The Freirian model--a place in health promotion and education.
Abstract: When considering a framework to guide health promotion professionals, there are many models and theories to choose from. The purpose of this manuscript is to showcase the Freirian Model, and discuss implications it could have on health promotion. Friere's ideas have been directly linked to the concept of health promotion; health and disease are socially determined, therefore collective action and the full participation of learners is critical. The World Health Organization supports empowerment strategies, and considers them prerequisites for health promotion. With continuing focus on community-based participatory research, health promotion professionals should consider the Freirian Model as a worthwhile approach.
Subject: Physical fitness (Analysis)
Public health (Analysis)
Medical personnel (Training)
Medical personnel (Analysis)
Author: Ickes, Melinda J.
Pub Date: 01/01/2011
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2011 Source Volume: 26 Source Issue: 1
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Organization: Organization: World Health Organization
Persons: Named Person: Freire, Paulo
Accession Number: 308741535
Full Text: INTRODUCTION

Paulo Freire has been considered one of the most influential thinkers with regards to education in the late twentieth century. Freire's work, including Pedagogy of the Oppressed, has been one of the most quoted educational texts. His ideas have been widely used in different capacities such as adult education, community organization, health education, alcohol and substance abuse prevention, development work in agrarian cultures, and coalition building (Smith, 1997, 2002). He was a Brazilian educationalist who was known for his theory of liberation education, which distinctly related educational practice and liberation. He believed that education was a means of "freeing" people from a "culture of silence" (Freire, 1970). According to Freire, liberation occurred when the oppressed were able to see the potential for change and utilized that to transform their environment. He believed the principles of social justice; liberation, equal access, and empowerment were necessary to help individuals and communities address the larger socioeconomic causes of oppression and poor health.

Combining his democratic and liberatory vision of education, Friere believed the focus should be on acts of cognition, not merely a transfer of information. Freire insisted education was not neutral, but occurred in the context of people's lives (Freire, 1970). To promote the learning process, individual empowerment fostered a critical role in learning outcomes. Empowerment was defined as a process through which individuals or communities gain mastery over their lives and environment (Rappaport, 1987); a social action process that promotes participation of people, organizations, and communities in gaining control over their lives in their community and larger society; and the power to act with others to effect change (Wallerstein & Bernstein, 1988). Van Wyk (1999) suggested that without active involvement, growth and development become quite impossible to attain.

In Freire's eyes, students were viewed as fully empowered participants in the education process, which significantly shifted the traditional mentality of teacher-control. He believed a reciprocal relationship should exist, with the mentality of "teacher-student with students-teachers" (p.80). Traditional education uses "banking" as the mode of information transfer, with the emphasis placed on the process of teachers depositing knowledge into the students. This in turn has created students who accept the passive role imposed on them, and therefore learn to adapt to the world as it is and not to act upon it and impart change (Rudd & Comings, 1994). Freire recognized the importance of the dynamic interaction between personal growth and participation in community change (Wallerstein & Bernstein, 1988), and felt it could be interwoven with many disciplines to evoke change.

HEALTH EDUCATION AND HEALTH PROMOTION: FREIRE'S APPROACH

Health promotion is defined as the process of enabling individuals and communities to increase control over determinants of health, and thereby improve their health (Wallerstein & Bernstein, 1988). Friere's approach has been directly linked to the concept of health promotion; in that health and disease are socially determined, therefore collective action and the full participation of learners is crucial to the educational process (Rudd & Comings, 1994). The World Health Organization (WHO) (2006) supports empowerment strategies as promising in their ability to produce positive health impacts, consequently depicting community action and empowerment as prerequisites for health promotion strategies. Van Wyk (1999) furthered that successful health promotion and education is nothing more than community empowerment. Therefore, in order to decrease health disparities and improve quality of life, such as those goals imparted by Healthy People 2010 (United States Department of Health and Human Services [USDHHS], 2000), each individual within a community must be willing to take control of their own life and well-being.

Gaining control has been recommended as a strategy for improving health (Wallerstein & Bernstein, 1988). In order to truly understand health behaviors our nation is struggling with, research has begun to examine underlying susceptibility to disease. Overwhelmingly, an increased risk of morbidity and mortality has been related to lower socioeconomic status, as well as racial and ethnic disparities (USDHHS, 2000). Risk factors for targeted health behaviors (i.e. leading health indicators of Healthy People 2010) include lack of control and disempowerment.

In many ways, Freire's ideas are similar to the guiding principles of health promotion and education: start from the problems of the community, use active learning methods, and engage participants in determining their own needs and related priorities (Wallerstein & Bernstein, 1988). Participation in decision-making is in itself considered health enhancing. Wallerstein and Bernstein furthered that a goal of health promotion and education should invite people to believe in themselves, believe that they have the knowledge and capability to use that knowledge throughout their lifetime.

Yet differences exist in that many in health education and health promotion assume individuals can make healthy decisions with enough information, skills and reinforcement (Wallerstein & Bernstein, 1988). Conversely, Freire assumed that knowledge did not come from experts, but rather emerged from a group sharing experiences, and then understanding those influences that affected their lives (Freire, 1970). Thus, Freire's model provides a potential framework to support health promotion initiatives, building on group consciousness raising and collective action (Miner & Ward, 1992). According to Freire, simple transfer of information from one person to another did not necessarily motivate action. Moreover, he believed the group dynamics influenced the individual's ability to take responsibility for their own health (Van Wyk, 1999). See Table 1 for a comparison of traditional health promotion and education models and a Freirian-based empowerment model.

According to Wallerstein and Bernstein (1988), an empowering health education effort involves much more than improving self-esteem and self-efficacy, or other health behaviors that are independent from environmental or community change, as traditionally focused. The targets include individuals, group, and structural change. The process should encompass prevention as well as other goals of community connectedness, self-development, improved quality of life and social justice. Gaining control of the health behavior should also be considered an essential strategy for health education empowerment, all the while focusing on specific prevention messages.

When relating Freire's model to health education and health promotion, Miner and Ward (1992) explain that the health educator becomes a catalyst who facilitates the group process, in order to help uncover group values and underlying assumptions. Guiding group processes becomes important in helping to identify needs regarding health education, but also to aid in the decision-making process with regards to health (Van Wyk, 1999). Recommendations include the teacher becoming a co-learner/equal partner with the student in the learning process (Freire, 1970), which would promote long-term individual and social changes conducive to disease prevention and health promotion (Miner & Ward, 1992).

THREE-PHASED PROCESS

The approach to the Freirian model has been considered a simple, three-phased process. First, the naming phase attempts to identify the community problems and determine priorities. It has also been designated as the listening phase, since conducted as an "equal partnership" with the community members. A critical component includes establishing rapport with the group by the teacher/ facilitator (Wallerstein & Bernstein, 1988). This helps to extend the process beyond the initial "needs assessment" and encourages community members to become active in all stages. Friere valued group learning, which he believed supported interaction with others, and helped with the development of the individual. Collective knowledge then results from these group dynamics; small group discussion of past experiences and critical reflection occurs within the group. Group members are encouraged to openly express their perceived needs and interests (Miner & Ward, 1992).

In the second phase, also known as the reflection phase, questions are raised in an attempt to answer why the problem(s) exist. The teacher/facilitator initially presents the students with complex problems without obvious solutions. Problem-posing-strategies allow the teacher/facilitator to situate learning in the student's own experiences. The goal is to facilitate critical reflection and promote autonomous thinking among group members (Rindner, 2004). This has also been identified as the dialogue stage in which "codes" are created. A "code" is considered a concrete physical representation of an identified community issue through the use of role plays, stories, photographs, songs, etc. The codes are designed to further discussion in relation to community reality. An effective code is considered to exemplify a problematic situation that is multi-dimensional, related to the community, and open-ended without solutions (Wallerstein & Bernstein, 1999). Friere believed that the form of the materials supporting the educational process contributed to the determination of whether or not an educational activity would empower or oppress. The visual mode of learning tended to be a less abstract reality than written descriptions (Rudd & Comings, 1994).

Community members involved throughout the process are able to comfortably express their responses when dealing with emotional and social issues. However, even when presented with codes, critical thinking does not necessarily occur spontaneously. It is recommended that facilitators provide leadership by using a recommended 5-step questioning strategy that helps move discussion from the personal to the social analysis and action level (Wallerstein & Bernstein, 1988). To do this, community members are asked to 1) describe what they saw and felt; 2) as a group, define the many levels of the problem; 3) share similar experiences from their lives; 4) question why this problem exists; and 5) develop action plans to address the problem.

The third phase is the action phase, which emerges directly from the problem-posing discussion. Community members attempt to figure out what options exist and what could be done to change the situation(s). With this community involvement, it becomes a "process centered" as opposed to "outcome centered" phase. Group members collectively develop an action plan which is consistent with their perceived needs and chief concerns, in order to mobilize and apply resources to challenge existing social structures (Miner & Ward, 1992). The community applies their learning from the group-learning to a real-world setting and then is encouraged to bring back the results to share for discussion. Through this strategy, participants become reflective, self-conscious agents, and critical thinkers who are capable of change (Rudd & Comings, 1994).

To summarize, Wallerstein and Bernstein (1988) described the application of Freire's model in the acronym "SHOWED": What do we "SEE" here? What is really "HAPPENING"? How does the story relate to "OUR" lives? "WHY" have they become/done this (relate to specific behavior)? How is it possible for the individual to become "EMPOWERED"? What can we "DO" about it?

CONSTRUCTS OF FREIRE'S MODEL

According to Sharma (2006), measurable constructs are important, particularly in the quantitative paradigm of research. However, with Freire's Model, this is considered fairly challenging. Yet, within the three above-mentioned phases, five constructs have been identified: dialogue, conscientisation, praxis, transformation, and critical consciousness.

The first construct is "dialogue" which consists of the exchange between the learners and the educators on concrete awareness about the context of facts. The second construct, "conscientisation" occurs when efforts are made to identify and address the systematic forces of oppression, or barriers preventing them from a clear perception of reality. This enables the learners to become more attentive to their own means of improving their circumstances (Van Wyk, 1999). The third construct is defined as "praxis." This entails reflective action, in which theory and practice are linked. The fourth construct is transformation, which constitutes the process of changing "objects" into "subjects." This thereby enables learners to see the theory behind the reality and transform the structure so they could become "beings for themselves." Finally, the fifth construct is "critical consciousness" which refers to the political organization of those negatively affected. Understanding each of the constructs and the relationship within each of the three previously discussed phases enables Freire's approach to be used in a variety of settings and areas of interest.

EXAMPLES IN HEALTH PROMOTION AND EDUCATION

A review was conducted to summarize how Freire's Model has been used in health promotion and health education. Few studies specifically mention using the Freirian framework, although Freire's mentality has been adopted more frequently in health education and health promotion with recent strides to implement community-based participatory research. Concepts found within Freire's Model are often ingrained with other health behavior theories which attempt to alter adverse behaviors by changing individual attitudes and providing self-management strategies (Nelson et al., 2010). Studies which applied Freirian principles with health promotion and health education interventions are summarized in Table 2.

Seven studies clearly applied the Freirian principles, yet the majority focused on empowerment as a main program component. Topics such as nutrition, tobacco prevention, drug and alcohol abuse, HIV/AIDS and domestic violence were among the resulting studies. Targeted populations included children and adolescents, homeless individuals, as well as those in multiethnic communities. A common theme among these populations is a sense of underrepresentation and/or increased susceptibility to common health issues (USDHHS, 2000). As discussed previously, many of these individuals report lack of control and disempowerment, both of which are clearly targeted within the Freirian Model.

LIMITATIONS OF FREIRE'S MODEL

Airhihenbuwa and Ludwig (1997) conclude that it should not be assumed this is a model or curriculum which can be haphazardly applied to any situation, or is not without flaws and barriers. Such limitations include what some consider a cumbersome and lengthy process. The development of group trust and rapport must be carefully developed to ensure effective group process and collaboration. In many communities, this rapport may be difficult to attain, which may undermine the success of the Freirian approach. Unfortunately, in some communities, empowerment approaches are viewed as threatening to those in existing community power structures (Miner & Ward, 1992) and may be met with resistance.

On the other hand, some believe there is "circular logic" to Freire's style, which may make it difficult to comprehend and tease out measurable constructs (Sharma, 2001). Since many funding opportunities demand firmly established and measurable outcome goals (Miner & Ward, 1992), this could be difficult for the continuation of sustainable programs. Therefore, evaluation must not only attempt to measure "constructs" but also the long-term behavioral, policy, and social related-changes (Wallerstein & Bernstein, 1988).

DISCUSSION

According to Sharma (2001), the Freirian model has not been used much in health education in the United States. This was consistent with the findings upon a review of the literature whereas only seven studies in health promotion and education specifically discussed the influence of the Freirian model on their approach. The Freirian approach offers the potential to work with communities which are often very different from that of the health promotion professional. It also enables those in health promotion and education to target groups who might be underserved. Through this approach, mutual growth and change can occur with both groups (Wallerstein & Bernstein, 1988).

Studies in health promotion and education have incorporated a variety of the concepts ingrained in Freire's approach, and have found positive results. For example, the 'problem-posing' model allowed facilitators to avoid the limitations of many behavior change interventions, with the opportunity to observe participants' attitudinal changes. The 'problem-posing' model also enabled participants to construct their own realities, engage in self-reflection and build on their experiences. In addition, the use of discussion facilitation is effective and can be the underpinning of a behavior change intervention (Nelson et al., 2010).

When individuals are brought together to discuss their own perceived problems and come up with their own solutions, there is a sense of individual and community empowerment (Gomez et al., 1999). By empowering community residents to shape their own agenda for health action, human resources are mobilized, and social networks that bring a community together are strengthened (El-Askari et al.,1998). However, in order for the Freirian approach to be effective, there is a need to determine how to best collaborate with the community in order to build support in which behavior change can take place (Wallerstein & Bernstein, 1988), and be sustainable over time.

Moreover, Sharma (2001) mentions many of the studies were qualitative in nature, and there is a definitive need to also incorporate quantitative, empirical studies. Evaluation must also look at empowerment as a long-term process, such as building self-esteem or participation in community organizing efforts (Wallerstein & Bernstein, 1988). Follow-up and longitudinal measures should be undertaken to truly evaluate empowerment-based approaches.

CONCLUSION

It is necessary to continually engage in the critical reanalysis and re-creation of Freire's work, while used as a foundation for future work (Airhihenbuwa & Ludwig, 1997). It is important to assess conditions for change: success can only exist through working with the reality and resources of a community (Wallerstein & Bernstein, 1988). How to provoke dialogue and collectively work with community members becomes crucial in the success of any program, and in order for community-based leadership to emerge. The World Health Organization (2006) describes community action and empowerment as prerequisites for successful health promotion strategies, and therefore building on lessons learned from those programs which have already found success using a Freirian Model is important for future steps in achieving our country's health goals.

REFERENCES

Airhihenbuwa, C., & Ludwig, M. (1997). Remembering Paulo Freire's legacy of hope and possibility as it relates to health education/promotion. Journal of health education, 28, 317-319.

El-Askari, G., Freestone, J., Irizarry, C., Kraut, K., Mashiyama, S., Morgan, M., et al. (1998). The healthy neighborhoods project: A local health department's role in catalyzing community development. Health Education & Behavior, 25, 146-159.

Freire, P. (1970). Pedagogy of the oppressed. New York: Continuum.

Gomez, C., Hernandez, M., & Faigeles, B. (1999). Sex in the new world: An empowerment model for HIV prevention in Latina immigrant women. Health Education & Behavior, 26, 200-212.

Miner, K., & Ward, S. (1992). Ecological health promotion: The promise of empowerment education. Journal of health education, 23, 429-432.

Nelson, A., Lewy, R., Ricardo, F., Dovydaitis, T., Hunter, A., Mitchell, et al. (2010). Eliciting behavior change in a US sexual violence intimate partner and violence prevention program through utilization of Freire and discussion facilitation. Health Promotion International, 25, 299-308.

Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology, 15, 121-148.

Rindner, E. (2004). Using Freirean empowerment for health education with adolescents in primary, secondary, and tertiary psychiatric settings. Journal of Child and Adolescent Psychiatric Nursing, 17, 78-84.

Rudd, R. E., & Comings, J. P. (1994). Learner developed materials: An empowering product. Health Education Quarterly, 21, 313-327.

Rusness, B. (1993). Striving for empowerment through nutrition education. Journal of the American Dietetic Association, 93, 78-79.

Sharma, M. (2001). Freire's adult education model: An underutilized model in alcohol and drug education? [Editorial]. Journal of Alcohol and Drug Education, 46, 1-3.

Sharma, M. (2006). Applying Freirian model for development and evaluation of community-based rehabilitation programmes. Asia Pacific Disability Rehabilitation Journal, 17, 42-49.

Smith, M. K. (1997, 2002). Paulo Freire and informal education. In the encyclopedia of informal education. Accessed July 2, 2008 from www.infed.org/thinkers/et-freir.htm.

United States Department of Health and Human Services. (2000). Healthy People 2010. 2nd ed. Washington, DC: Government Printing Office.

Van Wyk, N. C. (1999). Health education as education of the oppressed. Curationis, 12, 29-34.

Wallerstein, N., & Bernstein, E. (1988). Empowerment education: Freire's ideas adapted to health education. Health education quarterly, 15, 379-394.

World Health Organization. (2006). What is the evidence on effectiveness of empowerment to improve health? Accessed July 2, 2008 from http://www.euro.who.int/Document/E88086.pdf

Melinda J. Ickes, PhD, is affiliated with the Department of Kinesiology and Health Promotion, University of Kentucky, 111 Seaton Building, Lexington, KY 40506, Phone: 859-257-1625, Fax: 85-323-1090, Email: melinda.ickes@uky.edu
Table 1. Comparison of Traditional and Empowerment Health Education
Models

Traditional                     Empowerment

Teacher as expert               Teacher as co-learner
Teacher determines learning     Community determines learning
Curriculum based                Anti-curriculum, dialogical
Use of preprinted materials     Use of codes
Teacher lectures                Teacher engages in dialogue
Emphasis on individual change   Emphasis on individual, group
                                  & community change
Passivity of student learners   Empowerment of individual,
                                  group, & community
Classroom learning              Learning takes place in the
                                  real world

* Adapted from Rindner (2004)

Table 2: Summary of Freirian Model in Health
Promotion and Education

Author/Year     Goal of Intervention

Wallerstein     Alcohol Substance
& Bernstein,    Abuse Prevention
1988            Program, a community
                and school-based
                participatory
                prevention program.
                Goal to reduce
                morbidity and
                mortality among
                multi-ethnic middle
                and high school
                students.

Rusness,        Eating Right is Basic,
1993            a community-based
                nutrition program,
                with a homeless
                population who are at
                risk for malnutrition
                and hunger as a result
                of poverty.

Rudd &          Goal to decrease
Comings,        smoking attitudes
1994            and behaviors in a
                school-based smoking
                prevention project for
                5th-9th graders.

El-Askari et    A Healthy
al., 1998       Neighborhoods
                project with a goal to
                catalyze community
                development and
                organization in a
                multiethnic public
                housing complex.
Gomez et        Goal was to
al., 1999       evaluate the impact
                of a multifaceted
                empowerment
                program for Latina
                women on HIV risk
                behaviors.

Ridner,         Goal was to facilitate
2004            adolescent self and
                collective learning in
                psychiatric setting.

Nelson et       Goal was to decrease
al., 2010       prevalence of sexual
                and intimate partner
                violence in Hispanic
                migrant farm-working
                communities.

Author/Year     Application of Freirian Model

Wallerstein     The program attempted to
& Bernstein,    empower youth to make
1988            healthier choices in their own
                lives, as co-learners with health
                professionals and patients; the
                value of students' experience
                as contributing to social
                knowledge about substance
                abuse; critical thinking with
                students asking their own
                questions of patients and
                themselves; and group dialogue
                to explore root causes and
                motivate students to engage
                in creative actions that address
                problems in their communities
                and society as a whole.

Rusness,        Nutrition problems were
1993            integrated into a reflection on
                the problems identified by the
                homeless participants. Included
                empowerment goals and a
                family approach.

Rudd &          Adolescents were empowered
Comings,        to develop their own
1994            health education materials
                (photonovels).

El-Askari et    Used concept of creating
al., 1998       critical consciousness to engage
                individuals in problem-posing
                dialogue, focused on the
                learner as an equal partner.

Gomez et        The focus was on
al., 1999       empowerment. Women
                participated in informational
                meetings, friendship circles,
                and workshops.

Ridner,         Used the concept of
2004            empowerment, encouraging
                the nurse to be a co-learner
                with the adolescent. Built self
                and collective learning through
                group processes, peer teaching,
                and development of critical
                thinking skills.

Nelson et       Encouraged men to reflect on
al., 2010       their experiences with sexual
                and intimate partner violence
                in their lives through discussion
                facilitation and come to their
                own understanding of their
                behaviors--building on the
                concepts of empowerment and
                problem-posing.

Author/Year     Salient Findings

Wallerstein     Those involved reported
& Bernstein,    increased self-esteem and
1988            self-responsibility, increased
                awareness of social structures
                incompatible with desired
                change, increased sense of
                community and solidarity with
                others in the group, positive
                changes in interpersonal
                relationships, and greater
                recognition of opportunities
                for positive social change.

Rusness,        Written evaluations
1993            documented that the process
                of empowerment had begun.
                Women were surprised by
                their ability to have a dialogue
                with others about issues that
                were important to them. The
                women noted enhanced self-esteem,
                a sense of community,
                and a greater realization of
                personal power.

Rudd &          Changes in the positive
Comings,        direction (not statistically
1994            significant) were found in:
                health locus of control, intent
                to smoke, and smoking
                behavior.

El-Askari et    The community successfully
al., 1998       advocated to improve public
                safety by installing street
                humps and increased street
                lighting. Initiated additional
                health actions including
                removal of neighborhood
                tobacco billboard.

Gomez et        Women showed significant
al., 1999       increased in sexual
                communication comfort,
                were less likely to maintain
                traditional sexual gender
                norms, and reported changes
                in decision-making power.

Ridner,         No results presented; process
2004            outcomes discussed.

Nelson et       Through discussion
al., 2010       facilitation, a targeted
                and structured behavior
                change intervention assisted
                participants in realizing
                that their past actions were
                damaging to themselves and
                their community, while aiding
                the participant in employing
                self-initiated responses, to alter
                their behaviors.
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