The human mind represents a state of consciousness and subconsciousness that cannot be directly assessed or defined. The cognitive and subjective processes of people are individual, which make it possible to conceive the reality of each user in a unique way. One tool by means of which the deepest region of human psychology can be analysed is psychoanalysis (Papel et al., 2005; Poscheschnik, 2009), a research technique consolidated by the neurologist Sigmund Freud around 1896 (Alvarenga, 2006). This procedure allows for a possible interpretation of dream manifestations, longings, lack of self-esteem or free association of details (Tubert, 2000). The historian Roudinesco and Plon (2005, p. 1232) went further into Freud’s definition of psychoanalysis in 1922, determining that ‘Freud provided the most precise definition of the psychoanalytic framework by underlining that its theoretical “pillars” were the unconscious, the Oedipus complex, resistance, repression and sexuality (…)’ In turn, it is worth noting that the psychoanalysis proposed by Sigmund Freud constitutes one of the most important references for the understanding of the psychodynamic model, a conceptual framework that tries to provide a theoretical point of view on different elements, such as the human being and its development, or the proliferation of disorders, both physiological and psychological (Tubert, 2000; Roudinesco and Plon, 2005).

In the same way, these elements have been of special relevance in the field of education in Higher Studies, specifically in the Degree in Nursing, when forging a professional design of action and development of care. This requires an analysis of the complex reality of contemporary society, valuing its cultural aspects, social relations, the transmission of knowledge and the wide diversity of dynamic factors that make up the human being (Roudinesco and Plon, 2005), including information and communication technologies (ICTs). This factor, in relation to health sciences, has undergone multiple changes over time, even modifying the way of university teaching and health education. In fact, research in health informatics focuses on the applications of artificial intelligence in healthcare, generally centred in academic institutions. Therefore, the relationship between new technologies, health education and learning in health sciences is a relevant union in our days and, for this reason, it should be valued (Juanes Méndez, 2016). In order to develop such an interpretation of the prevailing reality, not only is the education provided at universities in the health sciences relevant, but also the self-realisation of the individual and the evolution of the inner world of students in this branch of health. This will allow a greater conception of human society by consolidating holistic and integral care, maintaining the perception that health is not something professional, but is based on the active and dynamic participation of people, with the aim of achieving the common good and individual improvements, with pre-eminence of the collective and social (Acuña González et al., 2014). This plays a relevant role when it comes to understanding Health Education (HE), understood as a set of intersectoral actions whose aim is to promote people’s well-being, a key function of health professionals, by providing the human community with the necessary competences for the promotion and protection of their comprehensive health (Riquelme Pérez, 2012).

Within the field of health education, the World Health Organization (WHO) has proposed three theoretical educational methods, which present different perspectives (Papel et al., 2005), with the aim of teaching and raising awareness among the population about different situations, including child abuse, which has accompanied humanity throughout its history (Suárez, 2001; López Jaramillo et al., 2013). This is one of the most heartbreaking and violent acts that can be practised on children and that are accepted for religious or disciplinary reasons (Suárez, 2001). These practices of physical, social and psychological affliction of children have even been used as educational and learning methods. In fact, in Roman society, it was considered that the ‘pater famili’ abandoned, sold or even killed their children (Cunyas Chalco, 2019). It was not until the Middle Ages that infants were recognised as human beings, but with the conception of the child as a corrupt being, who must be socialised, redeemed through discipline and punishment (Fry, 1993; Enesco, 2009).

In the second half of the 19th century, publications focused on child abuse began to appear, describing its impact, especially at the physiological level, as demonstrated in 1860 by the French physician Auguste Ambroise Tardieu (1818–1879), who came to describe quite particular injuries in paediatric cases. Almost a century later, in 1946, the radiologist John Caffev enunciated the first formal concepts on child abuse, when publishing studies on multiple bone fractures in infants, coming to value another relevant detail: the incoherent explanation that parents of abused children can provide (Cunyas Chalco, 2019). In the 1970s, the first conceptual frameworks on child maltreatment emerged, in order to understand, firstly, the functioning of these acts based on the supposed presence of psychiatric disorders in the parents or guardians of the children. As the twentieth century progressed, more subtle theoretical variants, both sociological and socio-environmental (Gil, 1970), proliferated in the search for an understanding of child abuse.

In relation to these parameters, the general aim of this study is to describe the conceptual frameworks on child maltreatment according to the explanatory models of HE proposed by the Pan American Health Organization (PAHO) and the World Health Organization (WHO) by comparatively analysing the different theoretical frameworks (PAHO/WHO, 1996), in addition to identifying relevant insights into concrete forms of intervention in nursing education and practice for the promotion, maintenance or restoration of health in accordance with child maltreatment (Figure 1).

The study will also represent a significant shift in existing research by examining the use of various explanatory models as an efficient tool for nursing practice and ultimately for the various health professions. This study is a very timely contribution to the international analysis of the teaching of health education, as well as child maltreatment, in Higher Education programmes and specifically in nursing. The University of Castilla-la-Mancha (Toledo, Spain), the University of Reggio Emilia (Italy) and the University of Coimbra (Portugal) form the collaborative network of this research.

Every human being is immersed in a context or suprasystem that influences, to some extent, his or her health-illness continuum. Social, environmental or physiological factors or aspects influence the thoughts, feelings and actions of the person, independently of the conscious vision of the subject (García, 1998). Likewise, the child’s natural and artificial environment, which can influence his or her psychological and affective development, should also be taken into account. Being surrounded by architectural barriers, without free spaces or playgrounds, can aggravate the psyche of the abused infant, interfering with his or her integral well-being, causing emotional damage that can come to symbolize indelible marks for the whole life of the person (Ramírez Calixto and Cedeño Sandoya, 2018). And it has been evidenced that child abuse contributes to a high degree of emotional maladjustment on the part of minors, a fact that leads to the need, on many occasions, for a reevaluation and cognitive-emotional attention (Weissman et al., 2019; Bonet et al., 2020). This is fundamental since an incorrect emotional regulation strategy can lead to psychopathologies (Kim et al., 2021), including self-injurious behaviours (Guérin-Marion et al., 2020). Therefore, in this section, which concerns a common good of human society such as the state of health, nursing care emerges as a public service and an opportunity for the population (Miguélez-Chamorro and Ferrer-Arnedo, 2014). The care provided by nursing staff functions as a frontier or transition between population levels, sectors and health services (Cuevas et al., 2008), always seeking to act as a coach, facilitator, companion or educator (Miguélez-Chamorro and Ferrer-Arnedo, 2014).

Thus, nursing, and more specifically, community nursing, is highly linked to HE, which fosters the consolidation of self-care competencies by the individual and at the family level (SITEAL, 2018; Soto et al., 2018). This includes the basic functions of health promotion and education, disease prevention, care of sick or disabled people, rehabilitation and reintegration of individuals into the social framework. In this regard, the International Council of Nurses in the United States that the responsibilities of nurses include ‘promotion of a safe environment, research, participation in health policy formulation and management of health systems and patients, and education’ (Shamian, 2014). Therefore, when educating the human community, explanatory models must be taken into account that serve as a basis for shaping the process of action in the face of unmet needs or demands that constitute a problem for the human population.

Within the framework of health education itself, PAHO/WHO offers three methods with different approaches, which are not mutually exclusive (Gil, 1970): (1) the didactic or prescriptive method; (2) the awareness-raising method and (3) the participatory method focused on human development. The prescriptive method, also called the first-generation method, is a model that is framed in the development of an approach aimed at the detailed exposition of goal-oriented contents, without valuing the subject’s demand. A dissemination of information is carried out in which a classical pedagogy is applied, generating the sole guilt of the patient, while a prescription or detailed message is elaborated (Fernández Oliva et al., 2004), without feedback to the professional who imparts this model. The awareness-raising (or second generation) method focuses on an integrative pedagogy, in which the subject plays an active and dynamic role, encouraged by the educator. In this case, such analysis is based on the premise of studying multidimensional causes, delving into social, environmental or psychological conditions, thanks to the feedback generated by the people. These kinds of models function as systems that generate self-confidence and progressive independence on the part of individuals, with the ultimate goal of social development (Lois, 2013). As sociologist Everett M. Rogers (1931–2004) put it, such progress would be ‘a broadly participatory process of social change, which seeks to expose social and material advances (including equality, freedom, and other valued aspects) to the majority of the population through gaining control over their own environment’ (Rogers, 1976). Finally, it is worth mentioning the third-generation models or participatory methods centred on human development (such as the co-orientation model), which present a different perspective on health education in that it is not the health professionals who initiate the educational approach, but the human community that possesses the capacity and self-sufficiency necessary to make its own decisions, thus influencing its management and state of community health. The nursing profession is a participant in this process, not a key figure, as the basic protagonist is the population itself (Figure 3).

These conceptual frameworks have evolved over time, thanks to the changes in the health paradigm offered by speculative contributions such as the theory of health beliefs or the theory of self-efficacy, postulated by Bandura (1986), Mora and Araujo (2008). The same applies to the theoretical analysis of child maltreatment, which is described by the WHO as a computation of the abuse and neglect of children under 18 years of age. It encompasses the various types of physical, psychological or sexual abuse that may threaten or cause harm to the health of children or violate their rights (Arrieta Vergara et al., 2014). Within this scope, it would include what is done (action), omission and what is done inappropriately, i.e., negligence (Doria Martínez and Navarro Chong, 2016). Likewise, at present, the transmission of knowledge, using computer technologies, virtual resources and simulation systems, constitutes one of the great technical-scientific revolutions (Juanes Méndez, 2016), having special relevance in the health sciences, contributing multiple dimensions to the educational process (Ochoa Vásquez, 2009). And, therefore, they can be used as teaching tools on child abuse, both in their theoretical aspects and in the ability to diagnose and prevent possible cases, especially new variants of child abuse such as cyberbullying or sexting. In this sense, it is essential to integrate ICT into the university teaching environment, through computer programmes that systematise the information on the area to be dealt with, in this case, child abuse.

However, this poses a huge challenge for teachers, who have to reinvent themselves and know how to manage these new models of education, channelling information effectively in order to achieve, as effectively or more effectively, the necessary competences in health science subjects. The educational disciplines involved in teaching-learning combine transversal, specific and general competences with informatics fields such as data science, information technology and behavioural informatics (Juanes Méndez, 2016). According to the researcher Pérez López: ‘This will be the only way to be able to adequately process the incessant avalanche of information […]; on the other hand, it is also the only way to avoid irrational consumerism, i.e., that which causes the most striking or easy to assimilate to end up being the chosen or most credible thing” (Pérez López, 2006, p. 928).

After analysing the history of the explanatory models of health education and the conception of child abuse (according to a possible aetiological cause), a correlation can be seen in terms of the paradigmatic change in the study and explanation of different aspects, such as the human being, its development, health and the existence of affections, in this case, abuse in paediatric cases.

For this reason, a comparative relationship is proposed between the different theoretical frameworks, which allows a relevant vision of the concrete ways of intervening in education and nursing practice, for the promotion, maintenance or restoration of health in cases of child abuse. Thus, taking the three non-exclusive focal methods (Culp et al., 1989) of PAHO/WHO as a basis, the following overview of evolution and theoretical designation is given:

The prescriptive method focused on a transmission of information, in which the sole culpability lies with the patient (based on the professional-subject relationship of Hippocratic medicine; Entralgo, 1970; Gracia, 2002; Guadarrama and Campos, 2020), with the main determinants of illness being biological factors. In this case, neither social interaction nor cultural or economic influence is taken into account, but rather an imposition of factors and values. Traditional explanatory methods of child maltreatment can be accommodated within this theoretical line, because links between child maltreatment and the personality of the maltreater are exposed. See the consumption of toxic substances, altered expectations of what is expected of children (Riquelme Pérez, 2012), and even an intergenerational transmission of the experiences of maltreatment (Milner, 1995). Thus, in this first correlation, the first-generation model of health education encompasses the exposition of the psychiatric-psychological theoretical framework, the sociological model and the one centred on the paediatric case, all of them explanatory models where the prestige and coherence of biomedical science prevails (Moreno et al., 1995; Gómez-Cantarino et al., 2020).

At the same time second-generation models in health education were developed in the 1960s, reflecting a cultural anthropology approach, allowing a deeper understanding of the subjectivity of each subject, thus achieving a more contextualised approach (Moreno et al., 1995). Thus, the intrinsic characteristics of the person and those consolidated by contact with society are valued. From this new line of health education, models based on behaviourist postulates will be forged that allow progress towards new approaches, such as ecological ones (Colom Cañellas, 2004; Hernández-Girón et al., 2012), thanks to the configuration of a precise technology or methodology. When addressing the explanatory models of child maltreatment, it can be seen how the second-generation models of health education are the basis for the consolidation of the theoretical frameworks of social interaction on child maltreatment developed in the 1980s (see Belsky’s ecological model or Cicchetti and Rizley’s transactional hypothesis).

Similarly, there is a clear transition between second and third-generation models with respect to child abuse, a fact that can be explained by a paradigm shift in health. This would justify the existence of Milner’s theory of social information processing and the stress and coping postulates of Hillson and Kuiper. Models developed during the 1990s, when the “eco-epidemiological” paradigm was consolidated, which analyses the health problem through multiple determinants, belonging to various spheres, not only biomedical, but also psychological and social (Hernández-Girón et al., 2012). This emerging health paradigm can enable both a specific therapeutic approach (at the individual level) and a preventive approach (at the population level; Hernández-Girón et al., 2012; Hernández et al., 2017). Therefore, the existence of this new vision of understanding a public health problem has made it possible to conceive child maltreatment from a broader and more holistic theoretical perspective (Table 4).

At the same time, it should be noted that there are insufficient elements to determine which of the explanatory model or paradigm is the correct one. This will depend, in part, on the approach to each case of child maltreatment and the competencies displayed by the health professionals, especially those belonging to the nursing discipline when addressing the problem under study (Hernández-Girón et al., 2012). This situation highlights the need to raise awareness and teach higher education students, who are studying nursing, about the various existing explanatory models and the paradigmatic changes in health knowledge that exist, so that the complex reality of each case of child maltreatment can be taken into account (Roudinesco and Plon, 2005). It is here where the use of ICTs as a systematic mechanism of university teaching should be used, facilitating simple, attractive and dynamic learning that allows the necessary competences to be obtained in this field, and even to promote and generate future specific computer programmes on child abuse within direct user care. Studies carried out (Arredondo, 1993; Hernández-Girón et al., 2012; Priegue Caamaño and Cambeiro Lourido, 2016) reflect the responsibility of education professionals in influencing the future competences of the new generation of professionals. Therefore, this aspect becomes even more important when it comes to health issues. Despite this, there is often a lack of knowledge and adequate university training on child abuse, both within and outside the family (Soto et al., 2018). Although it is true that this situation is usually solved with new future lines of research focused on this panorama, in order to be able to tackle a serious public health problem such as child maltreatment (Gonzalez et al., 2021).

After analysing the general approach of this study, some reflections are raised. From the professional perspective, it is emphasised that teachers must be prepared and responsible for training future generations of nursing professionals to acquire the minimum competences to prevent and deal with a situation of child maltreatment. This can be presented in a theoretical as well as a practical way. The theory provides the basic building blocks that guarantee the implementation or follow-up of a process. This foundation can be corroborated with the Nursing Care Process (NCP), developed by the nurse theorist Linda Hall (1906–1969) in 1955. With this theoretical framework, it is possible to show the correct and precise sequences for action by any nursing professional in the face of a health condition, allowing the work carried out to be evaluated and studied. Despite this, at present, the theoretical efforts of nursing professionals to develop knowledge through theories and models have not been successfully implemented in clinical practice, considering that this is based on the performance of routine procedures. However, such care acts have a clear logic, as they are derived from theoretical postulates.

Thus, through practice in the different rotation devices, both in primary care and specialised care, as well as in secondary education centers, it is a good time to develop the competences acquired on a theoretical level on child abuse, considering this training to be more focused on higher courses within the degree and postgraduate nursing degree.

Likewise, it is exposed that the evolution of the theoretical postulates on child abuse is correlated with the educational theoretical methods proposed by the WHO, which establish different perspectives of teaching and awareness of the population on multiple public health problems, bearing in mind cultural patterns that influence the sense, evolution and thought of human society. This demonstrates the need for a transdisciplinary approach to child maltreatment, where there is no one explanatory model more suitable than another, but the choice of the health education paradigm and, within this, the most recommendable child abuse theory will depend on each situation. It is also important to highlight the importance of valuing the use of information and communication technologies (ICT) in this field, due to their high capacity to manage and systematise information, making them a relevant tool for the correct training of future health professionals, especially in the case of child abuse, as it is a public health problem. In the words of researchers Nuria Fabrellas and Jordi Galimany ‘Health professionals themselves should promote and consume the use of these applications, as we are witnessing a democratisation of health information that can facilitate health promotion and disease prevention’ (Fabrellas Padres and Galimany Masclans, 2019, p. 7).

SG-C, AC-O, and JR-M contributed to the conception and design of the study. SG-C, AC-O, JR-M, CG, and MU-G performed the data collection, organisation, and analysis. SG-C and VM-P wrote the first draft of the manuscript and sections of the manuscript. All authors contributed to the article and approved the submitted version.

This research was funded by the European Regional Development Fund (ERDF), Own Research Plan. Resolution of 19/01/2021 (DOCM 27/01/2021), 2021-GRIN-31242. University of Castilla-La Mancha (UCLM).

The authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.