Keywords

FormalPara Key Concepts Definitions

Critical dialogue helps to form critical consciousness and critical attitude for action. It is a key element to question social structures that (re) produce health inequities. Based on people’s universe and the factors affecting their existence, critical dialogue for Freire produces critical knowledge that will create more effective forms of resistance and intervention in the world (Freire, 1974).

Participation based in Freire’s approach prioritises research ‘with’ and ‘for’ people. This means research committed to respond to current problems in society. Effective participation and social change require critical thinking (Freire, 1974, 1996). This can be achieved through participatory methodologies, deep engagement of participants and interdisciplinary collaboration.

Empowerment Education proposed in Freire’s theory is an effective education model that promotes personal and social change through participation in group action and critical dialogue. It involves people’s efforts to enhance control over their lives by identifying their problems and critically thinking about its social and historical causes to develop strategies towards a healthier society (Wallerstein & Bernstein, 1988).

1 Addressing the Needs of Groups Living in Situation of Vulnerability

Research approaches and methods are specific procedures for designing research processes and for collecting and analysing research data. The methodological choices in doing research should be aligned with the researcher world’s views and values as it will become integral part of his/her personal and professional identity. The health promotion of voiceless and marginalised groups such as those affected by poverty, social exclusion and homelessness need to be a priority if we want to reduce health inequities and inequalities in society. In the attempt to build strong links with these groups to implement change and improve contexts of vulnerability is important to engage in critical research programmes that are oriented towards community empowerment and participation (Simpson & Freeman, 2004; Wallerstein, 2002; Wallerstein & Bernstein, 1988).

The understanding of health promotion as the process of enabling people to increase control over their lives, and to participate in decisions to improve their own health (WHO, 1986), places social justice as a fundamental condition for this (WHO, 2008). Thus, health promotion research must be guided by critical reflection on social structures that influence people’s health with the identification of their health needs and aspirations. Freire’s theoretical approach for an empowering education can be an avenue for personal and social change as it is committed to create an equal society with focus on the disadvantaged groups and communities (Ledwith, 2016). Such a process requires the direct involvement of individuals and communities in the achievement of change, combined with political action towards the creation of an environment promising to health. In addition, community-based participatory research (CBPR) seeks to create more opportunities in which people who have historically experienced oppression and lack of power can feel comfortable and safe to raise their voices on issues that are affecting their lives; Discovering and expanding their own knowledge towards the elimination of inequities. Although the most effective way to promote health and decrease health inequities is by creating fair economic, social and political conditions for all, practical strategies in which practitioners and researchers can work with communities to address poverty, stigma and lack of social participation need to be more explored (Wiggins, 2011). This chapter sustains that participatory research processes using Freire’s critical pedagogy can be a vehicle for this.

2 Paulo’s Freire Approach to Enhance Empowerment, Participation and co-Production of Health Knowledge

Paulo Freire’s key concepts are perceived as foundation to any practice that has a social justice intention (Ledwith, 2016). Paulo Freire (1974) developed a popular education movement in the 1960s, in Brazil, to address a massive illiteracy in the northeast of this country. From 1962, his method was spread in all Brazilian states to reach two million of illiterates living in the most deprived regions (Paulo Freire Institute). Paulo Freire’s educational approach is more than a method, it is an orientation connected to his view of the world, and his commitment to an education that must be liberating, capable of encouraging critical thinking and critical participation to intervene in different contexts (Freire, 1974). However, with the military coup in Brazil in 1964, Freire was forced into exile as the new regime considered his ideas to be subversive. Despite the Government attempts to silence Freire, his work continued to be disseminated in other countries of Latin America, Europe and in the USA, even after his death in 1997. Freire’s principles of popular education and critical pedagogy have been widely used for diverse disciplines, beyond education, including health and social sciences.

Research evidence shown the potential of Freire’s critical pedagogy to enhance empowerment and improve health of vulnerable and stigmatised groups (Wiggins, 2011; Wallerstein & Bernstein, 1988). The use of critical pedagogy in health promotion research has been associated with health behaviour change on several health-related factors (Wiggins, 2011). However, Freire’s approach substantially extends traditional health education’s emphasis on people’s responsibility for their own health decisions. This dialogic approach allows for the co-creation of a new health knowledge when participants are encouraged to bring their own health definitions and experiences to achieve critical understanding about their realities (Rodriguez et al., 2019). As the impact of socioeconomic factors such as income, wealth and education are the fundamental causes of a wide range of health outcomes, Freire promoted a type of knowledge that did not come from experts passing their information into a passive audience. His focus was on the collective knowledge that emerged from a group sharing experiences and understanding on their daily lives. Instead, the emphasis and blame just on the individual health-risk behaviour, the socio-economic influences affecting his individual and societal live are linked and equally explored.

3 What Are the Fundamental Elements and the Key References of the Proposed Approach?

Critical pedagogy is a theory and practice that have critical dialogue and critical attitude as key elements to question social structures that (re) produce inequities (Freire, 1974). Freire’s central premise is that education is not neutral and takes place in the context of peoples’ lives. A critical consciousness integrated with people’s realities and aspirations will form the basis of actions for change. Without a critical consciousness, according to Freire, individuals are not able to integrate themselves into a society marked by intense contradictions and power relations. They need opportunities to participate and make their own decisions reflecting on their responsibilities, and their roles in terms of social transformation (Freire, 1974, 1996). In doing this, the groups perceived as ‘voiceless and powerless’ would increase capacity for choice towards social justice, instead of remaining passive to the life events. When individuals begin to see themselves and their society from their own perspective, they become aware of their own potentialities: ‘Society now reveals itself as something unfinished, not as something inexorably given; it has become a challenge rather than a hopeless limitation’ (Freire, 1974 p. 10).

Critical consciousness on the personal, social, economic and political factors that directly affect peoples’ lives and health can be translated into a critical knowledge that will create more effective forms of resistance and intervention in the world. The formation of a critical consciousness based in the participant’s universe, leads them to question structures of domination, power and social injustice. Therefore, research activities aiming to achieve meaningful understanding of wider health issues, can generate situations of collective reflection leading to social change, ethical and political positioning. This involves the creation of opportunities for individuals, groups and communities to feel comfortable and safe to elect what is relevant to their health-related discussion and debate.

3.1 Core Values for Participation and Social Change: The Freire Approach

The learnings from previous research and a knowledge exchange programme on youth homelessness using Freire’s approach and CBPR (Rodriguez et al., 2019, 2020a, b) highlighted the following principles:

  • Research impact

Research that is committed to respond to current problems in society is committed to impact on people’s lives. The use of critical pedagogy of Paulo Freire in research processes can improve understanding of the links between health, poverty and health care systems for priority groups such as ethnic minorities, homelessness, people in prison, women victims of violence, people with disabilities, among others. It can also act to stimulate critical reflection towards a critical spirit for changing structures that (re) produce abrupt social inequalities/inequities.

  • Deeper understanding of life contexts – listening people and communities

It starts from the assumption that if we want to be more effective as researchers and agents of social change (Freire, 1974), while doing research, teaching, or managing a health promotion service, we must be able to deep understand the context in which people are living. Otherwise, we will not create the best opportunities to listen their felt issues or themes. A wider investigation of the cultural context in which the health promotion debate is embedded is required during all stages of the research, as this context ‘meaning’ is not something easily exposed or accessible through academic studies. In a Freirean approach, the listening stage with community members is a continual process involving all research phases. It is conducted through an equal partnership with community members to identify problems, determine priorities and tailor programmes to local needs (Wallerstein & Bernstein, 1988).

My work experience in Brazil at third sector (Fernandes & Rodriguez, 2009, 2015) highlighted how this deep understanding is a core element for practitioners and researchers interested to work with vulnerable groups. This represents a strong foundation to further trust building relationship with participants, enabling engagement and knowledge construction. Other authors confirmed that health promotion programmes are likely to be most effective when researchers are sensitive to local social and political realities, and when they are embedded within appropriate theoretical, pedagogical and cultural frameworks (Simpson & Freeman, 2004).

  • Co-creation of knowledge – Empowerment education

The critical pedagogy approach, as others approaches in Social Psychology (Moscovici, 1998) and Geography (Van Blerk & Kesby, 2013) supports the belief that there are different types of knowledge. Local communities and people can identify their own health needs and joint solutions to achieve a better life using the knowledge from experience. Thus, all people are experts on their lives, there is no hierarchies of knowledge, and everyone should be able to express their needs and opinions when safe opportunities are created to listen their voices. In practical terms, when substantial time is reserved to interact with research participants, before the research starts, during and after, and in their own territory. There is the development of a trust, that is more likely to last. From this meaningful interaction, a co-created knowledge that is collective, diverse and inclusive can flourish. Collective because we are working ‘for’ and ‘with’ people, diverse because we need to involve different people from different backgrounds, especially those with lived experience on the issues we want to address and inclusive because the way we are going to involve them should be based on their own terms and not in ours.

  • Critical thinking, participation and interdisciplinary collaboration

We must develop research ‘with’ and ‘for’ people. A research based in Freire’s approach prioritises critical thinking, participatory methodologies, deep involvement of participants and interdisciplinary collaboration. Therefore, health promotion interventions in community settings should be made not only for the people, but also by the people. Effective participation and social change require people to engage in a process of self-reflection, self-discovery and consequent transformation (Wiggins, 2011).

However, critical thinking about issues does not occur spontaneously. Wallerstein and Bernstein (1988) presented 5-step questioning strategy to move discussion from the personal to the social analysis and action level. Following these steps, people are asked to (1) describe what they see and feel within their life contexts; (2) as a group, define the many levels of the problem they want to resolve; (3) share similar experiences from their lives; (4) question why this problem exists and (5) develop action plans to address the problem. This process recognises that despite social justice in health is a complex challenge in society, with no immediate solutions, this can be a nurturing way to explore possibilities of action. It requires new insights from interdisciplinary work and integrated responses from various sectors.

  • Critical dialogue for action

Critical dialogue is another key element of Freire’s approach. For Freire (1974), it is the practice of dialogue that helps to form critical consciousness and critical attitude for action. After the initial listening and dialogue stage, the action emerges directly from the problem-posing discussion. After a deeper cycle of critical thinking and reflection, people will fell more ready to test out their analyses in the real world. Participatory health promotion research that engages people in critical analysis of the root causes of inequalities will form the basis for action. As long the research is driven by critical dialogue and thinking, there is a powerful opportunity to make people question their realities, understanding their situation with a fresh eye. The health and social inequalities in society are not just as a result of individual failure but as a consequence of structural problems and social contradictions.

4 Contribution to Health Promotion Research

Freire’s theoretical approach combined with CBPR has proven to help researchers, teachers and health practitioners to understand and to discuss health promotion from the perspective of the individuals they are working with. This approach in health promotion fosters the gain of control as strategy for health equity. It suggests that deeper participation of people in group action and critical dialogue must be a priority as this enhances their control and beliefs in their own ability to implement change. In the past, traditional health promotion research had mainly targeted individual behaviours change to address inequality/inequity, rather than social or environmental risks to health. A new generation of health promotion theorists, from the World Health Organisation (WHO, 1986, 2008), recognises both, the role of individual control and social action in health as well the social determinants of health.

Freire’s approach applied to health promotion emphasises the need to create more opportunities for people to participate in society, achieving understanding of the environment to make healthy choices in the daily lives, especially for those living in contexts of vulnerability. In parallel, there is a need to acknowledge the tensions and continued negotiation with structures of power as an inherent part of this process of increasing people’s autonomy. Strengthening communities and involving people in critical thinking through Freire’s approach and community-based participatory research is not a simple task. Many people had no opportunities or experience on community participation in any level. In this case, research programmes of health promotion that use critically informed approach based in Freire’s work can contribute to stimulate critical dialogue, critical thinking and a co-production of knowledge that will forge actions to bring about change.

The five core values presented in this chapter reinforce the commitment to construct a common agenda for social justice and the right to health of marginalised groups. A new knowledge in a critical and significant way emerges from the encouragement of people in being confident to express their own health needs and to value their own health knowledge and experiences. Freire’s approach enables people to understand, to produce and critically use health information. The benefit of using this reflective approach goes beyond research participants and reaches to both researchers and health/education professionals. Those who are seeking to understand the complexity of health promotion issues from the perspective of people, end up revisiting their own values, comfort zones, power relations, fears and feelings that embed their practices. Being fully aware of these important elements strength their commitment to continue pursue social change in their work.