Health Education and Prevention 9781119611936, 1119611938, 9781786304100

Table of contents :
Content: 4. Qualitative Methodologies for the Investigation of Health Conceptions --
4.1. What are the main qualitative methodologies used in international publications? --
4.2. Which biopsychosocial interpretative model of conceptions should we use? --
4.3. How to model the biopsychosocial dimensions of conceptions on addictions? --
4.4. Are there many health conceptions from infancy? --
4.4.1. Domain A: biomedical health --
4.4.2. Domain B: social and environmental influences in prevention --
4.4.3. Domain C: perception of the social and societal environment --
4.4.4. Domain D: mobilization of relational competences and influence on the emotion of social relations --
4.4.5. Domain E: psychoaffective perception of others and the management of emotions --
4.4.6. Domain F: the physiological and psychoaffective consequences of a behavior in health --
4.5. Should we fear what children and adolescents have to tell us? --
4.5.1. What diversity of conceptions? --
4.5.2. How do conceptions of health evolve within a group of children? --
4.6. What are the elements to prioritize for intervening in health? --
4.7. What are the advantages for public health from this approach to health conceptions? --
5. The Convergence of Research Tools, Interventions and Training --
5.1. How is a tool an inseparable element from human activity? --
5.2. Why is the transferability of "good practices" a fantasy? --
5.3. How to expand the notion of tools in prevention? --
5.3.1. What are the epistemic and epistemological principles of health intervention? --
5.4. Why talk about the tool syndrome in health education and prevention? --
5.5. What is the real process of conception of a prevention tool? --
5.6. How does using photographs enable a reconciliation of research and intervention? --
5.6.1. Methodological overview of the use of photographs. 6. Formative Perspectives for More Effective Prevention Actions --
6.1 What are the andragogic foundations for better apprehending the complexity of systems of conceptions? --
6.1.1. On which points of vigilance is it necessary to focus training? --
6.2. In teaching, how can a better apprehension of the complexity of systems of conceptions be developed? --
6.3. What foundations of an explicit pedagogy should teaching follow? --
6.3.1. Why is it imperative to make the implicit explicit? --
6.3.2. What should lessons in health aim for? --
Conclusion --
Appendix --
A.1. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4-20 years old) address health --
A.2. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4-18 years old) address health themes --
A.3. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4-18 years old) address themes related to the health thematic --
References --
Index --
Other titles from iSTE in Health Engineering and Society --
EULA.

Citation preview

Health Education and Prevention

Health and Patients Set coordinated by Bruno Salgues

Volume 1

Health Education and Prevention

Frank Pizon

First published 2019 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address: ISTE Ltd 27–37 St George’s Road London SW19 4EU UK

John Wiley & Sons, Inc. 111 River Street Hoboken, NJ 07030 USA

www.iste.co.uk

www.wiley.com

© ISTE Ltd 2019 The rights of Frank Pizon to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988. Library of Congress Control Number: 2018967378 British Library Cataloguing-in-Publication Data A CIP record for this book is available from the British Library ISBN 978-1-78630-410-0

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix

Chapter 1. Conceptions and Deciding for One’s Health . . . . . . . . .

1

1.1. “Conception” and “decision”: what do they mean? . . . . . . . . . . 1.2. Is educability in health possible? . . . . . . . . . . . . . . . . . . . . . 1.3. What are the factors of efficacy in prevention at the international level? 1.4. Why speak of leading practices in health? . . . . . . . . . . . . . . . . 1.5. What are the unwavering links between “research” and “intervention”? . . . . . . . . . . . . . . . . . . . . . . . . .

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1 3 6 9

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Chapter 2. Social Representations of Health Conceptions. . . . . . .

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2.1. Can we speak of quantitative preponderance? . . . . . . . . . . . . 2.2. What qualitative studies are available to us at the international scale? . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Why is there still a paradox in health education? . . . . . . . . . . . 2.4. What meaning should be given to the terms used in publications? 2.4.1. The term “perception” . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2. The term “belief” . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.3. The term “knowledge” . . . . . . . . . . . . . . . . . . . . . . . . 2.5. What are the benefits and limits of the notion of social representation in the field of health? . . . . . . . . . . . . . . . 2.5.1. A notion enclosing health within a “social whole” . . . . . . . 2.5.2. The contested theory of the central core . . . . . . . . . . . . . 2.5.3. Other elements for a critical analysis of the notion of social representation in health . . . . . . . . . . . . . . . . . . . . . . 2.6. What are the preliminaries for a new theorization of conceptions in health? . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2.6.1. Why replace the subject in a central position? . . . . . . . . . . . . . 2.6.2. What limits are attributed to the KVP model (knowledge, values, social practices)? . . . . . . . . . . . . . . . . . . . . .

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Chapter 3. A Renewed Theory of Conceptions in Health . . . . . . . .

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3.1. What are the paradigmatic foundations of health conceptions? 3.2. Why combine health paradigms? . . . . . . . . . . . . . . . . . . 3.3. How to avoid the pitfall of simplified thinking? . . . . . . . . . 3.4. Theorization of conceptions in health . . . . . . . . . . . . . . . 3.4.1. How to consider the subject from a biopsychosocial point of view? . . . . . . . . . . . . . . . . . . . . 3.4.2. What are the seven criteria that characterize conceptions in health? . . . . . . . . . . . . . . . . . .

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51 52 54 56

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Chapter 4. Qualitative Methodologies for the Investigation of Health Conceptions . . . . . . . . . . . . . . . . . . . . . .

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4.1. What are the main qualitative methodologies used in international publications? . . . . . . . . . . . . . . . . . . . . . . 4.2. Which biopsychosocial interpretative model of conceptions should we use? . . . . . . . . . . . . . . . . . . . . . . . . 4.3. How to model the biopsychosocial dimensions of conceptions on addictions? . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Are there many health conceptions from infancy? . . . . . . . . . . 4.4.1. Domain A: biomedical health . . . . . . . . . . . . . . . . . . . . 4.4.2. Domain B: social and environmental influences in prevention . . 4.4.3. Domain C: perception of the social and societal environment. 4.4.4. Domain D: mobilization of relational competences and influence on the emotion of social relations . . . . . . . . . . . . 4.4.5. Domain E: psychoaffective perception of others and the management of emotions . . . . . . . . . . . . . . . . . . . . . 4.4.6. Domain F: the physiological and psychoaffective consequences of a behavior in health . . . . . . . . . . . . . . . . . . . 4.5. Should we fear what children and adolescents have to tell us?. . . 4.5.1. What diversity of conceptions? . . . . . . . . . . . . . . . . . . . 4.5.2. How do conceptions of health evolve within a group of children? . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. What are the elements to prioritize for intervening in health? . . . 4.7. What are the advantages for public health from this approach to health conceptions? . . . . . . . . . . . . . . . . .

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Contents

Chapter 5. The Convergence of Research Tools, Interventions and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. How is a tool an inseparable element from human activity? . 5.2. Why is the transferability of “good practices” a fantasy? . . . 5.3. How to expand the notion of tools in prevention? . . . . . . . 5.3.1. What are the epistemic and epistemological principles of health intervention? . . . . . . . . . . . . . . . . . . 5.4. Why talk about the tool syndrome in health education and prevention? . . . . . . . . . . . . . . . . . . . . 5.5. What is the real process of conception of a prevention tool? . 5.6. How does using photographs enable a reconciliation of research and intervention? . . . . . . . . . . . . 5.6.1. Methodological overview of the use of photographs . . .

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103 103 105

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111 112

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114 115

Chapter 6. Formative Perspectives for More Effective Prevention Actions . . . . . . . . . . . . . . . . . . . . . . .

131

6.1 What are the andragogic foundations for better apprehending the complexity of systems of conceptions? . . . . . . . . . 6.1.1. On which points of vigilance is it necessary to focus training? . 6.2. In teaching, how can a better apprehension of the complexity of systems of conceptions be developed? . . . . . . . . 6.3. What foundations of an explicit pedagogy should teaching follow? 6.3.1. Why is it imperative to make the implicit explicit? . . . . . . . . 6.3.2. What should lessons in health aim for? . . . . . . . . . . . . . . .

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132 132

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136 140 140 141

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

145

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

149

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

175

Introduction “Health Education”: a Vast Enterprise

We will not mince our words: the terms “education” and “health” do not go hand in hand so easily. Their proximity deserves to be constantly questioned. We owe it to ourselves to always seek to identify what does or does not allow these terms to resonate. Associating the terms “education” and “health” highlights the irrevocable tension between giving way to the person who has the capacity to make decisions, and the temptation to educate “for” a health whose characterization is itself debated in the social sphere. What can we do? How can we avoid seeking freely given and behaviorist submission? How can we ensure that the subject retains this decision-making position, taking into account their life environment and their own uniqueness? How should we react to the recurring challenges in public health that question the role of the subject in terms of much larger societal problems? These questions are sources of doubt, and doubt contributes to removing what is taken for granted. The fundamental epistemological posture for health education probably consists of placing the person and groups at the heart of the approach, followed by integrating the weight of living contexts. It is not knowledge that prevails, but what the subject does with it. Knowledge, both heterogeneous and composite, functions such that allows the person to build their own rationality to lead (or not) a possible life. This will be the focus of this book, which endeavors to shed light on a number of points that constantly call into question health education practices. This book, based on previous work on social health representations and concepts, aims to see how a renewed theorization could allow us to form a

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link between the subject (in their biological, psychological and social dimensions) and an educational approach that integrates their singularity. After a decade of work in health education, our reflection therefore falls into a perspective of theorization of one of its constitutive aspects, potentially the most important: that of comprehending and taking into account health concepts. The author’s thesis work, carried out in 2008, was one of the first to look at health education in the school environment using a psycho-ergonomic view of development within the wider framework of education sciences and activity analysis. Nearly 10 years later, the scientific field of health education has developed. It has even percolated in the scientific sphere, questioning scientific objects with diverse approaches in the fields of public health, sociology, anthropology, psychology, management and, of course, the educational sciences. As proof of this evolution in the university environment, teacher–researcher posts are now dedicated to health education, journals are devoted to it, a scientific network has been reinforced (UNIRéS, university network for health education), symposiums are multiplying and the hexagonal bibliography has expanded, even though it struggles to cover its delay at the international level. This field of research inherently calls for multidisciplinarity. Although collaborations of this kind are always modest (similar to other fields of research in education), the various insights that current health education benefits from allow a step back to be taken after 10 years, following the appearance of this field of research. While certain people reproached it for not being a “discipline”, we now see that it has “disciples” through the development of an interesting and much more diffuse movement within the scientific community than at its initial appearance. It is almost amusing that this field of research that remained marginal for several years has now found its place, notably in university disciplines where it was not expected nor wanted. However, we will retain from this evolution the positive character generated by this gradual movement of multidisciplinary appropriation. What ensued was the redefinition of the health education profile, even a shift from “education for…” (confined to teaching problems and centered on education science), toward a contrast of the terms “education” and “health” at the crossover of educational and health theoretical foundations. Nevertheless, the juxtaposition of these two terms allows the description of a reciprocity, which also pushes for the consideration of convergences. It is in

Introduction

xi

this perspective that this book’s approach belongs: identifying what will push forward the theorization of a field that is currently scientifically wellestablished, without necessarily focusing on a disciplinary approach which in no way allows for the apprehension of the entire complexity. It is therefore necessary to include psychology, social psychology, sociology, education sciences and, of course, public health. In order to address what could be considered as “fundamental” in this field of research, several red lines will be unraveled in the following lines. Indeed, putting “education” and “health” into perspective is not neutral, whether from epistemological or epistemic points of view, notably with the integration of public health issues. This questions the role of the subject, on the one hand, and their position within groups or society, on the other hand. Looking at understandings of health places a set of elements in tension. In this process of analysis and theorization, we must therefore fall back on a variety of disciplines to which the frames, models and methodologies refer. By approaching the “health” of “educational” preoccupations, it then quickly becomes necessary to understand from where the author speaks, from where the author questions, observes and collects, then analyzes and discusses. The researcher himself benefits from adopting a posture that allows him to reinterrogate the objects of research that he manipulates. The objectification of methodologies, for collection as well as analysis, becomes a gauge of scientific rigor. Linking “education” and “health” pushes the researcher in his entrenchment, sends him back to his role as a citizen, to what he is himself. Describing these links jostles him in terms of his personal and professional history. He cannot extract himself completely from what he is. It is on this point that human and social sciences lack, it seems, hardness. But what hardness do we mean? That which distinguishes so-called “soft” sciences from so-called “hard” sciences. Jacques Ardoino (1993) attempted to clarify these aspects: “While this notion (‘soft’) designated, more traditionally, that which remained entangled, still waiting to be ‘unraveled’ through a reduction of elements that are increasingly simple, and increasingly ‘pure’, the modern meaning, enriched by contributions from cybernetics, developed in the context of a systemic approach and not without link to the Lewinian theory of the ‘field’ (borrowed from the physical electromagnetic model), suggests a more ‘molar’, global, indecomposable, grasp. However, at a second, more detailed reading, ‘molar’ could be profitably replaced by ‘holistic’, better characterizing the complexity of human phenomena. Effectively, ‘molar’, from ‘mole’ (gram molecule,

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molecular mass of a substance), in chemistry, is in opposition to atomics (simple decomposed elements), whereas holistic, derived from holism (general epistemology), designates, in contrast with atomics, a position according to which we cannot understand the parts without knowing the whole. In this perspective, ‘complex’ should be carefully differentiated from ‘complicated’ (the latter notion has the potential to allow the decomposable and irrevocable characteristic of its objects)”. By thus exposing our posture and research process which has led to the theorization of concepts in health, we once again highlight the entire complexity inherent to our objects, their contexts, the subjects themselves and the researchers who encounter them. Edgar Morin (1977) specifies that “complexity first imposes itself as impossible to simplify; it occurs there where the complex unit produces its appearance, where distinction and clarity become lost, where disorder and uncertainty disturb phenomena, where the subject-observer surprises himself in the object of his observation, where antinomies cause reasoning to diverge… Complexity is not complication. That which is complicated can be reduced to a simple principle such as a tangled coil or a sailor’s knot. Certainly, the world is very complicated, but if it were only complicated, that is to say tangled, multi-dependent, etc., it would only require applying well-known simplifications […]. The real problem therefore is to not relate the complication of developments to rules that have simple bases. Complexity underlies it”. And he adds, “such a confluence of before-then disjointed notions brings us closer to the principal core of complexity which is not only in the linking of the separate/isolated, but the association of what was considered as antagonistic. Complexity corresponds, in this sense, to the irruption of antagonisms at the heart of organized phenomena, to the irruption of paradoxes or contradictions at the heart of a theory. The problem with complex thought is then to think together, without incoherence, two ideas that are, however, contrary”. Faced with this intrinsic and extrinsic complexity linking “education” and “health”, we will look at several approaches. In other words, we seek to vary the points of view to showcase several sources of insight. This posture comes with great epistemological vigilance in order to avoid “naturalizing” knowledge (Berger, 2007). Multireferentiality is not considered as a research methodology: it remains a posture that guides our research activity (Ardoino, 1993) but must remain prudent. This in the interest of avoiding at all costs the articulation of heterogeneous paradigms (Monjo, 2003) and better

Introduction

xiii

understanding some of the overlap, sometimes revelatory of contradictions in the subjects and often difficult to elucidate. It was our object of research that led us to go through a plurality of paradigms (Fortin, 2005) in order to leave the pervasiveness of a medicalized introduction to health behind. To iterate the words of Guy Berger (2007), “everything is relative to position” (“from where I stand, I think that…”). This also brought us to consider our research practice as a social practice comparative to other social practices, carrying, as we will attempt to demonstrate, its own norms and paradigms. We are not, therefore, aiming for a syncretism that would push us to take from everywhere simply to “oblige”. Instead, we rely on the cultural and historical reading of our research object to legitimize this multireferential approach. Thus, a work path is defined, a personal walkway that attempts to state an objective with the help of different sources of insight and engaging only its author. We are aware that the models we propose can sometimes lead to categorical thinking which then amplifies the differences between categories and minimizes the intercategorical. “Our knowledge does not dispel what we do not know” (Berger, 2007). This allows the definition of the complexity of things by positioning our work at different levels (subject, group, organization, institution) altered by mutual modifications. This approach arose from the embarrassment in which practitioners always found themselves when they started to rethink their methods, no doubt to optimize them, with a more deliberate praxeological intention, but also to attempt to better understand or even to theorize them, from a perspective which is then closer to scientific curiosity, notwithstanding ethical preoccupations. Where women and men undertake and achieve projects together, they interact. The social link thus becomes the object of research, questioning the practices. The issue of power which is always associated concerns the lived and tangible experience of “subjects” (a term that has been favored over “individual” from the beginning of this work, increasingly used in the field of public health), as much as the functioning of the social body, organizations and institutions or the interpersonal relations of domination and submission. It may seem that, behind a common language, words have a shared meaning. This is not always the case, and the underlying paradigms propel us into a form of complexity of which the multireferentiality enables the measurement of what separates and what unites within a melting pot of

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concepts fed by knowledge of varied nature, which we will return to. It is this melting pot that interests us in our work: the differences then take on as much importance as the common points. Adopting this multireferenced view means moving away from simplistic views and ways of thinking. In the face of complexity, mediatization can generate “undifferentiating” linguistic productions, to use the words of Ardoino, but can also spread knowledge and open up for the necessary expression of these differences. “We are at constant risk of remaining prisoners of the unidimensional analysis of language, a posture which can be maintained through an undifferentiating syncretic perception, if mediatized. Working without sufficient demand on language productions, which are both a material and a tool for approaches that are undertaken, therefore falls back on accepting to generate alienation, while heavily jeopardizing the decisions that must constantly be taken in the plan of action” (ibid). This is why it is preferable to find, sort, distinguish, recognize and differentiate the very diverse meanings that could be attached to the terms used, based on the interlocutors, the various partners, such as in terms of larger conjunctures in which situations fall. Jacques Ardoino (1993) added: “The luxuriance, proliferation and richness of social practices concretely forbid their classical analysis using a decomposition-reduction method. This is probably one of the reasons for the contemporary rehabilitation of the term complexity”. The temptation to reduce what is “complex” into “simplified” units is great, although we know that the whole is superior to the sum of its parts. Paradox and contradiction become imperatives imposing themselves on the researcher. The opposing argument cannot be secluded in a laboratory. It benefits from both instances of formal research as well as informal spaces that convoke research without having necessarily invoked it in anticipation. It is probably in this tight link between “research” and “intervention” that our works naturally anchored themselves initially in a doctoral thesis on tobacco-free schools, and then in the design of the education, health, and territory mechanism. The question of mechanisms implemented to intervene between “education” and “health” remains at the heart of the reflection that we wish to engage in here. Following the collection of scientific data comes the permanent question of how to intervene within a translation (language experts will speak of “transposition”) which seems to have been admitted into a professional field between scientific knowledge and practical application? Then appears the ghost of “good practice”, of something that will be “good” to apply in order to tranquilize the practitioners by acting in

Introduction

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the most adapted way. However, be careful: we have not fallen into a fantasy of believing that the contexts resemble each other and can be overcome by the power of interventions with enough strength to do so. For the latter, inexorably, incessantly push us back to a principle of reality. Nevertheless, believing in a subject that has the resources and potential to allow the appropriation of what the facility (in the sense of “what is put at its disposal”) provides as methods of proceeding seems to us to be an essential path that we will attempt to shed light on, at least in part, including a trip to the training field at the end of the book.

1 Conceptions and Deciding for One’s Health

Before intensifying the relationship between “conceptions” in health and making “decisions” in health, it is necessary to detail the meaning attached to each of these two terms. In a perspective that encompasses both research and intervention, we will therefore show what we mean through “practices”, by positioning them both in public health perspectives and with educational purposes, asking the broader question of educability. 1.1. “Conception” and “decision”: what do they mean? The term “conception” is an essential marker in this book. Its polysemy is reminiscent of the way in which work collectives think, negotiate and gradually stabilize health intervention measures. However, this term mostly defines the perceptions in health formed by the subjects in their individual and collective dimensions, in their ways of characterizing “their” health and adopting behaviors coherent, or not, with what they are or believe to be. Finally, it evokes the conception of health intervention tools, which will be used productively between theory and practice. Since tools are regularly diverted away from their initial use (a mason’s trowel works equally well for spreading cement as for hitting cement blocks with the handle to level them), the use then reveals the way in which the user considers the instrument that he wields in his hands. The word “conception” refers to the dimensions that we have just described, but also presents the question of how to disseminate new knowledge or unprecedented tools in the social sphere. We postulate that the modular thinking that integrates a potential flexibility for the

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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reappropriation by “users” is a channel with great interest for considering the content of training for prevention actors. The second term, “decision”, takes on a particular character in our research works that quickly converged into a need to give it a particular emphasis. On matters of health, “deciding” (or not) is central to a subject’s journey. It is the sign of an “ability to act” (Le Bossué, 2003), or in other words, of a power to overcome or remove obstacles, without it necessarily involving an “increased awareness of the interdependence of the structural and individual sources of change” (ibid) by the subject. This “power to act” is part of the important ideas in the analysis of activity and the field of health, notably the notion of empowerment. Jacques Leplat (2016) cited the works of Pierre Rabardel (2005) that distinguish the “capacity to act” from the “power to act”. These two possible phrases differentiate “what the subject who defines his sphere of capacity can mobilize, and what is effectively possible, what is within the power of the subject in the singularity of the situations and conditions of activity” (Rabardel, 2005, p. 18 in Leplat, 2016). For Jacques Leplat (ibid), it consists of finding “this distinction in the differences between knowing how to do a task” and “having the possibility to do it”, to which it is necessary to add “being inclined to do it”, and “finally doing it”. These words retrace, in very different ways, the paths used to apprehend the activity of the subject: “knowing how to do” essentially refers to competencies with aims and conditions of execution; “having the possibility to do” reminds us that we can know how to do it, but might not necessarily have the possibility; “being inclined to do” suggests the idea of the in fine omnipotence of the subject who can decide not to act. Jacques Leplat (ibid) added that “all these dimensions of action power are also to be examined under an angle of development”. Nevertheless, we will not talk about an allpowerful subject who conditions his decision-making on matters of health, but rather of this “power to act” (or not) based on the perceptions he has and the way he uses them in the situations he encounters, and that put pressure on him in matters of decision. Thus, we highlight the fundamental distinction between considering the subject on the one side and the object on the other, and, in contrast (which is the posture guiding this text), considering that these two aspects form a whole which also plays a mutually transformative role; the subject transforming the object while itself being metamorphosed by the object (Ricoeur in Pastré, 2015). “The evolution of Ricoeur’s philosophy allows us

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to see how the theme of the subject, which was the central question of western philosophy for three centuries, takes a potentially decisive turn in the 20th Century to move from the epistemic subject to the capable subject or man” (ibid). It is a question of removing the subject from an ignorance, which he could voluntarily be given in order to accept that he positions himself to act before he has the knowledge. The subject thus “uses, at his convenience, knowledge as a resource to direct his action” (ibid). The question that fundamentally fuels our reflection consists of clarifying the role of knowledge in the subject’s activity with regard to his life experience. It also allows us to uncover what generates a resource or obstacle for the subject, as well as recognizing its extremely constructive and transformative role in action. 1.2. Is educability in health possible? Talking about education or health sends us back, in the first instance, to the crucial issue of social inequities. Education seeks to empower, but systems have a lot of trouble avoiding an increase in the latter. In the field of health intervention, social inequities are so strong that they push us to attempt to think differently, to mobilize intersectorality (Kempf et al., 2013) and to implement a “proportional universalism” (Lang, 2014), a notion that allows us to reason in order to rethink the principles of equity because everything is linked. For example, our level of mastery of language conditions our access to testing, our reasoning and analysis capacities, in turn fed by our culture (scientific, artistic, literary, historical, etc.), and our capacity to perceive the world that surrounds us. All these elements play a part when we make decisions on matters of health. Thus, we know that a high sociodemographic level notably increases screening for breast cancer because of more frequent check-ups (Duport et al., 2007). Environmental conditions and the quality of life show that access to a doctor and financial aspects (including the possession, or lack thereof, of accommodation) interfere with the quality of screening (Duport et al., 2008). There are many similar examples. They necessarily question the role of education in health behaviors, but by putting them in perspectives of varied and heterogeneous health determinants that are beyond the subject and refer to the quality of his environment. Nevertheless, education allows the subject to regain his place and overcome certain obstacles. As such, in iatrogenic patients (iatrogenesis

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induced by Vitamin K antagonists (VKAs)), participating in activities of therapeutic education quarters their risk of hemorrhage under VKA therapy (Saint-Leger et al., 2004). “The representation of patients is linked more to belief phenomena1 that allow for the anticipation, expectation and evidence of the emotional load of the illness” (Cannone et al., 2004; Marie et al., 2010). However, evoking education (whether of health) is accepting to believe in the educability of the subject. But of what educability do we speak? For Philippe Meirieu, this notion is scientifically false (Meirieu, 2009). The relationship between our health status and our learning capacity has largely been described (Bantuelle and Demeulemeester, 2008) and underlines the fact that children and adolescents cannot be reduced to “learners”. Indeed, the term educability assumes that the “part taken by the educability of all persons refers back to the existing tension between a demiurgic temptation, on the one hand, and the cessation of transmitting anything, on the other hand” (Jourdan and Berger, 2005). Even if we avoided approximating pedagogy to a demiurge, the first having nothing of the divine, it is troubling to note that the approximation of the two terms in the expression “health education” has contributed largely in rethinking the role of the subject and the intervenor. The words of Philippe Meirieu (2010) usefully complete this description of an exercise of social control when he talks about the use of Ritalin to “regulate” the concentration and learning capacity of children. At the risk of provisionally reducing health to medical treatments, he mentions “the systematic use of chemical or technical reconditioning prostheses”. In the end, we reduce the child to a set of circuits and claim to be able to “educate” him through a sum of targeted punctual interventions. The subject disappears and, with him, the only truly educational work which consists of creating the most favorable conditions for a person to become engaged in teachings and to find within himself the strength to grow. All this indicates a confusion: we think that education consists of “making” an individual – of finding in order to repair. It is therefore important not to adopt this view of care and treatment when thinking about educational actions. Nevertheless, it is not a question of adopting a pusillanimous attitude, erasing all innovative attempts to educate. Moreover, from a public health point of view, the same tension is seen when a minister forces patients suffering from Alzheimer’s to see their physician again for the renewal of prescriptions. This thus once again positions the 1 A term that we will take the precaution to question later in the book.

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treatment as a prescribed finality, whereas the physician can play a listening or supporting role. Talking about education means talking about educational contexts and cultures. In France, the mechanistic and individualist perception of the subject in the educational environment is supported by pedagogy based on objectives, which follows a behaviorist vision of teaching. The subject becomes “able” on the condition that he is set steps to achieve, which are prepared for him. There, we find an epistemic approach to the subject which has heavily inspired the teaching of disciplines. Requestioning the idea of a capable subject who is not only considered by his ability to reason, but also by what he does and experiences in situations, allows for a paradigm change favoring the approximation of “education” and “health”. Nevertheless, these questions are not new. In Greek civilization, while medicine focused on the body, philosophy explored the spirit in an attempt to resolve an existential issue. Aristotle described the “intemperate or akratic man” caught in conflict between reason and desire, “that is to say, the one who recognizes that he should change his behavior, yet whose behavior does not change” (Agostini and Mallet, 2010). For Socrates and Plato, two models of educational relationship oppose each other. According to Agostini and Mallet (ibid), there is a democratic model that leads the subject to overcome his resistances and a more totalitarian model in which it is necessary to reach the end of all resistances regardless of the cost to the subject. For Socrates, there is a conflict between the two discourses in reasoning. Thus, in the case of a subject giving up tobacco, “on the one hand, his reasoning tells him that smoking is no longer good for him; on the other hand, it also tells him that the pleasure of smoking is important” (ibid). The subject is described as “ignorant”. Education is responsible for engaging him in full, leading him by the entirety of his being (mentally and bodily) to identify the importance of a change in behavior. Socrates therefore advocates the development of the knowledge of self, always deeper in order to give meaning to the risks encountered. For Plato, efficacy is prioritized in terms of personal development. It can then be considered that “what counts is not that the educated person truly adheres to the principles of the education that has been transferred to him;

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that his action conforms to it. And this, regardless of the price of this conformity” (ibid). These quotations from Plato and Socrates raise an opposition: “Democratic or totalitarian, coaching or indoctrination, the educational relationship remains a manipulation. Following the sense that education knowingly transforms the state of the learner, this change is the aim of education” (ibid). Since health must refer to the personal life of the subject, we will not presume here to solve an impossible equation whose richness arises from the tension it generates. However, our research objectives, at the heart of this tension, propel us to cast a careful eye on the conceptual frames that we are led to manipulate. Platonist, Socratic, or Aristotelian views invite us toward this contemplation. 1.3. What are the factors of efficacy in prevention at the international level? As we have endeavored to demonstrate, words have their importance. They say much on the status of the one whose entry into learning is awaited, whether pupil, student or patient. He can be tagged with the formidable term of “learner”, which could even be written on the badges of student nurses, as is sometimes seen. There would therefore be, following an implacable logic, the “knowers”, or rather the “ones who know what is good for the learners”. Of course, the irreducible asymmetry between the “master” and the “pupil” prevents us from exaggerating our words. Nevertheless, behind a badge hides a subject who acts and whose action has a transformative role on himself (even if this action has been arranged with the commendable intention of facilitating his learning and, by reciprocity, also participates in the transformation of the teacher or educator in health, at least if the latter is ready for self-analysis. This “learner/knower” approach questions the level of efficacy reached for health intervention. Effectively, we suggest the hypothesis that the transformative role of one on the other is inherent to the meaning given to these two terms. What a commendable intention it is to seek to be more efficacious! But what does international literature say on the factors of efficacy? Let us take the example of addiction prevention.

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The analysis of research led at the international level showed, at the end of the last century, a relative efficacy of intervention programs in academic environments (Tobler, 1997; Tobler et al., 2000; Thomas, 2005), but discerned several elements that allowed a greater efficacy to be envisioned: the need for sufficiently long preventative actions (a single intervention – a single shot – is not enough), the pertinence of intervening during school time and the importance of training the interveners in the implementation of prevention (teachers, parents and social workers) (Figure 1.1). However, a recent publication shows that, since Tobler and Thomas’s meta-analyses, nothing has fundamentally changed in 20 years. In a recently published article (Kempf et al., 2017), we have now understood, based on a corpus of 32 scripts in the English language, that since Tobler and Thomas, the literature has always highlighted the same factors of efficacy. This literature review also identified a certain number of protection factors for the use of psychotropic substances, which are interesting to develop in the context of early intervention: the support of adults, especially parents, and the quality of the relationship between adults and young people, the feeling of wellbeing linked with the living conditions within the academic structure and the importance of prevention messages in media campaigns, for example, that have had a positive impact on the levels of experimentation with psycho-active substances (Figure 1.1).

Figure 1.1. Magnified schematic of the factors of intervention efficacy in the school environment on the theme of preventing addictions from Tobler (2000) and Thomas (2005), enriched by Kempf et al. (2017) (literature review)

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In terms of risk factors, this recent study of the literature mainly identifies environmental factors (James, 2011; Huang et al., 2013) that are not specific to children and adolescents. Risk factors expressed in a dominant way in our literature review are stressful situations, between peers, with which children and adolescents are confronted. Aggressive and violent situations (Ridenour et al., 2012; Liu et al., 2013), peer pressure and peer influence (Donovan et al., 1991; Gaffar et al., 2013) have a significant impact on early drug abuse. Another lesson from this literature review is linked to the age of the young audiences who are affected at the international level by prevention actions and the intervention locations. The majority of studies in our corpus were carried out in school contexts. Few of them look specifically at children between the ages of 6 and 11, whereas the majority is based on the 10/14-year old slot. These studies mainly focus on first experience with substances, particularly alcohol, tobacco and cannabis. In this body of scientific texts, we have also examined emerging studies that look at new dependencies: Internet, smartphones and video games. However, although the prevention of legal and illegal drug use has been the object of numerous studies among adolescents for more than 30 years (Kandal and Logan, 1984; Botvin et al., 1995; Chen and Kandel, 1995; Duncan et al., 1997; Botvin and Kantor, 2000), the prevention of behavioral dependencies such as Internet or video game addiction has been investigated less (Bennett et al., 2008). Moreover, the issues linked to the use of online games have only been around in the DSM-II since 2013 (American Psychiatric Association, 2013, p. 795). A preventative approach founded on an ecosystem approach is considered appropriate by several authors. It is an assurance of the positive effects of interventions in terms of the reduced use and delay in age of experimentation, among others (Collins et al., 2011; Inman et al., 2011; O’Neill et al., 2011; Lan and Lee, 2013; Spoth et al., 2013), thus joining earlier studies of preceding literature reviews (McLeroy et al., 1988; Stewart-Brown, 2004). We observe that in all the articles of this literature review, neither health professionals nor addiction experts2 are present in the preventative actions 2 Olivenstein then said “Addiction is a meeting of a product, an individual and a society”.

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concerning children. As previously mentioned, the academic context is overrepresented in the 32 articles of the corpus and it is therefore not surprising that teachers are often led to intervene. Other professionals, such as social workers and psychologists, are also represented, but to a lesser extent. Parents are invited to participate in all studies and their active presence has proven to be necessary when attempting to act efficiently with children. These data validate the legitimacy of adults (parents, teachers, educators, social workers) (Duff et al., 2003) with an educational mission aimed at younger children. Nevertheless, this literature review serves as a reminder of the small number of research works on the prevention of addiction in young children and adolescents. This observation can be extended to health education and prevention in general, especially in France. Although we were convinced 20 years ago of the benefit of investing in these fields of research, the observation, unfortunately, persists. 1.4. Why speak of leading practices in health? In order to specify our intention of favoring the term “practices” over that of “behavior”, we will lean on the theme of addictions. With regard to the prevention of addictions, in which the expression “addictive behavior” prevails, it seems useless to review the use of the term “practices”. Nevertheless, preferring “practices” over “behaviors” means changing the thought paradigm. We have just addressed efficacy factors such as they are identified in the literature after passing through filters for protection factors and risk factors. However, the use of these terms brings up dimensions that are centered around behaviorist approaches aiming to get the subject (or, in this conceptual approach, the individual) to adopt favorable or protective behaviors. Yet we know that the wide variety of models that attempt to explain the complexity of the addiction issue are linked to the intricate weaving of the biological, psychological and social dimensions of the subject who is himself within a particularly dynamic environmental context which influences his abuse. Over the last 20 years, the approach first used for psychotropic substances has gradually moved toward consumption modes (Paquet, 1998),

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challenging the danger of products regardless of their licit or illicit status (Roques, 1999) and resulting in the notion of “addictive practices” that should be managed within a global approach (Reynaud et al., 2000; Reynaud, 2002). The wholeness of the approach, across the term “practices”, underlines the interest of considering addictions systematically. This wholeness is intrinsic to questions of public health3. In a French article entitled “Addictive practices in the workplace: impasse of the concept and new perspectives”, Gladys Lutz (2015) showed that “the medical, judicial, and moral perspectives, by defining the practical addictive field and the workplace through their essentially toxicological and normative background, fail to problematize these issues and contribute in masking them. […] They even take part in a sort of disqualification from other approaches that could shed light on them. The medical, judicial and moral contexts nullify all questioning on the ambivalence of sense and the effects of consumption of psychoactive substances in connection with work”. This reflection falls back on epistemological foundations that have a direct incidence on the how the usages, the subjects who consume the psychotropic drugs and the environment in which they evolve are considered (Morel, 2007). In 1998 and 2002, professors Paquet and Reynaud described the dynamic of the relationships held by users with psycho-active substances: non-use (absence of consumption), use (consumption that does not result in any health consequences), misuse which includes use at risk (situational risk, driving, pregnancy, etc.), quantitative risk (consumption above certain quantities: long, regular, significant, etc.), harmful use (consumption mode detrimental to health), and dependence, which is characterized, in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (1994), by the “inappropriate” use of a substance, leading to clinically significant distress or dysfunction. We see that although the historical anchoring in the field of psychiatry had an incidence on the terms used, these correspond to considerations that evolve over time. Nevertheless, it remains difficult to remove addictions from this idea of “use” which also puts into question the educational postures addressing these questions of addiction. Thus, many adolescents (and even more children) did not enter 3 In his paper entitled “The extraordinary science of addictive junk food” (Pulitzer Prize 2010) on E. coli in minced beef, Michael Moss, investigative reporter at the New York Times, showed how agro-industry multinationals used salt, sugar and fat to get us hooked.

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into consumption or “use”. To use the words of Prof. Didier Nourrisson, speaking of a “non-using” public qualifies it by an act that it does not carry out, for example, “non-smokers”, “non-consumers”. Pascal Courty, doctor in psychiatry and education science at the university hospital of ClermondFerrand (France), insisted on the word “consumer” in the 2000s. For him, since we live in a so-called “consumer” society, it is not surprising to “consume” psychotropic drugs. Alain Morel (2006) in turn brought up terms that are equally rich in meaning in the fields of care and drug abuse: “drug addict in treatment”, “ex-addict”, “dependent patient with a prescription of substitute drugs”, “abstinent or stabilized drug addict”. Prof. Laurent Gerbaud added that “the drug addict is a consumer ideal: once he starts consuming, he cannot stop himself”. Across the diversity of terms used, we note the legacy of care and the interest in considering, through preventative actions, the subject rather than his characterization via the products that he does or does not consume. Thus, we can pertinently establish prevention approaches that focus on the subjects and their practices in the varied situations which they might encounter, and which call for responses that are themselves heavily influenced by these psychosocial contexts. These social interactions between peers or within a joint community position themselves crucially between collective behaviors and individual behaviors. They allow the structuring of who we are and what we become, as well as the decisions that we make. Alain Morel (2006) refers to the syndrome of the “banana”: “An experiment carried out in the laboratory of an American university and reported by Patrice Nominé (2004): 1) put twenty chimpanzees in a room; 2) hang a banana from the ceiling and set up a ladder providing access to the banana; 3) ensure that there is no other way of reaching the banana other than by using the ladder; 4) install a system to make freezing water rain down over the entire room as soon as the ladder is climbed; 5) the chimpanzees quickly learn that they should not climb the ladder;

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6) stop the freezing water system so that climbing the ladder no longer sets off its annoying and painful effect; 7) now, replace one of the 20 chimpanzees with a new one. The latter, almost as soon as arriving, will of course try to climb the ladder to get the banana and, without understanding why, will be beaten by the others; 8) replace another one of the original chimpanzees with a new one, who will, of course, make the same attempt. The latter will also be beaten and the one introduced just before will hit the hardest; 9) continue the process until there are only new chimpanzees; 10) thus, none of the chimpanzees will try and climb the ladder, and if there were one who for some reason dared to set foot on the first rung, he would be massacred illico presto by the others. Most remarkable is that not a single chimpanzee will act differently henceforth, and without the slightest idea why. Thus, the ‘bananamania’ myth was born. This is how myths are born… Except that in matters of drugs and addictions, there is always someone who will climb the ladder, despite all the warnings, wanting to eat the banana all the same” (Morel, 2006). This example highlights an objective that has been taken up many times in the institutional texts for national education (the 1998 bulletin marking the appearance of these texts) or in health education research: that of “constructing a free and responsible individual”. Yet, in the end, who is responsible? The subject? The environment, through the configuration of these chimpanzees’ testing room? Of what and in terms of what? This idea of “freedom” and “responsibility” remains to be clarified and it is highly likely that one book will not suffice. A “practices”-based approach allows, from our point of view, the modification of the order established by the “behaviors”. Moreover, “addictive behavior” is quite an unclear expression and rather difficult to

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define. In order to trace the outline of this approach, we will emphasize the idea of “bringing to” and “bringing to do”. However, the idea of “conductivity” constitutes a potentially important obstacle for addressing prevention. It assumes a transmission, like a body conducting heat or electricity, which is itself due to the characteristics of the conducting body. This idea brings with it another notable difficulty with regard to the prevention of addictions: the theory of spiraling that leads to the idea that there is therefore a passage from so-called “soft” drugs to “hard” drugs, which is absolutely not systematic. In fact, this reasoning coincides with that of believing that addressing emotional and sexual life will incite them to move onto the act. Let us be rid of these old demons that reduce subjects to their behavior. The term “practice” is of a completely different nature. It places behaviors within the action and what they are based on. It refers back to “know-how”, to something that is “put (or not) into practice”, “a way of acting”, a “power to act”. The use of the term “practice” gives as much importance to the subject as it does to the social and societal environment lying on his shoulders, which determines the health of subjects. The subject is no longer a “conductor”, he “acts” as he can with his own strength or weakness, as a social being confronted with social norms. In his life, he develops practices that permit him to “live a possible life” (Lecorps and Paturet, 1999). These practices then become favorable for analysis. We will complete the term “practices” with “health-determining practices”. Health determinants help the subject to be seen in a more global perspective that is beneficial for their health. In addition, the word “practice” is to be connected with concepts in health. Linking “concepts” and “practices” means moving away from the too-restrictive term of “behavior”. A behavior has the particularity of being confined to the domain of addictions. However, the words that will follow in this book are broader. They invite us to consider the subject “in” and “by” what he does in his daily life. We will not center our words around how he “behaves”, on the attitudes he adopts and shows, but rather on the unwavering link between the way in which he perceives the world and the decisions that he makes to adapt to situations, and that are translated – or not – through acts. His practices refer to a whole, oscillating between what the subject does, what he could do or does not do at all, and what he has decided to do without necessarily managing to. It is therefore a question not of reducing the subject to his behaviors, but rather of looking into the whole which constitutes and

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determines him. Speaking of “practices” means integrating this complexity, which is inherent to the subject with the power to act or not in a favorable manner for their health. We have mentioned the importance of bringing together the determining practices for health, for which the subject has (or has not) the power to act, in order to speak of “health-determining practices”. Taking these practices into account in the field of prevention will then question the underlying health concepts. Similarly, this approach becomes particularly useful in research as an intervention, in education and training. By engaging in a reflection of health practices and the links that can be established with health concepts, we then enter into an approach that turns the traditional – perhaps even “traditionalist” – centering of teaching allegedly “fundamental” disciplines on knowledge on its head, as observed in the French educational system. This centering is not very effective in the field of health. Moreover, the regular use of this term in the media by the national Minister for Education or parts of the general inspection who refer to “fundamental disciplines” is surprising: fundamental with regards to what? For whom and according to what societal intentions? As if the mastery of language, mathematics, science and history should compete with a view to be classified, to put forward a hierarchy by order of importance, thus relegating what is “secondary” to the background: visual arts, music and of course, the field of health, the poor parent of educational systems. We may lament it, but it is how the French educational system has been structured for decades. This system increases social inequalities and makes it difficult for the most underprivileged social strata to progress in society. When we look at how, from one French government to another, the dogmas that animate thoughts on education hover between a traditional view of disciplines and a more open view, we concomitantly find, in the successive laws on education, postures suggesting a shift from the subject placed at the center of the system (the 1989 orientation law) and knowledge that has slowly predominated (orientation law from February 14, 2002, reinforced by the 2005 law). Health education does not escape these constant fluctuating movements. We put forward the hypothesis that the possible relationships between “education” and “health”, which we have progressively argued through these words, have difficulty finding their place in the French education system because they refer to a fundamental epistemological rupture between systems geared mainly for the transmission of knowledge and a desire to bestow subjects with a power to act. The institutional context of school in France is a carrier of “culture” that implies

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specific, coded and normalized – even normative – instrumented usages, deeply anchored in disciplinary teaching. Nevertheless, certain school practices are evolving in part and their visibility, notably through the additional value of approaches favoring goodwill in academic establishments, enables the progress of the institution. This progress slowly finds itself forced to take into account the resources that school establishments mobilize to overcome difficulties such as school dropouts, violence in school, etc. Making students express themselves on their feelings of wellbeing, on the way in which they perceive a health theme, is becoming more acceptable, as long as we do not forget the “fundamentals” borne by the disciplines of the same name. 1.5. What are the unwavering links between “research” and “intervention”? In the following part of the book, we will commit to a posture linking “research” and “intervention”. In Chapter 2, we will use an international and national bibliography in order to detail the epistemic grounding of the social representations applied to the field of health, and then the outline of terms related to these representations. This will be a case of adopting a critical eye (in the sense of a reconsideration, but also of a fruitful theoretical inspiration) with regard to the use of the term “representation”, applied to the field of health. In Chapter 3, we will address a framework of theorization of conceptions and systems of conceptions in health. From an initial definition of the conceptions that we have mobilized in our works prior to this book, we will propose a set of seven criteria that allow, on the one hand, the theoretical centering of a conception of health and systems of conception and, on the other hand, the presentation of an interpretative model of these conceptions. This theorization will allow us, in Chapter 4, to address mechanisms that take contexts into account, leading to the creation of tools between research, intervention and actions for teaching. By leaning on the use of the corpus of images developed and on a conception that is continuously used, we will update the bases for a pedagogy and an andragogy that are explicit in health, falling within a practice-integrating model.

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We also envisage, in Chapter 5, new avenues to explore that seem promising within works of research as well as for prevention interventions. For this, in Chapter 6 we propose setting out the criteria for situations of compilation associated with foundations for an andragogy in health that is more effective through teaching.

2 Social Representations of Health Conceptions

Although acting ahead of time using the most effective prevention possible is part of a societal plan’s leitmotif, we should nevertheless question the data underlying this prevention. We will see how, at the international level, there is relatively little data to help adapt prevention strategies to the young audiences they target. This chronic deficit of qualitative research is paradoxical in character, given that prevention is considered indispensable. We will see how the use of certain terms from disciplinary fields, notably social psychology, needs to be questioned. It is a case of generating a paradigm change which will bring us closer to the reality of the subject as a singular being, and allow us to remove the subject from the mind-set of the “social whole” within which it is often trapped. In addition, we will not miss this opportunity to question the various conceptualization attempts that have shown that other thought paradigms are possible. 2.1. Can we speak of quantitative preponderance? The preponderance of epidemiological studies using a quantitative approach to representations presents a certain number of limitations for apprehending perceptions in health. It is interesting to ask ourselves about the observation of an investigation using these mainly quantitative methodologies. If the objective of these epidemiological studies is to follow the state of health of populations, then they bring us very little information

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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on the dominating representations or conceptions. Putting this type of study at the forefront generates several risks: the risk of a decrease in information by accepting, for example, an underestimate of tobacco and alcohol consumption (this being the law in reports), a skewing of the numbers and an oversight in the conditions of production of the statistics (bias in the investigation, measurement and analysis). Studies that measure health practices and behaviors are numerous. Those of the largest scale are piloted in France by the OFDT (Observatoire français des drogues et des toxicomanies – French Observatory for Drugs and Drug Addictions): Baro-santé, EROPP, ESPAD, ESCAPAD, ETINCEL (for electronic cigarettes), PELLEAS (for the screen use of French adolescents), ARAMIS (for drug use), HBSC, etc. Let us take the last example. HBSC (Health Behaviour in School-aged Children) is a standardized study carried out in 41 countries in schools with young children aged 11, 13 and 15 years. It is set in the long term, integrating biopsychosocial dimensions and also allowing for the collection of data on the health behaviors of young people, the perception of their health, and on certain health determinants including social integration. It is also addressed across complementary dimensions, notably number of friends, appraisal of time spent with them, directly or indirectly, and the opportunity to discuss worrying things with them. The typical conclusions drawn from these studies are of the following nature: “Between 11 and 15 years, the proportion of friends of the opposite sex increases and, with age, the time spent with peers increases significantly, more strongly in boys, especially after class. Of course, the time spent does not predict the quality of the inter-individual links: if the time physically spent with friends increases, then the indirect exchanges that enable technological evolutions are also on the rise (text messages, Internet, and social networks).” (Le Luong, 2012). In addition to the undeniable interest of better understanding the health practices and behaviors generated by these studies, they propose phrases around which the 11- to 15-year-old audience must position themselves. Here are a few examples: – “in general, how many nights per week do you go out with your friends?”;

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– “on how many days per week do you spend time with your friends on the telephone, sending messages (texts, etc.) or contacting them using the Internet?”; – “is it easy or not for you to talk about things that really bother you (things that are important, serious, etc.,) and with which people?”. These weighty investigation require an important analysis period. They propose trends that are useful for identifying part of the adolescents’ behaviours and their frequency, but they only describe a portion of it. First of all, because it is not possible to measure everything, and second, because the main limitation comes from its major advantage: standardized collection. If we continue to follow the previous example, this study’s adaptability to socially mobile and heterogeneous contexts constitutes an important collection bias. Habits evolve very quickly and not from one “generation” to another, but within the same generation. In 2018, 15-year-old adolescents rarely send text messages, or only do so in college to spread information on classroom changes, or when they do not have access to Wi-Fi. Large bandwidth subscriptions still present a high cost, but we predict that in the next few years, the democratization of Wi-Fi will be the gauge for new practices. The dominant use is (at the time of writing) that of social networks such as Snapchat or Pinterest. We know, for example, that at the same time, adolescents are deserting Facebook in record numbers. In contrast, their parents’ generation – people of 40 years of age or more – are heavily represented, and comprise the largest-growing demographic for this type of network. We will not go into the details of Internet media use, but it is also necessary to contend with the “propensity to ‘share’ on several platforms at the same time (which) constitutes a blind spot for work on the Internet and in media sociology” (Millette, 2013). A second comment focuses on the conception of the questions that the HBSC surveys asked the adolescents. Pupils (remember, this study takes place in a school context) were asked to position themselves on questions that are not rooted in a recent qualitative collection, but that came from a college of experts on the relevant health themes. There is a high risk of measuring “adult” indicators, meaning indicators that adults wish to learn about, which may not adolescents be a real concern of. Although this perspective has the benefit of soothing the adult world on these practices, we learn only a few things about the new contours outlined by adolescents on what we measure. Certainly, science takes a long time, which is not

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compatible with a context of rapid evolution, particularly when it is a question of digital habits, but it is a significant point of vigilance in hoping to get closer to the reality of things. Nevertheless, at the European and national scale, these measures with all the limitations that we have just highlighted do not induce any debate. These studies, certainly interesting, enable the updating of global trends (as is there ambition), but they must be taken for what they are. When we look from an educational point of view, then they provide mainly contextual elements. However, they do not give us the option of gearing up to act on the representations and conceptions of children and adolescents based on what they tell us with their own words (and not with the words of adults), about the dimensions constitutive of their health, their behaviors, and their relationships with their peers and adults. In addition to the absence of any questioning of the contents of these studies, their main virtue is to safeguard the population and leaders by letting them believe that we “know”, when ultimately we know very little on the way in which modern adolescents see the world. This is a major obstacle for the prevention and education in the field of health, which we will come back to in Chapter 5, dedicated to the tools for investigating health conceptions. The “institutionalization” of these studies piloted by the State is an important criterion for reflection on the social and societal finalities that underlie them. 2.2. What qualitative studies are available to us at the international scale? Although “on the epidemiological plan, we know what must [should] be done for a population to remain ‘in good health’, […] it is much more complicated when we lean on the question of educating for individual behaviors and the avoidance of risky practices…” (Berger, 2011) by placing ourselves in a holistic perspective of health, which integrates multiple dimensions: “physical health, mental health, social health and the ability to be included in a network of social relationships, sexual health and the ability to recognize and accept one’s sexual identity, emotional health and the ability to recognize one’s own emotional states and to react appropriately, are therefore designed in permanent interaction” (ibid). In fact, bringing “education” and “health” together forces us to look into open qualitative approaches in order to research how health is outlined, what its

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issues are, and even its perspectives from the point of view of children, adolescents and adults. We see that qualitative health education research works that investigate social representations are essentially structured around themes of health with, as a main thematic, education on emotional and sexual life, and the prevention of addictions or consumption of psychotropic substances. Published works are mainly centered on adults. As examples, we quote the works of Leyrit et al. (2007), Araújo et al. (2009), Berger et al. (2009a, 2009b), Carvalho et al. (2010), Pizon et al. (2010), Simar and Jourdan (2010), Mbazogue-Owono (2011, 2013), Cardot and Berger (2013), and Montino and Sartoretti Guignard (2013). Faced with this predominance of epidemiological surveys and qualitative works revolving around professionals or future professionals, we sought to identify qualitative methodologies including children, adolescents and young adults in international publications (Pizon and Roychowdhury, 2018). Our investigations were structured around 3 themes: (A) health in general, (B) health themes and (C) health related themes. Seven databases were used, PubMed, Revue.org, Google Scholar, Emerald, ScienceDirecct, SAGE Journals and SUDOC, around key words linked to health in its biopsychosocial dimensions and in connection with health themes. The first observation is the relative scarcity of international publications using a qualitative or mixed methodology. Of the 55 articles identified in a first reading on the theme of health in general, 30 were selected for a more detailed analysis and only 12 were kept. These texts look at the manner in which children, adolescents and young adults (4–20 years old) address health (Appendix A.1 and Table 2.1). These works come from England, the United States, Russia, Kenya, Spain and Hungary. None of them look at several countries at a time. It appears that a high and diverse level of knowledge and representations on health is identified (Backett and Alexander, 1991; Pridmore and Lansdown, 1997; Piko and Bak, 2006; Davó-Blanes and La Parra, 2012). We note that the studies choose a variety of approaches, but without real comprehensiveness, giving the impression of having been carried out with the flow of opportunities linked to research themes: study of the incidence of prevention campaigns using social marketing (Fairbrother et al., 2016), the emotional aspects linked to health (Kamakina, 2016), the perception of adolescents and young adolescents in terms of behavior that is favorable

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or unfavorable to health (Hobbes et al., 2006; Garcia et al., 2007), the influences of the Internet on the feeling of wellbeing (Hernán-García et al., 2015), and the study of the influence of a health education approach within a young Kenyan audience (Onyango‐Ouma et al., 2004). Titles

Main results

Fairbrother, H., Curtis, P., Goyder, E. (2016). Making health information meaningful: children’s health literacy practices. SSMPopulation Health, 2, 476–484.

Children showed that they had access (and interacted) with a wide variety of sources of information on health, including social marketing campaigns, school, family, media and advertising, as well as health professionals.

Kamakina, O.Y. (2016). Features of psychology of health of primary school children. Procedia-Social and Behavioral Sciences, 233, 192–195.

Revealed an emotional richness in children’s perception of health.

Hernán-García, M., Botello-Díaz, B., Marcos-Marcos, J., ToroCárdenas, S., Gil-García, E. (2015). Understanding children: a qualitative study on health assets of the Internet in Spain. International Journal of Public Health, 60(2), 239–247.

Internet is beneficial to health and wellbeing. The results underline the importance of the Internet as a source of information, communication, entertainment and educational games.

Davó-Blanes, M. C., La Parra, D. (2012). Children as agents of their own health: exploratory analysis of child discourse in Spain. Health Promotion International, 28(3), 367–377.

The pupils of primary schools have a constructive concept of health in which they are conscious of the role that they play in bringing change on a personal level and in the school environment, but also, to a lesser extent, in a broader social context.

Garcia, C.M., Duckett, L.J., Saewyc, E.M., Bearinger, L. H. (2007). Perceptions of health among immigrant Latino adolescents from Mexico. Journal of Holistic Nursing, 25(2), 81–91.

The health perceptions of adolescents are described using the words and images of participants based on the three thematic axes that emerged from the data: being in good health, healthy influences and behaviors, and the influences or behaviors unfavorable to health.

Piko, B.F., Bak, J. (2006). Children's perceptions of health and illness: images and lay concepts in preadolescence. Health Education Research, 21(5), 643–653.

Children have considerable knowledge on the health risks and illness. They also seem aware of their health and display positive attitudes toward health and health promotion.

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Hobbs, R., Broder, S., Pope, H., Rowe, J. (2006). How adolescent girls interpret weight-loss advertising. Health Education Research, 21(5), 719–730.

Many girls cannot identify why advertising generates emotional or visual reactions.

Onyango‐Ouma, W., Aagaard‐Hansen, J., Jensen, B.B. (2004). Changing concepts of health and illness among children of primary school age in Western Kenya. Health Education Research, 19(3), 32–339.

Pupils can change and widen their concepts of health and disease through health education geared toward action. There is a clear difference between drawings before and after the intervention.

Pridmore, P. J., Lansdown, R.G. (1997). Exploring children’s perceptions of health: does drawing really break down barriers?. Health Education Journal, 56(3), 219–230.

All methods provided roughly the same number of categories, whereas drawing and writing revealed more on how ideas were articulated. Labeling and writing generated more information on the perception of physical signs of good or poor health, as well as on the appearance and use of drugs and eating habits. Drawings helped to decipher writing difficulties. The results also suggest that the method using writing alone is a rapid way to identify the main conceptions.

Backett, K., Alexander, H. (1991). Talking to young children about health: methods and findings. Health Education Journal, 50(1), 34–38.

The study indicated that the majority of children seem relatively well informed on foods that are classically deemed “healthy” and “unhealthy”. However, questions on personal food preferences and the effects of different foods on the body revealed contradictions and confusions. This article underlines that, like with adults, speaking to children about beliefs and behaviors linked to health is an arduous methodological task.

Table 2.1. Qualitative or mixed scientific publications looking at how children, adolescents and young adults address health (see detailed table in Appendix A.1)

We see the same scarcity of publications on the theme of health (Appendix A.2 and Table 2.2). Thus, only four articles address the subject of the perception of tobacco or alcohol consumption in young people between 7 and 20 years of age (Lucas and Lloyd, 1999; Portacellato et al., 2002;

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Johnson et al., 2003; Farmer et al., 2016). Three articles look at the representations and knowledge of cancer among young people between 7 and 16 years of age (Bluebond-Langner et al., 1990; McGregor and Reeve, 1992; Oakley et al., 1995). Finally, three articles focus on the perception of diet in young people between 4 and 18 years of age (Zeinstra et al., 2007; Swaminathan et al., 2009; Schultz and Danford, 2016). These studies were carried out in the following countries: United States, England, Denmark, India, Canada and the Netherlands. Titles

Main results

Farmer, S., Porcellato, L. (2016). Thinking about drinking: Exploring children’s perceptions of alcohol using the Draw and Write tool. Health Education Journal, 116(6), 541–560.

The majority of the data gathered (71 %) were made up of generalities expressed with regard to alcohol.

Schultz, C.M., Danford, C.M. (2016). Children’s knowledge of eating: An integrative review of the literature. Appetite, 107, 534–548.

This study shows that, even before receiving a formal education, preschool children had a rich knowledge linked to diet. They also understand concepts linked to diet, nutrition and the body that come from their sensory experiences, which they consider as being the right ones.

McGregor, S.E., Murphy, E., Reeve, J. (1992). Attitudes about cancer and knowledge of cancer prevention among junior high students in Calgary, Alberta. Canadian Journal of Public Health, 83(4), 256–259.

The students in the survey (n = 246) think that cancer is a serious illness that does not respond particularly well to treatment and that is caused by many things. Around half the students said that the prevention of tobacco consumption was an important factor in the fight against cancer. The majority of students (71 %) wanted more information on cancer. The results of the survey show a need for cancer prevention tools in school programs.

Swaminathan, S., Thomas, T., Kurpad, A.V., Vaz, M. (2009). Perceptions of healthy eating: A qualitative study of school-going children in South India. Health Education Journal, 68(2), 94– 110.

Their way of apprehending a healthy diet gave rise to several concepts. Children’s perceptions of the significance of healthy eating. Considering food as healthy or unhealthy varies based on several sociocultural factors. This age group’s limited experience with food consumed is reflected in the responses given.

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Thastum, M., Johansen, M.B., Gubba, L., Olesen, L.B., Romer, G. (2008). Coping, social relations, and communication: a qualitative exploratory study of children of parents with cancer. Clinical Child Psychology and Psychiatry, 13(1), 123–138.

All the children knew the name of their parent’s illness: the observations and expressions of children leads to the identification of four adaptation strategies used by the younger generation: helping others, parenting, distractions and the act of keeping it in mind.

Zeinstra, G.G., Koelen, M.A., Kok, F.J., De Graaf, C. (2007). Cognitive development and children’s perceptions of fruit and vegetables; a qualitative study. International Journal of Behavioral Nutrition and Physical Activity, 4(1), 30.

The study obtained a list of preferred and hated food groups. It also generated a list of the vegetable consumption situations and healthy diet strategies invented by parents and children. This study shows that the stage of cognitive development of children plays a role in their preferences and perceptions of fruit and vegetables in terms of their concept of health.

Johnson, J.L., Bottorff, J.L., Moffat, B., Ratner, P.A., Shoveller, J.A., Lovato, C.Y. (2003). Tobacco dependence: adolescents’ perspectives on the need to smoke. Social Science & Medicine, 56(7), 1481–1492.

The many ways that tobacco dependency is experienced in the lives of young smokers shows that they call on different aspects: social, pleasure, emancipation, emotional and straightforward tobacco dependence.

Porcellato, L., Dughill, L., Springett, J. (2002). Using focus groups to explore children’s perceptions of smoking: reflections on practice. Health Education, 102(6), 310–320.

The responses were short and simplistic. There were some that were incoherent or difficult to understand. Emergence of many themes: knowledge of smoking, points of view of adults who smoke, points of view of child smoking, and ideas for the prevention of smoking.

Lucas, K., Lloyd, B. (1999). Adolescent smoking: the control of mood and body image concerns. Health Education, 99(1), 17–26.

When adolescents of different ages and genders were questioned, those who smoked noted more stress in their life. They expressed it by talking about adaptation strategies to free themselves of cigarettes or focusing on the problems encountered when smoking. To a lesser extent, smoking was perceived as a social coping element.

Bluebond-Langner, M., Perkel, D., Goertzel, T., Nelson, K., McGeary, J. (1990). Children’s knowledge of cancer and its treatment: Impact of an oncology camp experience. The Journal of Pediatrics, 116(2), 207–213.

80% of the children encountered participated in a spontaneous manner in the discussion on cancer and its treatment. This was a study over 2 years based on mixed methods with 50 children participating in a summer camp.

Table 2.2. Qualitative or mixed scientific publications looking at how children, adolescents and young adults address health themes (see detailed table in Appendix A.2)

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In order to broaden our research, we also investigated themes related to the theme of health (Appendix A.3 and Table 2.3). Nine articles found pertained to emotions and feelings, pain, and the beliefs of young people (5– 17 years old) with regard to health, disease and their perceptions and understanding of various themes linked to health. These studies were carried out in developed countries only (United States, Canada, Greece, Finland and England). Titles

Main results

Misailidi, P., Bonoti, F. (2008). Emotion in children’s art: Do young children understand the emotions expressed in other children’s drawings?. Journal of Early Childhood Research, 6(2), 189– 200.

The results showed that (1) at the age of 3, children demonstrated and understood the emotions expressed in pictures; (2) happiness, sadness and fear were the emotions the most easily recognized by the participants.

Kortesluoma, R.L., Punamäki, R.L., Nikkonen, M. (2008). Hospitalized children drawing their pain: the contents and cognitive and emotional characteristics of pain drawings. Journal of Child Health Care, 12(4), 284–300.

The differences obtained in this repository show more neediness, distress and tension among hospitalized children compared to non-hospitalized children.

Larsen, J.T., To, Y.M., Fireman, G. (2007). Children’s understanding and experience of mixed emotions. Psychological Science, 18(2), 186– 191.

The older children showed a better understanding of mixed emotions compared to the younger children in the study.

Dell’Api, M., Rennick, J.E., Rosmus, C. (2007). Childhood chronic pain and health care professional interactions: shaping the chronic pain experiences of children. Journal of Child Health Care, 11(4), 269–286.

This study aimed to understand how children perceived their interactions with the health professionals who influenced their experience of chronic pain. The experiences of children with the health professionals play a role in their approach to current and future encounters on matters of healthcare.

Bruce Morton, J., Trehub, S.E. (2007). Children’s judgements of emotion in song. Psychology of Music, 35(4), 629–639.

Verbal and musical indices linked to emotions were coherent (both refer to the same register of sadness or joy). The perceptions expressing the musical lexicon or indices were on the same lines.

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Kortesluoma, R.L., Nikkonen, M. (2006). “The most disgusting ever”: children’s pain descriptions and views of the purpose of pain. Journal of Child Health Care, 10(3), 213–227.

The results show that young children can competently communicate their experiences of pain. The words that they use give a good indication of the importance of pain.

Pederson, C., Parran, L., Harbaugh, B. (2000). Children’s perceptions of pain during 3 weeks of bone marrow transplant experience. Journal of Pediatric Oncology Nursing, 17(1), 22–32.

The children of the study group described their perceptions of past pain, the expectations linked to pain and to experiences of pain. They explained that pain was a “discomfort” and an “injury”.

Pridmore, P., Bendelow, G. (1995). Images of health: exploring beliefs of children using the “draw-andwrite” technique. Health Education Journal, 54(4), 473–488.

The main categories of responses identified on beliefs linked to health were as follows: diet/healthy foods (fruit and vegetables), physical exercise, hygiene, not smoking and sleeping well. These results largely echo the study by Williams et al. (1989).

Table 2.3. Qualitative or mixed scientific publications looking at how children, adolescents and young adults address themes related to the theme of health (see detailed table in Appendix A.3)

2.3. Why is there still a paradox in health education? The lack of publications adopting a partial or total qualitative methodology for international studies looking at children, adolescents and young adults is cause for debate. Several hypotheses can be put forward. The first is linked to the publication strategies of research teams and the review policies for questions of health. When publications pertain to results from a quantitative questionnaire, the qualitative phase of validation of this questionnaire is rarely part of the publication. The background teams are often dominantly quantitative and this first phase is not part of any robust publication strategy. In France, except for the works that we lead, we have not found a single publication on the health of children, adolescents and young adults with uniquely qualitative methodologies. A second hypothesis could be qualified as a “health education paradox”, in reference to the French paradox which highlights the increase in social health inequalities despite the progress in the quality of care. This Health Education Paradox could also be built on the Prevention Paradox described by Davison et al. (1991) and, more recently, in the field of prevention of

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addictions by authors who highlight that on the whole, the biggest drinkers in college (a relatively small group), who should generate the most disturbance in their surroundings, ultimately cause the least in comparison to the larger group of low level drinkers (Wetzman and Nelson, 2004). Similar behavior has been shown in the Swedish army (Rossow and Romelsjö, 2006). However, Skog (1999) nuances the description of this Prevention Paradox. In a publication that appeared in the International Journal of Epidemiology, Hunt and Emslie (1991) link this Prevention Paradox to an intervention in high-risk audiences and explain its relative effectiveness by its high cost. The definition of the “health education paradox” that we propose here illustrates the fact that for decades, we have woven prevention and health education policies based on very little qualitative data from research and enabled the description of how children and adolescents view their health and the theme of health. This paradox reveals that the data underlying the actions mainly come from intervention practices. Although the links uniting “research” and “intervention” are powerful and particularly intertwined in the field of prevention, it makes it no less paradoxical to note that, at the international level, research looks very little at the emergence of conceptions in health from a qualitative perspective. Confining this characterization of conceptions to information collected in the context of health intervention practices does not contribute to the national or international visibility. On the contrary, it keeps them in a diffuse position, either only a little formalized or not at all, leaving room for significant dimensions in the perception of what assumes importance or not for actors of prevention. 2.4. What meaning should be given to the terms used in publications? With regards to the international literature on the qualitative approaches of studies focused on health in young people, three terms emerge in a dominant manner: “perception”, “belief” and “knowledge”. 2.4.1. The term “perception” The term “perception” can be defined according to the CNRTL (Centre national de ressources textuelles et lexicales – National center for textual and lexical resources – CNRS/France) as a “complex psychological

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operation in which the mind, by organizing sensory data, forms a representation of external objects for itself and acquires knowledge of what is real”. A perception can therefore be reduced to sensations resulting from sensory organs only, but must be expanded to a mental process. Thus, psychoanalysis makes the distinction between external perception and internal perception, the first being founded on sensations derived from sensory organs, whereas the second leans on the awareness that we have “internal” mental processes1. In the definition that it gives perception, psychology reinforces the idea of “awareness of…” and “relation to the world”. Studies on so-called “perception” will therefore aim to characterize how we promote awareness of our relationship with the world around us through our perception of various objects such as health. Moreover, this term notably makes sense in quantitative surveys (Godeau et al., 2015; Tuchman, 2015). The word “perception” has a valence that is both quantitative and qualitative, especially when it is associated with another term: risk perception, danger perception, etc. It remains a lexicon that is not clearly substantiated at the theoretical level. Speaking of “perceived health” usually relates to studies within public health, which tend not to use social representation terms in order to avoid being dragged into fields of study such as human and social sciences. In relation to the phrase “perceived health”, we find the inferences: disease, indicators, quality, questionnaire, scale, factors and determinants, predictor, etc. The term “perception” seems to have fallen into a common meaning, including in the qualitative studies that we have surveyed (Pederson et al., 2000; Porcellato et al., 2002; Piko et al., 2006; Garcia et al., 2007; Zeinstra et al., 2007; Swaminathan et al., 2009; Farmer et al., 2016), in which we did not find theoretical references defining it. 2.4.2. The term “belief” Speaking of “belief” refers to a “reservoir of preconceived values and ideas”: we talk about “personal” beliefs (in the sense of a personal and pragmatic dimension, of the idea of immediate application for the subject) and “shared” beliefs (in the sense of a social group, which allows the questioning of school, family, etc., contexts). Belief, therefore, contrasts with scientific knowledge in the sense that it comes more from a conviction 1 www.cnrtl.fr/lexicographie/perception.

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or faith that a subject or a group of subjects cannot impose onto others in the same way as scientific knowledge imposes itself on us. Belief has a speculative dimension that tends toward the constitution of an opinion. Religious philosophy defines the consequence of belief as the “adhesion of the spirit which, without being entirely rational, excludes doubt and is made up in part from personal conviction, from an intimate persuasion”2. The Marxist current adds a dimension of fascination for an object or a person to the notion of belief. Although credulity suggests adhesion to a belief, it is doubt which frees us from it. “Authentic belief is not only that which I hold in me, but also that which I admit. And this notion of confession is perhaps what sheds the most light on that of belief” (Lacroix, 1949). Nevertheless, linking “belief” and “credulity” in this way leads to the consideration of the underlying vision, strong in its own rationality, of the scientist looking to define this belief. The characterization of a belief, expressed by Anne Vause (2010), is interesting in this regard. She proposed a schematization based on two axes (Figure 2.1): an axis of development between the individual and the social body, and a second axis between the absence of validation (“belief”) and “empirical” validation. The progressive idea is that knowledge has personal “validity” (we could speak of the validity of knowledge in health) in contrast to belief which defines itself by the absence of validation.

Figure 2.1. Beliefs and knowledge of teachers according to A. Vause (2010)

2 www.cnrtl.fr/definition/croyance.

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However, the idea of “validity” becomes doubly difficult in the field of health: who validates? The “expert”? The subject himself? Both? Is a belief necessarily invalid? It seems preferable to us to consider that a belief necessarily presents a form of validation by a subject (or a group of subjects) since the latter “believes” in its content in order to describe the reality around them. 2.4.3. The term “knowledge” The same applies to knowledge: if a scientific expert alone can deem knowledge as valid, this supposes that knowledge can be “invalid” or “erroneous”. This term is a real problem in the field of health, because thinking that health knowledge is wrong arises from a quick shortcut. However, it cannot be invalid if we adopt the position that validity can emanate from the subject, or a group of subjects (within a shared life for example) as easily as from the expert who is then no longer the only one “able” to validate. In the therapeutic education of a patient, the “expert” patient appears as the translator, a veritable intermediary between the medical world and other patients, who can bring biomedical analysis experience, the tangible and lived, in the face of rationality of symptoms and treatments. Biomedical knowledge can be likened to “justice of the peace”: they determine what is “healthy” and what is not. Nevertheless, this depends on the proof provided (whether I know what is dangerous or protective, and what is not). For Canguilhem (1992, 2005), “the organism is an organization, a structure that functions, it requires stability and regularity – somewhat like a machine assumes the circularity of its mechanisms; and yet, if this regularity were too strict and rigid, the organism would not be viable to midterm: its well-oiled mechanics would derail at the slightest irregularity. This is the paradox of disease: it shows that in a certain sense, the organism is inferior to the perfect machine, but in another sense, it is superior to it because, for all the weaknesses that the machine does not have, the organism is, however, capable of overcoming them” (Durrive, 2009). For this, the subject leans on what he believes to build alternative responses to the situations encountered. Following the discussion of these few points of caution, and in order to characterize the term “knowledge”, we use the definitions of Vause who notably falls back on the works of Legendre. “Theoretical knowledge” can be verbalized, and is part of explicit learning, in contrast to “pragmatic

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knowledge” that we are not necessarily aware of and is not verbalized (which has methodological implications). “The development of thought therefore occurs in a context of social mediation, through the appropriation of tools initially built by culture” (Legendre, 2007). This leads us to consider a third form of knowledge, which we qualify as “common sense knowledge”, and which provides an option for avoiding the term “belief”. This type of knowledge borrows elements from scientific knowledge, sometimes misunderstood, poorly assimilated and positioned at the heart of processes of the interpretation or reinterpretation of reality. Popular experience of life situations within a community is at the root of common sense knowledge and plays a role in the processes leading to their development. We could consider that this type of knowledge sits somewhere in the intermediary between science and personal experience (pragmatic knowledge), borrowing knowledge that circulates in the general population from the social body. Popular sayings are a significant example of common sense knowledge, between collective experience and science. They secure the subject or subjects on phenomena that arise in daily situations. From this point of view, this common sense knowledge necessarily has interpretative validity of situations, which removes us from a lexical field geared toward error. It allows the integration of the sacred, the profane, even the magical (see Parkson opus cited by Moscovici, 2001) without using the word “belief”, which refers to religious or mystical dimensions. Another point which we find important to highlight is the absence of a clear compartmentalization in the subject of “scientific knowledge”, “common sense knowledge” and “pragmatic knowledge”. Each of these types of knowledge have their own validity and communicate with each other. Thus, in our corpus of data, when we questioned children aged between 9 and 11 years on alcohol, we noticed that a certain number said that “alcohol makes you mad” (Pizon and Pironom, 2014). This knowledge is a copy of common sense elements that are probably confirmed by these children perception of situations experienced. This allows us to make a troubling parallel with absinthe. In the 19th Century, absinthe was a muse with a nefarious reputation who inspired many artists (Paul Verlaine, Emile Zola, Edgar Degas, and even Vincent Van Gogh). All the evils were rendered to this spirit, particularly the ability to make people go mad. Antialcohol movements then led campaigns against it, making absinthe the only drink to ever be completely banned in France in 1905. And yet, 100 years later, children tell us about this madness that can be associated with alcohol.

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Figure 2.2. “Alcohol kills!” or when the French postage stamp becomes 3 an object for prevention . For a color version of this figure, see www.iste.co.uk/pizon/health.zip

The robustness of common sense knowledge through time and its resistance to change is a powerful characteristic of this kind of popular knowledge. It is built on collective experience and more often than not proposes a seductive vision, often steeped in shortcuts and easily confirmed through hasty conclusions made by the subject based on his or her own personal experiences. This aspect also reveals the need for the interpretation of reality in the face of the complexity of the world. A radical rupture (Canguilhem, 2005) in a person’s life (the development of cancer or a chronic disease, a violent death in the family circle, etc.) can disturb the apparent robustness of these different registers of knowledge. The subject then develops new knowledge, more operational and triggered by their personal pragmatic experience since they are constructed through experiencing these new situations (Canguilhem this described with the term “lability” of causal sequences, meaning a capacity to disappear and leave space for something else). Let us take the example of a study carried out on carers of Alzheimer’s disease and related illnesses (Lecat et al., 2017). They speak of the radical 3 We leave the reader to come up with an idea of the possible uses of this stamp. You will notice that it has been magnified and that the stamp can be used alone by detaching the prevention messages around it.

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transformation of their view of the disease when supporting a close relative, and the knowledge that they acquired on the symptoms and their management. Later, we will come back to the central question of learning in the development of new knowledge. Through this example, we perceive how the evolution of health conceptions is translated by new knowledge, which is liable to bring a renewed response to originally experienced situations. In the case of the carers, it could be the placement in an institution, or the death of a relative affected by the disease; such a perspective can be experienced as a relief. Nevertheless, the three types of knowledge that we propose in Table 2.4 in no way predict the rationalities made by the subject when facing a situation. They simply constitute the ground for the decisions that the subject will make. Characteristics

Scientific knowledge (Ks)

Constitutive elements of this knowledge

Scientific data leading to scientific theories, concepts or notions, or illustrating them.

Field of validity

Valid for a group of scientific experts at time “t”.

Development process

Experimental or non-experimental scientific protocols.

Common sense knowledge (Kcs) Popular elements that are interpretative of reality, with a robustness through time and resistant to change. Valid for a group of subjects in a given environment and a shared life.

Built on the profane, the sacred, even the magic, which belongs to each culture. Collective development process.

Pragmatic knowledge (Kp) Sensitive elements that are more or less rationalized and made aware of. Valid for the subject based on his experience of situations. Built through the diversity of situations personally experienced “in” or “outside” of a collective. Generated from the experiential testing of scientific or common sense knowledge in situations.

Table 2.4. Classification of types of knowledge (K = knowledge) and associated characteristics (constitutive elements, field of validity and development process) (Pizon, 2018)

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The articulation of knowledge of a diverse nature also contributes to defining the social norms we encounter. In the field of health and prevention, we note that they evolve at various rates. In 2006, an IFOP survey revealed that of the population questioned, 80% adhered to a decree banning the consumption of tobacco in public areas. There are many examples: the resistance to the legalization of cannabis, the opening of shooting ranges, the positive social image of electronic cigarettes, etc. Norms regulate our daily life, setting “regularities”, calibrating and establishing thresholds of acceptability and tolerance. Built socially, they are imposed onto the subject, who accepts them or not. Either way, these attitudes can be described in reference to this norm, which defines socially acceptable principles of behavior and provide a better understanding of the contexts. 2.5. What are the benefits and limits of the notion of social representation in the field of health? It is pertinent to define this concept of “social representation” in more depth in order to perceive more clearly what it implies on both the epistemological and methodological levels in health education and prevention. Effectively, although many works of research in health claim to investigate so-called “social” representations, it appears to us necessary to first detail what characterizes these representations, and then to bring this conceptualization of the issues encountered in terms of research closer to health education and prevention. 2.5.1. A notion enclosing health within a “social whole” Talking about social representations means inevitably bringing up the permanent tension that has become an obsession in both human and social sciences, about the place of the subject and the place of the social. According to the authors (and we will not escape this dilemma), the reflection consists of assigning more or less importance to one or the other. The mutual alteration of one on the other nevertheless brings a nuance to the way in which this notion of representation is conceptualized, but there is little consensus; in a more or less marked way, it brings properties enabling a removal from the social whole back to the discourse on the subject. The term “social representation” is one of the founding notions of social psychology, but has also been a part of sociology since the deep crisis of the

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1970s. We could even consider that the word “representation” has become a sort of metanotion proper to all human and social sciences. This concept designates the set of beliefs, information and attitudes that social groups develop and share with regard to “objects” that are important in their environment. It designates a form of social knowledge, a thought that is socially elaborated and shared by the members of the same social and cultural whole. This is a way of appropriating and interpreting daily reality and the relationship with the world. A social representation is therefore an image of a collective reality that is strongly suggested by society to the individual (the term often preferred over “subject” in psychosocial texts). A social representation is constructed based on experiences and information, knowledge, models of thought received and transmitted through culture, education, social interactions, etc. This phenomenon of “constructing” is included in the original Latin of the word “representation” (repraesentatio), in the sense of “the action of replacing before someone’s eyes”. The “constructed” character of a representation is considered as a pragmatic response with the practical aim of organizing, in an attempt to exercise power over one’s environment by elaborating a common reality that the members of the same social group will consider as socially and culturally adapted. The action of representation by an individual covers all knowledge linked to their history, their life, their relations with others, but also the cultural aspects from the social groups that the individual interacts with. It is determined by what is “shared” by these groups and by the ways of thinking that they have produced. Social representation favors an understanding of the world or, at least, proposes an operational interpretation. In the field of health, the function of a representation is to enable the individual to give sense to their environment and organize their health behavior such that the image they have of themselves and the world around them generates a life experience. In order to have representations, a reconstruction of reality must take shape. Following from this, we can identify the cognitive processes that underline the activity of subjects. If we look in more detail at the main papers on social representations, we note that many authors (Moscovici, Abric, Herzlich, Jodelet, for example) have brought their definition of social representation, which they link to the ability to construct, even evolve. Nevertheless, we bear in mind that there is no consensus on the fact that a social representation can be transformed, with

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all the implications that this might have when it comes to intervening in health. Several definitions coexist, but it is possible to separate three common trunks and a few main branches that could be seen as elements of complementarity providing a broader span of a nuanced definition of social representation. Jean-Claude Abric considers that “social representation is the product and process of a mental activity through which an individual or a group reconstitute the reality with which they are confronted and attribute a specific significance to it” (Abric, 2001). For Gustave-Nicolas Fischer (1987), “social representation is the process of perceptive and mental elaboration of reality whereby social objects (people, contexts, situations) are transformed into symbolic categories (values, beliefs, ideologies) and conferred with a cognitive status, enabling the apprehension of aspects of normal life through a reframing of our own attitudes within social interactions”. In the 1960s, Serge Moscovici (1961), who speaks from a psychosociological point of view and as a science historian, distinguished four phases in the construction of a representation:

Figure 2.3. Construction phases of a representation according to Moscovici (1961)

– phase 1: passage of the object to the figurative model. The subject pulls information from the object, selects it and memorizes it. This is the de-contextualization phase of the object through the reflection of reality or “figurative model” or even “graphic core”; – phase 2: passage from the figurative to categorization. The figurative model will claim the status of evidence. For the subject, these are the realities; they will be used to categorize and interpret what is experienced, hence the selection of the environment;

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– phase 3: passage from categorization to the active model. This refers to an active model which will direct our behavior and relationships with others. Moscovici uses an anchoring phase or the activation of the core of the representation; this core gives meaning to events and conditions the behavior of individuals; – phase 4: constitution of the representation. In fact, here, the representation consolidates itself and generates specific expectations and anticipations. Moscovici thus demonstrated the roles of social representations in the institution of a consensus reality, their sociocognitive functions in the integration of the new, and the directing of communications and behaviors. He also underlined that social representations can be studied broadly as contents whose dimensions (information, values, opinions, etc.) are coordinated by a main organizer (behavior, norms, etc.) or in a focused manner such as through structures of knowledge that organize the set of meanings relating to the object in question. Historically, his work falls within a psychoanalytical context within which it is susceptible to giving more importance to social dimensions. Although we cannot consider him as truly falling within the Durkheim school of thought (Herzlich, 1984), he nevertheless gave it new life in the 1960s. The context was also dominated by social psychology’s behaviorist ideas (stimulus/response). According to Denise Jodelet (1991), “social representations are practical thought modalities oriented toward communication, comprehension, and understanding the social, material, and ideal environment. As such, they present specific characteristics in terms of the organization of the contents, mental operations, and logic. The social bookmarking of contents or representation processes must refer to the conditions and contexts from which the representations emerge, to the communication by which they circulate, to the functions they serve when interacting with the world and others”. We note that, from a contextual point of view, Denise Jodelet was prefaced by Serge Moscovici, in 1989, in the context of a study on support for insanity in the psychiatric environment. In an earlier paper, Jodelet (1984) highlighted six points of view on the construction of social representation (Figure 2.4):

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Figure 2.4. Six points of view on the construction of a social representation according to Jodelet (1984)

1) an approach that puts a particular emphasis on “the cognitive activity of the subject in the representative activity”. The subject is a social subject, carrier of ideas, values and models from the group that he belongs to or ideologies transmitted through society. Social representation builds itself when the subject is in “a situation of social interaction or when facing a social stimulus”; 2) another point of view insists on “the significant aspects of the representative activity. The subject is the producer of sense”. Through his representation, “the meaning that is given to the experience in the social world” is expressed. The representation is social, because it is developed from social codes and values that are recognized by society. It is therefore a reflection of this society;

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3) a third approach views the representations from the angle of discourse. “The social properties are derived from the communication situation, from the social belonging of the speaking subject, from the finality of their discourse”; 4) the social practice of the person is valorized in a fourth perspective. The subject is a social actor: the representation that he produces “reflects the institutional norms arising from his position or the ideologies linked to the position he occupies”; 5) from another perspective, the dynamic aspect of social representations is highlighted: the interactions between members of a group or between groups that contribute to the construction of representations; 6) a final point of view analyzes the manifestation of representations by postulating the idea of a “reproduction of socially established chains of thought”. The subject is determined by the dominant ideologies of society in the group within which he evolves. 2.5.2. The contested theory of the central core The theory of the structuring core has been widely diffused to define what characterizes a representation. This controversial theory gives this central core three main functions: – a generating function: the central core is the origin of the different elements of a representation. It gives them meaning and value and, because of it, these elements can transform; – an organizer function: it “determines the nature of the links that connect the elements of the representation with each other. In this sense, it is the unifying and stabilizing element of the representation” (Abric, 1997). It is only when the central core is modified that the representation transforms; – a stabilizing function: it helps to reinforce the idea of a sort of permanence of a representation and therefore its resistance to change. The central core can be considered to be constituted of elements that give sense to the representation based on the function or nature of the represented object, the relation of this object with the subject or group, and the values and norms system (the ideological context) that provide them with a

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framework. The nature of the object and the finality of the situation define the central element(s) that either take on a functional dimension or a normative dimension. The functional dimension would imply that the central elements are directly involved in the realization of a task. Abric quotes a study by Lynch in 1989, on the urban environment, highlighting that the central core of the city’s representation was formed by elements relating to urban tracking and displacement. The normative dimension, in turn, refers to central elements that are constituted by a norm, a stereotype, or a dominant attitude toward the object of the representation. The central core is therefore the most stable element of the representation. It would be very difficult to modify it, which is why Mugny and Carugati (1985) refer to a “hard core”. Peripheral elements are organized around it. A representation’s resistance to change comes from this hard core, difficult to modify and with a hold on the subject. When Abric (1994, 2001) talks about the evolution of representations, he refers to three aspects: – anchoring: this is “the social rooting of the representation and its object”. This process has several aspects related to; – the meaning: the represented object is invested with significance via the group affected by the representation. Its social and cultural identity are expressed through the meaning; – the utility: “the elements of the representation not only express social relations, but also contribute to constituting them… The interpretation system of the representation’s elements has a function of mediation between the individual and his environment, and between members of a same group”.
The common language that is created by the individuals and the groups, based on a shared social representation, allows them to communicate with each other. The reference system thus developed in turn exercises its influence on social phenomena. Based on the elements that we have just described, according to Abric, “the anchoring process, in a dialectic relationship with objectivation, articulates the three basic functions of the representation: the cognitive

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function of integrating newness, the function of interpreting reality, and the function of orientating behavior and social relations”. Its rooting in a preexisting thought system integrates new data, the individuals or members of a group classify them and then arrange them into socially established thought frameworks. Expectations and constraints are simultaneously associated with elements of the representation in terms of prescribed behaviors. 2.5.3. Other elements for a critical analysis of the notion of social representation in health In an illuminating text in 2001, Serge Moscovici applied himself to distancing the question of social representations on the historical and conceptual levels. By citing the sociologist Émile Durkheim, he reminded us that “we cannot know where a representation begins and where it ends, and in addition, our impossibility of isolating a belief or a proposition. Each subject relies on a set of interconnected insights that allow, by their association, the interpretation of the world that surrounds him”. According to Moscovici, “it remains to be seen how each member of a group stores them in their mind and communicates them” (ibid). This idea favors a reflection on Jodelet’s definition, which considers that a representation is strongly oriented toward communication, with an initial questioning on how other subjects consider it when it comes to gathering their representations. And Moscovici adds that, “for many, social representations are just that: a class of representations, of socially shared cognitions, that magnify the group and deny the individual all significance”. Representations are necessarily social in the sense that psychological means alone are not enough to lead to “impersonality, normativity” (ibid). In Moscovici’s words, we find this deep tension between the social and the subject which we refer to in our introduction on social representations. They also bring our attention to the place of norms, a very present notion in the field of health, which some authors even qualify as “social norms of reference”. This convocation of “social norms of reference”, from research on teaching practices, was first seen in works on the didactics of technology in college, before percolating widely in different fields: in linguistics (Gajo, 2000), in cultural or social fields (De Singly, 2010), or in

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the field of health at work (Coutarel et al., 2005), medicine (Bloy, 2010), or even prevention (Larose et al., 2000). After this initial tension between the social and the subject, and the interrogation which ensues on the weight of norms on the subject, the structuring character of a representation as well as its “operational” character, in the sense of mental, psychoaffective and social operations is, from our point of view, essential, notably in matters of health. This operationality is developed around the idea of a “construct” at the personal and even collective level in order to get to something that “makes sense” or that “produces sense”. This idea is reinforced by the “utilitarian” aspect of the representation. In terms of health, the operationality of a representation is a very interesting criteria that legitimizes its existence in terms of what feeds into it, and only allows a construction in its finality, while providing the subject with the possibility of interpreting the situation in which he finds himself and proposing a reading of it which seems acceptable. Nevertheless, although a “social” representation is shared with a given “social” group, this is not the case for all the psychoaffective dimensions that regulate the life of the subject himself and that are translated by behaviors which the latter deems “adapted” or “unadapted” to his own health. The regulatory and normative functions of social groups in terms of behaviors in no way predict the effectively shared character of certain representations in health. However, the conceptual obstacle that we wish to highlight here in relation to questions on health is from the point of view of the evolution of a representation. Although the authors agree on its “dynamic” character, insisting on the fact that it is not fixed in time and can be led to evolve, the definitions of elements that influence a social representation essentially pertain to the social context. This implies that our action cannot be removed from the influence of the representation. Thus, the consensual character that should cover social representations within a group participates in the resulting main criticism. In texts on social representations, the influence of the subject and what he lives and feels is too often erased. Serge Moscovici (1961) considers that “the gap between the collective elements and individual elements appears smaller when seen up close than when defined from far”. In 2001, he wrote: “The problem with the dynamic of representations no longer appears to be their change or their diffusion, but

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rather, as raised almost a century ago, the creation of new representations from others that are their next cause.” The idea of a representation that removes itself for the benefit of another reinforces the notion of a construction with a new practical and operational aim. The field of health and prevention cannot escape the rapid evolution of social life contexts, nor the significant porosity that is currently observed through what Internet media shows, reminding us of the unwavering links between the subject, groups and society. The so-called “social” networks generate adherence to multiple groups themselves or, short of joining, it gives a visibility of the various practices. This term “practices” (in the sense of practices that the researcher can analyze) is actually hardly used in definitions of a social representation, although we know that health practices are fundamental to the subject’s perception of behaviors to adopt or not. And, even more importantly, the biological, social and psychological, even psychoanalytical questions that present themselves to the subject with regard of his health cannot be removed. They are constitutive of the subject, they unsettle him. They are so invasive that they reach his deepest privacy. However, the “social” versus “personal” aspects of representations are not alone in causing debate. Thus, the principle of coherence or even of a hard core structuring them is also up for discussion (Flament, Abric and Doise, 1998). It is relevant to remind ourselves that this notion of a hard core was described in detail in 1987 by Abric after he had proposed it in 1976. From the contextual point of view, it falls within the structural approach of Aix (Abric, 2001). The hard core of the representation, or the central core, is marked by the collective memory of the group, but also by the system of norms to which it refers itself. There is a group homogeneity at the level of this central core. The central core has the function of generating the significance of the representation and determining its organization. Stable and coherent, it resists all change and ensures the permanence of the representation. It should be noted that all studies looking at social representations should attempt to find this central core. As for the peripheral elements, they are characterized by the personal experiences and history of individuals. There is group homogeneity from the point of view of these peripheral elements, since their function consists of adapting to the concrete reality and protecting the central core. They are in motion, evolving, transforming themselves and adapting.

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Although the idea of having a form of hierarchy fluctuating between what is “central” and what is “peripheral” seems rather appealing a priori, it nevertheless remains that, in terms of methodology, it is very difficult – impossible even – to claim to accede to one or the other. This is all the truer when, using Abric’s (ibid) words, “an isolated social representation does not exist. All representation is in relation to a set of other representations that constitute the symbolic and social environment of individuals”. This notably complicates the perception of the interlocking game, which is ongoing between the representations themselves and within what constitutes them. 2.6. What are the preliminaries for a new theorization of conceptions in health? 2.6.1. Why replace the subject in a central position? In order to leave this “social whole” the limits of which we have demonstrated in the various uses of the term “representation”, some authors have tried to define the term “conception” and linked it to that of “representation”. In our previous publications (2014, 2016, 2017), we regularly referred to a paper by Pierre Clément (2010) who attempted to expand the definition of the notion of representation by describing an interweaving game of “individual conceptions”, “collective conceptions”, “individual representations”, and “collective”, even “social”, “representations”. For Thomas Fournier (2013), from a piece of work prior to his doctoral thesis, “in the Giordan and Astolfi vein, Clément picks up the definition of the term “conception” in complete opposition to the term “representation” very early on (1994). […] For him, the term conception has the advantage of not being at the center of the conflict between cognitivists, like the term representation. Indeed, although the debate is not as active as it was several years ago, the term conception is still surrounded by a conceptual gray area”. We will nevertheless nuance the words of Fournier by demonstrating the existence of a rupture, but especially of a continuity between the works of Clément and those on social representations. To understand the roots of Pierre Clément’s words, the didactic approach should be highlighted, particularly science didactics, which is his area. In the background, this therefore generates a set of presupposed didactics centered on knowledge

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and its transposition, and which could pose a problem were we to expand the propositions to the field of health and prevention. What does Pierre Clément tell us about conceptions? The first contribution of his article in 2010 addresses the notion of “common sense” which, to us, seems to constitute an interesting path of reflection in the field of health. The proximity and opposition of this notion of common sense in scientific knowledge, largely repeated in didactic science works, allows us to first look at “what makes sense” for the subject or a group of subjects. We can bring this definition of “common sense” closer to Denise Jodelet’s definitions, which refer to a “naïve, natural knowledge, this form of knowledge is distinguished from, among others, scientific knowledge” (Jodelet, 2003), which constitutes a first proximity with works on social psychology. Pierre Clément, leaning on genome research, nevertheless shows that the partition between common sense and science is not all that full proof and that the scientific world is not free from being snared in an epistemological point of view by previous propositions that now come from common sense: “The dominating idea that the human species should have many more genes than other animals because of its extraordinary performances that were assumed to each have an appropriate genetic support” (Clément, 2010). He reminds us that Doise (1991) considers scientific knowledge as a form of social representation, similar to how other authors address social representation as an element revealing a common sense. This is an interesting dilemma that supports our point of view on the unstable position of the status of knowledge, according to its nature, compared to the definition of a social representation. With regard to the contents that we have previously outlined, “common sense” can therefore be characterized, according to the authors, by a collective dimension (for the psychosocial streams around what is shared, thus proposing a social representation of the world) and an individual dimension (for Clément, around that which is constructed by the subject, element constitutive of a conception, but which can be shared to in turn become a collective, or social, representation). We lean more toward Clément’s sense when considering, based on the situations that the subject is confronted with, that the conceptions will be mobilized: “Conceptions from the same person are the same in their head, but are expressed differently based on situations, and seem to vary”

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(Clément, 2010). It is therefore necessary to multiply the situations in order to diversify the collection of “situated” conceptions and thus gradually aspire to accede to conceptions: “Because a situated conception is not only produced by the situation, it always reveals parts of the conceptions of the person questioned, the part that can be expressed in the proposed situation” (Figure 2.5).

Figure 2.5. Conceptions result from the conjugation of several situated conceptions (Clément, 2010)

Following how he described the shift in the particularisms of situated conceptions gradually allowing the characterization of more global conceptions, Pierre Clément proposes to differentiate individual conceptions from the collective conceptions that will organize themselves systemically. He brings collective conceptions closer to collective representations or social representations. Looking at the organization of the words presented in Table 2.5, we see that the term “conception” encompasses the notion of representation.

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At the individual level

Situated conceptions

Conceptions

Conception system

At the collective level The content converging from The content of the response the responses of several people converging toward a precise placed in the same precise question in a specific situation. situation. The coherences brought out by The coherences brought out by the researcher from individual the researcher from responses conceptions on the same theme, of a person placed in several identified in several people situations relating to a given (social group) (collective theme (individual conceptions conceptions = collective on this theme). representations or social representations). Set of conceptions (social representations) correlated to each other. They can also be linked to individual characteristics such as opinions on the social, religious or political levels.

Table 2.5. Definitions according to Clément (2010) of situated conceptions, conceptions, social representations and conception systems

2.6.2. What limits are attributed to the KVP model (knowledge, values, social practices)? The terms contiguous with “representation”, “social”, or “collective” versus “individual”, historically come from “Durkheim who wanted to highlight the supremacy of social thought over individual thought” (op. cit. in Herzlich, 1984). We know that Durkheim sought to undo the hold of introspective psychology and to distinguish this separate class of representations, collective representations, that are the basis of another psychology: collective psychology. He achieves this by explaining that “if, initially, collective representations are a direct function of social structure, next, they acquire power to generate other representations: collective representations of a second level that are relatively autonomous in terms of the social substrate” (ibid). Clément’s approach is, therefore, different since he places collective representations on the same level as social representations, even using the equals sign. The terms “conceptions” and “representations” correspond, according to the authors, to different definitions. For us, and due to the absence of a more adapted conceptualization for questions linked to health, we have preferred to use the word “conception” in our publications. Two main reasons motivated this choice: the first is linked to the fact that Pierre Clément

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established an interesting link with situations that reveal parts of a conception, and the second comes from a critical reading of the KVP model that he develops. The KVP model enables the delimitation of three poles (Clément, 2010) that interact. In other words, “analyzing conceptions as possible interactions between three poles” (ibid). The illustration that he proposes to articulate these three poles in order to investigate a conception is extracted from a school handbook, which he considers as revelatory of this process. These analysis criteria also served as theoretical support for other handbooks, notably in the international Biohead-Citizen study in his component pertaining to the conceptions of teachers in nineteen Mediterranean countries (Quessada et al., 2007; Clément and Quessada, 2008). Nevertheless, this KVP model deserves to be questioned and cannot be applied directly in the field of health and health education. If we look at each of these three poles as they are defined in the field of didactic transposition which feeds this model, they once again ask the fundamental question of the subject’s place. Clément’s didactic approach (in the extension of works by Martinand, Verret, or Chevallard) aims for the diffusion and acquisition of “valid” knowledge. Here, knowledge is considered in the field of classic didactics to inevitably be scientific in nature. The “savant” is “the one who knows”. Clément (2014) thus identified a Didactic Transposition Delay, which is the time separating the discovery of major scientific knowledge and its transposition into a science teaching handbook. Moscovici and Jodelet defined social representations in opposition to scientific knowledge, but we prefer to consider that scientific knowledge is part of the whole construction of conceptions, without, however, making it into the whole. In health, the knowledge that constitutes a conception cannot be summarized by scientific dimensions. We have shown that other knowledge percolates, whether they are common sense or pragmatic. The latter allow the third pole of the KVP model to be addressed from a different angle and on an equal footing with the subject, without seeking to overbearingly accord a status of superior validity to either one or the other of these forms of knowledge. The second pole (V = values) is also problematic, notably the use of the term “value”, in the sense where Fischer (1987) refers back to its symbolic dimension, on a similar level to beliefs and ideologies. He speaks of a transformation of social objects (people, contexts, situations) into symbolic categories (values, beliefs, ideologies) that confer them with a cognitive

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status enabling the apprehension of aspects of normal life through a reframing of our own behaviors in social interactions. Nevertheless, this only accentuates what reveals a value, or rather what defines it. It is even more complicated to characterize a value. For us, a value is a social “construct” that has the necessary power to normalize individual and collective behaviors. Value therefore accedes all the more to a status of conception rather than the status of a constitutive element of this conception.

3 A Renewed Theory of Conceptions in Health

Based on the rereading of several elements (definitions and characteristics of social representations, nuances provided by Clément’s works, health field specificities with the central position occupied by a capable subject taken in an environment that weighs heavily on them), we find it necessary to propose a renewed theoretical characterization of the notion of a conception in health. Our words fall within a debate opposing the “representationalists”, who consider that representations are a reflection of the properties of the world and are external to the subject, to those for whom the subject alone constructs their properties of the world (Clément, 2010). 3.1. What are conceptions?

the

paradigmatic

foundations

of

health

First of all, it seems essential to us to position the foundations of health conceptions from a paradigmatic point of view. Our aim is to explain our posture clearly in order to better define the place of the subject, but also that of the researcher. “If there were no available and constraining paradigm, discord and chaos would quickly become endemic, just like in social sciences. […] Only the coherence, the stability socially introduced by the paradigm that links alternative propositions, makes a continuous and cumulative work possible” (Kuhn cited by Moscovici, 2001). Although Monjot (2003) considers that “symbolic generalizations, models, values, examples: such are the elements introduced into the composition of a

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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paradigm”, we prefer to take the term “paradigm” in the sense chosen by Edgar Morin (2015, p. 138) when he defined the paradigm of complexity as the “thinking principle which considers the world and not […] the revelatory principle of the essence of the world” and opposed it to the paradigm of simplicity. He thus proposed two paradigms, two visions of the world and two paths of thought. 3.2. Why combine health paradigms? We will lean on the works of Jacques Fortin (2005) that define four health paradigms: the rational paradigm, the humanist paradigm, the social dialectic paradigm and the ecological paradigm (Figure 3.1). Having regularly presented these paradigms to students in “Public Health and Education” masters programs, we know that there is a pitfall to avoid in order to understand their reality: it is the pitfall of “exclusivity”. This amounts to thinking that a subject is positioned according to a precise paradigm, without the ability to move from one to the other, with their coherencies, even their incoherencies. However, it should be remembered that the subject can conceive the world around them with potential complexity, perhaps adopting a biomedical view that prioritizes the understanding of theoretical knowledge of “good” behaviors (rational paradigm), or by placing themself at the center of the interpretation with biological, psycho-affective and social dimensions that are their own (humanist paradigm), or by overestimating the importance of social relations (social dialectic paradigm), or even by opting for a more systemic vision (ecological paradigm).

Figure 3.1. The four health paradigms (according to Fortin, 2005) from the least comprehensive (rational paradigm) to the most inclusive (ecological paradigm)

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The first paradigm is rational (“man as he should be”). It translates an efficient rationality based on scientific knowledge; it is classical pedagogy. The health intervenor has wisdom, a truth, brings objective knowledge and prescribes a behavior, the attitude of an attentive student (general status of a patient and rationalization of behaviors). This paradigm inspires the medical discourse on disease and health risk advice and prevention. In addition, the disease dominating the patient leaves no space for the freedom of decision. The second paradigm is humanist (“free wellbeing”). It translates into a freedom, an autonomy to think, to act and to decide, allowing the realization of self. It takes into account the desires, emotions and perceptions that contribute to the construction of knowledge by life and experience. The health intervenor supports the inner journey toward values, and ideals, by latching onto the development of competencies (psychosocial, controlled body, sensoriality, etc.). In addition, the patient applies this to the disease, dominates his body and suffering, is responsible, autonomous and free to make a decision (and, because of this, can feed into an ethical debate). The third paradigm of the social dialectic translates the collective and personal responsibility of a social being. It takes into consideration the environment (relationship/control of man, degree of social liberty). It is the capacity to master one’s existence despite the weight of a cultural context in learning and despite affective needs and conscious and unconscious imitation behaviors. The health intervenor helps to make the individual expectations that motivate collective demands emerge (the notion of empowerment, of the capacity to be responsible for one’s health) by taking into account the cognitive, emotional and social dimensions. The fourth paradigm is ecological. It translates into an overall realization of a being whose personal development is linked to that of their environment. Humans are in interrelation with an ecosystem (interpersonal interactions, education, subject-object-agent, individual-society-species, etc.). Here, learning is a systemic and personalized process. Taking the cognitive, emotional, and social dimensions into account, it is oriented toward support for a favorable health behavior. It looks at the whole life context or group: complete democratization of education, integral development of the person, personalized total education.

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We have chosen to position a theory of conceptions in health within a complex approach (and not simplifying) “of” and “through” this set of paradigms. We have therefore been careful not to define subjects according to a single paradigm (the temptation is great and is often seen in a number of papers on health education) in order to adopt a potentially more encompassing vision of the subject and their environment based on the dominant visions translated by the expression of their conceptions. Later, we will see that we have shown restraint, including in terms of the methodology, with regard to the elements described in the introduction as a dangerous game of categorization. This means leaving space, at least on the theoretical plan, for the intercategorical “in-betweeners” that so often characterize the humanity of the subject, our humanity. The humanist paradigm that gives the subject back their power over themself and their environment can, for example, combine with an ecological paradigm, positioning the subject in a whole whose reciprocal transformative role between the environment and the subject in question should not be underestimated. 3.3. How to avoid the pitfall of simplified thinking? The complexity of the world and the subject invites us to maintain a certain caution and insist once again on the following fact: what is “hard” or “peripheral” is very difficult to outline, contrary to what certain psychosocial theories suggest. Among the five functions of the central core described by Abric, we find concretization, regulation, prescription of behaviors, protection of the central core and personalization. The last term interests us the most. However, rather than talking about the personalization process of the collective representation described by Abric in 1994, we would rather just discuss personal conception. This denomination has a function that we consider fundamental and on which we should not delay: that of giving the subject, and their imperfections, certainties and uncertainties, their place back, while also integrating (and we have not mentioned this, as it would lead us into a psychoanalytical field) the ego as well as the superego. The literature review on representations shows that if a conception is qualified as collective, it therefore pertains to a social representation. The term does not bring any real added value, but presents the benefit of extracting the part that the subject is responsible for, the social influences considered primordial by the authors who defend the idea of the existence of social representations. Thirty-three years ago, Herzlich (1984)

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specified that “for the social representation of psychoanalysis, the problem was to see how, across their assimilation of psychoanalytical concepts, social subjects constructed a new reality of psychic life, theirs and that of others. The notions that come from psychoanalysis – the “unconscious” or the “complex”, for example – become categories of the understanding and language expressing, for those who used it, immediate evidence”. Our scientific contribution strains to introduce the term “contribution” into educational and teaching dimensions that enable a subject/social dialectic oriented toward the acquisition of knowledge of varied natures: scientific, common sense or pragmatic. It is a way of reaffirming the power of the subject over the collective. It is a way of definitively leaving this psychosocial or disciplinary didactic vision, “nearly mechanical”, to use Herzlich’s words, between “a collective representation and individual behavior” (we have previously spoken of “practices”). This also makes room for the irrational and allows a withdrawal from the personal predictive to which (too) many studies on representations claim. Referring to “individual or personal conceptions” and “collective conceptions”, therefore, requires a certain reserve in terms of the way in which the links that unite them are considered. This generates a distinction that does not necessarily need to maintain a convergence with psychosocial theories that place the social in the foreground. Certainly, as we have shown, this posture presents the advantage of returning to the collectives the added value of the subjects that constitute them, but it assumes that a robust conception cannot be collective due to its power of influence over a subject. This social perspective poses a major methodological problem: it relies on our ability to identify – or not – a conception that is “common” to several subjects in order to affirm the social character, as if conceptions were disconnected from each other. However, with subjects, conceptions form a system: a system of thought of the world and a system of action on the world. We use the term “conception” in this perspective by considering that the subject is not the crucible for a conception that functions in a self-sustaining way, or removed from other conceptions. We put forward the hypothesis that it will be systemically connected to a multitude of other approaches. Let us now return to our study on natural caregivers. Their conception of illness works in relation to that of family, of intergenerational support, of the care and support continuum, etc. These systems, complex by nature, are very difficult to identify and fall back

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on the researcher’s humility and what one believes one knows about the perceived reality of the world. 3.4. Theorization of conceptions in health 3.4.1. How to consider the subject from a biopsychosocial point of view? The coexistence of the two terms (“social representation” and “individual representation”) does not seem sustainable to us. We have seen that a representation is necessarily social. Referring to an individual representation brings out what a representation is founded on, which is a socially elaborated and shared knowledge. Speaking of conception without falling into the temptation of positioning it in relation to the term representation (in contrast to Pierre Clément who interconnects them) generates a fundamental paradigm change. Effectively, this allows the subject to be accorded all his complexity, to be placed centrally in his use of disparate knowledge (and not only scientific knowledge, as a didactic centered on knowledge would have us believe), and this, in view of socially lived situations, while avoiding overestimating the social as an element that necessarily prevails in the construction of this conception. The singularity of the subject also constitutes its richness, distancing a social part that can be expressed more marginally in certain questions linked to health. Finally, the term “conception” opens up essential educational perspectives in order to render the subject an actor in their own health, taking into account the obstacles or levers that they encounter at the individual (biologically, but also psychologically) and social (in his life community, including at the family level, with a transmission through the education he receives) scales. Asking things in this way means positioning the subject in the “biopsychosocial” whole that constitutes them, without reducing them a priori to one or the other of these dimensions, nor overdimensioning one in terms of the other. Making the subject an actor in their own health means also accepting that they are the crucible of various conceptions that work systemically, and this, more or less elaborately depending on the subject, in health situations and themes. It means subscribing to the fact that the subject reacts to the complexity of the world using their “own” methods: simple or

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not, sometimes simplifying (Morin, 1977), in order to live a possible life, fluctuating between several health paradigms. 3.4.2. What are the seven criteria that characterize conceptions in health? In order to define a conception in health, we propose seven criteria, the specifications of which are as follows: 1) it designates, for the subject, the operational set of scientific knowledge (Ks), common sense (Kcs) and pragmatic knowledge (Kp) on the biopsychosocial scales; 2) the subject uses their personal and collective health practices to empirically test this knowledge set by developing alternatives that lead them to taking or not taking decisions for their health; 3) a subject possesses not one but several conceptions that fall back, through games of ruptures and continuities, on the elaboration of systems of conceptions with an operational target in one or several given situations; 4) a conception cannot be modified. It is replaced by another, more operational, that in turn feeds into the subject’s system of conceptions to a more or less significant degree; 5) certain conceptions can be considered personal, in the sense that they are not shared within a collective, but it is mainly the way in which conceptions make up a system with each other that gives the subject their singularity; 6) the experiential character of health conceptions strongly links the systems of conception to the situation(s) that participated in their construction and to those allowing the subject to remobilize them. Reciprocally, the subject acts on the situations and also participates in their transformation; 7) in terms of methodology, the conceptions or systems of conception will reveal themselves or not, more or less distinctly, in health practices and through the language used; the subject themself does not necessarily have access to their own health conceptions. The reconstructed character of these notes by the researcher therefore requires caution regarding access to conceptions which the subject is not necessarily conscious that they cannot express or which they refuse to express.

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With the criteria that we propose here, our aim is to draw the reader’s attention to a point that we feel is fundamental: the powerful links uniting the subject and the situation that they live. Thus, the characteristics of a situation in which conceptions in health are revealed must retain an essential place in the interpretation of conceptions because of the psycho-affective reactions and social interactions that result from the “testing of reality” of these conceptions. As such, for a sixth form student going to college and being offered a cigarette, the new characteristics of the context influence their decision to accept or not the cigarette that a friend is offering. However, what conditions the decision more particularly is testing the situation through the biopsychosocial dimensions that will lead to envisaging (or not) one or more alternative responses in this context. This is a “costly” and ambitious internalization process for the subject: “This reconstruction radically transforms the elementary psychic functions and frees the person from their dependence on the environment and their instinctive reactions in view of it” (Saussez, 2005, p. 49). However, this is a big challenge for the subject since their equilibrium depends on it. Prevention then finds itself endowed with an extremely complex mission, since the elements of theorization that we put forward here rely on the postulate of the subject’s possible construction of alternatives in health. The preventer is and remains a companion, whose only ambition is to see the subject take power for their health. This perspective has the merit of leaving the subject free space to decide what is good for them or not, favorable or not for their health (Eymard, 2004, p. 16). The objective of prevention is not to transform the subject at all costs, with or without their assent, but to accompany them in constructing other responses when faced with new situations or situations encountered regularly. This passes through the elaboration of new conceptions and/or unprecedented systems of conception. By prioritizing the term “elaboration” and supplanting the term “transformation” or “evolution”, we follow a different logic to that found in a certain number of psychosocial papers that consider social representations as able to transform or evolve. Nevertheless, we join them in abandoning what is not functional for the subject (Table 3.1): “Any questioning of one of them (which means any questioning of an element of the central core) automatically brings about a transformation or abandonment of the representation” (Abric, 2001).

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Position

Reversible situation

Irreversible situation

Peripheral system

No modification of representations No change in practices

No modification of representations No change in practices

Central core

No modification of representations No change in practices

Transformation of the representation Change in practices

Questioning

Table 3.1. Conditions of transformation of social representations (Abric, 2001, p. 92)

However, the systematic introduction of the conceptions we put forward does not rank conceptions with each other, nor does it distinguish the central elements from peripheral elements. We have seen that this notion of a central core is controversial and, from our point of view, it is extremely complicated to distinguish central and peripheral. To complete the first milestones of this theorization of conceptions in health, we would rather consider conceptions as creating systems with each other with an operational aim. The subject will mobilize this system in order to act in the situation in which he finds himself. It is then a case of accompanying the subject in the elaboration of new conceptions, but also trying to use the network of conceptions at work in the apprehension of situations. Education science invites us to set up educational situations to help the subject identify how to mobilize varied conceptions in their health decisions. This approach fundamentally requestions what is put forward by Abric (see Table 3.1) in the reversibility or irreversibility of a situation, by once again according to the subject a power to act, allowing them to more than just endure a social situation. Nevertheless, we are aware that, in the field of health, a new approach does not have to involve a change in practices. Conceptions participate, for the subject of an interpretation of reality, without a mechanical change necessarily acting on health practices. The links between conceptions and practices exist, but conceptions remain the keys to reading the reality constructed by the subject. After mentioning these general elements, let us take each of these criteria that we have just proposed in order to, on the one hand, describe the theoretical biases that underlie our theory of conceptions in greater detail and, on the other hand, show the finalities of this theory from the point of view of the subject, the researcher as well as the main incidences in terms of prevention.

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3.4.2.1. Conceptions have an operational aim CRITERION 3.1.– A conception in health designates, for the subject, an operational set of scientific knowledge (Ks), common sense (Kcs), and pragmatic knowledge (Kp) on the biopsychosocial level. As discussed previously, we clarified the different registers of knowledge mobilized by the subject which allow them to begin working on operational conceptions. Each of these registers of knowledge has its own field of validity. This validity is scientific for some (Ks); for others, it is found in the social sphere, within shared communities (Kcs); and finally, for the third group (Kp), it is generated in and by the random action of daily life. Putting forward multiple types of knowledge with different registers of validity in this way enables a release from the impasse of a prevention that identifies what would come from a “mistake” by the subject. Mistake is not failure (in the sense that it allows the subject, by failing, to learn to proceed differently). A “mistake” in the restitution of the knowledge that we highlight (Ks, Kcs, Kp) would require an invalidation of the subject’s knowledge through references from science itself, as well as in reference to the common sense shared in a life community or even with regard to life experiences acceptable within this same community. In prevention, it is therefore not a question of generating a preventer-judge model (to judge the validity of a knowledge), but of accepting that the subject constructs their own forms of validity of knowledge in order to argue their decisions. It is this mechanism that interests us for matters of prevention. This knowledge finds its roots in daily life with multiple dimensions: biological, psycho-affective, social and societal. These three biopsychosoci(et)al axes interpenetrate and outline the six domains that we will describe later (see interpretative model of conceptions in health, Chapter 4, section 4.4). Each of these domains calls for composite types of knowledge that commingle and interweave without tight partitions between them. It is therefore no surprise that acting in prevention is so complex. The subject is constantly caught in an infinite spiral as they fight to see alternatives that will lead them – or not – to decide on a response to a situation presented to them. It is probably there that each state of knowledge (Ks, Kcs, Kp) plays a role that will largely be determined by what is of most use to the subject. Who has not tried to argue a personal decision on health

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by referencing elements that are both scientific and common sense, or acquired from the experience gained by its practice, and this in an even wider biopsychosoci(et)al perspective. Tobacco or alcohol consumption constitutes a good example of the density of arguments that can be deployed to talk about one’s product use management, even for low consumption rates. Thus, the arguments used for a glass of red wine with each meal fluctuate between research and pleasure, conviviality, the “protector” role of wine for the body (in reference to the idea that is widely present in the media), or even the feeling of controlling and maintaining one’s consumption at a level deemed to be low. Not a single health theme (diet, sexuality, drug consumption, etc.) can escape from these argumentative frames, supports for false contradictions, that are rooted deep within. Although the biopsychosocial entry remains structural for the observer’s attempt to generate order in this intermingling of knowledge, it also pushes for the conservation of a form of humility when faced with the context. Indeed, this multidimensional mesh, between conscious and unconscious, is not necessarily accessible to the subject themself: either because they cannot resolve themself to express it, or because they do not have the mental access to the elements that constitute it and to the mechanisms that animate it and make the whole of this cognitive, emotional and social weave evolve. The question of the evolution of this weave and its disruptive (or not) role for the subject will add density to our reflection on the fact of its absolute rooting in health practices. 3.4.2.2. Conceptions allow the construction of alternatives for health decisions CRITERION 3.2.– The subject uses their personal and collective health practices to empirically test this set of knowledge by developing alternatives that lead them to taking or not taking decisions for their health. Conceptions and practices are connected by an unwavering and reciprocal link. The subject, a social being by definition, holds emotions and affectivity, constructs themself and attempts to affirm themself through decisions concerning their health that they (often wrongly) believe they can master. The subject observes and feeds off their surroundings, as well as the behavior and attitudes of their peers and their family. They are enriched by the incidences of their own postures, experiments, attempts, successes or

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failures (in the positive sense of an error as a source of learning, not, as we have previously mentioned, from a “mistake” that they have committed). In terms of health, many things will then depend on their ability to analyze a situation. They will sample a certain number of indices that will help them to understand (with more or less difficulty) what they live and from where alternative responses will emerge (or not) and lead them to make new decisions (or not), and then to argue them (or not). Here, probably the most important challenge of prevention takes shape. “Preventing” by leaving all the space to the subject means making them aware that other alternative responses are accessible to them. They can then behave differently, and find a new equilibrium that allows them to live a possible life. From this extremely strong link between practices and conceptions, a promising path emerges: the perspective of new situations. This involves living “something else”, identifying through action the other imaginable possibilities. However, in fine, only the subject will decide what is acceptable, otherwise they will do anything to find an escape route and to go around the decision toward which we tried to lead them. This mechanism of acceptability (or non-acceptability) is not necessarily conscious. These rationalities arise from mental processes that are beyond the consciousness that the subject has of himself. It relies on multiple rationalities, fed on the knowledge that we have previously described, but also on emotivity. Prevention can play a determining role in these complex processes by proposing other acceptable paths, even though we know that the most fragile subjects are also those who have the greatest difficulty in projecting themselves and envisaging several alternative responses to a given situation. Experiential approaches of contexts encountered fall fully within this perspective of living another possible. Experimenting is one thing, but talking about this experience becomes even more structural. Verbalization favors the utterance of what is lived during situations. Because of language, a gradual conceptualization of experience occurs. It is on this condition that the preventer is able to claim the setting into motion of the subject who will mobilize their knowledge differently and will make them evolve if they have lost operationality. Empirical testing therefore needs to be accompanied to go beyond mere

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experience and to identify what it is constituted of in its biopsychosoci(et)al dimensions. Typically, it is the equation that prevention actions mobilizing theater forums on addictions, for example, attempt to resolve. However, for the subject, the effects are often weak. On the one hand, the sketches are only interesting if they directly involve the adolescents who are not just spectators. On the other hand, the one-time nature of this kind of action, very limited, does not enable a learning process to begin. Extension through other sketches designed by the adolescents would favor, for example, progress in the learning processes, which we will discuss in the second part of this book on pedagogical pathways. At this stage of our argument, we insist on this example to emphasize that it is important not to fantasize about the effects of a one shot action. Conceptions in health, because they must be operational for the subject, are deeply dependent on the construction of their underlying empiricism. We are not in a Cartesian construction and argumentation. Social and psycho-affectivity generate a conception logic for a wide variety of fields in daily life that will not be perturbed by an ephemeral and one-time prevention action. We will see that these conceptions probably have much stronger connections with each other than imagined, implying an intervention time in prevention long enough to hope to act with at least a minimum level of efficacy. 3.4.2.3. Conceptions form systems with each other CRITERION 3.3.– A subject possesses not one, but several conceptions that fall back, through games of ruptures and continuities, on the elaboration of systems of conceptions with an operational target in one or several given situations. It would be a simplification to think that conceptions in health are independent from each other, or that they are separate from other conceptions of family or work for example, from the big questions of society to the “little nothings” of daily life. Conceptions form systems in the sense that links are at work, but they also unravel. If we take the metaphor of a spider web, each intersection constitutes a conception and only the threads allow its existence. These threads represent the mental links that the subject establishes between two conceptions. However, this web has a three-dimensional weave. This kind of multidimensional representation of a system of conceptions is actually largely used in artificial intelligence research, to symbolize the connections between language concepts, for example, or knowledge. We now know that

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one of the current challenges is to integrate an “affectivity” and “socialization” into this artificial intelligence, which would voluntarily bring it closer or further to the human spirit, and which acts on the expression of the links established between our conceptions. This idea of a system is not new. It is argued for in social psychology and includes the idea of an interrelation as a notional network (see references cited by Lheureux and Lo Monaco, 2011). The operationality of a system of conceptions is, from our point of view, crucial to understanding the finality of the mechanisms involved. The solicitation of this system occurs through and in action, but also after an action. This retroactivity is the basis for the justifications that the subject can give for their acts. Even if they have no consciousness at all (or refuse to be conscious of everything), this allows them an a posteriori reconstruction. Moreover, the research methods founded on explicitation or even the mobilization of confrontation or self–confrontation interviews rely on this principle. On the basis of this mesh that gathers conceptions together, we consider that a conception does not function autonomously. It can, in certain circumstances, have a dominant position or, in other contexts, give up its “bridgehead” position to another conception. Due to this, we definitively reject the idea of a central core because, potentially, all conceptions can become a “core” or occupy a “peripheral” place. The systemic architecture of conceptions makes this organization versatile and potentially modular. This has two main consequences: the first is that we cannot definitely confirm where the system of conceptions of a subject is positioned, and the second is that this gives prevention varied intervention possibilities for the evolution of this system. It is interesting here to cite books on social psychology that extend the cautious questioning with regard to the “peripheral” and the “central”. The works of Florent Lheureux and Grégory Lo Monaco (2011) support the hypothesis of a theoretical integration of the concept of intracore negotiability and the formulation of research perspectives concerning the social representation dynamic and its role as a reading frame for reality. These results lay interesting refection milestones between representation dynamics and negotiability. From our point of view, systems of conception allow a withdrawal from the structural approach of social representations that consider that the transformation (a term that we will not take up for conceptions) of social representations occurs through the

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modification of its central core. As such, the idea developed in this framework is that “a situation that is contradictory to the structural configuration of the representation can, based on the conditions described by Flament (1994), generate a change in the central core and therefore in the representation as a whole” (ibid). Nevertheless, the works of Lheureux and Lo Monaco (2011), “due to the negotiability of certain central elements, question the clarity of the border between central and peripheral systems”. We insist on the idea of the versatility1 of conception systems to emphasize that they constantly adapt to lived situations, including when these consist of making the subject express themself about an event, behavior, etc. A reported situation from the point of view of the subject remains a situation inviting them to mobilize other systems of conceptions. Thus, when a group of young people finds itself in a focus group situation during a prevention action, the latter is meant to make them talk, because it is in itself a generator of its own normative bias: “I am facing an adult (the situation can, however, vary greatly based on the function of this adult: nurse, teacher, health promoter, etc.) and I will give my responses based on what they ask me, on what I can claim in terms of expectations, and depending on what I am ready to say in front of my friends”. As a result, we must be aware that each conception can, of course, be described individually, but that only a part of the subject’s complexity is then investigated. This part will be revealed through argumentation frames that the subject will develop to account for the links that have been established between some of these conceptions. These links are more or less stable. Moreover, in terms of decision making in health, games of rupture and continuity will appear, testing the action of this three-dimensional web. The compelling action and necessity for our mind to find an efficient response, or not, will make this complex mesh evolve or not. We will now see how. 3.4.2.4. Conceptions cannot be modified CRITERION 3.4.– A conception cannot be modified. It is replaced by another, more operational, that in turn feeds into the subject’s system of conceptions to a more or less significant degree.

1 The structural approach in social psychology privileges the term “dynamism”.

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This criterion, which directly implicates prevention, seems fundamental to us for both programming a health intervention and identifying at which level to interfere. A pitfall would be to think that, to be pertinent in prevention, it is sufficient to act on a conception to “change” it. A conception is operational and rooted in knowledge that, for the subject, has a form of coherence and validity. It exists because it presents the double benefit of interpreting reality and having an impact on it. If this is no longer the case (which is what we previously mentioned using the term “rupture” versus “continuity”), the subject reviews this conception and evacuates it. Of course, the subject does not necessarily go that far. The subject can make do with a conception that he possesses and weave new meshes with other conceptions, which will allow him to construct new rationalities, without having to rethink one of his conceptions. However, these new links or new conceptions are not constructed just for pleasure. They exist because a situation justifies their presence. Conceptions and systems of conceptions are tightly linked to the subject’s practices, feed them and vice versa. Incidentally, we have placed practical knowledge (Kp) in our previous summary table (Table 2.4) in a median position (between scientific knowledge and common sense knowledge) because they borrow from the contents of the others. Experiential approaches in prevention (Morel and Couteron, 2008) are interesting to question in this pragmatic perspective. Alain Morel, a doctor of psychiatry, considers that “the experience as that which is lived, observable, proven, spoken by the subject and linked to their history, constitutes the most fundamental “entry gate” in the understanding of addictions” (Morel, 2010). Experience (personal rather than professional experience) is described in social psychology by Jodelet as covering “two dimensions: a dimension of knowledge and a dimension that is proven, of the psychological involvement of the subject”. Other sociology writers associate activity and subjectivity (Rochey, 1992; Dubet and Martuccelli, 2014). It is also interesting to note that the idea of experience in the subject can also be linked to a consumerist approach in marketing, because it goes to find the other in order to trigger a purchase, touching them at the heart of their emotions, but also in the knowledge that they associate with the product. It is enough, for example, to refer to the Revue française du marketing. In order to avoid confusion and hasty correlations with disciplinary domains that have their own field of validity, for conceptions we

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will speak of pragmatic experiences using the nature of the knowledge of the same name that it generates, and that is added to the scientific or common sense knowledge that the subject possesses. The operational aim of conceptions allows alternative responses to situations experienced to be envisaged. It is, therefore, the inoperability of a conception or system of conceptions that leads a renewal (of a conception) or evolution (of a system of conceptions in reference to the versatility of these systems, which we discussed as the third criterion). 3.4.2.5. The subject is rendered singular by their systems of conceptions CRITERION 3.5.– Certain conceptions can be considered personal, in the sense that they are not shared within a collective, but it is mainly the way in which conceptions make up a system with each other that gives the subject their singularity. At this stage in our work, we think that the conceptions a subject possesses are not that numerous. The proof is the relative speed at which a saturation of data is observed when conceptions are collected from children or adolescents. In the end, they quickly end up telling us the same thing again. By varying the collection methodologies (use of photographs, open questions, focus groups, etc.), the data cover a relatively small breadth. Several hypotheses can arise from this observation: do our methodologies need to be even more diverse and/or does the collection bias mean that we access the “same thing”? Is the obstacle of the subject’s access to their own conceptions so great that they irremediably limit us in what we can collect? Perhaps we are not looking in the right place by trying to stagger each conception? This last hypothesis caught our attention in particular. Effectively, since the whole is always more complex than the component elements, is it our way of conceptualizing the position and connections between these conceptions that hinders our perception of these dancing shadows lurking around the corner? This fifth criterion finds its roots in this very question. If children and adolescents do not have so many conceptions in a field, why is it that each being remains unique and possesses their own logic of action and representation of the world and themselves? We suggest that conceptions

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form systems with each other. These systems are constructed and work differently from one subject to another. Due to this, individually describing conceptions is not enough, because the links that connect them (with more or less robustness) have as much importance as the conceptions themselves. This is constitutive of human complexity. In addition, in the same way as for a conception, we are not necessarily conscious of the links that we establish between conceptions. This system of conceptions is also geared toward operationality. It is probably more malleable than a priori thought and can even be influenced. Based on the circumstances or situations that we encounter, we will mobilize a relatively small number of conceptions by establishing links between them. The perception of a situation experienced, therefore, has an immediate effect on the way in which the system of conceptions at our disposal is mobilized. Mentally, this system in three dimensions is used in several ways, putting conceptions that seem dominant forward. However, in another situation, this same conception could take a secondary place and erase itself for the benefit of another. This way of thinking, more complex still, is nevertheless promising in terms of prevention. It means that it is not necessary to want to replace one conception for another at any cost (we saw the in fourth criterion that a conception cannot be modified). However, it could be pertinent to act on the links connecting the different conceptions (for example, family, the danger of tobacco and the quality of social relations) in order to make this system of conceptions evolve, and then generate new conceptions that will render the others no longer operational. This is why it is completely pertinent in prevention actions on affective and sexual life to give all the working space to emotions, feelings and the relationship with the other. Talking about contraceptive methods with adolescents refers to the need to take care of oneself and others. The singularity of the subject falls within this extremely broad span which helps them construct themself, but also gives meaning to lessons to help them envisage several responses (we have spoken about alternatives) to the situations which they live in order to modify their decisional operations. 3.4.2.6. Conceptions are formed through situations CRITERION 3.6.– The experiential character of health conceptions strongly links the systems of conception to the situation(s) that participated in their

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construction and to those allowing the subject to remobilize them. Reciprocally, the subject acts on the situations and also participates in their transformation. We have already insisted on the importance of the experiential dimension for the subject. Effectively, this point is crucial to not giving way to the other of conception construction mechanisms or systems of conceptions that are above ground. This is all the more true if the links of reciprocity associate the subject to the situations that they live. The subject does not only experience a situation, they act and therefore dispose of a modifying action: they can potentially transform the situation in question. Voluntarily or not, this transformative action depends on their decision making and their practices. If we observe how the system of conceptions structures itself from a temporal point of view, we can put forward the hypothesis that conceptions and the system in which they are found gain from being apprehended in different ways based on time (short time, long time) and explain the extent of the plasticity of our mind and the decisions they generate. The space occupied by the situation is probably not sufficient for identifying this established fact. Only time can help us to understand the seemingly irrational behaviors of the subject or the contradictions. This also reinforces the links with the situation, its evolution which irredeemably disturbs the subject, who adapts as best as they can (and not always as they want) to the context. Helping the subject to conserve a record of these experiential phases of life is highly structural for him. Thus, when a college or university works on improving the quality of life of students, giving adolescents a camera to keep a record of their evolutions over the course of time allows, on the on hand, to find what they identify in their close environment and, on the other hand, to generate a support for exchanging on the changes made. Effectively, the decoding by children and adolescents of the “product” or “process” of a life situation is essential for using what is explicit in order to discuss the implicit. These terms fully participate in the apprehension of reality, of its transformations, and its place in this game of actors. “Lived” and “discussed” combine to mobilize and remobilize the systems of conception. As such, Edwige Rude-Antoine (2017) specifies that in pediatric oncology, “the doctor chooses their words to announce, to deliver medical knowledge to a conscience. But the words chosen will have greater value for one person than for another. There are in fact no two identical announcements, because each doctor will consider what is important to say differently, and how to say it”.

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3.4.2.7. The subject does not necessarily have access to all their conceptions CRITERION 3.7.– In terms of methodology, the conceptions or systems of conception will reveal themselves or not, more or less distinctly, in health practices and through the language used; the subject themself does not necessarily have access to their own health conceptions. The reconstructed character of these notes by the researcher therefore requires caution regarding access to conceptions of which the subject is not necessarily conscious, that they cannot express or refuse to express. We cannot set the criteria for a conception or system of conceptions without setting up, in the background, a theoretical and methodological reflection questioning the links that connect the researcher to the subject. It seemed fundamental to us to integrate these dimensions within the very heart of the characterization of our object. Do not misunderstand us, the theoretical elements that we have proposed in the preceding lines arise, as they do for all theories, from a vision of the person and the issues that they allow one to identify and question. Organizing a theorization in this way can be considered as revelatory of a system of conceptions from which the researcher does not escape. Our cultural and research-based impregnation (in the sense of what we look at in our work) participates in a whole to address reality and model it. This whole is not neutral and is accompanied by humility and doubt, gauges of caution in our works. A conception in health has an objective (for example addictive behavior), whereas the ideology addresses a class of objects (addictions in society and their social control) whose borders are always open. Ideology is one of the greatest dangers to science. It appears as a set of cognitive conditions and constraints presiding over the development of a family and is found at a much broader level of generality than conceptions. These same cognitive conditions and constraints link certain conceptions together, on the one hand, and they reject different or antagonistic conceptions, on the other hand. All theory, even (especially) if it claims otherwise, entails an ideology. This seventh criterion notably aims to be a means of questioning the researcher on not being satisfied with language, with the use of words by the subject on the object that they observe. Health practices are the foundation of a subject’s knowledge: they are manifested through “knowledge in the act”,

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which must be radically distinguished from discursive knowledge in a health practice. “The theses of Vygotsky and Piaget are completely convergent on this topic and the developments proposed by Vygotsky in 1934, in his last book “Thought and Language” are forerunners of Piaget, coming well before the works of the latter on the theme of “Succeeding and understanding” in the 1970s” (Vergnaud, 2002, p. 65, cited by Rix-Lièvre and Lièvre, 2012). “Here there is an epistemological rupture between knowledge in the act which is at the action level, and discursive knowledge which is at the action discourse level” (ibid.), and this in the sense of knowledge “revealed” through acts and knowledge “revealed” through discourse. This act/discourse opposition is one of the fundamental tensions that has structured human and social sciences for decades. We do not aspire to resolve it here, but it has the merit, in this field of ours, of radically positioning the importance of practices and the subject’s discourse pertaining to it. This has largely fed into research methodologies such as the analysis of activity and ergonomics. We also note that in citing these lines, a new class of knowledge appears in our exposition: knowledge in the act and discursive knowledge. We consider them as consequences of scientific, pragmatic and common sense knowledge. Acts and discourses reveal a mental imagery that is translated into knowledge on other knowledge. At the epistemological level, it seems essential to us to distinguish these registers of knowledge. Ks, Kcs and Kp knowledge belong to the subject who shows us, through their acts and speech, a reconstruction that comes from their own knowledge. The researcher themself, who in essence wants to understand, is caught up in the assumption of their own knowledge. The caution lies in saying it, but science pushes the researcher to control its bias. It all calls for humility. The researcher has their own conceptions on the conceptions of the subject they study. We lean on the works of Saussez (2008, 2009) who highlights three assumptions of the researcher linked to the term “conception” in the field of teaching: – first assumption: it is an underexplained and discussable development logic. There is a form of hierarchy in the degree of complexity of a conception depending on whether it refers to an empirical or behaviorist model of teaching, or comes from a constructivist model. Kember (1997), in an extension of Kugel’s (1993) work, therefore proposed to organize conceptions from the “least” evolved to the “most” evolved. Nevertheless, in terms of science, nothing validates this hierarchy, since it is more a question

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of a relatively shared layman theory. This tells us more about the researcher’s own conceptions and shows the extent to which they can be an obstacle to science; – second assumption: the determining character of cognition on action. This assumption is of particular interest in health. It refers us back to the Health Literacy that gives knowledge a founding position in order to enter the process of behavior change. Conceptions then come from an explanatory role in the determination of a person’s conduct (Richardson, 1999, in Saussez, 2008). The explicit links between conception and action are difficult to show and correspond more to a bias than to a scientifically described reality (Kane et al., 2002); – third assumption: the apparent transparency of language. The problematic of putting an experience into words remains very partial in works on conceptions. To use the words of Saussez (2008), “researchers behaved as though the significance of words give evidence of a person’s knowledge on a phenomenon. Isn’t such a position revelatory of an implicit theory concerning language?”. “Language is then conceived as a pipeline serving to transfer thoughts between an emitter and a receptor” (ibid.). The seven criteria defining a conception

Criterion 1

A health conception designates, for the subject, the Conceptions have operational set of scientific knowledge (Ks), common an operational sense (Kcs), and pragmatic knowledge (Kp) on the aim biopsychosocial scales.

Criterion 2

Conceptions allow the construction of decisional alternatives

The subject uses his/her personal and collective health practices to empirically test this set of knowledge by developing alternatives that lead him/her to making or not making decisions for his/her health.

Criterion 3

Conceptions form systems with each other

A subject possesses not one but several conceptions that fall back, through games of ruptures and continuities, on the elaboration of systems of conceptions with an operational target in one or more given situations.

Criterion 4

Conceptions cannot be modified

A conception cannot be modified. It is replaced by another that is more operational, that in turn feeds into the subject’s system of conceptions to a degree of greater or lesser significance.

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The subject is rendered singular by his/her systems of conception

Although certain conceptions can be considered personal, in the sense that they are not shared within a collective, it is mainly the way in which conceptions make up a system with each other that gives the subject his/her singularity.

Criterion 6

Conceptions form in situations

The experiential character of health conceptions strongly links the systems of conception to the situation(s) that participated in their construction and to those allowing the subject to remobilize them. Reciprocally, the subject acts on the situations and also participates in their transformation.

Criterion 7

The subject does not necessarily have access to his/her conceptions

In terms of methodology, the conceptions (or systems of conception) will reveal themselves or not, to a greater or lesser degree of distinction, in health practices and through language.

Criterion 5

Table 3.2. Summarized presentation of the seven criteria that enable the characterization of a conception and a conception system (Pizon, 2018)

4 Qualitative Methodologies for the Investigation of Health Conceptions

Our literature review revealed a limited number of international publications using a qualitative methodology to investigate the “perceptions”, “representations” or “conceptions” of children, adolescents and young adults on matters of health. 4.1. What are the main qualitative methodologies used in international publications? The methodological approaches retained in the international publications that we identified followed three main methods, with a more or less narrative intent, that can be combined with each other: the “Draw and Write” method, interviews or even focus groups. It is of interest to note that drawings are the most frequently employed technique. Sometimes, drawings alone are used (Oakley et al., 1995; Piko and Bak, 2006; Misailidi and Bonoti, 2008), but, most often, they are combined with one or more sentences written by the child or adolescent, describing the content of their drawing, a method sometimes called “Draw, Describe and Write” (Farmer et al., 2016), or sometimes the drawings are combined with interviews (Onyango-Ouma et al., 2004). We see some designs associating an individual interview and drawing (Kortesluoma et al., 2008) or a collective interview and drawing (Pridmore and Bendelow, 1995). Using interviews is rarely the only method in the methodologies that we identified. Although interviews with a single person are mentioned

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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(Dell’Api et al., 2007; Thastum et al., 2008; Swaminathan et al., 2009), more complex forms of interview with two people also appear, combined with a focus group (Kortesluoma and Nikkonen, 2006; Zeinstra et al., 2007) or even an interview followed by a debate in small groups, then linked to a simultaneous parent/child interview (Fairbrother et al., 2016). One single publication refers to very directive forms of questioning during interviews (Pederson et al., 2000), bringing them closer to the open questions asked within a quantitative questionnaire (McGregor and Reeve, 1992), the interview most often being addressed in a semidirective or open manner. Focus groups are regularly mentioned as a unique collection methodology (Lucas and Lloyd, 1999; Porcellato et al., 2002; Davó-Blanes and La Parra, 2012). On a lesser scale, we noted methods using ethnographic techniques with a small number of adolescents. These were sometimes accompanied by participant observation (Bluebond-Langner et al., 1990; Johnson et al., 2003; Garcia et al., 2007). Certain methodologies are not as well-known and are only seen in a single publication within our literature review. This is the case, for example, of the technique of unfinished sentences and projection images (Hernán-García et al., 2015), which includes animated films combined with an interview (Larsen et al., 2007) or even listening to musical extracts in order to record the expression of emotions (Bruce Morton and Trehub, 2007). The “Label and Write” method is associated with the “Draw and Write” method given by Pridmore and Lansdown (1997). The main conclusions from the articles included the fact that there is no ideal method. It is, however, interesting to combine collection methods. One publication drew our attention by proposing the most complex technique in nine stages (Backett and Alexander, 1991): (1) drawing, (2) physical activity, (3) collect “while eating” in order to ask about foods that are “healthy” or not, (4) meeting with the parents, (5) ideas box, (6) photograph manipulation activity, (7) peers, (8) disease and (9) classification activity. The authors highlighted the need to set up collection situations that hold meaning for children (aged between 4 and 12 in their study). It is also interesting to note that photographs are used only in this ninestage methodology, whereas it is widely used in the field of prevention:

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photovoice, photolangage, photoformation and photoexpression. Our previous work on the conceptions of children and young adolescents on addictions (Pizon and Pironom, 2014), and then on health (2016), largely made use of drawings and showed the benefit of these methodologies. 4.2. Which biopsychosocial interpretative model of conceptions should we use? In order to analyze the conceptions in health, we built an interpretative model of the conceptions of pupils in their last year of primary school on the thematic of addictions. This model had three domains of interaction: biomedical, psychoaffective and social, as previously described by Engel (1977, 1979). Historically, in medicine there are two complementary models: biomedical and the biopsychosocial (Vannotti and Célis-Gennart, 2000). Our interpretative model of health conceptions leans on the second, by taking into account the interrelations between the biological, psychological and social aspects of disease. This model, inspired by the works of Engel, do not limit questions of health to biological factors but, while integrating them, also mobilize psychosocial dimensions. “Engel describes minutely, moment by moment, how the psychological and social dimensions simultaneously transform with the biological modifications linked to disease; these biological modifications are analyzed based on subatomic particles all the way to molecules, and then cells, organs, systems. Engel was less interested in the modalities that led the biological function to influence the psychological and social dimension of man, and even less so on the possible influences of these two dimensions on the biological life of the subject” (ibid). Here, we mainly fall into a context of prevention, because this biopsychosocial model that the World Health Organization definition mentioned as of 1948 shows the benefit of inducing a systemic approach to the subject. The latter is not considered in relation to an illness or absence of illness, but rather within a complexity inherent to his psychoaffective and social dimensions. To use the words of Deep (1999), “health and disease are not separate entities, but actually form a spectrum with optimal health on the one side, and death on the other. Although it is almost impossible to be in perfect

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health, anyone a can change theirr lifestyle to improve theeir state of heealth. At any moment, the heealth of an inndividual caan be placed along the sppectrum. hanging, bassed on wheether the Howeveer, this placcement is constantly ch experiennces of dailyy life – influeenced by bio ological, psycchological annd social factors – have a possitive or negaative effect. This T is why the t biopsychhological model applies a to a larger seleection of cirrcumstances and due too this, is superiorr to the bioloogical model””. At a theoretical level, this seet of explanaatory hypothheses for heaalth have biologiccal, psycholoogical and soocial factors on an equal footing, in a system of compplex, multiple and circuular causalities. This meaans that by defining three main m circles, the interacttion of thesee circles alsso benefits ffrom the model. Often, thesee “inter” cirrcles are nott taken into account, as seen in s ons, among which we have retainned an exam mple on many schematizatio obesity (Figure 4.1)) and anotheer on anorex xia and bulim mia (Figure 44.2). We mplete represeentations, su uch as in Figgure 4.3 (inspired by also finnd more com the worrks of Smithh, 2002) or Figure 4.4 taken from Patrick Pellège and Chantall Picot’s (22010) book,, which prroposed a first f sketch of the interactiions betweenn the biopsycchosocial dom mains. It should s be nooted that we did not find scientific puublications prroposing a figuree for a bioppsychosociall model con ntextualized within the work in questionn. Figures 4.1–4.4 are theerefore obtaiined from onnline courses, articles or popuular work.

Figure e 4.1. Biopsycchosocial mod del applied to obesity o

Qua alitative Method dologies for the Investigation of Health Concep ptions

Figure 4.2. Biopsychosoci B ial model appllied to anorexiia and bulimia a

Figurre 4.3. Biopsyychosocial mod del applied to health (work insspired by Smiith, 2002)

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Figure 4.4. Biopsychosocial model applied to sexuality (Picot and Pelège, 2010)

4.3. How to model the conceptions on addictions?

biopsychosocial

dimensions

of

In the context of a first study on the theme of addictions (Pizon et al., 2014), we refined this model by outlining seven domains with three main entry points (Figure 4.5), biomedical (A), social and societal (C), psychoaffective (E), and three fields of interaction: consumption in the social space (B), relationship between the subject and the social body with its effects on the subject (D), connection with the product and level of use (F). The interaction of all of these domains allows the subject to make a decision during a situation linked to his health (G) (Fortin, 2004). This research was carried out with 237 pupils between 10 and 11 years of age, at the end of the third cycle (middle class, first and second year) in 11 classes located in seven elementary schools in Auvergne, France. The classes were chosen for their social diversity and their representation of urban schools in the region of Auvergne (priority education and non-priority

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education) and based on the willingness of teachers to participate. Data was collected during the 2011–2012 and 2012–2013 school year, during class time with pupils in the presence of teachers. Each pupil was given a code guaranteeing the total anonymity of their data.

Figure 4.5. Biopsychosocial model targeting the empowerment of the subject in his decision-making capacity in complex situations applied to addictive practices (Pizon, 2014)

Collecting data consisted of diffusing an individual questionnaire on products (tobacco, alcohol, other drugs) and video games. Pupils were invited to individually fill four sheets following an identical structure. Each sheet required that the student write three affirmations (“things that you are sure of”), three rumors (“things you have heard of”) and three questions (“questions that you ask yourself”). The analysis of the content was carried out by grouping items in blocks of sense (Bardin, 2001) in order to determine the significant sections for the categorization of data. A triple coding allowed the categories and subcategories identified to be set (Table 4.1). Following this qualitative analysis, a quantitative treatment of data was carried out using the SAS 9.3 © software.

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Domains

A

B

C

D

E

Domain contents

Knowledge on the nature of psychotropic products or non-products, of their modes of consumption, of their danger to health, of support and health possibilities, etc.

Level of consumption of populations (adults, youths, etc.), knowledge of recommendations and prevention messages.

Social and societal environment: culture, family, values, social regulation, access to products or non-products, bans and laws, etc.

Relational competencies, psychological and affective management of social pressures (submission, resistance, peer pressure), social impact of consumption.

Psycho-affectivity, emotions (anxiety, fear, knowledge of self, etc.) based on age, personal judgment with regard to the product.

Categories

Code

Characteristics of the psychotropic products or non-products.

A1

Modes of consumption and polyconsumption.

A2

Danger, risks to health, death.

A3

Medical management and help with quitting.

A4

Prevalence in the population.

B1

Restitution of prevention messages or social recommendations.

B2

Reasons for its creation or existence.

C1

Knowledge of the law and influence of the law on consumption (banned).

C2

Price, traffic, commercialization and access to the product or non-product.

C3

Influences and cultural or familial situations (practices, situations and stereotypes).

C4

Obligation to consume and peer pressure.

D1

Social consequences (transgression, aggression, accidents, prison, virtual and real confusion, desocialization, etc.).

D2

Fears and worries with regard to self and self-image.

E1

Attraction, initiation and feeling of spiraling.

E2

Appreciation of the image of the product or non-product or of consumption.

E3

Qualitative Methodologies for the Investigation of Health Conceptions

F

G

Perceived or experienced relation with the products or non-products, their effects, regulatory behaviors, habituation, use and the effects of dependence. Adopting a behavior that is favorable to health, taking care of yourself and of others, identification of postures and of the possible choices, capacity to make alternative decisions.

Perception of a level of use (from non-use to dependence).

F1

Physiological and psychological effects (drunkenness, fix, distress, pleasure, loss, etc.).

F2

Motivations for consuming or not.

G1

Paradoxical consumption.

G2

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Table 4.1. Distribution of items in domains following 19 categories of indexing the conceptions of children between 10 and 11 years of age on addictions (Pizon and Pironom, 2014)

The first result lies in the great diversity of the collection, with 3355 items collected. The thematic of addictions is the object of particular richness, regardless of the theme addressed, even with a young audience. The items collected are distributed into 19 indexing categories allowing all addictions and factors linked to addictive practices to be dealt with together (Table 4.1). When considering each of these themes, we note that 29.22% (n = 979) of the items collected concern alcohol, 26.93% (n = 902) tobacco, 23.10% (n = 774) video games and 20.75% (n = 695) drugs. The second dominant result pertains to the disequilibrium observed in the distribution of items in the seven domains of categorization. Domain A (identification of the nature and danger of products and non-products) is the most represented with 49.90% of items while the social and societal dimension (11.34%, domain C) and the psycho-affective dimensions (6.03%, domain E) are, respectively, in third and fifth position. By looking at the domains closest to domain A, the most represented, we observed that domain B, the interaction of the social with products and non-products, grouped together 8.57% of items (taking into consideration the perceived prevalence in the population and prevention messages) and domain F, with the interaction of the subject and products or non-products, gathered 17.55% of items (taking into account the level of use and the physiological and psychological effects).

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The third result shows that it is worth identifying what arises from the “certainties”, “questions” or “rumors” expressed by the students of our corpus. From this point of view, we note that for the four themes (alcohol, tobacco, other drugs, and video games), the certainties are always a majority (nearly 48% for alcohol and video games, 46.12% for tobacco and 41.87% for other drugs), rumors account for around a quarter of the items of each theme, whereas there were more questions on drugs (35.65%), but also for tobacco (29.83%). If we refine these observations, reading these items shows that, for the same student, a certitude is often followed by its questioning or review, showing its unstable character: for example, “tobacco is dangerous for your health”, “is it true that tobacco is bad for your health?”, “when you smoke, your lungs go black”, “why do your lungs go black when you smoke?”, “alcohol, it isn’t good for your health”, “what do they put in alcohol to make it dangerous?”. Moreover, the questioning of one could be the certainty of another, and vice versa. If we look more specifically at the items in domains A, B and F, these constitute 75.52% of our data collection. Throughout domain A, danger, risks to health and death are the most represented with 384 items on the characteristics of the product or non-product (182 items), whereas only eight items address the modes of consumption and polyconsumption (for example for drugs: “you inject a dangerous product”, “drugs, that can be a form of cigarette or injection”) and only one item is linked to helping with quitting (“are there medicines?”). The link to death is present, equally as an affirmation, a rumor or a question, and mostly with regard to tobacco (“do cigarettes kill?”, “can we survive?”) and alcohol (“can it [alcohol] kill a person?”, “with alcohol, if we drink a lot, can we die?”), and less for drugs in general (“they are very dangerous, they can kill”). Nevertheless, concerning drugs, we have identified a strong expression of ignorance (“what are drugs?”, “what is a drug?”). We know that a lot of incorrect knowledge circulates in the general population. This data collection shows that, from a very young age, questions appear and show the importance of providing the first elements of a response. Some children overshoot the separation which would remove tobacco and alcohol from the category of drugs (“[drugs], they’re like alcohol”, “hash,

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alcohol, shisha, cigarette”, “is alcohol the same thing as drugs?”, “there are also drugs in tobacco”, “video games are a drug”). Another, more marginal element is the curiosity surrounding products (“[drugs], are they nice?”, “what does it taste like?”). For domain B, nine items address the prevalence in the general population and half of them refer to adolescence (“they say that there are young people who drink alcohol”, “that adolescents are often on drugs”, “why does everyone use tobacco?”). The restitution of prevention messages or social recommendations is well represented with 67 items, mainly on tobacco and alcohol1. It can be described from the point of view of the messages propagated (“smoking is bad for your health”, “alcohol can kill”, “tobacco can kill”), with very few references to family (“my mother told me that…”). The record of expressions is uniquely constituted of affirmations or rumors with only five questions (for example “why are there photos of lungs on cigarettes?”, “playing is good, but not for too long?”). For domain F, alcohol (26.76%) and video games (21.32%) dominate while tobacco is the least represented (7.32%). Sixty items enable the highlighting of the perception of levels of use and the dependency phenomenon, because they show the mechanisms generating dependence (“how do they make us addicts?”, “can we become addicted?”, “why do they immediately become addicted [to alcohol]?”). Video games are cited most as an example to signal a usage that could become problematic (“you become addicted”, “computers, you can become addicted”). Another salient point concerns the physiological effects perceived by the subject (136 items). We note the recurrence of the expression “makes you mad” in connection with the consumption of alcohol or other drugs, completed by references to other effects felt by the brain (“it is nice”, “it ruins your brain”, “it can give you a migraine”).

1 The limits of prevention slogans were once again demonstrated in a recent INPES study highlighting that if 71% of 12- to 30-year olds answer that they must “eat five fruit and vegetable per day”, only 6% stated that they put this recommendation into practice.

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4.4. Are there many health conceptions from infancy? An idea floating around the world of adults consists of thinking that children are blank slates in terms of health conceptions. On the contrary, their conceptions are formed very early during development and the systems of conceptions that they elaborate are certainly very fragile, but very much present. This instability is seen, for example, when a child is asked to state a certainty (“something he is sure of”) or a rumor (“something he has heard of”), and a question. Often, the question takes on the notions of the certainty or the rumor: “I know that alcohol is bad for your health” versus “is it true that alcohol is bad for your health?”. In order to better understand how children perceive health, a new model, extended to health in general (Pizon et al., 2016), allowed us to lean on these seven domains constructed from three main entries, biomedical (A), social and societal (C) and psycho-affectivity (E), and from three main domains of interaction: social and environmental influences in matters of health prevention (messages, recommendations) and the state of health of the population (B), influences on the emotions of social relations and links between individual and collective behaviors (D) and finally, the consequences of individual behaviors on the state of health at both the physiological and psychoaffective levels (F). The interaction of all these domains allows the subject to make decisions in situations for his health (G) (Fortin, 2004). This exploratory research was carried out with 196 children educated to CE2, CM1, CM2 and sixth year, aged between 8 and 12, in 10 classes in the Allier department of the Auvergne region during the school years 2013–2014 and 2014–2015. The recruitment of classes was done on a voluntary basis. The teachers of primary school classes were all women. We looked for diversity in the size of the institutions that were, in our sample, mainly implanted in rural areas (six classes), but also in the urban environment (four classes). Four rural classes were situated in a network of priority education. None of the urban classes of our sample were in priority education locations. One class had a double level (CE2 – CM1). The young age of the audience involved in this study required taking into account in the methodological plan the more or less advanced mastery of written language, by using verbal language.

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The research protocol therefore uses a photoexpression constituted of a corpus of 60 color photographs. This body of images was built following the same conception framework as the photoformation that appeared in 2011 in the Profedus tool, INPES/Public health France. This database, largely tested in teaching situations, allowed the efficacious update of adults’ conceptions in the field of health. Each stage of the collection protocol was the object of a document detailing each instruction, as well as the organization of special conditions in order to limit the risk of transfer and collection bias by five different surveyors due to the geographical distance between the classes in this study. The transfer instructions were the following: – instruction 1: choose a photo that, according to you, characterizes “good” health; – instruction 2: choose characterizes “poor” health.

a

photo

that,

according

to

you,

The collect was done in two phases. Each photograph was numbered from 1 to 60, and the pupils were invited, in a first phase, to write on the back of their sheet the number of the image (without taking the photo with them in order to allow several pupils to select the same image) corresponding to instruction 1 (“good health”) and to write the reasons for which they chose that representation. On the other side, the motivations for their choice corresponding to instruction 2 (“poor health”) were also reported. In a second phase, each pupil took turns to reveal their choice in front of their peers. This spoken corpus was individually collected and recorded. The analysis of the corpora was carried out by grouping the spoken and written content in blocks of sense (Bardin, 2001) in order to determine the significant sections for the categorization of data. A triple coding allowed the categories and subcategories identified to be set. Following this qualitative analysis, a quantitative treatment of data was carried out using the SAS 9.3 © software. We propose 13 categories for indexing health conceptions, as described in Table 4.2.

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Domains

A

B

C

D

E

F

Domain contents Perception of biomedical health through the stages of life and identification of its influencing factors. Social and environmental influences on matters of health prevention (messages, recommendations) and the state of health of the population.

Social and societal environment (bans, help, support of others).

Influences on the emotion of social relations and links between individual behaviors and the collective.

Perception of others, of emotions and of the feeling of personal fulfillment.

Consequences of individual behavior on one’s state of health at both the physiological and psychoaffective levels.

Categories

Code

Description of a health capital degrading over the course of life.

A1

Dangerousness and its consequences (illness, death, hospital and medicinal treatments).

A2

Protection factors (sport, diet, etc.).

A3

Restitution of prevention messages or of health recommendations circulating in society.

B1

Possible place in the environment in favor or not of health (nature, fresh air, etc.).

B2

Bans and normative constraints in society (the “good” and the “bad”, image of psychotropic products, etc.).

C1

Mutual help and support in a collective.

C2

Importance of social relations (friendship, sharing, etc.).

D1

Effects of individual behavior on another (accidents, etc.).

D2

Visible signs of wellbeing or malaise (judgment, physical appearance, handicap, etc.).

E1

Knowledge of self and of what provides a source of wellbeing or of malaise.

E2

Physiological incidences of a behavior or personal use (physical issues versus physical fulfillment).

F1

Psychoaffective incidences of a behavior or personal use (malaise versus feeling of wellbeing).

F2

Table 4.2. Categorization in domains of health conceptions in children in CE2, CM1, CM2 and sixth form (Pizon et al., 2016)

The body of data constituted 822 items: 410 were from the written corpus and 412 from the spoken corpus, and 50 items were indexed into two categories. For example: “cigarettes damage your health, with alcohol, there

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could bee violence” (indexation ( A and D2), “it is bad to smoke, and alcohol, A2 it can kill k you” or “it is bad too smoke and d drink, it damages d youur body” (indexattion C1 and A2), “when you drink, you y get drunkk, so it damaages your body” (indexation A2 A and F1). Eachh item from m the two corpora c was distributed into 13 caategories correspoonding withh the domainns A, B, C, C D, E andd F. The quualitative analysiss of the discourse d coontent and its dominnances allow wed the characteerization of each e of the siix domains (Figure 4.6).

Figure 4.6. Biopsychoso ocial model tarrgeting the em mpowerment off the subject in n his capacity to make decis sions for his health in compllex situa ations (Pizon, 2018) 2

4.4.1. Domain D A: biomedica al health Biom medical health is perceivved through the stages of o life (birth, illness, death) with w the undderlying ideaa of a “healtth capital” thhat deterioraates over the courrse of existeence (categorry A1). Risk k factors (cattegory A2) rrefer in a striking way to thee dangerousnness of psychotropic prooducts (tobaccco, and then alccohol, sometiimes privilegging the term m “drugs”), which w lead too illness, hospitallization and death. Mediicinal treatments have a particular status that fluctuates between their own hazardousnes h ss (“too muuch medicinee, it can

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make you ill, grandma died because of medicines, she took too many”, “too much medicine can make you ill”, “medicines can make you ill”) and the fact that medicine is revelatory of “poor health” (“when you take medicine, it is because you have bad health”). Medicine is a means of “recovering good health”, but this idea does not take precedence in the discourse on medicines, marked by nuanced words (“to be in good health, medicines are good, but you shouldn’t take too many either”, “medicines heal people who are a bit ill”). Category A3 is characterized by a discourse oriented toward protection factors: essentially sport (“sport is good, you breathe, it’s really good”, “when you do sport, you can feel better, develop muscles”, “they climb, they do lots of sport, it prevents them from watching television”), but also diet (“if you eat fruit and vegetables, you are in good health”, “with vegetables, you can be in good health”, “because apples have vitamins”). 4.4.2. Domain B: social and environmental influences in prevention This domain refers to the social and environmental influences in matters of prevention in health and the state of health of populations. Two main lines of conception structure the discourses of the pupils in our corpus. The first looks at their significant capacity to reproduce prevention messages and the main sanitary recommendations circulating in our society (category B1): “doing sport is healthy”, “you have to eat five fruit and vegetables per day”, “because you have to eat vegetables to be in good health, you must not eat fat”, “alcohol is bad for your health”, “to be in good health, you shouldn’t smoke or drink”. The second very positively positions environment (nature, “fresh air”) as a source of “good” health and a rupture with sedentariness (category B2): “nature represents our life, without nature, we would not be here, if there were no trees”, “good health is going out into the fields and breathing a bit of air”, “picking up trash means we can have a clean space”. 4.4.3. Domain C: perception of the social and societal environment This domain translates our perception of the social and societal environment that constitutes the structuring object of the discourse. Domain C

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refers to the bans and constraints circulating in our society. The norms that are conveyed outline a “good” and a “bad” and, more particularly, concern the image of psychotropic products (category C1) (“smoking, it’s bad”, “it isn’t good to smoke and drink”) or a sport practice (“sport is good, it means being in good health”). Another predominance of the discourse is structured around the need to “take care of others” via the provision of help or mutual support in a collective (category C2): “health, it isn’t just eating and doing sport, it’s helping each other and being interdependent”, “because I think that it is more like health, you have to take care of babies, look out for their health”. 4.4.4. Domain D: mobilization of relational competences and influence on the emotion of social relations The mobilization of relational competences and the influence on the emotion of social relations allow the distribution of the corpora in domain D between the perceived importance of social relations among friends or within a family sphere (category D1), and the fact that a certain number of pupils identified the incidences of individual behavior on others, mainly by expressing the risk of accidents (category D2). In category D1, the items that emphasize friendship and sharing (“it means being happy, hand in hand”, “health, it isn’t just eating a balanced diet and doing sport, it’s also having friendships”, “they are having fun with friends, and it shows that they are happy”) are grouped together. In category D2, accidents are highlighted in a dominant way as resulting from deviant behavior that endangers others (“you can have road accidents”, “alcohol can make you do anything, killing people”, “alcohol can lead to the driver losing control and dying”, “driving too fast, he will be caught on camera, he must have had too much to drink before driving”). 4.4.5. Domain E: psychoaffective perception of others and the management of emotions This domain looks at psychoaffective dimensions and, more particularly, at the perception of others and emotions, as well as at the identification of a potential feeling of personal fulfillment. As such, the “visible” signs of wellbeing or malaise provide additional structure for category E1, in

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reference to the judgments and perception of others based on their physical appearance, their emotions and eventually their handicap (“they seem to be in good health, to be happy”, “the little boy looks like he’s in good health [because he is smiling]”, “she is happy, she is jumping”, “he is laughing, he seems to be in good health”, “she is so small compared to the ball, she is disabled”, “it shows bad health, because he fell off his bike”). Category E2 groups together the content of the corpora that are more clearly oriented toward self and toward what is a source of personal wellbeing: “because having fun is a good way of letting go”, “being free to go motor biking”, “it is good for your health and it is good, we take pleasure in eating it [the apple]”. 4.4.6. Domain F: the physiological consequences of a behavior in health

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This last domain raises the consequences of behaviors in health at both the physiological and psychoaffective levels. Thus, the physiological effects of a behavior or personal usage show the risks of physical issues versus physical fulfillment (category F1): “we can fall, we can hurt ourselves”, “when you are lying on the floor, you are not in good health”, “the house collapses, dust, horrible death”. Category F2 groups together the psychoaffective incidences perceived following a behavior or usage: “it isn’t good to drink alcohol, it controls your brain”, “when you do sport, it means you are healthy”, “climbing teaches us to overcome our fears”, “going for walks makes gives us fresh air, it relaxes us, makes us breathe, calms us”, “the broken walls and it’s all dark”. 46 photographs of the proposed 60 were chosen more than once. The snapshots selected the most often in our corpus were image no. 4 (a hand holding a glass of beer and a cigarette [121 chose/freq. 29.58%]), image no. 16 (medicine boxes and bottles of syrup [35 chose/freq. 8.56%]), image no. 60 (a group of cyclists in the forest [32 chose/freq. 7.82%]), image no. 15 (a young child in fits of laughter [39 chose/freq. 7.09%]), image no. 17 (a colorful display of vegetables [21 chose/freq. 5.13%]), image no. 44 (an adolescent balancing on a rope in mid-air [20 chose/freq. 4.89%]) and image no. 39 (a knife chopping an apple in half [19 chose/freq. 4.65%]).

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4.5. Should we fear what children and adolescents have to tell us? This question might seem surprising. However, it is expressed most particularly by teachers who largely refer to the risk of being confronted with the privacy of the subject. In previous publications, we showed that this feeling is present in the academic environment, from primary school to college (Pizon et al., 2010; Pizon and Jourdan, 2010a, 2010b). It is no doubt implicitly linked to a top-down model used by teachers in health education. It is even an argument for avoiding all involvement in prevention processes out of fear of having to manage dimensions expressed by students that are too personal. 4.5.1. What diversity of conceptions? The first exploratory study highlighted the wide variety of conceptions around addictions and addictive practices in children between 10 and 11 years old in our corpus. This diversity of conceptions is distributed over all the biological, psychological and social dimensions that characterize an addiction or an addictive practice in the literature. However, we note a clear overdimensioning of the perceived danger of products or addictive behaviors2 in the phrases collected. We can propose the hypothesis that the input by product, which our methodology leans on, constitutes a collection bias which is translated by this overdimensioning of the biomedical domain around products or non-products (dangerousness, risks to health, death) and brings together 75.52% of the 3,350 items collected. From this work, on the methodological level, a second study has just been engaged in order to describe the positioning of these pupils with regard to their perception of situations of social interaction, in festive or initiation situations, for example. As we have mentioned in our work on conceptions of addictions, the items of our corpus show that there are more questions than certainties or, at least, that knowledge has an unstable character: a child who expresses a certainty will question its validity just after (for example: “tobacco is dangerous for your health”, followed by: “is it true that tobacco is dangerous 2 Between 1999 and 2008, the proportion of adults who considered the consumption of tobacco as dangerous from experimentation doubled, going from 21% to 43% (source: OFDT – Observatoire français des drogues et des toxicomanies / French Monitoring Centre for Drugs and Drug Addiction).

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for your health?”). In addition, ignorance or translations of experiences are expressed (with a dominant conception, for example: “alcohol, it makes you crazy”). These ought to be clarified with the pupils. An intervention with a young audience at the end of their primary school education cannot do without the provision of information on the understanding of substances and their danger, starting from these initial conceptions that we have mentioned. The very clear underestimation of the psychological and social registers also reinforce the need to work on these dimensions using activities that develop psychosocial competences. Few links are spontaneously established with social interactions. Similarly, on the psychoaffectivity level, there is probably important pedagogical work to be done on emotions (anxieties, fears, knowledge of self, etc.) or on personal judgment capacities. The elements that we have just described therefore join those put forward by Saint-Leger et al. (2007) who recommended approaches to develop in health education. Here, the posture of health education is placed in a holistic perspective in order to reunite the different dimensions (physical, social, mental, etc.) and consider the subject in his life environment in order to act on the set of determinants conditioning his health (Roberge et al., 2009). In addition, the literature has largely insisted on the risk of treating health questions on the personal scale only, forgetting that the subject is socially inserted, which in part determines his very behavior (Ridde and Guichard, 2011). The results of this study must also be put in perspective with the limiting character of adopting a pedagogical approach that is uniquely informative. This falls back on assuming that behaviors are exclusively founded on scientific knowledge and reasoning. However, the important dimension of emotions runs the risk of being treated separately even though aspects linked to mental health play a key role (Wells et al., 2003; Stewart-Brown, 2004). Several spoken items showed that even stronger elements exist in certain children from a very young age. Thus, we were able to unveil paradoxes linked to addictions. This is the case for the notion of pleasure (search) versus suffering (avoidance), or even passivity (dependence) versus activity (indulgence). Although conceptions relating to these addiction paradoxes are poorly represented in our corpus, we know that they constitute a fundamental lever for putting into words what is too often left in the intimate sphere of the subject. We take, as an example, two relatively significant

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phrases (reproduced verbatim): “why was it invented if it’s dangerous?” or “why do they smoke if they know it can kill them?”. The contradictions raised by the children are very useful for deconstructing and reconstructing what prevails in making a decision in a complex context. The objective of such work would be an improved control of the implicit, often reserved for pupils in successful situations. Talking about addictions to a young audience is not enough for them to acquire knowledge. The development of competences on the psychoaffective and social plan probably constitutes one of the major lines of intervention. This study underlines that a number of prerequisites are indispensable before entering peer education on the theme of addictions. Our results demonstrate that, in the 10/11 years age group, this peer education is not recommended (Pizon, 2013). 4.5.2. How do conceptions of health evolve within a group of children? Let us take the example of a longitudinal exploratory study consisting of the following: in one age group, a class of CE2 pupils to CM2 (Cury and Pizon, 2018). This work was carried out in order to see how the pupils’ conceptions of health evolved over three years of collection. It showed how the worry expressed by the teachers with regard to addressing the personal aspects of a subject is difficult to argue against based on the nature of the data collected. This collection, in contrast, provides an opportunity to discover that the diversity of content can also arise from confidentiality, even without the pupils confiding. The study was carried out with 19 students between 8–10 years of age, from 2014 to 2016. We used a photoexpression constituted of 60 photographs3 displayed on a board in the classroom. These images are the same as those in our reference study (Pizon et al., 2016). The progression of the collection was first presented to the pupils. The individual selection was organized into two stages: a written phase and a verbal restitution phase performed by each pupil in front of their class group. 3 At the time of publishing, this corpus was reduced to 40 photographs, corresponding to the images chosen the most often (see supra).

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A first question was written on the chalk board: “What does it mean to be in good health?”. The pupils then chose a photo that would allow them to position their answer to the question asked. Finally, they presented their snapshot and verbally explained their choice in front of the whole group. The same data collection was done around the question: “What does it mean to be in poor health?”. The results of this study showed that over the course of three years, a densification of the lexicon linked to protection factors was observed via the use, on average, of two to four recurring terms such as “healing” and “vitamin”, evolving toward “unwind”, “airing”, “oxygen” and “vitamin”. Concerning risk factors, pupils doubled the number of terms used between CE2 and CM2. The expressions or words used densified: from “lungs”, “cancer”, “disease”, “coughing”, “medicines”, to “migraine”, “toxic”, “CO2”, “chemical product”, “pollution”, “cardiovascular disease”, “heart”, “blood fluid”, “fatal illness”, “tooth decay”, “black lungs”, “cancer”, “disease”, “death” and “fracture”. This increase was accompanied by the use of generic words (“disease”, “injuring yourself”) in CE2 evolving toward more detailed words (“cardiovascular”, “blood”, “oxygen”, “tooth decay”) in CM2. In parallel, we noted, for the three class levels, the use of a lexicon specifically linked to perceived emotions, whether for visible signs of wellbeing (“cute”, “playing”, “laughing”, etc.) or malaise (“crying”, “hurting”, “scared”, etc.). Overall, we nevertheless noted a decrease in the elements of this lexicon over the three years (from 20 different terms in CE2 to 12 words in CM2). The number of terms characterizing positive emotions remained constant over three years (12–11–11). In contrast, the number of terms linked to negative emotions decreases significantly, going from eight in CE2 (“crying”, “sad”, “hurting”, etc.) to one in CM2 (“sad”). The emotions corresponding to visible signs of wellbeing are mainly verbalized in CM2. This study highlighted “atypical pathways”, meaning that they did not follow an evolving class trend. In this regard, two pupils, Mattéo and Lucas, positioned themselves in a different way to their comrades. These dissimilarities are more specifically over two years (Mattéo) or one year (Lucas). They show how the singularity of one student, via the conceptions of health expressed, is a richness in pedagogical exploitation that can be done with the rest of the class group:

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– Mattéo’s path: this pupil benefited from a PAI (projet d’accueil individualisé – individualized induction project) for medium dyslexia and dysorthographia. The objectives of his integration pertained to the cognitive domain, and also the social and affective domains, in order to develop his self-confidence. The results showed that in CE2, Mattéo placed his health around the management of emotions: “he is scared of falling” (category E1), but also physical activity: “he is running with the ball, he is doing sport” (category A3). In CM1, Mattéo distinguished himself from the collective by referring to psycho-affective dimensions: “when we laugh, it is because we are in good health” (category E1). In CM2, with category E1 “when we are joyous, in good shape and happy, it means that we are in good health”. We noted that he singularized himself from his comrades. He did not cite biomedical elements, in contrast with the class which, as a whole, overdimensions them. Over three years, Mattéo’s positioning remained dominated by category E1 (visible signs of wellbeing or malaise). – Lucas’s path: this pupil did not have any school or learning difficulties. He is the only pupil in the class who did not follow the collective in his responses twice over the course of three years. We note a good level of argument higher than the rest of the class, with a combination of arguments allowing his responses to be indexed in two, sometimes three, categories of meaning. From CE2 level, he combined social dimensions (“it is not good to smoke”) (category C1), biomedical dimensions (“smoking for too long can kill”) (category A2) and the physiological effects of the consumption of psychotropic substances (“alcohol can make you do anything”) (category F1). In CM1, he followed the collective more by centering on biomedical dimensions (“there are toxic or lethal medicines” – category A2 – and “it is good to do sport” – category A3). In CM2, he prioritized visible signs of wellbeing (“they are pleased”) (category E1), while establishing a link between tobacco and cancer (category A2) or alcohol and accidents (category D2).

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The presence of atypical pathways brings certain added value to the educational level within a class collective, in order to work on questions of alterity. The class as a whole gave priority to biomedical entries (domain A), prevention messages (domain B) and the physiological incidences of behavior or consumption (domain F), whereas these two students, at one point during their education, put forward the perception of the other (domain E) or the social and societal environment (domain C). Mattéo’s recurring position over three years, emphasizing the importance of visible signs of wellbeing or malaise, also showed the possible resistance to conceptions over time. Nevertheless, this judgment specificity constitutes pedagogical added value at the class scale, for varying the points of view and potentially feeding exchanges between pupils. We can measure the educational benefit because the voice of their peers provides alternative responses in the characterization of “good” or “poor” health. Here, it is a case of making productive use of the statements, at least at the level of a class-group, but with the potential to open a reflection within the collective of pupils. Overall, the students in our corpus have addressed a large variety of health dimensions over the course of these three years. The three main categorization inputs that fall within a biopsychosocial interpretative model are present in the whole repository: biomedical health (A), social and societal health (C) and health on a psychoaffective level (E). We also find the three possible domains of interaction: health in the social space (B), the relationship between the subject and the social body with effects on the subject himself and vice versa (D) and the individual health behaviors (F). Over 13 categories of indexation (Pizon et al., 2016), 11 are represented in our study. The two missing categories are the description of a health capital (A1), and health and support in a collective (C2). These overall results show that, despite the reduced size of our group (nineteen members), the pupils collectively cover the set of health domains. Although the repository includes 10 times fewer pupils than the study in 2016 (126 pupils between 8 and 12 years of age), these 19 students bring up 85% of the health dimensions highlighted in the previous study. No new category appeared over the course of the three years. A small number of pupils can therefore conserve a great richness of issues and address most of the dimensions in health. Regardless of the collection, domain A (biomedical) remains the most represented. The analysis of the written and spoken corpora has allowed us

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to note an increase in the use of more specific terms concerning risk and protection factors. Domain C (social and societal environment) is the least present, with the corpora not once referring to help, nor to mutual support in a collective. Domain E (perception of others, emotions and the feeling of personal fulfillment) is less and less apparent from CE2 to CM2. This is translated by a net decrease in the number of different terms pertaining to emotions throughout our collection. The visible signs of wellbeing are nevertheless perceived identically over three years in contrast with visible signs of malaise, which tend to disappear in CM2. The use of the same collection material (an identical 60 photographs) over three years is not an obstacle to apprehending the conceptions of pupils and giving them the opportunity to position themselves. We noted that a certain number of pupils used the same photograph, but the analysis of their spoken items shows that the conceptions are not redundant. We highlighted an evolution in the diversity of protection factors mentioned (microbes, medicines, etc.) and a densification in arguments concerning the consequences of using psychotropic substances (illness, accidents, etc.). The lexical analysis reinforces this observation. These data are congruent with the literature on health literacy and constitute an important protection factor (Langis, 2014). We thus note an improvement in the integration of knowledge in the field of health with a good assimilation of prevention messages. The latter are better reproduced and argued. We can suggest the hypothesis that several factors influence this argumentative progress: the influence of the media, family, school, etc. 4.6. What are the elements to prioritize for intervening in health? At the beginning of Chapter 1, we were surprised by this paradox of health education that consists of establishing prevention actions, even though very few international publications use qualitative inputs to look at how young people perceive the world around them. The works that we recount are promising and can serve as a basis for rethinking prevention, especially the inputs chosen, closer to the perceptions of children and adolescents. Based on the theory of conceptions that we have developed, we have shown the critical importance of taking into account the conceptions feeding off of various knowledge (Ks, Kcs, Kp). Addressing these registers of knowledge cannot be done without identifying where children

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and adolescents position themselves, and therefore multiplying the studies in this regard (!). There is no reason to conceal the preexisting situation, and it is necessary to accept that it could upset the established order of many prevention actions. As such, referring to paradoxes in health (we took the example of “why sell or consume a product if we know it is dangerous?”) is pertinent, just like “alcohol drives you mad”, because it makes room for the words of children or adolescents and, in consequence, of the conceptions that they express. These conceptions will lead us down a road that we should not fear to use as adults. On the contrary, there is great interest in improving our comprehension and putting aside all pusillanimous attitudes. The other lesson from these results on the conceptions of children is that they emphasize important gaps in knowledge that have scientific validity. Due to this, it would appear crucial to improve this level of scientific knowledge, which will allow children to be stabilized around elements that, little by little, help to withdraw them from their questioning. It should be noted that while the children were being questioned on health in this broad way (the collection based on photographs presented this characteristic the most), some of them said that they were a bit destabilized because they could not identify the “correct” answer. If we promote the development of decision-making capacity, we must be aware that providing anchoring points for the construction of alternatives is fundamental. Scientifically stabilized knowledge (similar to knowledge that is subject to controversy) is a source of clarification of the alternatives presented to the subject, who will or will not take them into account. From our point of view, it seems unrealistic to generate prevention actions on the development of psychosocial competences by letting children figure things out along with the knowledge (Ks, Kcs, Kp) that they possess. The register of this knowledge includes biomedical, psychoaffective, social and even societal dimensions. 4.7. What are the advantages for public health from this approach to health conceptions? We know that health is in permanent tension with registers of uncertainty that lean on both our level of scientific ignorance (the e-cigarette is a good example of the current difficulties with evaluating the degree of danger) and common sense knowledge, which can be an obstacle in the same way as the pragmatic knowledge that the subject anchors in his own experiences.

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Throughout existence, from childhood to the end of life, the subject learns, develops and makes his system of conceptions evolve. A permanent issue in public health is proposing opinions that are potentially contradictory to the conceptions percolating in the population. Between ruptures and continuities, a prevention message will or will not find a receptive place for the subject and have or do not have an influence on his behavior. The integration from a very young age of prevention messages (Pizon et al., 2012, 2014, 2016) shows the great permeability of children even though the messages settle into emerging conceptions in still-rudimentary reasoning systems. Later, the place of these messages in the adolescent and adult population clashes with pre-existing conceptions around systemic logics. A great delusion of prevention is overdimensioning the determinant character of early intervention without utilizing the permeability of these underdeveloped systems of health conceptions. It is necessary not only to work on what can feed them by providing information or recommendations, but also to intervene on what they must allow, meaning decisions adapted to the subject in terms of the environment in which he evolves. The phenomenon of media repetition of certain messages (“eat five fruit and vegetables per day”) can easily be quoted by a large proportion of the population and yet, it means nothing, as we know, in terms of behavior change. The subject functions following an economy: the acceptability of a response to a situation is the means of making a set of conceptions tenable by creating the least mental instability possible. In general, the human mind despises instability. It requires constants and equations that can be resolved relatively easily. In the field of health, the apparent irrationality of certain responses corresponds solely to the perception of the one considering them without knowing all the ends and results. The subject constructs rationalities that are his own and on which educational and prevention actions attempt to act. These rationalities do not arise from a “good” or “bad”; they are there, constitutive of the subject and the capacities that the subject is able to deploy. The action levers to consider must apply to the development of these capacities as a priority. In order to contribute more effectively to the constitution of systems of conceptions that are more favorable to health and that allow for a better response to public health issues, it is necessary to fundamentally change this paradigm in prevention actions. It is not a question of privileging an

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interventional tool such as a Graal, since, in particular, it puts forward interactions between subjects in a socioconstructivist perspective. The delusion consists of believing that there will inevitably be something in the head of the participant because the members of a group interact during a prevention session. It is also not a question of distancing the programs that are solely founded on information because their only contribution will be ineffective and there will be a need for psychosocial competences only, which are deemed more effective for setting the course toward development (Tobler and Thomas showed this in their meta-analyses of intervention programs from the 1990s). Part of the response is probably to find a balance between the development of knowledge and the development of the subject’s capacities. It must start from what the subject knows and teach him to understand how he makes decisions in order to multiply possible alternatives. This passes through an on-the-spot reflection of the place that we give to others, in their alterity and capacity to develop, and therefore passes through a better understanding and identification of the things that interact in the context of prevention policies.

5 The Convergence of Research Tools, Interventions and Training

5.1. How is a tool an inseparable element from human activity? The tool is a topic that has accompanied humanity since the dawn of time. An extension of the body, revealing the power of the mind when faced with the constraints of a situation, it is a human construct that has, reciprocally, contributed to feeding its modernity. The idea persists that anything can be made possible because of the appropriate tool. The idea that a tool brings us beyond our capabilities is born naturally (in the sense of a proximity with nature), that is, it allows us to overcome constraints, regardless of whether it is “right”. It therefore follows that the uses and practices associated with tools are equally “good” and “bad”. Highly present in the field of intervention programs in public health, the notion of “good practices” nevertheless gains from being rethought: “good” in relation to what? For whom? What is “bad” and how would it be identified? Who has the capacity to identify it? According to what kind of actors and contexts? Oriented toward which audience? 5.2. Why is the transferability of “good practices” a fantasy? Recommending good practices is not sufficient for transforming them. As such, for example, we know that with regard to type 2 diabetes, general practitioners do not follow medical insurance instructions. They know them, but they have difficulty applying them, because they respond badly to the needs of their daily practices (Bachimont et al., 2006): “The interactions

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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between the doctor and the patient are essential, and the doctors are forced to adjust their prescriptions, which induces a heterogeneity of practices”. To use the title of a 2010 publication: a constant question asked is “how to rationalize without standardizing?” (Castel and Robelet, 2010). Thus, “examining how new institutional logic can be associated with these professional dynamics is consequently an important challenge for a sector that, like that of health, is confronted by a plurality of institutional logics” (Dupin et al., 2015; Baly et al., 2016). Criticisms of the emphasis and use of “good practices” are sometimes scathing: “The recommendations of good practices are examples of the neoliberal governmentality in the health sector, as seen in the doctrine of New Public Management. Based, on principle, on evidence-based medical knowledge, they benefit from an aura of scientific legitimacy. In France, they are generated and diffused by state agencies that work with medical insurance to regulate medical information and frame practices, in the name of mastering health expenses, the quality of care provided, and public health objectives. In order to achieve these targets without directly questioning the autonomy of the medical profession, the promoters of good practices multiply the tools, notably conventional ones, of their integration” (Rolland and Sicot, 2012). The integration of doctors’ professional prescription refers back to their job and the epidemiological and financial challenges of health: for example, the appropriation of normative instruments by blood donation doctors, between resistance to health reforms and individual practices, falls within a professional and personal trajectory (Crespin, 2016). This becomes a filter for reading health protocols and interferes with their “good” application. The works of Hélène Lambrix show that it is possible to highlight several institutional logics (Friedland, 2012) by analyzing the evolution of objects used by doctors in the past (Gherardi, 2012) to understand the agency of actors over the course of institutional change (Lounsbury and Crumley, 2007). The complexity of situations (Morin, 1977) that we will mention in the introduction takes all its meaning from here, and shows the dilemmas, even the tensions, that can exist from the very first biomedical level on matters of health, before even addressing the psychoaffective and social aspects (Engel, 1977). In order to question the health practices of professionals, it is worth looking at the dominant scientific recommendations that allow for the development of health education and the outlining of a set of health factors in children (Saint-Leger and Young, 2009 in Guiet et al., 2011). We will

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retain three factors that are deemed efficient in the literature: (1) all health theme interact and cannot be dissociated from the behavioral level (StewartBrown, 2006); (2) there is a risk in treating health problems at the individual level and forgetting that the subject is socially established, and that this often determines the individual behavior (Elbaum, 2007; Ridde, 2007; Ridde and Guichard, 2008; Arcand, 2009); (3) adopting a thematic approach would assume that behaviors on health matters are solely based on scientific knowledge and reasoning. The role of emotions and implicit psychological factors is treated independently, whereas the aspects linked to mental health play a key role (Weels et al., 2003; Stewart-Brown, 2006). This holistic approach to health, placing the subject in a social whole that interacts with them, dominates in health promotion and summarizes the intentions carried out via prevention in the school sector relatively well. However, school programs, deeply rooted in pedagogic didactics, generate practices that are often very different to research-based recommendations. 5.3. How to expand the notion of tools in prevention? In the field of research and intervention, the topic of the type of tools is a focal point providing something concrete in the face of the complexity of situations. In the professional or research world, it is always reassuring to talk about tools. This covers a pragmatic character, giving the impression of being at the gates of the action. A tool has materiality, of course, but also an immateriality that is interesting to question. We will take the time to detail several epistemic and epistemological principles relating to health intervention mechanisms, leading to multiple levels of use of these tools with regard to the professional challenges between the actors of a territory. 5.3.1. What are the epistemic and epistemological principles of health intervention? Let us take the example of a research-intervention mechanism called Education, santé et territoires (EST, “Education, health, and territories”), which requestions the place of the tool from a methodological point of view in research and at the level of health prevention intervention methods to better understand the links between tool conception and mechanism design.

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5.3.1.1. What differentiates a mechanism from a health intervention program? First, the systemic EST approach brings an important semantic precision to the field of prevention by distinguishing a “program” from a “mechanism”. The term intervention “program” (in the sense of predetermined interventions in public health, and with a predefined temporality) does not allow a characterization of the intentions and finalities of EST. Instead, we will use the term “mechanism” via a double value: personal and operational (Hoc, 1980) or collective (Vial, 1999). Several personal mechanisms of operations can compose a collective mechanism. For Vial (1999), “the term ‘mechanism’ is more appropriate, if we are to understand by it an outline of the relation that should occur differently each time based on the conditions of the exercise and the uncertainties of human relations, a set of principles and not a plan to follow”. The realization of a repertoire of operations contributed to bringing “mechanism” and “task” closer together. It offers control of the process based on the point of view of the subject. This work analysis process, based on what is done by the subject, seems to us to be an indispensable lever for overcoming evaluative constraints of the action of professionals in the field of prevention. The control of the process will find itself improved by this because it is closest to the professional, even when considering the operational constraints (Karnas, 1987). To use the words of Peeters and Charlier (1999), “the notion of mechanism has been subject to variations in understanding based on the historical and institutional contexts. It is characterized by a relative plasticity that should not be denied”. To entrench their discourse, they referred to a symposium that, because of different inputs, has tended toward contributions with a theory of the mechanism. Two approaches to this term emerge from exchanges: a “totalitarian” approach that puts forward “the idea of a structure, of homogeneous order” around a cumulative logic, and a “rhizomatic” approach, which “highlights a generalized flow, complex open sets closer to the undifferentiated or chaos”. The history of the term “mechanism” shows, according to Beuscart and Peerbaye (2006), that this word “has progressively established itself in the common lexicon of social sciences”. Its presence and increased integration in recent works are notably revealed by the growing number of theses in sociology comprising the user in their designation. Research in the central

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register of theses thus shows that the subject of 30 theses in preparation containing this term “mechanism” have been submitted since January 2000, against 14 over the course of the 1990s, and a single one registered before 1989. The word “mechanism” is deeply polysemous depending on the domains to which it is attached. In Bruno Salgues’s book Industrialisation de la santé: identité, biopouvoir et confiance (Industrialization of health: identity, biopower, and confidence) (2016), “mechanism” is notably addressed in the sense given by Giorgio Agamben who integrates the notion of the sum of technologies by adding to it the notion of function and application in health. The mechanism then becomes a consumable like other measuring functions via the mobile phones of diabetics. For our part, we will position the mechanism in a formative perspective that leads us to consider the network of actors and their activity within a mechanism. 5.3.1.2. Why associate “training” and “support”? Our reflection on the foundations of a pedagogy or andragogy in health therefore relies on the “Education, health, and territories” mechanism. This leans on a network of professional actors that has been woven over several years in the department of Allier, and essentially groups together professionals in national education, teachers of the departmental site of the graduate school for professorship and education, professionals from the associative world (health prevention, social, socioeducational, sportive), social protection and insurance organisms, as well as local collectives. Organized into formal and structured work groups or in project groups that are formed from action opportunities, this network of actors diffuses and develops its expertise in different professional networks as well as in the decisional and political instances of collectives and State services. To this, a transmission and continuity dynamic between professionals is added. To support this dynamic, the teaching/support duo probably constitutes the added value of a mechanism. First, it allows a continuum. Next, it comes from a unique training model (over 1 or 2 days) that is largely considered as poorly operational in the literature. The co-writing of the history of an intervention mechanism between professionals of various status arises from a process that is costly to them, because they must gradually enter (or not) into a collaboration. Although these synchronization steps within work collectives have been the object of

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many publications (Caroly, 2010), we prefer to turn toward the challenge constitutes by the establishment of teaching at the territory scale in order to serve as a favorable basis for the deployment of prevention actions among young people. Nevertheless, the term “territory” is resolutely polymorphic because it is invested in by diverse disciplines and fields of intervention. Even though human geography, and particularly one of its branches, the development of the territory, has contributed to clarifying the definition, the comprehension and utilization of this term takes multiple forms. The latter, nevertheless, have a common feature, in the sense that it is necessary to refer to the notion of organization in order to characterize a territory. Effectively, whether it is a case, for example, of “health territories” determined by regional health agencies, “administrative territories” delimited by State services, or “life territories” in ethology, a specific form of organization is always specified and gives substance to the territory. These organizations are either thought up in advance to serve as a framework, or they are formalized following studies assessing invariants such as, for example, certain animal behaviors. Concerning the more delicate words that must be fixed in terms of organization, such as the social relations between subjects, the notion of territory appears less adapted, whereas that of a network, especially in sociology, appears to be more pertinent for clarifying these phenomena. One of the characteristics of a network is that it frees itself from the points outlining a possible border. In other words, the notion of a network does not aim to determine its limits, but rather to grasp how these structure or apprehend its regular evolutions. The EST process, on which we base our reflection, made the choice to take these two terms (“territory” and “network”) into account, because they fall within the professional reality of the actors concerned by this mechanism. Indeed, their interventions are determined both by the logic of institutional organization, and the social habits of their very own life space. Incidentally, the exploratory study that we carried out revealed this particularity, identified by the actors themselves, namely that a certain proximity and reactivity in the professional exchanges allowed them to precisely indicate the extent of their intervention territory. It is therefore in this space that is both “territory” and “network” that the actors position their field of action, perhaps even their need to interact with others. In accepting not to individually hold all the keys for resolving certain

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situations that are presented to them, they practice multiple collaborations, more or less formalized, in a space that they conceive collectively. 5.3.1.3. How to link conception and usage of a mechanism? Here we will take the term “conception”, in the sense of “the conception of a mechanism”, reinforced by the teaching/supporting duo, which we also apply to the term “use” of a mechanism (Figure 5.1). The structure that we propose for supporting a teaching and support mechanism consists of linking the “conception” of the mechanism and its “usage”. The specificity of what we describe here is to address, from the beginning of the prevention intervention mechanism: – on the one hand, the trainers of the mechanism (for the case of the “education, health and territories” mechanism, they were departmental); – on the other hand, the interveners “in” and “out” of school (prevention actors, teachers, etc.).

Figure 5.1. Possible structure of a teaching and support mechanism for professional actors intervening in prevention on a territory

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In this way, the conception of an intervention strategy first goes through (1) the training of trainers, and then (2) the training of local actors. These training actions will then be prolonged by (1 bis) deferred debriefing moments with the trainings who were trained previously and by (2 bis) the in situ support for prevention actors (Figure 5.2). The atypical character of this organization is to fall within a double movement of the training of trainers (here, in the directions of departmental trainers) and the training of interveners. This constitutes an interesting preliminary to the establishment of an intervention mechanism, by anticipating the support phase for both the trainers (who can be assisted during the training of trainers debriefings) and for the interveners, whom these departmental trainers are then led to follow in the field1.

Figure 5.2. The three levels of teaching that allow the establishment of a prevention training and support mechanism

This allows a withdrawal from the paradigm of a training shaped by fields of exercise, whether from the field of trainers mobilized in the mechanism or that of prevention actors. This implies that the trainers (themselves trainers of trainers) pushing the mechanism take into account, 1 This allows the trainers to then face this reality by accompanying the actors in prevention in front of audiences benefiting from their interventions.

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from the initial phase of training, the realities of the field of intervention of trainers and prevention actors. This schematic presents the interest of streamlining, in a repeated manner, the dialog between theory and practice. Effectively, the conception “thus presents itself as a process that structures action” as much through the interactions that this process generates between actors as through “the formulation of rules aiming to direct the action” (de Terssac and Friedberg, 1996). These authors emphasize the need to “go from action to conceive”, given that the actors themselves regulate their action. In addition, there is no separation of “conception” and “execution” that is confused in the repeated movement that we have previously described. From the point of view of the usage of a mechanism, the logic is the same and does not disconnect the theoretical and methodological inputs of the action in the field. For these inputs to be given meaning, an appropriation resulting from both taking into account the support and training of preexisting conceptions (emerging phase), and then the analysis of experiential situations (analysis phase) is required. The use of Photoformation, for example, is based on this model; we will look at this in the following sections. 5.4. Why talk about the tool syndrome in health education and prevention? If there is a syndrome in the field of prevention, it is well and truly that of “a tool for a tool”. To be convinced of this, you need only look at the activity of certain prevention structures that cause these aspects to be grossly overdimensioned and are very demanding of “adapted” tools. The tool even manages to prevail on the prevention mechanism, such as a Holy Grail overcoming the complexity of the world that surrounds us. It should not be denied, a form of social legitimacy in the researcher arises from their capacity to propose a tool that tends toward “good” practices. This “conception of the conception of a tool” is fed by the fantasy that a tool is a finality, whereas it only constitutes a method of acting and cannot be disconnected from the one who uses it. A tool is made to be diverted, but these diversions are bearers of sense. During an exchange with Pr. Didier Lémery in his perinatality unit, we brought up the difficulties of using a new ultrasound probe that limits the interpretation bias linked to interference caused by adipose tissue. Due to this, hospital practitioners apply the same pressure (too hard) on the tissue as with previous probes,

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generating false results by excessively compressing the same tissues. There, we describe a rather simple example for improving practices. However, in the field of education and prevention, there are completely different difficulties. Much more complex, they cannot be reduced to an operation or a normalized suite of operations. Here lies the difficulty, but also the origin, of the fantasy. Another clinical sign of the tool syndrome is that the conception mechanisms are sometimes increasingly turned toward games of interest between actors than geared toward the beneficiaries. As such, sometimes divergent approaches are negotiated, without being explicitly verbalized, but finding their consecration when it comes to placing logos! Through misunderstanding, the prevention tool can become (and can sometimes be summarized as) a heritage of these composite approaches. 5.5. What is the real process of conception of a prevention tool? The process of conception of a tool for health intervention is not a straight process disconnected from the first uses that stabilized its contents in terms of the intervention practices mobilizing it. However, it should be understood that diverting a tool from its first use is intrinsic to the very notion of a tool. This diversion process is a bearer of sense. In the last few years, in matters of conception of prevention tools, we observe deep evolutions. These tend to no longer favor the “representationalist” approach of the real, nor the lever of rationality for the actors (de Vaujany, 2006). The field of health could benefit from inspiring itself more on the works that saw a significant rise a few years ago. Social sciences, with the works of Rabardel (1995), Falzon (1996), and then Rabardel (2000) and Béguin (2004), were founders of this upheaval in the approach to the conception of an intervention tool. Later, other authors such as Bourmaud and Rétaux (2002), and Lin and Cornford (2001) seized this concept before Rabardel and Pastré (2005) proposed to definitively overcome the conception-usage opposition and connect them in a fruitful and rich imbrication of significances. Their main added value was to propose a paradigmatic rupture by mobilizing socioconstructivist frameworks aiming to consider the tool as a set of instruments and a learning vector, including the one using it. It is important to remember that their field of research falls within a professional

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didactic with the aim of analyzing work, with a view of training professional competences (Pastré and Vergnaud, 2006). The process of conception is therefore more complex than it seems: nonlinear, it links together construction, deconstruction, even reconstruction. We therefore move away from an applicationalist view of tool usage, which has a predetermined function from where a prescribed utilization emanates and is necessarily applied by the one who manipulates the tool. On the contrary, a tool is conceived to be diverted from its initial usage. We see that a conception linked to usage arises from ergonomics and the analysis of work. Yet the conception of a tool does not escape from the contexts of work. It therefore requires contributions from sociology to open up a wider perspective on this point, integrating work collectives. The diversions, these evolutions, even these transformations, are intrinsic to the tool from its manufacture to its different uses. First, a prevention tool will be filled with the health conceptions of its designers. The situations of conception of prevention tools could reveal the tensions and negotiations that arise from the clash of conception systems between members of a group. Effectively, we postulate that a situation of conception of a tool is fed by a wide variety of health conceptions, but not only those. Conceptions on learning and pedagogy, on the target recipients of the tool, etc., are therefore also mobilized. In a systemic way, more or less made aware of by the designers of the tool, conceptions of multiple natures then interfere and are able to stabilize themselves due to often complex negotiation processes (Kempf et al., 2015). When we designed Addi-Ado, an animation tool for children and adolescents on the prevention of addictions, these processes of negotiation between designers (technical advisor nurse, teaching advisors, teachers, researchers) showed their richness, but also the management difficulties inherent to the diversity of these designers. Despite a significant work of clarification on the aims and finalities of the tool, as well as multiple attempts to anticipate its uses, this negotiation work between designers was not able to envisage all the possible utilizations of the Addi-Ado tool. We had to test and retest its use with a panel of professional recipients of this tool (school nurses, teachers, social workers, principal education advisors). The first prescribed use of the tool was the object of many

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interesting diversions that highlighted what we qualify as “pedagogical variables”, in the sense of pertinent development elements of a pedagogical activity, and with an impact on the steering of an intervention session. The voluntarily adopted modifications in the use of the tool showed that the professional “testers” modified the sequence of the session (switching two phases for example), reacted to the expected size of the groups, chose to propose fewer activity cards with adolescents or children, etc. We thus observe a process of permanent decision-making aiming to adapt to an experienced situation to “manage” the group and its reactions. These decisions most often fluctuate between a will to maintain the objectives of the session, and the human management of the group. Inevitably, and in order to pursue our reasoning, we see that the conception of a tool and the conception of a mechanism intertwine so much that they are confused. 5.6. How does using photographs enable a reconciliation of research and intervention? Falling back on the language of words via images has a double function: what the subject “can” and “will” let us see and what the language will let the subject construct in order to enter into a form of conceptualization. The researcher, as a health intervener, needs to learn more. The use of photographs has therefore historically been marked by this convergence between science and intervention. As such, the use of images in a process of emergence of health conceptions is not new and falls within a history of health intervention practices geared toward interventions for children, adolescents, young to old adults, with or without particular specificities (great insecurity, chronic illness, psychiatry, etc., versus a larger public in the school environment for example) or even turned toward the formation of an andragogic perspective. This usage attempts to account for human function in a situation in its dynamic, its temporality and its complexity. An indispensable prerequisite for all interpretation of results in the field of health is to remember that biological, psychological and social perspectives are not mobilized sequentially by the subject, but must be permanently integrated on an equal footing and without exclusion (Berquin, 2010). The works of Vygotsky showed that, because of language, a child will gradually organize and develop its thought: “Language clarifies and directs the action of the child”.

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In our remarks, we will distinguish two levels that situate what helped us to reach the conception of a new tool, which we will present in our articulations with the previously described works of research: the e.photo expression©. The first level of presentation relates to the history of the use of images as tools for the collection of conceptions or representations. The second level allows the placement of the conception linked to the utilization of the research and intervention tool e.photoexpression©, edited by the MGEN (Mutuelle générale de L’Education nationale – General mutual of national education), in collaboration with the UNIRéS network (Réseau des universitiés en education à la santé – French network of health education universities), whose concept is to associate photographs with a digital tool mobilizing the theories of learning in order to intervene with children, adolescents and young adults on three levels: education, prevention and protection. 5.6.1. Methodological overview of the use of photographs Historically, we note that a majority of tools based on the use of photographs came from an intervention before being mobilized, declined even, by research. We therefore note, at the international level and over the span of years, a gradual movement of the densification of names of tools based on the use of photographs. We find traces of Photostory (Keremane and McKay, 2011; Skrzypiec et al., 2013), Photo-interviewing (Hurworth, 2004) and even Photo-talks (Serriere, 2010; Britisch, 2012; Powell and Serriere, 2013). The most well-known tools are Photovoice©, Photolangage© and Photoelicitation. They have been used in the field of research while also being used in that of intervention. 5.6.1.1. The Photovoice® tool DEFINITION OF PHOTOVOICE©.– Photovoice© consists, through the use of a corpus of photographs, of favoring the expression and the participation of members of a shared life (Freire, 1974).

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Photovoice© constitutes the first use of photographs described in the literature. It harkens back to Paulo Freire (Freire, 1974) in the context of interventions among highly vulnerable people or people in great poverty in Brazilian favelas. Paulo Freire, of bourgeois origin, was trained in law, philosophy and the sciences of language. He read Karl Marx and Catholic authors who strongly influenced his approach to pedagogy, and more particularly to adult education, since he could be considered as the founder of the pedagogic dialectic of adult training. In order to understand the foundations of his approach to education, we quote this phrase: “Nobody educates another, nobody learns alone, people learn together through the intermediary of the world” (Freire, 1974). We can link these words to a socio-constructivist vision of education that promotes social interactions in learning. Giving the floor in a perspective of personal and collective emancipation supported this approach, which is the basis for the Photovoice© approach, developed by Anna Blackman and Tiffany Fairey (Gavin, 2003). It involves providing the means for expression to people in vulnerable situations: women with AIDS in the Democratic Republic of Congo, sex workers in London, street children in Afghanistan, people living in refugee camps in Bhutan, etc. (Reto, 2008). The approach is described on the website: www.photovoice.org. The Photovoice© concept was described in 1997 by Wang and Burris. It is often repeated in English-speaking methododological books such as Introducing Qualitative Research in Psychology (Willig, 2013) or Qualitative Research Methods (Hennink et al., 2010). Nevertheless, to our knowledge, there is only one recent literature review mentioning the Photovoice© approach (Catalani and Minkler, 2010). It refers to an examination of the international literature, from 2008 onwards, in order to determine what defines the Photovoice© process, what the associated results are, and the level of community participation identified. This literature review looks at 37 articles. It seems that there is no relation between the size of the group and the quality of participation. However, a direct rapport exists between the quality of participation and the length of the project. Although the scarcity of evaluation criteria of the projects described in this corpus of articles does not allow the emission of definitive conclusions, in 60% of cases, a better understanding of the projects engaged

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in health is observed and a better empowerment of the concerned populations is described. 5.6.1.2. The Photolangage® tool DEFINITION OF PHOTOLANGAGE©.– Photolangage© consists of using photographs, usually in black and white, enabling the emergence within a group of persons of their representations on a thematic (Belisle et al. 2003). Photographs have been used for a long time in the field of health, without necessarily giving rise to a conceptualization of the approach engaged in the therapeutic education of patients through the use of images. The potential, as a support susceptible of enabling the expression of patients, was identified very early on, and then largely developed within a psychoanalytical stream (Vacheret and Joubert, 2008) similar to other schools of thought, notably approaches centered on the person (Rogers, 1967). The Photolangage© approach, developed in the 1960s in France by Claire Bélisle and Alain Baptiste, has a much larger field of application because, other than in therapeutics, it focuses on guidance and teaching. Originally, it was destined to “allow adolescents to find or develop, through a choice of photographs, their own position with regard to a given question, to become aware of it, to attempt to communicate it to others while listening to their deeper choices and attitudes” (Bélisle et al., 1991, 2003). Alain Baptiste presents the objectives of this technique on the website: www.photolangage.com. Photolangage© constitutes a mediation tool that facilitates communication and the exchange of information. It enables the emergence of representations and their individual and collective awareness. This approach appears, at its base, as an extension of guidance and teaching of what is implemented in the therapeutic field (Bessel et al., 2007, 2008; Vacheret and Joubert, 2008). It remains largely used in various clinical contexts (Lacoste, 2007). The corpus of images had the particularity of being in black and white until 2003, which constituted a bias in terms of the conception of the tool. At the international level, Photolangage© took first place, in 1986 in Australia (Cooney and Burton, 1986). Its usage was the object of works of research on spirituality, pursued 20 years later by Singleton et al. (2004). The Photolangage© technique, with photographs often in black and white, was also exhibited by Bessel (Bessel and Burke, 2005; Bessel et al., 2007),

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but with a centering on the evaluation of intervention programs, or teaching reforms and the apprehension of their complexity (Bessel et al., 2008). 5.6.1.3. The Photoformation tool DEFINITION OF PHOTOFORMATION.– Photoformation is a tool developed in training for adults in the field of health education and it presents three possible formative phases: prospective, analytical and appropriation (Jourdan and Pizon, 2010). Photoformation is an andragogic tool intended for the training of actors in health education in the academic environment (Jourdan and Pizon, 2010, 2016). Edited by the INPES in 2010, and then reedited in 2016, it contributes to the learning process of actors in the specific field of health education in the school environment, in reference to the context of health promotion (Saint-Leger, 1999; IUHPE, 2008). It proposes 60 photographs selected based on education models (behaviorism, constructivism and socioconstructivism) and health models (biomedical, biopsychosocial and ecological or ecosystemic). From these three education and health models, nine modalities of the relations between them are identified. At the theoretical level, this teaching tool falls within the works of Shön (1987, 2011) or Perrenoud (2001) on the reflective practitioner, and proposes, based on the works of Binz and Salzmann (2000), four situations or stages of teaching: a general introduction of expression, a prospective phase, an analytical phase and an appropriation phase. Photoformation can also take on an evaluative role at the end of a learning pathway. 5.6.1.4. The Photoelicitation tool DEFINITION OF PHOTOELICITATION.– From a corpus of images made available to participants or constructed by the participants, Photoelicitation allows one to express their point of view on a given theme (Heisley and Levy, 1991). An analysis of the literature suggests that Photoelicitation constitutes an interesting turning point for the investigation of health conceptions, and even of systems of conception. Largely developed in the United States, but completely unknown in France, Photoelicitation (Heisley and Levy, 1991) either lean on shots taken by the subjects of the study by placing them, or

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not, in a situation, or on the constitution of a collage made by the subjects based on a corpus of images that are cut out, then assembled to give an account of their point of view on a given subject (Phelan and Kinsella, 2011; Slutskaya et al., 2012) Whiting (2015) showed that Photoelicitation highlights ethical considerations and potentially takes longer and is more expensive to set up in research methodologies. Nevertheless, children appreciate the opportunity to become involved and the fact that their opinions are taken into account (Table 5.1). Box 1: Four approaches to photoelicitation

Box 2: The use of photography in Whiting et al. (2013)

Box 3: The potential benefits of photography

Autodriving: The participant “drives” the discussion or interview in relation to the photographs. The researcher can provide the photographs, but it is also common for the participants to take these themselves – they are able to see their own behavior and provide an interpretation of events. Reflexive photography: Participants take their own photographs, and are then asked to reflect on these in an interview, exploring deeper meanings. Photo novella: Participants take their own photographs, but it is done in a manner that assists in telling the story of their lives. Photovoice: Provides the opportunity for participants to take photographs of aspects of their community that need changing. It can be a powerful tool for influencing policymakers (Huworth, 2003).

Each child met with the researcher at least four times. This enhanced the building of a trusting professional relationship. The child was provided with a disposable camera with 27 exposures. Clear guidelines in relation to the use of the camera were provided. The child was asked to take photographs of the “activity I enjoy”. The camera was collected from the child’s home. The photographs were developed and the child was interviewed at home, and asked to reflect on and discuss each photograph in turn. The child was given the photographs to keep, but asked if he or she would like to provide two or three for presentations at conferences.

It is fun and engaging (Close, 2007), quick and enjoyable (Cook and Hess, 2007). It can be a visual prompt for later discussion (Cook and Hess, 2007). It allows the participant to take control and make decisions. Other techniques, such as drawing, may be influenced by the child’s skill and the pictures drawn by their peers (Punch, 2002). It is helpful when presenting and reporting the study (Coad, 2008). Children tend to have a strong interest in pictorial representations, including photographs (Coad, 2008). Photographs can provide a clear image from the participant’s perspective, which can be explored further (Morrow, 2001).

Table 5.1. Methodological advantages of Photoelicitation (Whiting, 2015)

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John and Malcolm Collier (1986) were credited with the first description of Photoelicitation as a qualitative collection method in anthropology (Table 5.2). The photographs allowed for three successive interviews led by the researcher or the participant. Very widespread in the United States, a recent English literature review (Whiting, 2015) showed the advantages of this methodology (Table 5.2). A literature review carried out for the YEMI project (Youth and E-cig Marketing Influence), in collaboration with Prof. Cristel A. Russell from the University of Washington and Dr. Simon Ducarroz, shows a great density of English language publications related to the utilization of Photoelicitation as a data collection method. These refer back to research methods, such as marketing and media (Aacker and Stayman, 1992), that are also the object of German research works, for example Schwarz and Hutter (2012) or Königstorfer (2014), the developmental or clinical psychology (Croghan et al., 2008; Rice et al., 2013), religion (Williams, 2010) and transplanted classes (Smith et al., 2010). Projective testing tool

Level of expected response

Extreme abstraction: Rorschach tests

Submerged feelings about self. Sexual emotions and fixations. Extremely free associations that dredge up thoughts passing through consciousness and subconsciousness.

Semiabstraction: Thematic apperception tests

Submerged feelings about self in relation to experiences in the real world. Free association about significance of circumstances which could take place in the real world.

Generalized representation: Defined line drawings

Lowest level of abstraction: Photographs of familiar circumstances

Concrete sentiments about circumstantial reality Free association about universal problems. Positive views about self with regard to the supernatural, universal or cultural values. Precise descriptive reportage Sweeping encyclopedic explanations Precise identification of event or circumstance Noticeable lack of submerged psychological responses But with a noticeable lack of free association Factual representation of critical area of the informant’s life can trigger emotional revelations otherwise withheld, can release psychological explosions and powerful statements of values.

Table 5.2. Nature of the data collected because of the use of a Photoelicitation (Collier and Collier, 1986, p. 125)

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Concerning health themes, we cite, for example, a study on the life environments linked to questions of diet and tobacco consumption (Fitzgerald et al., 2013), the relationship with tobacco for populations in situations of marginalization (Haines et al., 2010) and the consumption of cigars (LaTour et al., 2003). As a reminder, in our literature review on qualitative methodologies with children, adolescents and young adults, we mentioned another study based on Photoelicitation and pertaining to the interpretation by adolescents of publicities recommending nutritional diets (Hobbes et al., 2006). 5.6.1.5. e.Photoexpression©: the paper and digital alliance DEFINITION OF E.PHOTOEXPRESSION©.– e.Photoexpression is constituted of a corpus of images in color encouraging the emergence of health conceptions in an audience of children, adolescents or adults. It is associated with a digital application proposing pedagogic pathways (Pizon, 2017). Based on international literature on qualitative methodologies relating to the use of photographs, we developed a new tool falling between “research” and “intervention”, edited by MGEN, and given, between the 2017 and 2019 return to school, to all the laureates, in France, of the CRPE (concours de recrutement de professeurs des écoles – recruitment contest for school teachers) (Métropole and DOM-TOM) and the CAPES (certificat d’aptitude au professorat du second degré – second-degree professorship aptitude certificate). It involves a corpus of 40 photographs from a set of 60 images used in our qualitative research on the emergence of health conceptions in children between 9 and 11 years of age. The “paper and digital alliance” concept associates this corpus of photographs to a website in order to download an Android application. This tool, registered, is copyright protected. The theoretical reflections around the selection methodology of a corpus of photographs are based on the fact that when a photograph is chosen, it has a meaning for the interviewee, influenced in part by the context of the image and by what they want to express. For another interviewee, the same photograph can illustrate a similar concept. However, two interviewees will never have exactly the same initial reaction to an image. This corpus allows

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the collection of data that is qualitatively different to that from verbal interviews. According to Harper (2002), this can be explained by a physiological phenomenon: “The parts of the brain that process visual information are older than those that process verbal information. As such, images touch deeper elements of the human conscience than words; exchanges based solely on words use the brain’s capacity less than exchanges in which the brain processes images as much as words” (Harper, 2002). The approach on which e.Photoexpression© is founded is very open. All photographs could be appropriate, but it is important to fill several criteria that have prevailed on the constitution of the corpus: – esthetic criterion: the photo must have esthetic qualities (sharpness, framing, etc.); – significance criterion: the photos must be suggestive and potentially make sense for people, while being open to various readings; – heterogeneity criterion: the spectrum of photos must be as large as possible so that each participant can find one/several that allow them to express themselves. It is important to specify that our photos are in color in order to correspond with the current “media” dimension (society of the image, the media, etc.) in contrast to certain Photolangages. By following the three previously mentioned criteria, photography allows a co-construction of reality (or the object of the research) in this triadic interaction between researcher--photograph--subject. The photograph “made available” by the researcher thus becomes the object of re-appropriation by the subject who proposes a personal interpretation of it. The validation process for the set of photographs is done in reference to the criteria outlined above and is divided into five phases (Figure 5.3):

Figure 5.3. The five phases that prevail on the validation of a corpus of the e.Photoexpression photographs

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– pre-selection phase: choice of a first set of 60 photographs by a team of researchers and education and health professionals. Sixty photos responded to esthetic, significance and heterogeneity criteria; – pretest/test phase: this set was presented to groups of children and adolescents who were invited to verbalize what these images evoked for them. Each expression was recorded verbatim; – modeling phase: the set of photographs, on the one hand, and the corpus expressed for each photograph, on the other hand, were the object of a categorization leaning on the biopsychosocial model from the works of Engel (1977) that we have contextualized for health and prevention; – retest phase: this set was presented once more to different groups of children and adolescents who were invited to verbalize what these images evoked for them. Each expression was recorded verbatim and analyzed to see whether new categories of indexation of the discourse were identified by the researchers; – phase of stabilization of the corpus: twenty images never or very rarely chosen by the children or adolescents were removed to bring the corpus to forty photographs. Two e.Photoexpressions were produced: the first is intended for primary schools and the second for colleges and high schools. They are retrievable from: www.adosen-sante.com/ephoto-expression.html. The analysis of the content was carried out by grouping individual content into blocks of sense (Bardin, 2001) in order to determine the significant sections that permitted a categorization of the data. This set of data was then double encoded over the course of the three years by the two same encoders. Certain items were indexed in several categories when they referred to contents of multiple natures. In order to limit overinterpretation of the written corpus, we based ourselves on the verbal corpus that mainly encouraged the contribution of new elements and was rarely less rich than the written corpus.

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Figure 5.4. Sleeves of two French e.Photoexpressions dedicated to the collection of health conceptions. For a color version of this figure, see www.iste.co.uk/pizon/health.zip

5.6.1.6. Other tools (PhotoStory, Photo-Talks, etc.) We also find traces of PhotoStory (Keremane and McKay, 2011; Skrzypiec et al., 2013), Photo-interviewing (Hurworth, 2004) and even Photo-talks (Serriere, 2010; Britisch, 2012; Powell and Serriere, 2013) or Photonovella (Whiting, 2015). 5.6.1.7. A promising tool: Photonarration DEFINITION OF PHOTONARRATION.– Photonarration consists of making the systems of conception emerge from a cut-out, assemblage, collage of images from magazines. Each production is associated with a short text behind the sheet describing the nature of this production (Pizon, 2018). The term Photonarration is not often mentioned in the literature, or only marginally, with a similar sense to Photoelicitation, and does not really bring any methodological added value compared to the latter (Keat et al., 2009; Marinak et al., 2010). Here, we propose another form of use combining image and narrative text. The principle is as follows: based on a corpus filled with magazines (leisure, lifestyle, decoration, various specialized journals, etc.), images pulled from these magazines are proposed, cut out, assembled and glued in order to illustrate the answer to a first category of questions along the lines of: “Cut out, assemble, and glue the images that explain, according to you, what is…”. These various turns of phrase present the benefits of referring to different approaches to health (global for the first category, or risk or

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protection factors for the second category). The instruction is to write the reasons of this photographic assemblage on the back of the paper; in other words, what prevailed on the construction of this Photonarration. The analysis of the corpus of assemblages/collages is divided into four phases: – a global front and back analysis phase: this involves extracting an overall trend for each production, one or two dominant things that the subject wanted to express. For this phase, all the material produced is globally apprehended (photos, words, text); – an image by image analysis phase: each collaged image is a document, characterized by one or two keywords (face, fruit, sports activity, friendship, getting along, etc.); – a collaged word or expression analysis phase: spontaneously, the cutting and sticking activity of photographs from magazines generates the cutting and sticking of words from titles or subtitles. These terms reinforce the meaning given to the images used and are therefore the object of a specific analysis; – an explanation phrase analysis phase: the phrases written on the back of the paper by the subject to explain what they wanted to say enable an analysis of the content (Bardin, 2001) in blocks of sense coupled with an analysis of the connecting argument between these blocks. The narrative dimensions of these Photonarrations favor a better comprehension of the process through which the child, the adolescent, or the adult links conceptions related to different domains (sport, diet, family, interpersonal relations, emotions, feelings, etc.) corresponding to the thematic on which they are questioned (health in general or health themes). This collection and analysis methodology aims to overcome the recurrent obstacle of using a single photograph (Photolangage®, Photoexpression©, Photoformation, etc.) to go toward a densification of the discourse and the emergence of an argumentation that will allow a better apprehension of how conceptions form systems and rationalities emerge via this argumentation. At the ethical level, the narration remains decentered (as for all methodology based on the use of photographs) by avoiding talk about self, but by remaining within the thematic at hand.

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In terms of methodology, Photonarration can be considered with the addition of a focus group to support this narrative process and generate a positive confrontation of the systems of conception at work in order to talk about the chosen thematic within the collection group. Here are a few examples of collections. We focus on a study carried out with girls in their final year of boarding school in a French college (Milène Cléchet, Master 2 student in “Public Health”). The collection pertains to the understanding of rationalities constructed by adolescents around body image. Each composition is accompanied by text produced by a student. – Student no. 1:

Figure 5.5. Example no. 1 of a photonarration (collection carried out by Milène Cléchet) discussing achieving bigger breasts without surgery, always being well groomed, losing weight naturally and getting fat. For a color version of this figure, see www.iste.co.uk/pizon/health.zip

Text produced by student no. 1 associated with Figure 5.5: “In today’s society, the body is considered as an everyday object. Especially women’s bodies, which, in today’s society, must be perfect. Women must always be ready, well groomed, made-up, thin, must always do sport, eat well, and go on diets to have a shapely body.

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Women must always be thin like in all the magazine adverts in which models pose in size XXXS. Today’s society distorts the body and the body image of women”. – Student no. 2:

Figure 5.6. Example no. 2 of a photonarration (collection carried out by Milène Cléchet, with the quotes “The human machine” and “He who has the time to perfect his mind tastes real pleasure”). For a color version of this figure, see www.iste.co.uk/ pizon/health.zip

Text produced by student no. 2 associated with Figure 5.6: “Across these images, I wanted to show that the human body is just a machine. Here, I want to emphasize the mechanical side of humans. However, I concede to the animal argument of humans in order to shine light on the distinction between human and animal. What makes humans what they are, is the exercise of thought. As such, across these images, I want to show that the body is not the most important since it is a machine; what is important is well and truly the mind, the act of thinking that humanizes us, but that also allows us to enter into motion. Therefore, we should concentrate on the mind, the soul and reason; not the body. Those who take an interest in the mind

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rather than the body will be happy; in other words, the human body serves the mind. It ‘accommodates’ the mind”. 5.6.1.8. Summary of the main approaches using images All the approaches (Photolangage®, Photovoice®, Photoformation, Photoelicitation, e.Photoexpression©, Photonarration) have in common (Table 5.3) a perspective of emancipation in the broad sense (they are addressed to people considered as subjects, actors of their training and not passive individuals), a socioconstructivist approach to learning, the valorization and taking into account of the expression of participants, and a deontological framework and ethic based on the respect of the subject. Names

Photovoice

®

Photolangage®

Finality

Origin

Giving the floor to people in situations of fragility.

Great Britain: Blackman and Fairey, (Gavin, 2003),

Favor expression.

www.photovoice.org France: Belisle et al., 1991; Belisle, 2003, and then Australia: Burton and Coone (1986) www.photolangage.com

Photolanguage

Evaluate the impact of an intervention or teaching mechanism.

Photoformation

Compete in the teaching process in all its phases (prospective, analytical and appropriation).

Photoelicitation

Wider approach aiming for the restitution of an argument around images proposed by the subject of the study.

Theoretical bases Pedagogy of emancipation (Freire, 1969). Theory of “personal development”. Therapeutic field, support and training (Rogers).

United States: Bessell (Bessel and Burke 2005; Bessel et al. 2007, 2008)

Program evaluation to take into account its complexity.

France: IUFM network of trainers (Jourdan and Pizon, 2010)

Reflective practitioner (Schön, 1983), adult learner (Knowles, 1970), professionalization (Perrenoud, 1998).

United States – Germany (Slutskaya, 2012; Whiting, 2015)

Methodology from anthropology and visual sociology. “Autodriving”, facilitator of individual expression.

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e.Photoexpression

Biopsychosocial collection of health conceptions and health themes France (Pizon, 2017, associated with a 2018) corpus of resources via an Internet site and a digital application.

Theory of health conceptions and interpretative model of conceptions.

Photonarration

Narrative approach to health (cutting out/sticking of images) mobilizing a systemic entry of conceptions (health, family, etc.) coupled with focus groups.

Theory of health conceptions and systems of conceptions.

©

France (Pizon, 2018)

Table 5.3. The different approaches using photographs (historical and theoretical foundations)

6 Formative Perspectives for More Effective Prevention Actions

This chapter links the theorization of conceptions in health with the conception of tools and mechanisms. We place ourselves in a perspective of training health, education and prevention professionals. These lines of reflection are part of an increased awareness of the context of uncertainty resulting from how little knowledge we have on conceptions in health (those of young people, but also those of adults in training who are the object of a lesser number of publications1), and this in the moving and unstable societal context of our modern world. First, we will summarize the andragogic foundations that follow a posture of support and training in order to favor the elaboration of formative situations enhancing the subject’s construction of health alternatives that could help them to make decisions. Next, we will aim to integrate the irreducible subject/collectives/society tension in order to envisage a model of categorization of intervention situations that can be used to design training content.

1 See the journal Éducation, Santé, Sociétés, thematic issue 4(2), Interventions éducatives et santé: construire le dialogue entre le monde médical et les sciences humaines et sociales.

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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6.1 What are the andragogic foundations for better apprehending the complexity of systems of conceptions? In the previous chapters, we saw that the interconnection of conceptions in health is larger than the sum of the conceptions that constitute it. A trainer who works on topics of prevention cannot overlook and should focus on the importance of taking into account the conceptions of the public they address. 6.1.1. On which points of vigilance is it necessary to focus training? Previously, we put forward the theory that each subject conceives the world around them through multiple conceptions that systematically combine. It is probably here that one of the important difficulties presents itself to the teacher. The latter cannot so easily escape their own conceptions, both in the field of health and prevention, and in the field of teaching: how do they conceive the action of teaching? How do they address the interpersonal relations within a teaching group? How do they consider the teaching context and the work context of the people they address? And so on. All the conceptions form systems with each other, and access for the teacher to this system therefore arises through a complex task since they themself are caught up in a logic requiring that the systems of conception of the people in front of them be taken into account. The teacher a priori only knows a few things about the participants’ systems of conceptions. Paradoxically, however, the participants themselves are not necessarily conscious of the diversity that constitutes them or of the importance of clarifying, for everyone’s benefit, the variety of rationalities that each one has been able to construct through the exercise of their own work. This is because, as we have seen, we are not necessarily aware of all conceptions; they remain mobilized, with others, in the immediateness of an instant, in response to a situation presented to the subject. The formative game consists of creating conditions that are favorable to the emergence and/or mobilization of these conceptions and the constructions of sense that they generate.

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As mentioned previously, we maintain that putting things into words is not a condition necessary for their existence. On the contrary, the acts of the subject are rooted in conceptions that they are not always able to verbalize. In addition, any training should be careful not to overlook the beneficiaries in fine of the prevention actions. 6.1.1.1. First point of vigilance: considering the training group as a force With these introductory words, a first point of formative vigilance appears as the trainer’s ability to recognize that the group is a powerful lever. A training group has a collective force that can be used to pilot a training action. The diversity of participants is truly a factor of efficacy for training professionals that prescriptions often push to work together. Nevertheless, although in the professional world we observe an overprescription of objectives, very few of them explain to professionals how to collaborate. Yet, for 25 years we have known that it is essential to consider the collective aspects of work (Six and Vaxevanoglou, 1993). This is as A. Strauss indicated in his 1978 article “L’hôpital et son ordre négocié” (Hospitals and their negotiated order) when he showed that all the daily tasks carried out by the set of professionals in a hospital were not systematically detailed beforehand in formalized prescriptions, but rather through a continued process of regulation of rules, constituted of explicit negotiations, sometimes formalized and organized by the professionals themselves. The same observation is transposable to a number of work collectives. A training program should bear in mind this point of vigilance in order to help participants identify this part of their work and bring it out of the shadows. It is in this way that a group can confer an undeniable force for analyzing work situations by leaning on the interprofessionality of participants: “How can I speak, with my professional history, about the situation that I am given to analyze?” 6.1.1.2. Second point of vigilance: affirming the analysis of conceptions in training This involves creating opportunities in order to make systems of conceptions visible in teaching groups. In reference to the multireferential approach (Ardoino, 1993), we propose a transposition toward “a formative grid”, as described in the introduction, in order to become a guiding and structuring element for research and that, here, finds sense in formative interventions.

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Effectively, the combined insights of psychology, education science, public health, sociology, etc., allow for a pluri-disciplinary approach based on a collection from the discourse of the subject to situational observation. At the methodological and ethical levels, this point of vigilance leads us to create formative situations that reinforce the analysis of the subject-intraining’s conceptions, ensuring their association with this approach of emergence, and based on situations through which these conceptions are mobilized in the context of professional activities. This roots us even further into the analysis of work. Training in prevention means enabling identification in order to reach an analysis of professional situations; it is pertinent to keep track of what is done in the context of one’s job. This a minima involves the collection of written traces, which means all support could be the object of analysis. This analysis could be crossed with that of the observer, on the one hand, and that of the people in training, on the other hand. As such, work on prevention action supports gains even more meaning when it can be used with elements that come from experimental practices developed by the audiences in training. The whole challenge of teaching is to valorize the experience of professionals. These do not constitute a public wiped blank of all history. This history comes from an often dense personal trajectory, and the trainer must adopt an attitude of support based on its existence. Similar to how research carried out with adults on professional trajectories showed the games of rupture and continuity that we have already mentioned, our research work on health conceptions pushed us toward this open perspective in order to understand how people in training “think” of the world and lean on this existence in training. To extend this reflection, Hélardot (2006) explained that “the character by definition diachronic with all trajectories highlights very many questions on the modes of definition and analysis of temporalities and change. Human sciences have worked on this thematic in a theoretical and empirical way, in reference to a series of paired concepts: the opposition of short time/long time allows the identification of different temporality regimes and the exploration of their reciprocal influences; the definition of change mobilizes the distinction between a fast mode (that of a crisis, of a brutal event or rupture) and a slow mode (that of gradual evolution and sedimentation); the predictability/ unpredictability couple refers back to the question of causality and the

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classical opposition between determinism and contingence (or necessity and hazard); finally, the reversibility/irreversibility tension questions change as a more or less durable redefining of a “space of possibilities””. Nevertheless, in teaching, that which corresponds to the private sphere has no place in the public sphere. In this context, what is of interest to us is the meaning given to the “big questions” that are asked and the answers generated collectively (even if, in the background, questions of suffering at work could be highlighted). From the point of view of the conditions of emergence of this formative questioning (which has a problematization value), we do not pretend to exhaustively review the existing methodologies of the field of human and social sciences, but professional life stories constitute a path worth exploiting. These stories are prominent in the description of professional experiences that allow us to look into the underlying conceptions. Moreover, they are not limited to the field of sociology, as Daniel Bertaux already described in 1980: “In sociology as in other disciplines, the prevailing conjuncture is at the pluralism of theories and methods. Also life stories, finally rediscovered, are used in multiple ways. At the same time, however, because they lead us to a position at the articulation point of human beings and social places, of culture and praxis, of socio-structural rapports and the historical dynamic, it could be that from the diversity of their utilization, little by little a unifying approach overcoming the boundaries of sociology as such emerges”. 6.1.1.3. Third point of vigilance: favoring the development of an explicit pedagogy in prevention This point could be linked to the development in teaching of a pedagogy that is explicit in health, in a perspective of equity of prevention intervention. In the field of health, the subject’s response to a situation involves making a decision. However, what will allow the subject to appropriately respond to a situation, meaning in a way to live a possible life (following Philippe Lecorps’s sense), is their capacity to envisage decisional alternatives. This element seems crucial to us, and we found an interesting network between the different registers of knowledge (scientific, common sense, and pragmatic) that we have already developed. This complex process induces specific methodological approaches that are particularly pertinent to address in training in order not to forget the beneficiary public of the prevention actions.

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Let us take the classical, but very significant, example of a student entering college and their classmates offering them a cigarette. The child was able to construct, around the three components subject/group/society, a corpus of conceptions: on the dangerousness of the product (based on their level of scientific knowledge and their integration of prevention messages), on the image of the product (influenced by the evolution of societal norms on tobacco), on the peer pressure fed by pragmatic knowledge of lived situations, on the college, this new life-bearing largely distilled in family or friend spheres via common sense and pragmatic knowledge, etc. With the help of these registers of conception, he must at the same time evaluate the situation, consider their place faced with the group, manage the image they projects, position it according to the peer pressure and, in consequence, envisage responses that seem acceptable based on what they are and how they live. In this example, we note the extent of how humble we must be in terms of our understanding of the process that pushes the subject to construct forms of rationality in order to adapt to this situation of tension. The subject/group/society tension that we discussed at the start of this chapter is a constant in the decisions that the subject is led to make, and deserves to be highlighted and analyzed in training. For the subject, it is essential to learn to adapt to their reading of the world in order to adjust their decision-making through the construction of an “other way”. This point constitutes a crucial challenge in matters of teaching in the field of prevention. It relies on works relating to explicit pedagogy (Pernin, 2003; Gauthier et al., 2013) that we will apply to prevention in the following sections, in an attempt to move away from these “(preventative) misunderstandings that make the differences” (Bautier and Rochex, 1997). 6.2. In teaching, how can a better apprehension of the complexity of systems of conceptions be developed? In order to propose a tracking of the collection of conceptions, we will retain two main pathways: the nature of the situations of collection and the temporality of the collection. The nature and temporality of situations of collection depend on the idea of a health pathway. This pathway is not linear, but sinuous, constituted of life moments between healthiness and sickness. A continuum between the subject and the personal events that they encounter must be considered. In

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consequence, the life of the subject is taken as a whole that founds new health conceptions, reinforces others and creates systems of rationality that allow subjects to adapt themselves and to construct themselves. From a research point of view, the situations of collection of health conceptions cover the following dimensions: (1) biomedical and biological, (2) psychological and psychoaffective, (3) social and societal. These are not impervious to each other. In contrast, their combination is the basis of what characterizes most collection situations and determines healthiness. However, sweeping aside the biopsychosocial dimensions mentioned above involves characterizing for each one of them the type of knowledge mobilized with regard to the criteria defining a health conception (see Chapter 3): scientific knowledge, common sense and pragmatic knowledge. Potentially, for each of the biopsychosocial dimensions observed, knowledge can be mobilized by the subject and combined. However, certain situations of collection can show dominance: biological when the subject is questioned about the functions of nutrition, for example, psychological when the focus is on emotions, or social when centering on peer influence. These dominances do not mean that there is a perfect airtightness between these dimensions. For that, we will refer to the interpretative model of health conceptions that outline the areas of intersection between the “biological”, the “psychological” and the “social”. Six domains, three of which interact, are part of the indexing (Figure 4.5). The functioning of health conceptions generates the possibility, for the subject, to develop a response that is acceptable in terms of the situation they encounter. We consider that the product of the subject’s process of elaboration of alternatives feeds back and modifies the characteristics of the situation. By acting within a situation, the subject transforms it. This then fully becomes the revelation, and not only the source, of health conceptions underlying decisions that are made. The elaboration of alternatives and decisions follow the temporalities of a subject’s life situations and allow the researcher to follow different moments of existence. This postulate notably gives rise to the possibility of bringing works on health, prevention and the therapeutic education of the patient closer together in the life continuum of a subject in order to expand the breadth of observation and multiply the situations of health conception collection to better understand how these make systems with each other.

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Table 6.1 suggests a setting of criteria that would attempt to clarify “when” a prevention action is placed (the collection temporality), “how” we go about doing this (the biopsychosocial dominances of arranged situations), “what” we observe (the scientific, common sense or pragmatic knowledge of the subject), and “for who”. In other words, which decisions are of interest to us and which alternatives do we want the subject to construct in interaction or not with collectives. Temporality of observed situations: long time (normal life and chronic illness) – short time (stressful situations, crisis)

Normal life, daily life events. One-off illness, chronic disease, crisis situation (death, affective rupture, etc.). (1) Biomedical and biological dominance.

Nature of situations of collection of health conceptions: biopsychosocial dimensions

(2) Psychological and psychoaffective dominance. (3) Social and societal dominance. Scientifically validated knowledge (Ks).

Type of knowledge mobilized in situations by the subject(s)

Common sense knowledge (Kcs). Pragmatic knowledge (Kp).

Decisional processes at work

Alternative(s) envisaged by the subject or the group of subjects. Decision(s) taken by the subject or the collective.

Table 6.1. Proposal for a model of indexing of situations of health conception collection integrating the subject’s construction of alternative responses and decision-making

We consider it important to integrate situations that are both “ordinary” and “extraordinary” for the subject in our formative reflection (Backett and Alexander, 1999), especially if we extend this work on health conceptions to the therapeutic education of the patient. Daily life situations, their rhythm and their recurrent character must not exclude the ruptures in this continuum. By creating a disturbance, an “extraordinary” situation, the psychological process at work in the subject leads them to a form, even if only provisional, of resilience in order to redefine points of stability. Children with chronic

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illness develop as compensation explicative strategies that are rooted in both personal and collective dimensions (Sabouraud-Leclerc et al., 2013). On the other hand, situations of therapeutic education can go as far as associating the sick child in the management of their illness with caregivers (Chavigny et al., 2002). The challenge of teaching is to identify the situations, analyze them and describe the invariants or the variabilities according to the biopsychosocial nature of these very situations. Our works have shown just how strong the effects of the type of situation can have on what is carried out in prevention with a biomedical, or psycho-affective, or even social dominance (see Table 4.5). Consequently, it is necessary to bear in mind that the arrangement of situations constructed for prevention will have a direct effect on the type of conception, which is sought to be mobilized in prevention. Teaching has an important role to play in identifying this structuring aspect of the conditions for arranging a preventative situation in which, depending on the audience, their age or their gender, these actions do not mobilize the same systems of conceptions. Let us take the example of affective and sexual life. A study carried out through self-administered questionnaires laid the groundwork for our reflection. Verdure et al. (2010) showed, for example, that the majority of students (88%) thought it important that sexual and affective education be part of the education program, but the majority of pupils (68%) did not feel the need to speak to someone about sexuality. However, half the girls stated a need to discuss compared to 16% of boys (P < 0.001). Girls wanted to be among each other more significantly (35%) compared to boys (23.5%) (P = 0.001). Thus the conditions prevailing for the conception of more targeted situations of collection are laid. We would like to insist on the establishment of links between the subject and the situation across the biopsychosocial dimensions of a situation lived within the temporalities of a life course. Teaching for more effective prevention means integrating this aspect by pushing the beneficiary public to spell out what happens at the heart of this situation. Nevertheless, in response to these situations, the alternatives and decisions are not simply condensed to a process and a product. They enter us into a movement between alternatives and decisions in order to characterize the situations themselves and their reading by the subject. This iterative logic prevents us from falling into the stimulus/response behaviorist pitfall. The subject confronts a situation, but transforms it too. The decision then becomes an unstable point of equilibrium at a time “t”. The analysis in training of

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prevention situations from this angle favors a better understanding of the weakness of the beneficiary public’s analysis of situations, as well as an identification of this same public’s degree of support in order to understand the challenges of the situation that is experienced. 6.3. What foundations of an explicit pedagogy should teaching follow? By leaning on criteria constitutive of a health conception, we previously noted the articulation of three types of knowledge: theoretical, common sense and pragmatic. The way in which the subject mobilizes this knowledge of varying nature has as much, or even more, importance as the knowledge itself. Health practices alter this knowledge, by translating or not translating its operationality, and they do not always allow it to be summoned, at least not at the same level: pragmatic or common sense knowledge can take priority over scientific knowledge, perhaps even redirected toward another finality. Such is the difficulty of pedagogy in health, and which it is necessary to address in teaching. What can be done for the subject to “learn”? And what is the nature of this learning? Previously we underlined that an error does not have the expected “wrong” status. In health, it is not about pointing the finger at “what is right” versus “what is wrong”. Increasingly, we position ourselves in a posture of support and help for decision-making. In Chapter 1, we saw that the link between “education” and “health” is extremely complex. The subject must be capable of getting to grips with the multitude of interlinked parameters and become aware of this management in order to better understand themselves and anticipate their own reactions when faced with the unknowns of existence. This is the educational issue that interventions in health must attempt to answer. This is the challenge that a training to generate support that is more adapted to helping the conception of prevention situations must meet. 6.3.1. Why is it imperative to make the implicit explicit? Situations that are sources of learning require that the implicit be rendered explicit.

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We know that the most successful students have much easier access to this implicit. Often, they have a higher level of study and will go for screening more systematically, etc. When aiming to reduce social inequalities or, a minima, introduce a little equity, a desire to support the most destitute who are not favored by traditional teaching methods must be kept in mind. Often, they will not have the means to perceive what goes on implicitly, whereas this question is central in the field of health and prevention. An outdated demon of formal schooling floods the field of health intervention, what E. Bautier and J-Y. Rochex (1997) described more broadly in pedagogy according to a logic of “progression and profession of the student” as opposed to a logic of “learning and work of the learner”. This distinction is fundamental to ensuring that the form of intervention does not prevail on the background, nor the tool on the finalities of the prevention action. Effectively, the logic of progression dictated by the proposed activity can trap the child or adolescent in the idea that the achievement of this activity is in itself enough. However, the whole idea is to aim for sedimentation rather than accumulation or fragmentation. At the pedagogical level, this means that it is necessary to allow children and adolescents to enter into a process of sedimentation, which is a construction of sense. The operationality of a conception of a system of conceptions harkens back to the pragmatics of a situation. The concrete character of a prevention situation enables the presentation of situations close to their experiences or what they might experience to children and adolescents. 6.3.2. What should lessons in health aim for? We now know that it is necessary, within a formative situation, to keep knowledge, situations, alternatives and decisions together. To do so, the formative situation would gain from being considered as the starting point of a process for the resolution of a problem (Figure 6.1). The disturbance value of the situation allows the modification of the points of stability that a subject will have developed. This disturbance creates a rupture with the construction of sense that is no longer operational for responding to the problems posed by this new situation. The conceptions that would previously have brought stable references to the subject are now

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re-questioned. The attempts to re-mobilize these conceptions also disturb the systemic logic that was established, sometimes routinely. As such, we see that the description of the upheaval of order that was strongly established through situations experienced earlier also generates the possibility of characterizing the trigger situations. Such situations must therefore exercise sufficient power to create a disturbance. We can also put forward the hypothesis that, during a prevention intervention, the choice of situation will be a determinant of whether it makes sense for the subject.

Figure 6.1. Structuring elements of a pedagogy founded on the explanation of situations in order to act on system of conceptions in health

Figure 6.1 also allows a perspective that is of interest to the teacher and that can also support the construction of pedagogical finalities to be fixed. Effectively, the situation, the disturbance it creates, the conceptions or systems of conceptions mobilized, the alternatives envisaged, and finally, the decision (s) retained are dependent on the unwavering links in a complex come-and-go movement. The subject weighs all these elements, takes them into consideration to a certain extent and sometimes refuses to envisage certain ones. This elucidation with the subject is then put into words and images, the accumulation of traces of these biopsychosocial mechanisms leading to a review (or not) of earlier systems of conceptions.

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The challenge of training that aims for the development of this preventative strategy is to show how the role devoted to the preventer on health supports the subject in terms of (re)taking power over a situation. For a decision to be made, several alternatives must be developed, must find their coherence with pre-existing systems of conceptions and sometimes confront strong resistance from the subject who struggles to accept their evolution. In this case, they are either evacuated by the subject, or they generate a re-adaptation of the systems of conceptions. In all cases, this mental movement is based on back-and-forths seeking some kind of stability that will allow the living of a possible life that the prevention action can accompany. Intervening in prevention is one of the most complex educational tasks. It requires the mastery of an especially broad span of professional competencies. Training is essential to introduce future preventers to a movement concerning themselves, and thus helping them to become enriched with multiple views of the world. This review is the basis of our vision of research and intervention.

Conclusion

Concluding is a dangerous exercise for a researcher. The form of this work nevertheless entices us into this game, even if it is universally acknowledged that all conclusions can only be partial in matters of research. There lies what is probably the main lesson: research follows a pathway with no real definitive conclusion. No doubt, the aim is not to get to the end, but rather to always leave room for continuation. In this work, we aimed to find the meaning of lexical usages that percolate in the field of prevention and to propose a reflection of the relationships that unite “education” and “health”. The word “research” is itself etymologically the bearer of a meaning that guided our writing. It becomes an image when we look into the multiplicity of the meanings that animate it. Sometimes it is a term referring to water and forests and evoking a possible lack of trees that must be replaced, sometimes a term for roofing that gives the reassurance of paving by placing new tiles in missing areas, sometimes a geographer or historian term for tracing back to the source and sometimes an ornamental fantasy for the musician; this word built itself at the crossroads of sciences, arts and techniques. The idea of paving, of the quest for missing pieces, finds all its meaning in the field of health conceptions. We started with the observation of our ignorance, at the national and international scale, of health conceptions in children, adolescents and young adults. There are still very little work on this and it all still remains to be done. The second point that structured our demonstration refers to elements that, over these last few years, constructed the relationship between health and education, in a reciprocal manner. The first 10 years of the emergence of research on this thematic in France were

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fed from various disciplinary domains, borrowing notions, concepts or theories that were not always compatible with each other. This work was an opportunity to attempt to integrate these different pieces into a process that seemed essential to us for building more effective prevention: qualitatively improving what we know on how children and adolescents conceive health. From this entry point, we structured our work. The task is immense and therefore partially addressed here, but we leant on the most solid conceptual bases possible. We had to take things “from the source”, tracing back the meaning given to universally used terms (social representations, beliefs, knowledge, etc.) in order to better understand the underlying scientific realities. This work allowed the distancing of notions that could disserve what we wanted to observe. The level of theorization in our field of research is often the object of criticism, sometimes legitimate and sometimes exaggerated, but, regardless, this theorization is essential for considering the singularity of our objects. In attempting to develop a theory of health conceptions, we wanted to establish the convergences between works in the field of education and health. Our objects of research are intrinsically at the crossroads between education and health. They contribute to giving the subject a humanity, to considering him as a biopsychosocial being caught in his own logic, with his own turmoil, certainties and uncertainties in a life environment in which he grasps very few elements, but that pushes him to envisage alternatives for his health that will or will not guide his decisions. As researchers (we had the caution to remind ourselves), we cannot escape from our own conceptions. Science is there to help us move them away, but the singularity of a professional trajectory and the huge opportunity of being able to move away from all the researchers within the same fields of research remain indispensable sources for this double acculturation between education and health. Having finished writing these few pages, it is now possible to measure the task facing us in the coming years. There are multiple continuations of work on health conceptions, but we will retain the importance of investigating the systems of conceptions. We cannot emphasize, as we did in the introduction, the complexity of the world and exempt ourselves from it entirely. Multidisciplinarity is an essential perspective for moving forward with the understanding of rationalities built by children and adolescents. The stakes are high in trying to bring new paths for prevention. Work in education sciences shows that

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certain paths benefit from being reinvested in order to improve health intervention. However, reciprocally, health favors the management of urgency and sanitary priorities compared to education, which generates perspectives for the long term. This double culture is an extraordinary richness, because it puts all of its meaning into the diversity of points of view and scientific discussions. We could vow that this indispensable opening of the mind to apprehend our objects percolates all the way to the teaching of actors in prevention, and the teaching of teachers. Intervening in prevention is one of the most complex educational tasks. It requires the mastery of an especially broad span of professional competences. From a formative point of view, it seems crucial for future preventers to initiate a movement in order to help them to enrich themselves in multiple views of the world and to understand, little by little, that only one thing is clear, and that is that nothing is certain. This reconsideration is the basis of our vision of research as intervention.

Appendix

A.1. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4–20 years old) address health Title

Methods

Results

Country: UK Fairbrother, H., Curtis, P., & Goyder, E. (2016). Making health information meaningful: Children’s health literacy practices. SSM – Population Health, 2, 476–484.

Age: 9–10 First phase – interviews and debates in small friendship groups. Second phase – set of eight family case studies (children and parents were interviewed separately).

Children demonstrated that they accessed (and interacted with) a rich variety of different sources of food-related health information, including social marketing campaigns, school, family, media and advertising and health professionals.

Country: Russia Kamakina, O. Y. (2016). Features of psychology of health of primary school children. Procedia – Social and Behavioral Sciences, 233, 192–195. Hernán-García, M., BotelloDíaz, B., Marcos-Marcos, J., Toro-Cárdenas, S., & Gil-García, E. (2015). Understanding children: A qualitative study on health assets of the Internet in Spain. International Journal of Public Health, 60(2), 239–247.

Age: Primary school age The method of unfinished sentences, the projective drawing test “Health”.

Reveals an emotional richness of children’s feeling about health.

Mixed study with 360 children and 273 parents.

Country: Spain Age: 10–11 Focus group discussion, observation.

The Internet has assets for health and wellbeing. The results reveal the importance of the Internet as a source of information, communication, entertainment, play and learning.

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Davó-Blanes, M. C., & La Parra, D. (2012). Children as agents of their own health: Exploratory analysis of child discourse in Spain. Health Promotion International, 28(3), 367–377.

Country: Spain Age: 8–12 Focus group discussions: children perceive that their role is subordinated to the role played by teaching staff and health care professionals, and by adults in general.

Primary school pupils have a constructive concept of health in which they are aware of the role they play to make changes on a personal level, in the school environment, and to a lesser extent, in the wider social context.

Garcia, C. M., Duckett, L. J., Saewyc, E. M., & Bearinger, L. H. (2007). Perceptions of health among immigrant Latino adolescents from Mexico. Journal of Holistic Nursing, 25(2), 81–91.

Country: United States Age: 15–20 Focused ethnographic techniques (four adolescents were purposively recruited from two non-health-based community settings. Each of them were interviewed twice and completed a visual narrative project using disposable cameras, images), participative observation.

The adolescents’ perceptions of health are described using participants’ words and pictures, according to the three thematic patterns that emerged from the data – being healthy, healthy influences and behaviors, and unhealthy influences and behaviors.

Piko, B. F. & Bak, J. (2006). Children’s perceptions of health and illness: Images and lay concepts in preadolescence. Health Education Research, 21(5), 643–653.

Country: Hungary Age: 8–11 Draw and Write technique.

Children have considerable knowledge about health, illness and disease risks; they also seem health conscious and express positive attitudes toward health and health promotion.

Country: United States Age: 9–17 Photoelicitation.

Demonstrate some ability to critically analyze the more obvious forms of deceptive weight loss advertising; many girls do not recognize how advertising evokes emotional responses or how visual and narrative techniques are used to increase identification in weightloss advertising. This study examined how girls aged 9–17 years interpreted magazine advertising, television (TV) advertising and infomercials for weight loss.

Country: Kenya Age: 10–15 Interviews and the Draw and Write technique.

Students can modify and broaden their concepts of health and illness through action-oriented health education. There is a clear difference in pre- and postintervention drawings. For example, preintervention – house or car going to hospital; postintervention – clean food.

Hobbs, R., Broder, S., Pope, H., & Rowe, J. (2006). How adolescent girls interpret weight-loss advertising. Health Education Research, 21(5), 719–730.

Onyango‐Ouma, W., Aagaard‐Hansen, J., & Jensen, B. B. (2004). Changing concepts of health and illness among children of primary school age in Western Kenya. Health Education Research, 19(3), 326–339.

Appendix

Country: UK Age: 5–10 Pridmore, P. J. & Lansdown, R. G. (1997). Exploring children’s perceptions of health: Does drawing really break down barriers?. Health Education Journal, 56(3), 219–230.

The Draw and Write method, the Label and Write method and the Write Only method. The findings show that that no single method is best in all contexts and that an imaginative combination of drawing and writing can balance the strengths and limitations of each method. Country: UK Age: 4–12

Backett, K. & Alexander, H. (1991). Talking to young children about health: Methods and findings. Health Education Journal, 50(1), 34–38.

Interview was in nine sections:

1) 2) 3) 4) 5) 6) 7) 8) 9)

Drawing Activity Eating Parents Post-box Activity photographs Peers Illness Ranking exercise.

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All methods provided roughly the same number of categories, while Draw and Write revealed more on how ideas were interlinked. Label and Write provided more information on physical signs of health or ill health and the appearance and use of drugs and foodstuffs. Drawings helped to decipher poor handwriting. The results also suggest that the Write Only method is a quick way of identifying major categories of information. The study indicated that the majority of children seemed reasonably well informed about foods conventionally deemed to be “healthy” and “unhealthy”. However, questions about personal food preferences and the effects of different foods on the body revealed contradictions and confusion. This paper has highlighted that, as with adults, talking to children about health-related beliefs and behaviors is a daunting methodological task. Approaches must be developed that are meaningful within the children’s own frame of reference.

A.2. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4–18 years old) address health themes Title

Farmer, S. & Porcellato, L. (2016). “Thinking about drinking”: Exploring children’s perceptions of alcohol using the Draw and Write tool. Health Education, 116(6), 541–560.

Methods

Country: UK Age: 9–11 Draw, describe and write.

Results While no typical character was drawn, nearly half drew adults (48%) aged between 20 and 49 and 11% drew characters aged over 50. The majority of these (71%) were neutral descriptions or labels of the person’s appearance or clothing.

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Country: United States Schultz, C. M. & Danford, C. M. (2016). Children’s knowledge of eating: An integrative review of the literature. Appetite, 107, 534–548.

Age: 12–18 Integrative review of the literature. This study provides a list of 30 articles that are addressed to preschool and school-age children.

Country: Canada

McGregor, S. E., Murphy, E., & Reeve, J. (1992). Attitudes about cancer and knowledge of cancer prevention among junior high students in Calgary, Alberta. Canadian Journal of Public Health. Revue canadienne de sante publique, 83(4), 256–259.

Age: Junior high students Open questions: – What is cancer? – How do you get cancer? – If you have cancer, is it serious, can it be cured? – What would you like to know about cancer?

This review shows that even before receiving formal education, preschool-age children possess a wealth of tacit knowledge related to eating. They also understand concepts related to food, nutrition and the body that arise from their sensory-motor experiences, which they believe to be true. Given this evidence, understanding children's beliefs and tacit knowledge can be helpful in tailoring interventions that will prevent and reduce childhood obesity. Students in the survey (n = 246) consider cancer to be a serious disease, not particularly amenable to treatment, and caused by many things. About half the students mentioned avoiding tobacco use as important in preventing cancer. However, 27% were unable to identify any ways to avoid getting cancer. Specific knowledge of dietary practices recommended to reduce cancer risk was poor, with fewer than 10% of students mentioning high fiber or low fat as important dietary habits. Knowledge of factors related to skin cancer was better, with 53% of students mentioning avoiding sun exposure as a way to reduce the risk of skin cancer. The majority of students (71%) wanted more information about cancer. The results from the survey indicate a need for cancer prevention materials in the school curriculum. Their perception of healthy eating resulted into seven concepts: 1) No definite views 2) Diet composition

Swaminathan, S., Thomas, T., Kurpad, A. V., & Vaz, M. (2009). Perceptions of healthy eating: A qualitative study of school-going children in South India. Health Education Journal, 68(2), 94–110.

Country: India Age: 7–15 Interview. When a person says, “eat healthily”, what does it mean to you?

3) The manner of eating 4) The manner of cooking 5) Health benefits 6) A combination of two or more of the above concepts 7) Other views. Children’s perceptions on meaning of healthy eating and healthy and unhealthy foods varied depending on several social– cultural factors. The limited experience with foods of the younger age group is reflected in the answers given.

Appendix

Thastum, M., Johansen, M. B., Gubba, L., Olesen, L. B., & Romer, G. (2008). Coping, social relations, and communication: A qualitative exploratory study of children of parents with cancer. Clinical Child Psychology and Psychiatry, 13(1), 123–138.

Zeinstra, G. G., Koelen, M. A., Kok, F. J., & De Graaf, C. (2007). Cognitive development and children’s perceptions of fruit and vegetables; A qualitative study. International Journal of Behavioral Nutrition and Physical Activity, 4(1), 30.

Country: Denmark Age: 11 Interview.

Country: The Netherlands Age: 4–5/7–8/11–12 Duo-interviews and focus group discussions, structured guide with questions and game tasks.

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All children knew the name of their parent’s illness; the children’s observations and expressions led us to identify five coping strategies the younger generation used: helping others, parentification, distraction, keeping it in the head and wishful thinking. This study supported the idea that children of severely ill parents should be provided with adequate information regarding factual issues concerning their parent’s illness. The study obtained a list of preferred and disliked foods groups. It also obtained a list of vegetable-eating situations and parent and child-invented healthy eating strategies. This study indicates that the stage of children's cognitive development plays a role in their preferences for, and perceptions of, fruit and vegetables with regard to their concept of health.

Country: Canada Johnson, J. L., Bottorff, J. L., Moffat, B., Ratner, P. A., Shoveller, J. A., & Lovato, C. Y. (2003). Tobacco dependence: Adolescents’ perspectives on the need to smoke. Social Science & Medicine, 56(7), 1481–1492.

Porcellato, L., Dughill, L., & Springett, J. (2002). Using focus groups to explore children’s perceptions of smoking: Reflections on practice. Health Education, 102(6), 310–320.

Lucas, K., & Lloyd, B. (1999). Adolescent smoking: The control of mood and body image concerns. Health Education, 99(1), 17–26.

Age: 14–18 Ethnographic techniques: interviews that involved an open card sort using the set of 60 key phrases with 14 adolescents. Country: UK Age: Primary school children (mean age 7 years) Child-specific focus group interviews.

Country: UK Age: 11–14 Focus group discussions.

The many ways that dependence on tobacco is experienced in the lives of youth who smoke, highlighting different social, pleasure, empowering, emotional and fullfledged aspects of tobacco dependence in youth.

Responses were brief and simplistic. There were occasions where responses were non-sensical or difficult to understand. A number of themes emerged: knowledge about smoking, viewpoints on grown-ups smoking, viewpoints on children smoking, ideas about smoking education. When age and gender were controlled, adolescents who smoked: – perceived more stress in their lives; – reported using cathartic coping strategies more, and problem-focused coping strategies less; – perceived smoking as a coping resource.

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Bluebond-Langner, M., Perkel, D., Goertzel, T., Nelson, K., & McGeary, J. (1990). Children’s knowledge of cancer and its treatment: Impact of an oncology camp experience. The Journal of Pediatrics, 116(2), 207–213.

Age: 7–16

80% of the children were observed participating in free-flowing and spontaneous conversation about cancer and its treatment.

Ethnographic and participative observation.

It is a two year study on a mixed method study approach with 50 children attending a summer camp.

Country: United States

A.3. Qualitative or mixed scientific publications pertaining to the ways in which children, adolescents and young adults (4–18 years old) address themes related to the health thematic Title Misailidi, P. & Bonoti, F. (2008). Emotion in children’s art: Do young children understand the emotions expressed in other children's drawings?. Journal of Early Childhood Research, 6(2), 189–200. Kortesluoma, R. L., Punamäki, R. L., & Nikkonen, M. (2008). Hospitalized children drawing their pain: The contents and cognitive and emotional characteristics of pain drawings. Journal of Child Health Care, 12(4), 284–300.

Methods

Country: Greece Age: 3–6 Drawing.

Results

The results showed that (1) by age three, children demonstrated an understanding of the emotions expressed in drawings; (2) happiness, sadness and fear were the emotions most easily recognized by participants.

Country: Finland Age: 5–11 Interview and drawing. It is a mixed study with drawing followed by an ANOVA test.

The differences in thematic content indicate higher demands, distress and strain among hospitalized children than the healthy groups of children.

Country: United States Age: 5–12 Larsen, J. T., To, Y. M., & Fireman, G. (2007). Children’s understanding and experience of mixed emotions. Psychological Science, 18(2), 186–191.

Showing animated films followed by an interview. It is a mixed approach method. The study also showed the relationship of empathy, understanding and mixed emotions.

The older children showed a better conceptual understanding of mixed emotions compared to the younger children.

Appendix

Dell’Api, M., Rennick, J. E., & Rosmus, C. (2007). Childhood chronic pain and health care professional interactions: Shaping the chronic pain experiences of children. Journal of Child Health Care, 11(4), 269–286.

Country: United States–Canada Age: 10–17 Interviews.

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Children’s experiences with professionals influence their approach toward current and future healthcare encounters. This study sought to understand how children perceived their interactions with health care professionals to have influenced their experience of chronic pain.

Country: Canada Age: 5–10

Morton, B.J. & Trehub, S. E. (2007). Children’s judgements of emotion in song. Psychology of Music, 35(4), 629–639.

Children and adults listen to song fragments that combined emotive performance cues with meaningless syllables or with lyrics that had emotional implications.

The verbal and musical cues to emotion were consistent (both happy or both sad), and judgments based on word or musical cues were indistinguishable

It is mixed study (listening to sings was followed by an ANOVA test). Kortesluoma, R. L., & Nikkonen, M. (2006). ‘The most disgusting ever’: Children’s pain descriptions and views of the purpose of pain. Journal of Child Health Care, 10(3), 213–227.

Country: Finland Age: 4–11 Interview. Few of the children participating in the study needed encouragement to consider and describe their experiences of pain.

The findings show that young children can communicate their pain experiences competently. The words used by the children give a good indication of the severity of pain.

Country: United States Age: 5–17 Pederson, C., Parran, L., & Harbaugh, B. (2000). Children's perceptions of pain during 3 weeks of bone marrow transplant experience. Journal of Pediatric Oncology Nursing, 17(1), 22–32.

Structured interview guides. This is a descriptive and exploratory study to understand their pain and their coping strategies. It is a mixed approach study with both qualitative and quantitative methods.

The children in the study group described their perceptions of past pain, expectations of BMT pain and experiences of BMT pain. They explained pain as discomfort and hurt.

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Country: UK Age: 9–10 Pridmore, P., & Bendelow, G. (1995). Images of health: Exploring beliefs of children using the “drawand-write” technique. Health Education Journal, 54(4), 473–488.

Group interviews and discussions, Draw and Write. The method focuses on drawing; it still requires a certain degree of articulation, which may have been a problem for children whose first language was not English.

The major categories of response identified – diet/healthy food, fruit, vegetables, exercise, sport, hygiene, not smoking and sleep – broadly echo Williams, Wetton and Moon’s study.

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Index

A, B

D

activity, 2, 3, 36, 39, 66, 71, 76, 94, 103, 111, 114, 134, 141 addiction, 6, 8–10, 12, 13, 21, 28, 63, 66, 70, 77, 80, 83, 93–95, 113 adolescent, 4, 8–10, 18, 19, 21, 27, 63, 67–69, 75–77, 85, 92, 99, 101, 113–115, 117, 121, 123, 141 alternative, 31, 51, 57, 58, 60–62, 67, 68, 98, 100, 102, 131, 135, 137– 139, 141, 142 behavior, 1, 3, 5, 8, 9, 11, 13, 18, 20, 21, 28, 35, 36, 38, 42–44, 50, 52– 54, 61, 65, 69, 70, 72, 86, 91–94, 98, 101, 105, 108

decision, 1, 2, 11, 13, 34, 53, 57–62, 65, 68, 69, 80, 81, 86, 89, 95, 100– 102, 114, 131, 135–137, 139, 141, 142 didactic, 5, 42, 45, 46, 49, 55, 56, 105, 113

C

health education, 4, 9, 12, 14, 21, 22, 27, 35, 49, 54, 93, 94, 99, 104, 111, 118 intervention, 4, 8, 28, 63, 66, 94, 95, 101–103, 105–110, 112, 114, 115, 117, 121, 131, 133, 135, 140, 141

cancer, 3, 24, 33, 69, 96, 97 complexity, 9, 14, 33, 52, 54, 56, 65, 71, 104, 105, 111, 114, 117, 132, 136 consumption, 7–9, 11, 18, 21, 23, 35, 61, 80, 84, 85, 93, 97, 98, 121 context, 5, 9, 11, 14, 19, 20, 29, 32, 35, 37, 38, 40, 44, 49, 53, 58, 77, 106, 113, 117, 121, 131, 132

E educability, 3, 4 efficacy, 5, 7, 9, 28, 63, 133 epistemological, 3, 5, 10, 14, 15, 35, 46, 71, 105 H, I

K, L knowledge, 3, 5, 14, 21, 29–34, 36, 46, 49, 52, 55–57, 60–63, 66, 70, 71, 84, 93, 95, 100, 102, 105, 135, 137, 138, 140, 141

Health Education and Prevention, First Edition. Frank Pizon. © ISTE Ltd 2019. Published by ISTE Ltd and John Wiley & Sons, Inc.

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language, 3, 41, 55, 57, 62, 70–72, 86, 114, 116 learning, 4–6, 31, 34, 53, 55, 62, 63, 68, 97, 112, 113, 115, 116, 128, 140, 141

program, 7, 14, 102, 103, 105, 106, 117, 139 public health, 4, 10, 29, 100, 101, 103, 104, 106, 134 R, S, T

M, P methodology, 17, 21, 27, 64, 67, 71, 75, 76, 93, 119, 120, 125, 135 paradigm, 5, 9, 51–53, 56, 101, 110 practice(s), 9–15, 18–20, 28, 42, 44, 48, 57, 59, 61, 62, 66, 69–71, 81, 83, 93, 103–105, 111, 112, 114, 134, 140 prevention, 6, 8, 9, 11, 13, 14, 21, 28, 33, 35, 43, 44, 46, 53, 58–60, 63– 66, 68, 77, 90, 93, 101–103, 105– 107, 109–113, 123, 132, 134, 136, 138–142 actions, 11, 63, 99–101, 108, 131, 133, 134, 141, 143 message, 7, 33, 83, 85, 86, 90, 98, 99, 101, 136

rationality, 30, 31, 34, 53, 62, 66, 101, 112, 132, 136, 137 singularity, 2, 56, 57, 67, 68, 96 social representation, 4, 35, 37, 39, 41–46, 54, 58, 64 support, 5, 38, 53, 55, 107, 109–111, 131, 134, 140 tool, 1, 20, 32, 87, 102–105, 111– 115, 117, 118, 121, 124, 131, 141 training, 2, 7, 14, 15, 87, 103, 107, 109–111, 113, 116–118, 128, 131– 136, 139, 140, 143 U, W usage, 1, 4, 10, 15, 19, 20, 61, 76, 80, 83, 85, 92, 99, 103, 104, 109, 111– 115, 117, 120 work collectives, 1, 107, 113, 133

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