions develops gradually and involves adjustments in the social context and vice versa [21]. In children/adolescents, self-regulation refers to various capacities, for example, quick switching between different tasks, concentration on attention, and emotional control. The PYD approach allows people to reflect upon their current behaviour using a S.O.C procedure: Selecting personal goals and applying the resources that are needed to proceed, which includes strategies of Optimization and strategies of Compensation or Re-selection when the goals are not achieved [22]. This S.O.C method allows people to realign life objectives along the lifespan, keeping a positive development trajectory [23]. More recently authors have considered that there could be two different paths to person healthy and positive development: via promotion and via protection, depending on the situation of exposure to risk by the target population. A resilience approach (after risk exposure) and a positive development approach (when there was no previous risk exposure) [24] featuring two routes: 1) the Protection that comes from research on resilience and that includes risks and protection, and 2) the Promotion that comes from research on positive development (assets that lead directly to healthy development). This model also combines resilience and positive development in the same theoretical framework, including onboard individual factors, family, community and cultural education, and outlining eight areas of development that are both relevant to promotion of people’s healthy positive development and to preventive interventions and should influence public policies [24]. The need to integrate the concepts of resilience and person positive development becomes increasingly clear, as well as the importance of their application on a daily basis to different contexts (people’s "life worlds"). Another effort of integration was referred to in literature from a systematic review of effective programs [25]. Having developed from the need to identify effective interventions, the Behaviour Change Wheel intends to answer the question: "which social/environmental and internal conditions does an individual need to change and to enable behavioural changes?” The authors claimed that this characterization system can be applied to any intervention. The system COM-B suggests that if a behavioural change is to happen, at least three components are required: Capacity/ Competence, that is the physical and psychological capacities to change behaviours, especially knowledge and competence; Motivation, that is the intention to act, which includes emotional and impulsive processes, as well as a reflective decisionmaking process; and Opportunities, that is at the very least, a lack of external factors that interfere negatively and, preferably, the existence of benign external factors, that have to be timely identified by people, enabling their use and advantage. The Behaviour Change Wheel reinforces the role of context (Opportunities) as a key factor in the design and implementation of successful interventions since the behaviour can only be understood in relation to the context. Capacity/ Competence, Motivation and Opportunities, are all relevant to the promotion of people’s healthy positive development and to preventive interventions and should also influence public policies 4. DISCUSSION 4.1 Challenges for Psychology, Public health and Public Policies Defying the model of “individual perfection" After the "germ theory" [26], which had the merit of focusing interventions in preventive actions and avoiding the appearance of diseases, it is now time to mitigate the preventive focus on risk avoidance and protection of people. Prevention has nothing to do with avoiding people from doing "bad things", or even identifying what people need and providing it. The first objective Matos and Ramiro; JESBS, 26(2): 1-7, 2018; Article no.JESBS.43287 4 of a preventive action is to lead people to have positive relations with themselves and with the others [12], and this is where Prevention and Promotion come closer to each other, as said. While in the 80s the people and their behaviours were seen as "the problem" and thus the preventive solution was to "avoid" behaviours; in the 90s people were seen as "the solution". When it is chosen to focus on person’s positive development that means, not to adopt a promotion view, but to widen the perspective and goals of prevention, focusing on opportunities, social support and the environment, and enhancing the people’s social participation. Prevention is now considered as a way to spread curiosity and commitment, and has to do with the creation of communities where it is believed that "good things happen" and that people, meaning all of us, are part of these "good things". Promoting person positive development, i.e., promoting competence, motivation, opportunities and positive expectations is the best prevention strategy [12], thus making prevention and promotion two sides of the same coin. When it came to Prevention, we immediately used to see a list of several problems to be avoided (e.g., prevention of substance use, gambling addiction, eating disorders, bullying, violence, self-harm behaviour -including suicide-, sexual risk behaviour, teenage pregnancy, psychosocial risks, and drop outs by absenteeism); on the other hand, when it comes to Promotion, one used to think immediately of a list of the resources intended to "increase": promotion of self-esteem or self-concept, communication skills, socio-emotional skills and resilience; but indeed prevention and promotion are two sides of the same coin, and the strengthening of personal and social resources also prevents the risks associated with problematic situations. As prevention and promotion are two sides of the same coin, they cannot be reduced to sets of behaviours or situations to prevent or to promote [8], because persons are to be seen globally as competent and participative individuals, and not only as their risks and deficits but indeed strategies have to focus on their global perception of well-being, life worth and quality of life. Defying the model of “homogeneity intra-group, regardless of environmental contexts." Often promotional programs are organized by age: programs for infants, children, adolescents, young adults, adults, and elders, forgetting that the spaces, partnerships and intergenerational relations between generations promote knowledge, sharing, competence and initiative. Although generations may be different, they have some identical problems – the relationship with their body, insecurity in the affection field, the feeling of devaluation and misunderstanding; social isolation, lack of opportunities, loneliness, and uncertainty for the future. Therefore, there may be a social benefit when elders, adults and young people collaborate on common causes. As mentioned before, people may evolve positively along the life-span, using the S.O.C. proves: a Selection process (what interests them, what they are, what they need, what they like) and the Optimization of these processes or situations, which concludes with a Compensation process (overtaking areas where they are weaker) [22,23], and this may happen throughout life, which means that an intergenerational perspective can help to go through this process in a positive, rewarding and reciprocal manner. Finally, at present, the importance of environmental prevention that may include both 1) changes in social norms through comprehensive strategies that intervene at the level of society and in social systems, and 2) the transformation of cultural, social, physical and economic environments is recognized. The transformation of these environments interferes with several spheres such as individual choices, the quality of access and promotion opportunities, legislative measures, economic incentives, tax rates, the regulation of exposure to advertising messages, the monitorization of the minimum age of sale, as well as measures in specific contexts (e.g. schools), the preventive/promotion equation, the role of contexts and macro factors (economic, political and social). Interventions aimed at promoting health/well-being of populations require a mapping of each community, its strengths and capabilities, both individual and collective [10]. Recognizing the added value of living in a global society: The importance of educating to diversity and focusing on opportunities generated by diversity. It is commonly said that due to the amount of time that children and adolescents spend in school every day, the school is a natural choice for prevention and promotion. Matos and Ramiro; JESBS, 26(2): 1-7, 2018; Article no.JESBS.43287 5 But as times change, on the one hand, schools become increasingly multicultural, on the other hand, electronic communication devices become increasingly more frequent. This diversity is really an asset, an opportunity: schools must understand that students come from all over and that students are digital natives, and that technology also has the ability of bonding people. Thus, school is missing out on a valuable opportunity when they randomly prohibit children and adolescents to use technological devices instead of using them as educational tools, the school is missing out a valuable opportunity when they do not encourage multicultural growth [27,28]. Teachers cannot dismiss that we live in a multicultural and technological world, and that this fact can be an asset in their daily practice regarding prevention, promotion and all other areas, which in the end represent none other than enhancing individuals' competencies, strengths, assets and skills to deal with themselves, with interpersonal differences, and all life situations and environments. Bearing in mind all the evolution documented by the different models of development, problem prevention and health promotion, it is time to address the importance of translating all the framework into tools that the professionals in the field (whether they are physicians, psychologists, nurses, teachers …) may use effectively. There is no reason why their basic training (graduation) doesn’t give them the opportunity to learn about the contemporary models of positive youth development, problem prevention and health promotion, as there is – as mentioned – sound literature and evidence-based knowledge. 5. CONCLUSION Ten "powerful" concluding ideas: 1. The changes in behaviour include not only overt behaviours (verbal or motor), but also cognitive, emotional, motivational and cultural aspects, as well as the management of expectations. The changes should preferably occur from the development of personal and socioemotional skills, translated into a new personal and social identity and into the possibility of increased personal and social well-being. 2. The focus of preventive or promotion intervention must be in resources and in the positive aspects of the individuals, the situations and the communities and should promote the active participation of the populations. 3. Besides the participation of the individuals (which include the opportunity of participation and leadership) and building skills (with emphasis on developing skills for life), effective prevention programmes include the “orientation for the other” in a context of sustained relationships and solidarity inter and intra persons. 4. There is a minimum of two main paths for a healthy development: protection and promotion. A key starting point is to dismiss the idea that risk is simply the opposite of protection. 5. Definitions of what constitutes a risk and a protection vary in different cultures, which reinforces the idea that the diversity provided by the meeting of different cultures is a huge window of opportunity for positive development. Programs must be culturally relevant and adjusted and preceded by the identification of the level of preparation and motivation of the communities and people for a change. 6. Programs should preferably be multifactorial and include multiple levels of reciprocal influences and interactions, and must be anchored in sound theoretical models that are evaluated empirically. 7. The programs should not be focused exclusively on specific problems, or in individual characteristics but preferably in a broader, integrated approach that meets the common aspects of the various expressions of unwell/well-being. This demand for integrated responses is a necessity, given the demands of an effective rationalization of resources, resource management, sustainability, and the need to avoid an overload of messages addressed to the same groups, managing also the waste (in terms of material and human resources). 8. Interventions should be "modern" and leverage current resources that include, for example, the rationalized use of information and communication technologies that allow national and international communication networks, and partnerships that were not previously possible. 9. The creation and maintenance of familybased, social and institutional support networks should be privileged to ensure the design, implementation, evaluation, Matos and Ramiro; JESBS, 26(2): 1-7, 2018; Article no.JESBS.43287 6 continuity and sustainability of long-term changes. 10. 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