Happiness as a strength in the promotion of adolescent and adult young health

Objectives: to assess the relation between sociodemographic characteristics of young people associated with the subjectivity of being happy; to evaluate the relationship between the subjectivity of being happy and the perception of health status; to evaluate the relationship between the subjectivity of being happy and the school and family environments and peer groups at school. Methods: this is an observational study, with an intentional sample of 1,069 young Portuguese people, with ages varying from 14 to 24, most of them women, attending secondary education. The self-filling questionnaire was used. Results: there are statistically significant associations between the subjectivity of being happy and schooling, perception of health status, family APGAR, school and family involvement, absence of problems or teasing by peers at school. Conclusions: a positive and holistic care coupled with the potential of obtaining and consolidating healthy lifestyles for young people will enable health professionals to perceive them as agents of individual and social change.


INTRODUCTION
The complexity of developmental processes in adolescence is reflected in its stages: early, middle and late adolescence, progressively providing the individual with the assimilation of physical, intellectual and social experiences that will allow them to establish a new identity and new patterns of relationships to set goals and commitments.
In adolescence, the opportunity to obtain and consolidate healthy lifestyles arises, which means being an adolescent/young person with good physical and mental conditions, a positive image of oneself, self-efficacy and self-determination. Each person's resources, vulnerabilities, social context, peer groups and family condition the meaning given by adolescents/young people (the young term here is understood as synonym of adolescent) to their lifestyle (1) . This is a noticeable interconnection if associated with the Human Ecology Theory (2) .
The Human Ecology Theory identifies five milieu systems with which an individual interacts. Adolescents, when exposed to tensions caused by physical and emotional changes, are expected to mobilize forces that promote their well-being (2) . This well-being is conditioned by what the young person thinks and feels about their life, considering the different subsystems: family, school, peer group and their social involvement. This ability can be maintained even in adverse conditions and its evaluation varies depending on previous expectations, values and experiences (1) .
Most young people are in good health, but premature mortality, morbidity and injuries among adolescents are still considerable. Diseases can affect a young person's growth and full developmental potential and are often associated with alcohol, licit or illicit drugs, physical inactivity, obesity, unprotected sex, exposure to violence and traffic accidents. All these behaviors can put at risk not only to the current health of adolescents, but also to their adult life and, in some cases, to the health of their future children. This setting allows an understanding of the contribution of adolescents in increasing health costs, resulting from the treatment of noncommunicable diseases and the rehabilitation processes involved (3)(4) .
To minimize this situation, it is essential to change the focus of attention on the deficit for a focus on the person, thus evidencing the areas of health promotion and disease prevention due to health gains that are inherent in the medium and long terms. People-centered care may have different approaches when focusing on young people, from which stands the perspective of Strengths-Based Care (SBC) (5) .
The term strength, used as a synonym for ability, allows young people to cope with life's challenges. These strengths have subjectivity, as they are what each person, family, and health professional claims to be. However, they can be organized into three types: (1) Biological, which are related to the biochemical, genetic, hormonal and physical characteristics of each person; (2) Intrapersonal and Interpersonal, defining the personality and considered a part of the internal resources of the person; and (3) Social, originated in the environments of young people and which are at their disposal.
A series of assumptions about health, the person, the environment, and nursing support the SBC, from which eight core values derive: (1) health and healing; (2) uniqueness of the person; (3) holism and embodiment; (4) objective/subjective reality and construction of meaning; (5) self-determination; (6) integrated person and his/her environment; (7) learning, preparation and timing; and (8) collaborative partnership. These values interrelate and work together to form a whole, informing nurses about adolescents, their families and peer groups, as well as what to focus on and how to care for (5) .
The Nursing approach to young people should be based on the identification of the strengths' characteristics. In this sense, the strength-based model is used to work with young people, dividing it into 10 groups: (1) of wisdom and spiritual forces; (2) emotional; (3) of character; (4) creative; (5) relational and affectionate; (6) educational; (7) cognitive, (8) promoters and work-related; (9) of use of resources; and (10) of survival ability (6) . Within the framework of this article, the strengths of character are highlighted, whose defining characteristics are related to life satisfaction and happiness (5)(6) .
Happiness, the subjectivity of being happy (emphasis is placed on the use of this definition throughout the article) is, today, often related to the consumption of material goods. However, the subjectivity of being happy (SBH) is an attitude and a consequence. It is a subjective concept, appearing in the scientific literature associated to subjective well-being that highlights the perception of happiness, life satisfaction and the positive relationship of balance between emotions and is difficult to measure, although in the last years different instruments have been validated to interpret scientific findings (7)(8)(9)(10) . Positivity emerges as a protective factor for the adolescent's healthy development, being associated with self-esteem, satisfaction with life, optimism, subjective happiness and self-efficacy (8,(11)(12) . Positive humor appears to be associated with happiness as mediators of the relation of interpersonal and social aspects to health, even though other factors may influence it, such as social support, physical exercise, work, optimism and education (7,13) .
Of the scientific evidence that supports this article, those that support the factors related to the SBH are highlighted: (1) sociodemographic determinants -age, sex, schooling; the studies are not consensual about their relationship with SBH, because some point to a relation with the individual characteristics and others to sociodemographic characteristics -sex (7,12,14) ; (2) the school context -positive academic performance and involvement in school are influenced by life satisfaction, social support from teachers, parental involvement, peer groups and the self (e.g. school competence and social acceptance) and are crucial to SBH (7,15) ; (3) the family context -adolescents pointed to the defining characteristics of happiness: interpersonal relationships and daily life, which included the events of daily life and the family; positive emotions and feelings; satisfaction and fulfillment, including satisfaction itself; achievement of objectives; harmony and balance; well-being; and meaning/value. Families assume a special importance as the first support and safe base, as well as roles of protecting adolescents, from which they explore the world. There is a tendency to associate abstract feelings and concrete needs with happiness, for example, family conflicts and setbacks triggering unpleasant emotions (7,(16)(17)(18) ; in addition, there are also peer groups -the quality of friendships is central to the young person's social, emotional and cognitive development. Being satisfied with their personal life, being sociable, popular and proactive are factors that facilitate interpersonal relationships, allowing them to be integrated into the group and reducing the risk of victimization (19)(20) .
In the complex process of changing, young people represent, for being potential agents of individual and social change, a challenge to the health system. From that, the research question is presented: Is there any association between happiness and the school, family and peer group environments for adolescents/ young people from the city of Vila Nova de Famalicão?

OBJECTIVES
To evaluate the relation between sociodemographic characteristics of young people associated with the "subjectivity of being happy"; the relation between the "subjectivity of being happy" and the perception of the health status; the relation between the "subjectivity of being happy" and the school, family and peer group environments at school.

Ethical aspects
Research began after approving the project by the Ethics Committee of the Abel Salazar Institute of Biomedical Sciences (Instituto de Ciências Biomédicas Abel Salazar) -University of Porto, and by the Portuguese National Commission for the Protection of Data (CNPD).
Participation was requested to adolescents/young people and the authorization to the parents/guardians responsible for the education of minors by means of the signing of the informed consent form (ICF). Only to minors, whose parents/ guardians expressed in writing the authorization to participate, the questionnaire was given; of these young people, only those who freely agreed to do so answered it.

Study design
Data used in this article is a cut-off from the observational quantitative study (21) , designated by +SaúdeFamalicão, a program aimed at promoting health in family transitions, adolescents and which is enrolled in the Center for Research in Technologies and Health services (Centro de Investigação em Tecnologias e Serviços de Saúde -CINTESIS). The study period was from 2013 to 2017, in Vila Nova de Famalicão (VNF), a municipality located in the north of Portugal.

Population and sample
The population of adolescents and young adults in VNF consisted of 12,935 people, according to the 2011 censuses and considering the range of 14 to 24 years, corresponding to 9.7% of the city's population (22) . The population was reduced to 3,880 participants, constituting an intentional sample of 1,609 participants, which corresponds to a reliability of representation of 95%, with a margin of error of 1.87. The following inclusion criteria were defined: (1) being between 14 and 21 years old; (2) studying in one of the city's secondary, vocational and higher education schools; and (3) agreeing to participate in the study. And exclusion criteria: (1) educational institutions not accepting to participate in the study; (2) being over 21; (3) not obtaining the free and informed consent form signed by the parents or guardians of minors; and (4) not filling in the data regarding age and gender. Of the 13 existing institutions, 11 accepted to participate in the study. A total of 1,609 young people participated in research, with the majority (56.9%) being female, aged 14 and 21 (M=16.7 years old, SD=1.18 years), fashion at 17 years, with a normal distribution curve, and the majority attending secondary education (10 th grade-28%, 11 th grade-28%, and 12 th grade-31%).

Study protocol
For data collection, the instrument used was the self-completion, composed by the sociodemographic characterization, by the questionnaire "Health behaviors, risk behaviors and involvement of young people with their school and family", Portuguese adaptation (23) , and the instrument of assessment of family APGAR (24) .
For the treatment and analysis of data the following variables were selected: sociodemographic characterization (age, gender, year of schooling); perception of health status; school environment (school performance, level of involvement with the school); family environment (family typology, family APGAR, level of involvement with the family); peer group (having problems with peers and feeling provoked at school and level of involvement with peer group), and subjectivity of being happy.

Definition of variables
Subjectivity of being happy: It was considered a question of the questionnaire that guides participants in the following way: "Make your profile choosing five options", consisting of 39 characteristics, with the "happy" characteristic divided into two groups: Group A (GA) -"those who checked the happy feature in their profile"; and Group B (GB) -"those who did not check the happy feature in their profile".
Level of involvement with the school: Selecting Question No. 8 -"Do you think school staff care about you?"; No. 9 -"This year, do you feel that you are part of your school?"; and #10 -"How often do teachers at school treat students fairly?" After recoding, the sum of the responses obtained in these items was conducted and degrees were assigned according to the result obtained: low, from zero to two; average, from three to four; and high, from five to six (23) .
Level of involvement with the family: Questions No. 13 -"Who do you talk to when you have a problem or are worried about something?"; and No. 14 -"Who notices you when you are worried or angry about something?", from which the options from one to seven, related to parents or relatives (mother or stepmother, father or stepfather, sister or brother, uncle or aunt, grandfather or grandmother, another relative). Both questions were recoded and the following values were assigned: zero, if you do not speak to any family members or if no family members hears you; one, if you talk to a family member or if a family member hears you; and two, if you talk to more than one family member or if more than one family member hears you. After recoding, the sum of the responses obtained in these items was performed and degrees were assigned according to the result: low, if equal to zero; medium, from one to three; and high, if equal to four (23) . Level of involvement with the peer group: Questions No. 13 and 14 were also considered, but, in this case, the options were related to talking to a "friend". After recoding, values were assigned: zero, to young people that said they did not speak to friends when they were upset or worried and when friends did not notice them in situations similar to the aforementioned; one, to those who responded positively to one of the two questions; and two, to those that answered positively to both questions. After that, the sum of the answers was performed and degrees were assigned according to the result obtained: low, if it was zero; medium, if it was one; and high, if it was two (23) .

Statistical analysis
For statistical analysis, IBM SPSS Statistics 24 was used. A set of descriptive (frequency and percentages of variables) and inferential statistical analyzes were conducted to verify the existence of significant differences between the groups using the Chi-square test with adjusted standardized residuals.

Relation with sociodemographic characteristics
Of the sample, 846 (52.6%) of young people from VNF belong to GA and the remainder participants, to GB. In both groups, the majority were women and were between 16 and 18 years old. It should be noted that, in the gender and range of ages, it was in GA that higher absolute values were obtained. In the 10 th year of schooling of the GB, the highest percentage was found; in the 12 th , the highest percentage was found in the GA. Statistically significant differences were observed between SBH and schooling (χ2(3)=9.730, p=0.021), and for higher education, young people from VNF are happier than expected, and in the other years of schooling there were no significant differences (Table 1).

Relation with the health status
Young people from VNF had a good perception regarding their health status, and the highest percentage values were obtained in the "very good" item in both groups. In addition, there are statistically significant differences between the SBH and the perception of health status, with Chi-square of (χ2(4)=22.369, p=0.000), Table 2.

Relation with the school environment
In both groups, most young people had a positive perception of their school performance, with the highest percentage values observed in the "good" item. As to the level of involvement with the school, in both groups the majority marked the "high" item. In addition, regarding school performance and level of involvement, it was in GA that the highest absolute value was obtained (Table 3).

Relation with the family environment
Considering the family typology, it was found that in both groups the majority was distributed according to the item "nuclear family", and the highest absolute value was found in GA. In both groups, the family APGAR, most young people evaluated their family as "functional" and the level of family involvement obtained the highest percentage values in the "on average" item. In the family environment, there are statistically significant differences between the "subjectivity of being happy" and the family APGAR (χ2(2)=47.370, p=0.000) and the same was verified regarding the level of involvement with the family (χ2(2)=13.688, p=0.001), Table 4.

Relation with the peer group at school
As to the peer groups at school, most young people had no problems and did not feel provoked by their classmates in both groups. In addition, there was a "high" level of involvement with peers, being in GA where a higher absolute value was observed. There are statistically significant differences between the "subjectivity of being happy" and having problems with classmates (χ2(3)=22.158, p=0.000) and feeling provoked by classmates (χ2(2)=17.075, p=0.000), Table 5.

DISCUSSION
The experiences of young people in the family and social environments influence their self-assessment, with implications for their future choices and expectations, self-acceptance, skills development, school success and social interaction, among others (25) .
During adolescence, in its intermediate and final stages of development (14)(15)(16)(17)(18)(19)(20), young people establish a new identity and new relationship patterns, progressing towards the determination of a cohesive identity, with goals and commitments (26) . For young people who are part of this study sample, no significant association was found between the SBH and age and gender, which is corroborated in a study with Brazilian population, in which positivity was more related to individual characteristics than to sociodemographic characteristics (7) . This contrasts with the studies carried out by Matos and the team of the Social Adventure Project (Projeto Aventura Social), with Portuguese adolescents, in which the female gender reported being less happy more frequently (14) .
Most Portuguese young people enter higher education in the late stage of adolescence. The last report on the sociodemographic conditions of these students indicates that the majority (72%) is up to 25 years old, and the age of admission to 86.3% of the young people was 21. At this stage, some events occur: (1) the individualization of the young person through the psychological independence from the parents; (2) maintenance of family economic dependence; (3) the direct exit from high school to university, with inexperience in the labor market; (5) about 42% of young people do not stay in their parents' homes. In this context, young people have the possibility to increase their level of knowledge, from the experience to the novelty of facing new challenges, which can be the justifying factors for link found between the SBH and schooling, where the participants of this study are happier in higher education years than expected (27)(28) .
Adolescents who value and prioritize subjective figures as indicators of happiness, i.e., feeling good about themselves and with others and expressing this through the sense of well-being, pleasure, acceptance and autonomy (7,15,17) . The assessment of health is subjective, reflects the perception and depends on the conception that each person has. In this study sample, most had a positive perception, as it is expected to occur during adolescence (3)(4) . Although there is scientific evidence to suggest that young people with less healthy lifestyles have a less positive perception of their health, others relate happiness to good health (12,25) .
This study conceives the SBH as a multidimensional concept, influenced by systems and subsystems, from the perspective of the Human Ecology Theory, in which school, family and peer group environments stand out (2) . In this sense, most young people in the sample evaluated positively their academic performance and their level of involvement with school, a factor which included the perception of these people as to the concern school staff have with them, fair treatment by teachers and feelings of belonging to the school space. Studies show that social well-being favors positive academic outcomes, such as teacher support (7,12,15) . In the results, an association of the SBH with the 'functional" family APGAR was observed, which represents the satisfaction regarding family relations and communication, also verified in the level of family involvement. Studies show that the well-being of young people is related to positive experiences within their families. In adolescence, the context and family relationships expressed in their ability to dialogue, negotiate and respect differences are fundamental for the performance of a protective role and essential support in the development of young people. The parental role is progressively attenuating and adjusting limits, as the acquisition of autonomy occurs for young people (7,29) .
The relation with peers shows the association between the SBH and a good environment -not having problems and not being provoked -and the level of involvement. In this sense, studies show that better living conditions and social support from families, friends, neighbors and positive perceptions of the relation with peers influence the levels of happiness and well-being (7,12,30) . From this analysis, it is important to develop studies focused on the positive psychological characteristics of young people, in order to understand the role of individual resources and other protective factors throughout the development process, as proposed by other authors. Compliance with health processes was also highlighted (7)(8)(12)(13) .

Study limitations
The study limitations rely mainly on the fact that the variable "being happy" needs greater objectivity in its measurement. It is not simply because young people did not associate the happy characteristic with their profile, it means that they are not happy.

Contributions to the Nursing and Health fields
A set of contributions was unveiled to the areas of Nursing and Health, when realizing the importance of "being happy" to develop self-concept, in relation to the school, family and peer group contexts. Health professionals, particularly nurses, by basing their practice on care, can improve the strengths of young people in SBC by helping them address their concerns through empowerment, providing them with access to information and a decision-making based on critical thinking (5) .

CONCLUSIONS
Adolescence offers great opportunities to acquire healthier lifestyles. The family, based on the quality of the relationship established, the values and attitudes they transmit have an association with the behaviors of young people, constituting a resource for health promotion.
School institutions play a mediating role between young people, families and society, and should focus on the development and training of critical and conscious citizens. In this sense, health promotion of young people is urgent to strengthen educational and health partnerships, with strategies that value positivity, overcoming the barriers posed to spread health information.
Based on the Perceived Organizational Support (POS), health services should include, in daily practice, proactive initiatives to develop positive self-confidence in young people so that they believe people care about their well-being and consider their socio-emotional needs valuing their potential.
The positive, unique and holistic perspective of SBC and the fact that adolescence is an opportunity to obtain and consolidate healthy lifestyles will enable health professionals to realize the enormous potential of young people as agents of individual and social change. In addition, an approach focused on young people, on what they do best, and the resources they have can help them deal effectively with their lives, health conditions, and the challenges to a healthy lifestyle. In this context, the role of nurses in supporting young people, their families and the resources of community to adapt, develop, grow, thrive and transform are highlighted.