Paulo Freire’s research itinerary: contributions for promoting health in the teaching profession

Rev Bras Enferm. 2020;73(4): e20190164 http://dx.doi.org/10.1590/0034-7167-2019-0164 7 of ABSTRACT Objectives: examine Paulo Freire’s research itinerary as a theoretical-methodological framework and its contributions for promoting health in the teaching profession. Methods: qualitative participatory action research coordinated with Paulo Freire’s itinerary, carried out in culture circles, from April 18, 2018 to June 26, 2018. It involved the participation of 21 teachers from a federal teaching institution. Results: the method that was used promoted dialogue and reflection among the participants, enabling a health promotion intervention. It facilitated self-knowledge and reflection, resulting in significant changes in the participants, in a process in pursuit that seeks transformations. Final Considerations: Paulo Freire’s research itinerary was opportune, as a possibility for promoting health, mainly in terms of providing a framework that assists in the practical construction of knowledge and encourages participants to examine their reality in the pursuit of enhanced quality of life. Descriptors: Health Promotion; Occupational Health; Faculty; Qualitative Research; Autonomy.


INTRODUCTION
Health promotion has been discussed over the years, through studies that seek to understand and suggest ways for people to live properly and as alternatives to public policies. The modern definition of health promotion was formalized by the Ottawa Charter of 1986, which considers it to be the process of enabling individuals, families and communities to increase control over the determinants of health and improve their quality of life and health. Health promotion is more than a healthy lifestyle and extends beyond the sector to include overall well-being, transforming the idea, in place since the 1970s, of health focused on biological determinants and centered around concerns about the sickness of individuals and populations (1)(2) .
In view of the adverse social and health conditions that affect major sectors of the working population in the world, studies related to health promotion in the workplace are needed to identify and describe interventions implemented at this level (3) .
Work and its relationship with health are guided by sociocultural, economic and production aspects, such that this relationship differs according to the society in which it is lived. The relationship between health and work in the school environment requires an understanding of workers in education, work organization methods and the conditions unleashed in the health-disease process of these professionals. This knowledge provides input for investigating work processes and the repercussions on health, resulting from interaction between the environment and the individual (4) .
In an international context, a study on health promotion in schools claims that it is possible to ensure the implementation of health promotion activities in teaching institutions. It points out that it is possible to contribute to the improvement of educational work in schools through training related to health care and the development of life skills, particularly those associated with improving the overall culture and health (5) . Paulo Freire's research itinerary is opportune for developing an educational work aimed at promoting health in the work of teachers, in that it is concerned with unveiling the social reality. This method seeks to reveal that which is hidden, allowing the imagination and creativity of participants to find new action proposals for addressing this reality (6) .
The conflicts, contradictions, diversity or positivity which represent an existential health situation of a certain reality and that are experienced by men and women can be characterized through this methodology. Freire's dialogical approach broadens the scope of action of professionals in an interdisciplinary and intersectoral perspective, with greater resolution capacity of health actions and higher impact of the indicators of the population receiving care (6)(7) .
This framework is based on a critical-social pedagogy which has an ethical commitment to the emancipation and liberation of society to promote quality of life. This occurs through conscientization and dialogue among participants (6,8) .
Through this methodology it is possible to reflect on a problem situation in relation to a reality, which must be examined and recognized through a dialogical exercise. Such reflection strengthens and heightens awareness and the full exercise of autonomy, in addition to promoting participation as a form of empowerment and emancipation of individuals (9)(10)(11) .
In his works and thoughts, Paulo Freire uses concepts related to man within society, dialogue, culture, conscientization, the social/political being, transformation, praxis, oppressor/oppressed, banking education/liberating education and emancipation, based on principles of love, dialogicity, attentive listening, respect for others, altruism, bilateral knowledge construction, horizontality, autonomy and consequent individual and collective empowerment (12) .
Education in health, as a political pedagogical process requires the development of critical and reflective thinking to unveil reality and propose transformational actions that lead people to autonomy and emancipation as historical and social beings, able to propose and express opinions on health decisions to care for themselves, their families and their larger community (13) .
Participatory action research enables studies to result in a practice, based on researching a pedagogical movement, connected to social transformation. Rounds of conversation, by making horizontal discussion possible, are consistent with health promotion, as a means of empowerment by defending the formation of autonomous, critical, reflective and free individuals responsible for their health and well-being. Health promotion defends the value of knowledge and social participation, based on the articulation of technical and popular knowledge, and the mobilization of institutional and community resources, both public and private, to confront and solve a problem situation (14) .
This method was chosen since the study was linked to the Nursing and Health Promotion Research Laboratory (LAPEPS), connected to the Federal University of Santa Catarina (UFSC). It is an interdisciplinary group with a history of carrying out investigations with a qualitative approach, where educational processes in health of a participatory nature are within its scope of study. It started its activities in 1994 and, since then, has been using the theoretical-methodological framework of Paulo Freire in its studies, which has also been employed by many researchers from different areas of work with health promotion among women from "quilombola" communities, teachers, elderly people, children and nurses, among others (6) .

OBJECTIVES
To examine Paulo Freire's research itinerary, as a theoreticalmethodological framework and its contributions to promote health in the teaching profession. names that they randomly chose, and which will be maintained at all times necessary.

Type of research
This participatory action type research had a qualitative approach linked to Paulo Freire's research itinerary (12) , which consists of three closely interlinked stages: thematic investigation which seeks to identify the generative themes extracted from the reality of the participants; coding and decoding where the contextualization and problematization of the generative themes occurs, creating awareness of the world; and critical unveiling, where participants become aware of the reality in question and move toward transformation of the lived context (6,15) .

Study setting
This study was conducted in the city of Florianópolis, Santa Catarina, Brazil in a health education environment -the Federal Institute of Education, Science and Technology of Santa Catarina (IFSC). IFS is an institution for basic, professional and university education, organized into 22 campuses distributed throughout the state of Santa Catarina, with approximately 35,600 students. The Florianópolis Campus, where this study took place, has 6,218 students and 603 employees, corresponding to 391 teachers, and 212 administrative technicians. It was selected for its easy access, since the researcher works on this campus, in addition to its being the largest and oldest campus of the IFSC network (16) .
IFSC teachers from the Florianópolis campus participated in this study. The inclusion criteria were: full-time teachers, between permanent staff and those contracted on a temporary basis, with at least two years of teaching experience, giving health courses (nursing, technician, radiology technologist, radiation protection, caregivers for the elderly or health services receptionist) and available to participate in the culture circles. It was forecast that approximately 20 teachers would participate, and in the end there were 21 participants.

Data collection
In Paulo Freire's research itinerary, culture circles draw together researchers and study participants, transforming the topic of interest of the researcher into a collective interest as well. They can be held with a smaller and variable number of participants and epistemological rigor is ensured through a full and in-depth reflection of the reality in question, promoting the autonomy of the individuals in the process (9)(10)(11) .
Culture circles are a dynamic lived space for learning and knowledge sharing, where participants come together in an educational process to investigate topics of interest to the group. The key element is dialogue, leading to action and reflection among participants concerning existential situations (6,(9)(10)(11) .
The thematic investigation took place through five culture circles, scheduled in 15-day intervals during the teachers' meetings, from April 18, 2018 to June 26, 2018, on the premises of the IFSC. An average of 13 participants, depending on their availability, participated in the circles which lasted approximately an hour and a half. The meeting place was set up in a circle and the activities were video recorded using a tripod and mobile device, with the knowledge and authorization of the participants. The recordings were subsequently transcribed into text by the researcher. Records of the themes were also kept in field log where the researcher made pertinent notes from the culture circles.
Codification and decodification constitute joint steps, where the generative themes are contextualized and problematized, giving rise to awareness of the lived world through dialogue, which occurs naturally according to the participants' interest (12) . The participants replace pre-existing visions of their day-to-day and develop a critical and conscious perspective on the lived reality. Decodification is an analysis of the lived situation, a dialectic moment during which the participants start reflecting on their actions, questioning the situations they have experienced. During this stage, they reformulate their reflective power and recognize themselves as beings capable of transforming the world (6,12) .
This stage took place in the second culture circle, when the theoretical framework of health promotion and occupational health was presented to the group. It also occurred in the other culture circles, when group discussions and dialogue took place, based on the keywords offered by the participants which were recorded on the blackboard, and then classified and grouped according to their closeness and similarity to the themes.
It should be noted that the research itinerary proposed by Freire suggests a series of steps that are not linear, but are constantly interacting, in a constant process of construction (6,12) .

Data organization and analysis
The analysis process of the themes was based on Paulo Freire's research itinerary which include an analytical project done together with the participants. It was also supported by the theoretical framework for health promotion and occupational health. Since it was a study of a qualitative nature, the analysis of the themes took place based on what emerged in the culture circles and occurred concomitantly with their development.
Critical unveiling is a time of knowledge construction through revealing the concepts emerging at the individual level and becoming collective. It represents becoming aware of the reality, where the situation lived and shared in the codification stage is problematized, decoded and viewed from a new perspective. Consequently, that which was not known or perceived becomes known and revealed, moving toward transformation of the lived context. This is the action-reflection-action process (10,12,15) .
This stage occurred as of the first meeting, when the participants became aware of their reality during the discussions and already expressed actions and practices to transform their reality and promote their health.

Characterization of the study participants
In terms of the sociodemographic profile of the participants, such as age, sex, marital status, level of education, area of study and length of time teaching, the teachers were characterized as mainly female (72%), married (62%) and ranging in age from 25 to 50 years, with a predominance of those in their thirties. As for areas of study, 52% of the participants had studied nursing, followed by radiology technologists (33%), physicists (10%) and engineers (5%). The degrees of the teachers were specializations (9%), PhDs (48%) and master's degrees (43%). Length of time teaching ranged from two years to 28 years, but most (53%) had more than ten years of experience.

Research Itinerary and Culture Circles
The thematic investigation took place through culture circles. The first culture circle was held on April 18, 2018, with 19 participants, in order to do the thematic investigation. It was suggested to the group to divide in two and discuss health promotion in one and occupational health in the other. After this stage, the discussions were socialized in the culture circle, where there was an in-depth reflection on the reality and from which 36 generative themes of interest of the group emerged. At this time, the themes were recorded on the blackboard according to similarities and linked to health promotion and occupational health, which were to be discussed in the other culture circles.
The second culture circle, held on May 2, 2018, sought to start the process of coding and decoding the themes identified in the thematic investigation. A presentation was prepared on health promotion, particularly on public policies and international conferences related to occupational health, highlighting occupational health and environmental risk policies, as requested by the participants. The 16 participants were urged to express their opinions, making the discussion timely as the themes were dialogued in the culture circles.
Simply seeing oneself in this process is already health promotion, which I consider to be a major step. The group itself was therapeutic. We were able to talk, open up and say I feel this way and it's very similar to your colleague. It was a very special time. (Esperança) I consider these culture circles as group therapy. (Gab) The third culture circle occurred on May 16, 2018 and sought to continue coding and decoding the 36 identified themes. Seven teachers participated in this circle, due to the start of the curricular internship of the nursing technician course, which required some participants to be away from the institution on the field, in addition to others who had traveled to participate in scientific events.
The codification and decodification of the generative themes were based on the keywords registered by the participants on the blackboard, and then classified and grouped according to closeness and similarity. These words corresponded to the themes related to occupational health in the teaching profession and the practices that enable promotion of the health of the teachers participating at that time. Through dialogue-driven dynamics, the themes identified in the thematic investigation stage were coded and decoded. Two clouds were then drawn on a blackboard, one for health promotion and the other for occupational health, surrounded by the previously discussed concepts to facilitate the discussion. There was also an envelope containing strips of paper with the 36 generative themes identified in the first culture circle. The participants randomly selected a theme and expressed their opinion with interaction and discussion in a large group, in an effort to highlight practices for promoting health. Each participant affixed the strip inside the corresponding cloud or in the intersection of the two clouds, forming a chart for better viewing. Based on this discussion, the participants coded and decoded the 36 generative themes which, through convergence, resulted in 12 themes: eight for health promotion and four for occupational health.
From there, the participants discussed that work conditions and interpersonal relationships are factors that affect the occupational health of teachers, as well as the work environment and lifestyle habits. They unveiled that practices that enable health promotion may offer many benefits that would improve their quality of life.
In this culture circle, they coded and decoded that having a balance between work and personal life, not taking work home, forming mutual help and knowledge sharing groups in the workplace, reducing ill-effects through escape valves in the form of leisure activities to avoid stress, being prepared emotionally and having good social relations for good interpersonal relationships and eating healthily are practices for health promotion in the work of teachers. The culture circles promote dialogue among participants in the group, which enables and improves interpersonal relationships and draws people together and unites them, as can be seen in the testimonies of the participants. The fourth culture circle, held on June 13, 2018, in which 11 people participated, carried on with the discussion of the themes coded and decoded in the last culture circle. There was a larger time interval between the third and fourth circles because the scheduled date was postponed due to a national truckers' strike. In this culture circle, the participants randomly selected the themes that had been chosen in the codification and decodification and were encouraged to talk and dialogue in a big group, highlighting practices that promote the occupational health of teachers. The fifth and last culture cycle occurred on June 26, 2018, with seven teachers attending. The goal was to assess the work done, particularly the contributions of the health promotion-related themes to occupational health. This meeting focused on critical unveiling, through the action-reflection-action process and 7 of Paulo Freire's research itinerary: contributions for promoting health in the teaching profession Antonini FO, Heideman ITSB.
becoming aware of the reality lived, during which the teachers understood and promoted their health within the school context. They highlighted practices for promoting their health and indicated further actions to be carried out based on the group's discussions. The research method used was also assessed. There was time of reflection on the coded and decoded generative themes that arose from the culture circles. This occurred through an action-reflection-action process and becoming aware of the reality lived, so that, finally, the teachers could understand and promote their health within the school context.
The critical unveiling of the themes investigated revealed to the participants the relationship between occupational health and health promotion in the school context. They also identified that they can modify their reality with actions that enable improving their work conditions and environment, as well as interpersonal relationships at work and lifestyle habits. They also discovered that they can and should be allowed to engage in health promotion practices, both at work and in their personal lives, and that these actions should contribute to their occupational health and improved quality of life.
In summary, this was the goal of the last culture circle, but assessments were also performed during the other culture circles, when the participants expressed their opinions on the work done and suggested contributions for implementing them.
Perhaps repeating this work weekly or monthly, putting together a program for all the teachers, open to the community, would be good useful. (Bread) Paulo Freire's research itinerary allowed the participants to discover that they can and should be allowed to engage in health promotion practices, in both the work environment and in their personal lives. Such actions contribute to occupational health and thereby achieve the objective of this study.

DISCUSSION
As a methodology for working with collective bodies, culture circles are new and have been implemented in various contexts, based on Paulo Freire's theoretical and methodological framework. This method is linked to participatory action research, affiliated with the ideas of education, freedom and transformation of individuals and the environment in which they live. Rounds of conversation are considered to a liberating political strategy which is conducive to the human, political and social emancipation of collective bodies. The core objective of the critical pedagogy of the educator Paulo Freire is to contribute to the epistemological, theoretical and methodological foundation of the culture circles, enabling them to be more effectively harnessed for carrying out research (14) .
Sharing of knowledge and experiences of the reality in question helps unveil the complex relationships among the dynamics in health and disease processes and are able to capture these dynamics or deepen the dialogue with people (17) .
The action-reflection-action process equips people to understand the importance of concrete action for confronting contradictions and becoming aware of an existential situation, wherein the limits and possibilities of the reality that need to be transformed are discovered. Critical unveiling occurs when, upon perceiving the transformation process proposed by the circles, the participants undergo a process of metamorphosis, being transmuted into part of the experience lived by the collective body (6) .
A joint assessment is suggested, between the mediator and participants, of the lived experience and the transformations noted by them after completing Paulo Freire's research itinerary (6) .
One of the potential aspects, in particular, is the use of this research methodology for creating the possibility of dialogue and reflection among participants in culture circles. Paulo Freire's research itinerary promotes coordination between academic interests and the intervention in the study population, enables evaluating and reflecting on the lived reality and, through this, participants are able to gain awareness of the existential situation, and suggest and put into practice possibilities for transforming their reality, as is the intention of the method (6,(9)(10)(11) .
This method creates meeting places between people, breaking with hierarchical barriers, democratizing health knowledge and giving value to the day-to-day and ways of thinking of groups and collective bodies. Participants end up recognizing themselves in the group and through dialogue, share their anxieties and feelings, in a constant movement of action-reflection-action, share experiences and mobilize knowledge in the quest to transform their reality, thereby generating a social impact (6,(9)(10)(11) .
The experiences lived in culture circles are essential for knowledge sharing relations and open up infinite possibilities for interaction and maintenance of interpersonal relationships, a point underscored by the participants in this study (8) .
Paulo Freire's research itinerary, as participatory action research, contributes to self-knowledge and reflection, resulting in significant changes in the participants involved (6) .
Therefore, it can be inferred that the method permits interventions for promoting people's health and was considered a group therapy by the participants in this study. They underlined the relevance of culture circles, since they offer enrichment through theoretical content and encourage a process that seeks transformation and will have positive results on health practices (8) .
The participants considered that the Freirean research method can be a way to promote health, since Freire's concepts which lead to the emancipation, liberation and autonomy of individuals, when applied, transform people (12) .
Actions based on popular education -a theoretical and methodological premise systematized by Paulo Freire -has been an inspiration for many social practices that teachers, students and of Paulo Freire's research itinerary: contributions for promoting health in the teaching profession Antonini FO, Heideman ITSB.
intellectuals attempt to implement in their works. Participants take on active roles, through dialogue, share experiences and build collective knowledge, seeking empowerment, expanding the concept of health and producing different forms of care in health (18) . The National Health Promotion Policy emphasizes the need to produce and disseminate experiences, knowledge and evidence that support decision-making, autonomy, collective empowerment and shared construction of health promotion actions. The action research method, based on Paulo Freire's research itinerary, provides an ideal means for achieving this objective. It can be viewed as a methodological contribution for an emancipatory approach to health promotion (17) .
In this study, which reveals the precariousness, devaluing, suffering and illness of teachers within the context of the teaching profession, the search to comprehend autonomy in teaching is related to forms of teacher-centered care. The relationship between autonomy and care permeates aspects of teachers' health and teaching work. It can also serve as an axis for interdisciplinarity in their health care and is crucial for discussions about a care culture and the health of teaching staff. A teacher care culture is necessary in the field of education and the issue of autonomy could contribute to steps being taken to make it a reality. This can be achieved through discussions that problematize teaching work and teacher training, in addition to the comprehensiveness and interdisciplinarity of teacher care (19) .
The participants suggested that this project should be continued and extended to other professionals in the teaching community, since it can help improve the quality of life of all those involved.
It is hoped that the participants in this study will be encouraged to reflect on their practices and be able to incorporate the themes addressed in the culture circle into their daily lives.

Limitations of the study
The limitations of this study, since it was participatory in nature, are related to the time factor, among other factors. The participants commented that it was difficult to get the teachers together for the culture circles, due to the characteristics of teaching activities. Another issue was the limited number of current studies on the theme of health promotion in the teaching profession. Finally, there was the restriction of the study location, which was carried out on only one campus of the institution and not on others due to the operationalization cost of doing culture circles.

Contributions to the field of nursing, health or public policy
The results of this study demonstrate that Paulo Freire's research itinerary can enable health promotion interventions and that it is an alternative methodology for studies in nursing and the field of health. It also contributed to the knowledge of practices in order to promote the occupational health of teachers.

FINAL CONSIDERATIONS
The use of Paulo Freire's research itinerary, through dialogical actions that constitute the culture circles, enabled the teachers participating in this study to understand how the health promotion practices of teachers from an institution in the Federal Network of Professional, Scientific and Technological Education of the South of Brazil contribute to their occupational health.
In this study, Paulo Freire's methodology was beneficial, and the reflections of the participants led them to new action proposals for health promotion in the teaching profession. It also made dialogue possible between the researcher and study participants, which investigated the themes, unveiled the lived reality, which is the intent of the methodology, and enabled the participants to maintain or initiate new practices.
Freire's theoretical framework provides a possibility to promote health, especially when it is a framework that contributes to practical knowledge construction and encourages participants to change their reality in an emancipatory and liberating way, in the search for autonomy, which reinforces Freire's concepts.
The experiences in the culture circles were essential for sharing knowledge and experiences, providing infinite possibilities for interaction and maintenance of interpersonal relationships.
For researchers, the challenge of participatory research is that the researcher is also a party being investigated and needs to be part of the whole action-reflection-action process. It is research with and not about, which requires an open attitude and constant adaptation to the needs of the group, without losing the focus of the study.
It is recommended to conduct further studies related to the theme that was investigated, since they help enable significant change, especially at the collective level, in the way people relate to work. It is important that there be more studies that publicize the possibility of using this itinerary as a methodological tool in various fields of knowledge.