Abstract
Several years ago during a presentation at an applied psychology conference in Peru, I was asked how non-profit health services can reduce teenage pregnancies. This book would have provided an answer. It details decades of ground-breaking work on the social and health application of psychology, working through the auspices of a non-government organization called the Mexican Institute of Family and Population Research. This organization began life back in 1988, with a life skills programme called, ‘I Want to, I Can … Prevent Pregnancies’. Today, greatly expanded in focus, and named ‘Programming for Choice’, the process skills taught in the programme have been developed and applied to a wider range of poverty-related issues. Many of those are also, integrally, about health and well-being, including gender equity. They include, for example, such issues as ‘I Want to, I Can … Prevent Violence’ and, ‘… Care for my Health and Exercise My Rights’, as well as substance abuse prevention and healthy nutrition promotion. Programming for Choice has also been expanded geographically. Originally located within Mexico, today the programme has been implemented in at least 13 other countries, chiefly across Latin America. According to the book, Programming for Choice has reached more than 19 million people. This is, therefore, a book about impact, through poverty reduction services that are grounded in research on (a) psychology and (b) well-being.
Contextually, the book stands out in at least two key ways. First, it breaks with psychological tradition, emphasizing poverty reduction more than poverty per se. That message resonates with a recent special issue in this journal (Murray and Marks, 2010), and with a wider project linking applied psychology and poverty reduction (Global Special Issue, 2011; http://poverty.massey.ac.nz/#global_issue). Second, it connects with Development Studies, specifically the United Nations’ Millennium Development Goals of which the overarching goal is poverty reduction by 2015. Undergirding that objective is health promotion, access and capability enhancement (Sen, 1999). Conceptually this book defines ‘capability’ as psychological competency, including a personal form of agency, with performance (‘functionings’) often taking the form of life skills in health-related behaviour. Theoretically, the book draws heavily on models in health psychology. These include, for example, reasoned action/planned behaviour, social/observation learning, self-efficacy theory and the trans-theoretical stages of change model. Methodologically, the book is multi-disciplinary, drawing upon different approaches, but tends to be individualistic in orientation with a nod to systemic dynamics, not the other way round. Much of the programme hinges on empowerment. Specifically with individual empowerment and ‘personal agency’ in mind, it identifies social environmental barriers (subjective norms) like ‘pena’ (for socially induced shame) and considers how these can be challenged. The programmes are designed to foster expanded personal routines that are intrinsically liberating/motivating, and that are practised in a safe environment so as to build the confidence needed to sustain change. Thus, ‘I Want to, I Can … Prevent Pregnancies’ (1) provides information about birth control methods, (2) re-positions attitudes to saying No and (3) enables practising those skills first in the safety of the training itself and later in the community, via homework assignments and applications in everyday life. Analytically, the book relies mainly on qualitative testimonies from end-users, with further, more quantitative assessments reportedly either published in Spanish, and published or in press with international outlets. The testimonies themselves are moving and impressive, not least because many of them span decades, and recount how the programme changed people’s lives, not just individuals but whole families, communities and classrooms. Ultimately, therefore, this book marks a real contribution.
A standout strength in the book is its courage; courage to engage with the language, thinking and politics, of ‘development’. The history of psychology in this domain is arguably itself poor, and I could not agree more with the authors that the links between psychology and development are rarely acknowledged. Refreshingly, this book actively challenges dominant notions that development and economics, especially at the macro-level, are synonyms. In contrast to the norm, the authors adopt an overtly ‘bottom–up’ over ‘top–down’ attitude to poverty reduction, arguing that individual dynamics are possibly even more of a key to development than vice-versa. It is argued that this challenge to macro economics may be helped along by current political and market reforms in the world; by critiques of international aid; by the rise of behavioural economics; and by an awareness of the need to win over key political figures and institutions, in order to make any changes sustainable. This section of the book went some way to allaying some initial concerns I had when reading some of the earlier parts. In those, I had been reminded of Oscar Lewis’ (1959) Five Families, a text that popularized the idea of a ‘culture of poverty’ – stifling confidence; energy; motivation. The new volume goes further, positioning Latin American culture as a legacy of colonialism; as imprisoning the mind in ‘tight’ (top–down) collectivist norms, which undermine healthy behaviour (free choice, emancipation). That left me wondering about the processes underway in high-growth countries like Brazil. Nonetheless, the extent of socio-economic inequality in Latin America remains high and its link with poorer health well established. There is also a need to consider the potential value of the seemingly more collectively oriented ‘Community Social Psychology’ which has been very successfully developed and practised within Latin America (Sánchez et al., 2003). Beyond Latin America, the book is clearly optimistic about transferring Programming for Choice to other continents. Time, plus new process and impact evaluations will tell. Perhaps though, the book might have more critically acknowledged a greater diversity of pathways (and processes) towards health and development (e.g. MacLachlan et al., 2010). Regardless of that criticism, Programming for Choice has been running – and running effectively it seems – for more than 20 years. This in itself reflects an impressive degree of sustainability, at least within Latin America.
Who should read this book and what can they gain from it? I would recommend it to all applied psychologists with an interest in global social issues and psycho-social interventions – especially, of course, all forms of poverty reduction. Health psychologists in particular stand to gain much traction with the field and the great challenge to humanity it poses, not least because health – including its psychology – is so fundamental to poverty reduction. Policy makers, in heath and other sectors, would find the book an interesting and possibly challenging read, because the message includes at the same time both project aid and budget support, with institutions supporting the programme and getting it off the ground. I learned much from the chapter on advocacy, dissemination and processes for listening to need/demand, and for ‘scaling up’ supply. These were further useful counterbalances to the more individualized and micro-level approach in the rest of the book. Psychologists interested in the role of organizations (like me) will find material of interest, for example the section on ‘I Want to, I Can … Start My Own Business’. Life skills in health reportedly spill over into business development, for example through women’s work groups (Schein et al., 2011). I appreciated Chapter 6 and the Appendix, which included fascinating details of each of the major ‘I Want to, I Can’ programmes. Their figure-ground reversal between situation and person remains a key identifying feature in this work, especially a focus on motivation – which I agree capability theory says little about. Personal motivation, and the operational definition of capabilities, is something that sets this book apart from the majority of works on how poverty can be reduced.
What would I have said at that conference in Peru? First, I would have understood the question differently, namely as an issue of capability, and fostering capabilities to choose an education; career; family. Second, I would have said that awareness, knowledge and skills can be enhanced through culturally competent forms of modelling, observational learning and practice. Such programmes can be harmonized and aligned with institutional reform; and local community values. They can be evaluated both qualitatively and quantitatively. And through the lifelong commitment of scholars and practitioners, like the authors of this book, they can make a difference.