Telling stories, caring for life: narrative-based health education

Abstract

The use of stories in health education is not new and is basically meant to disseminate information and influence behaviors and habits focused on clinical results such as blood glucose control. Based on the criticisms to the limited ways in which stories have been explored in terms of the purposes they have served, it is therefore proposed that new narrative approaches be incorporated into health education, within the scope of critical pedagogical processes. References are made to Paulo Freire’s Critical Pedagogy and the ontological approach to the narrative developed by thinker Paul Ricoeur as a possibility of acquiring self-knowledge in the relationship with others. Considering that narrative texts express ways of understanding the world, the “world of the text”, then its existential meaning is highlighted, giving rise to the construction and reconstruction of diverse ways of being-in-the-world. Language plays a prominent role in this understanding of the text-world by the reader-student, who may agree or disagree with the plots, empathize or not with the characters, conform to the situations presented or find them strange. Narratives may end up problematizing the course of the storylines presented, as well as reconfiguring the stories, the others’ and their own, favoring reflections on vulnerabilities and potentialities in health care.

Keywords:
Health education; Narratives; Critical pedagogy

Resumo

O emprego de histórias na educação em saúde não é novo, servindo basicamente para disseminar informações e influenciar comportamentos e hábitos, com foco em resultados clínicos, como o controle dos níveis de glicose no sangue. Da crítica às limitações do modo como têm sido exploradas quanto às finalidades a que têm servido, propõe-se incorporar abordagens narrativas na educação em saúde, no âmbito de processos pedagógicos críticos. Tomaram-se como referências a Pedagogia Crítica de Paulo Freire e a apreensão ontológica do pensador Paul Ricoeur acerca da narrativa, como possibilidade de conhecimento de si na relação com o outro. Considerando que o texto narrativo expressa uma apreensão de mundo, o mundo do texto, ressalta-se seu sentido existencial, ensejando a construção e a reconstrução de modos de ser-no-mundo. A linguagem assume papel de destaque para essa compreensão do mundo-texto pelo leitor-educando, que pode concordar ou discordar com os enredos, simpatizar ou não com os personagens, conformar-se ou estranhar as situações. As narrativas podem incitar a problematização do curso das tramas apresentadas e a reconfiguração das histórias e de suas próprias histórias, em suma, estimulando reflexões sobre vulnerabilidades e potencialidades no cuidado à saúde.

Palavras-chave:
Educação em saúde; Narrativas; Pedagogia crítica

Introduction

The different pedagogical approaches that instruct health education practices express, although not explicitly or consciously, adherence to diverse epistemological, political, and ethical horizons (Bordenave, 1983; Becker, 2001; Silva, 2010).

Under different nuances, from more prescriptive to more dialogical models, those centered on the transmission of information and/or in the change of people's behavior have prevailed and, at times, adherence to prescriptions is seen as a simple act of the individuals’ will, being poorly responsive to other dimensions of care such as social contexts, personal and community experiences, and even the resources available to enable health care.

Based on this perspective, the purposes of health education are quite well defined by health professionals, whether aiming at promoting lifestyle changes among people, like changing their eating habits or achieving results that are in line with laboratory parameters. The range of means to achieve this type of purpose is quite comprehensive and includes everything from traditional educational booklets to technological resources such as the use of applications.

Among these resources, some initiatives have been focused on using narratives to mediate educational interventions, mainly in approaches for treating cancer, diabetes and hypertension, and studies on this subject seek to validate the use of narratives by proving their clinical and/or behavioral effects obtained through strategies such as randomized clinical trials (Lipsey; Waterman; Balliet, 2020).

Following this line of thought, the Centers for Disease Control and Prevention - CDC, USA (CDC, 2017) created photo-comics, including a bilingual publication (Spanish/English) in which the characters in the stories teach lessons to be followed, but they can also serve as warning and encouragement strategies for readers to adopt healthy lifestyles, highlighting the moral nature underlying them.

One of the justifications for this type of initiative is that photo-comics, given the fact that they are part of the Latin American popular culture, are an important vehicle for promoting healthy behaviors thanks to their strong emotional appeal (Goddu; Raffel; Peek, 2015; CDC, 2013).

When it comes to people living with diabetes, the success of interventions that make use of storylines has been evaluated based on glycemic control - that is, the type of strategy changes, for example, going from educational booklets to the use of narratives, but the objectives pursued remain the same.

Despite this instant and pragmatic approach presented by narratives in health education, anticipating results and prescribing habits and behaviors, it is worth pointing out that the use of stories in the health area has also been explored in other ways, that is, with more reflective goals, as in the case of Narrative Medicine.

In the sphere of the so-called Medical Humanities, Narrative Medicine is mainly focused on the education and training of doctors, aiming to develop narrative skills that allow them to strengthen their relationship with patients and their families using a more humanized and clinically more effective perspective (Fernandes, 2014).

The researcher who is considered the creator of this Narrative Medicine approach, Rita Charon, proposed a method that includes both attentive reading/listening and creative writing, thus relying on literary theory, philosophy, narrative ethics and creative arts. The author assumes that the readers’ ability to “immerse” themselves in stories as well as their ability to (re)create stories can help professionals improve their practices, causing them to support patients experiencing illnesses, thus going beyond diagnosis and treatment (Charon, 2016).

Following a similar type of logic, the perhaps less publicized proposal supported by Narrative Pedagogy stands out, which appears as a new pedagogical approach to nurse training focused on the process of learning and practicing interpretative thinking and it is based on Gadamer's hermeneutics and the pedagogy developed by Paulo Freire, the Brazilian educator (Ironside, 2006).

Alongside these proposals, it is worth mentioning the one that focuses on the therapeutic nature of narratives related to illness experiences as a way of processing the pain and wounds they cause in people's lives, assuming that each wound results in a story (Frank, 1995).

Inspired by these initiatives and seeking alternatives to the instant and pragmatic approaches traditionally found in health education narratives, we intend to discuss the possibilities of incorporating storytelling into pedagogical processes aimed at patients as a means of encouraging reflections about healthcare and, in the sphere of critical pedagogy, we aim to promote the identification and problematization of situations that undermine this care and propose ways to overcome them.

Considering that the stories found in health education have been criticized due to their limiting and merely pragmatic perspective, we took as references the approaches used by thinker Paulo Freire, guiding the critical horizons and pedagogical path, and by philosopher Paul Ricoeur, who sees narratives as a way of orienting ourselves in the world.

Diabetes education was chosen as the guiding principle of the investigation given the characteristics of its pedagogical approaches, which follow predominantly traditional proposals aimed at changing habits and consequently reducing glycemic levels in people with diabetes. (McBain et al., 2016; O’Donnell et al., 2018; Lamanna et al., 2019; Caro-Bautista et al., 2020; Vitale et al., 2020).

At the same time, it is worth noting that the field of diabetes education, although dominated by a biomedical logic oriented by lab results based on reference values or behavioral changes, has also incorporated important initiatives that, when associated with other theoretical perspectives, lead to other ways of thinking and acting in this field. (Funnel et al., 1991; Anderson; Funnel, 2005; Cyrino; Schraiber; Teixeira, 2009).

This type of openness in the field of diabetes education allows us to think about other pedagogical arrangements aimed at using narratives, in which the stories would not be limited to the self-reflection of professionals or patients, individually, but as a Care-based approach, that is, mediating their encounters. Considering these expectations and thinking about the functionality of such a proposal, we contemplate the idea of turning to narratives that, although they may be fictional, contain elements that can express the contexts and vulnerabilities relating to the care of those living with diabetes more directly.

Critical and problematizing pedagogy and the recognition of vulnerabilities in health Care

The proposal of an alternative approach to the traditional diabetes education model underlies the intention of placing it within the scope of an ethical and political project that criticizes the limiting approaches aimed at formulating and applying a set of techniques whose purposes are not recognized or prove to be worthless to their recipients.

It is assumed that knowledge production and health education practices are committed to ethical, political and epistemological stances that can be found in a gradient that ranges, roughly speaking, between those alienated from social reality, such as those focused exclusively on the dissemination of information about diseases (non-critical pedagogies), and those capable of analyzing social contexts, using their criticism as substrates for the necessary changes (critical pedagogies) (Monteiro; Donato, 2012).

By advocating for a critical pedagogy in diabetes education, the aim is to seek ways to promote approaches that allow for the recognition of obstacles to health care and ways to overcome them; sometimes, this recognition is hindered by certain prescriptive ways of living, subsumed for example, to the control of laboratory test results. More than that, such control can lead to an attempt to control those patients, whose experiences, struggles, fears and potential initiatives are seen as secondary or even ignored by healthcare services and professionals (Broom; Whittaker, 2004).

Education based on critical pedagogy aims to facilitate the understanding of reality, which is perceived as something unfinished and subject to change. This understanding occurs through the problematization process to be developed by the students themselves, based on the observation of social reality in its dynamism and complexity (Berbel, 1998).

One of the most important contributions found in this approach takes us to the proposals of the Brazilian educator Paulo Freire, for whom education, in addition to being aimed at content learning - ​​generally reproducing social reality - should also be concerned with the critical analysis of reality, thus carrying the political and emancipatory potential to bring about changes in this reality (Freire, 2016).

In short, the criticism against verticalized pedagogical models or those that offer restricted participation alludes to Freire's lessons, among which the following can be highlighted: 1) knowledge is not “transmitted”: it is the product of a joint construction that involves different types of knowledge and players; 2) “everyone knows”, not just technicians or experts; 3) students are active participants in the knowledge process, based on their concrete experiences (Freire, 2001).

When it comes to diabetes education, such an aspiration would mean that the desired critical pedagogical process would aim to recognize potentialities and vulnerabilities in the health care of people living with diabetes. Such recognition does not concern a mere process of identifying conditions that hinder or prevent care based on pre-established criteria or those “external” to these people’s experiences.

To understand the particularities of those living with diabetes, both in terms of the disease itself and its care, we must delve into the intimacy of their experiences. Such a diagnosis can represent a disruption in the individuals’ life and, sometimes, in their own identity, leading them to deny it, especially if they are asymptomatic. In turn, the discomfort caused by both symptoms and impositions related to self-care, which include controlled diets, physical exercise, glucose monitoring and insulin injections, can also be considered problematic (Cyrino, 2009).

Such situations, although common, cannot be generalized. Experiences cannot be captured as something pre-set, that is, just waiting to be discovered either by patients or health professionals. Understanding the intimate aspect of experiences and the vulnerabilities found in health care is a complex endeavor as it requires a process of interpreting factors that may be problematic, at that moment, for those individuals, in those circumstances.

In the field of diabetes education, although not directly addressing the narratives, the work of Cyrino (2009) stands out, who, based on the criticism against the knowledge-behavior binomial focused on skills aimed at self-care, articulating Freire’s pedagogical proposal anchored in the problem-knowledge-action process. Such initiatives strengthen the possibilities for innovation in this field as an “ethical, technical and epistemological issue [guiding the search] for another way of articulating communication and health practices” (p. 215).

The contexts that weaken healthcare and the chances for overcoming them are intersubjectively outlined, within which practical meanings of experiences prevail - on the one hand, the values, fears, perceptions that threaten health, and on the other, the horizons that show expectations and action possibilities for individuals and communities.

Just as the recognition of vulnerabilities in health care is an interpretative procedure, care itself, as discussed here, also implies a process of understanding that involves different experiences, types of knowledge and know-how guided by the sense of good life.

Confronting the exclusive focus on medical and drug treatment, this approach problematizes the central role given to pathophysiological control in health care aimed at people with diabetes, mediated by blood glucose monitoring. In contrast, it seeks to expand its purposes to practices that productively and creatively integrate this perspective of technical achievement into the real possibilities of its practical success, that is, focusing on the “meanings attributed to needs and demands for care, according to the experiences lived by individuals and population groups” (Ayres, 2014, p. 17).

Within the scope of a type of healthcare actively interested in the practical success of its actions, designated here by the concept of Care (Ayres, 2009), the dynamic nature of the experiences lived by individuals and population groups is reinforced, since not only their senses, but also their own experiences are shaped and reshaped in time, thus shaping and reshaping, in turn, positions and actions aimed at themselves and the world. Not chronological time (Chronos), but the time lived (Kairós) (Ricoeur, 2019).

The role of the narratives emerges from the importance of the Care-based experience and from recognizing the vulnerabilities that affect it, thus arising as a possible path for the practice of critical pedagogy.

Narratives as paths for Care

As it was not possible to exhaustively grasp Ricoeur's complex and dense production, some aspects of the author's books and texts were highlighted, in addition to some inputs made by his commentators, thus helping us understand how narratives could serve as a link for developing a pedagogical practice anchored in the assumptions of Freirean pedagogy.

The horizons that guide Ricoeur's work point to the possibilities available for human beings, which includes endeavors and achievements as well as struggles, afflictions and obstacles to their existence. Therefore, this thinker's question, considering the human effort to exist, is the following: “what can I expect, despite my insurmountable finitude, despite the evil and tragedy of the human condition?” (Grondin, 2015, p. 13). Ricoeur responds to this type of question with hope, opening himself up to the unprecedented nature of human initiative, using a line of thought marked by dialogue and confrontation between ideas.

The author highlights four “basic” activities present in all human life, namely: the abilities to speak, to act, to tell their story and to be morally attributable (Ricoeur, 1991). Such capabilities are based on the assumptions of freedom and that humans navigate the world using the essential act of interpreting. Based on the subjects who interpret the world and interpret themselves and others through the unfolding of their existence in the world, Ricoeur takes hold of hermeneutics from a philosophical perspective, which leads to:

[...] a rational and reflective listening of narratives and approaches that recognize a meaning and a direction to the human effort in order to exist. Humans are beings who “can” interpret their world and interpret themselves. (Grondin, 2015, p. 15).

The interpretation of the world, of oneself and the others offers a glimpse into the necessary conditions for a fulfilled life, a good life, thus being able to answer the question related to meaning, which is essential, as pointed out above, to the notion of Care.

Transitioning from structural analysis to a hermeneutic approach to language, Ricoeur highlights that the meaning constructed and put into practice in any narrative can only be adequately understood if we consider the referent that supports the relationships between its signifiers and meanings in its textuality and its application, or appropriation, by whoever interprets it. Therefore, the concepts of world of the text and world of the reader are essential in Ricoeur's hermeneutics. Such notions indicate “spaces” and “temporalities” that allow exploring both the text and its “effects” on the reader. The idea that the text projects a “world”, the world of the text (Ricoeur, 2001), gives the dimension of consubstantiality between the narrative text and human existence. On the other hand, the ability to understand a text, written or spoken, means not only the intelligibility of its formal structure, but a sense of sharing resulting from the possible dialogue between the world of the text, created by the narrative developed there, and the world of the reader, or what Gadamer (2004) will call “fusion of horizons”.

Such consubstantiality raises the condition of the text, going from a mere instrument for predetermined purposes to another level, that is, a way of apprehending human existence itself. In other words, this would mean rejecting the use of stories to influence behavior, in favor of using stories as a way of “providing food for thought” and creating the opportunity to decide what to do and how to do it (Ricoeur, 2011).

When dealing with the dialectic between the text and its reader, Ricoeur (2019) criticizes a certain typology constructed by a rhetorical approach to this relationship, which reduces the author's implication and its effects on the reader to two polar positions: that of the manipulated reader, “seduced and perverted by the narrator” and that of “the reader terrified by the decree of predestination of their own reading”. Alternatively, Ricoeur rejects this determination encased in textuality and defends, in line with Gadamer, the perspective of an infinite openness of the text, a relative freedom of the text in its “disturbing indeterminacy”.

[...] at the same moment that the text seems to close itself up upon the reader in a terrorist act, by splitting its recipients in two it reopens a play space that re-reading can turn into a space of freedom. (p. 284).

This openness lies in the transition from a rhetoric of reading to an aesthetics of reading, in the sense of Greek aisthesis, as the multiple ways in which a work affects the readers are explored, while interacting with them. The combination between passivity and activity leads to a particular experience in which the reception of the text coincides with the very action of reading it.

Taking the hermeneutics of literary works as a paradigmatic situation, Ricoeur (2019) distinguishes the first reading (innocent reading) from a reading at a distance (accomplished in the act of rereading). The first reading provides the primary understanding of the text, which corresponds to the reception of the work, mediating the horizon of expectations of the past and the horizon of expectations of the present, that is, a perceptual reception. The act of rereading, on the other hand, “gives rise to expectations of meaning that are not satisfied, which reading reinscribes within the logic of question and answer” (p. 301), focusing on the questions left open after the first reading (what were the questions of which the work was the answer?), resulting in the disadvantage of providing only one interpretation, among others. “Expectations are open, but more undetermined; questions are determined, but more closed-in upon themselves” (p. 301). The third reading aims to elucidate the partiality of the second reading, asking “what does the text say to me and what do I say to the text?” (p. 301), how does it challenge me?

Here, the idea of application, or appropriation, reveals itself more clearly as the process of reconfiguring stories, in the way they affect us, transporting us to other times and places where we experience things differently, giving rise to the release of emotions in the here and now of the act of reading, like an emotional discharge caused by the dramatic situation of the narrative. Such a process would correspond to the Aristotelian notion of katharsis, originating in Ancient Greece and taken as the awakening of pity and fear which would result in a state of purification or purgation. Ricoeur (2019) also adds to katharsis the sense of clarification, elucidation, which would produce the effect of setting the reader

[...] free for new evaluations of reality that will take shape in re-reading [...] [starting] a process of transposition, one that is not only affective but cognitive as well, something like allegorese [...]. Allegorization occurs whenever we attempt to translate the meaning of a text from its first context into another context, which amounts to saying: to give it a new signification which goes beyond the horizon of meaning delimited by the intentionality of the text in its original context. (p. 304).

In analogy to the feelings of fear or pity aroused by the tragic katharsis, Ricoeur focuses on the effects of the reader's reception of the work as a process of identification, within the scope of what was called the economy of affection (Ricoeur, 2019).

Ricoeur (2006), therefore, treats the idea of text not as an entity closed in on itself, but as the projection of a new universe different from the one where we live. For him, it makes no sense to distinguish between the “inside” and the “outside” of the text:

Appropriating a work through reading it is to unfold the implicit horizon of the world which embraces the action, the characters, and the events of the story told. The result is that the reader belongs to both the experiential horizon of the work imaginatively, and the horizon of his action concretely. The awaited horizon and the experiential horizon meet and fuse without ceasing. In this sense, Gadamer speaks of the "fusions of horizons", essential to the act of understanding a text. (p. 15).

Thus, we speak of a literary experience in which the text is a mediation between oneself and the world, between oneself and the other, between oneself and him/herself, a mediation corresponding to referentiality, communicability and self-understanding, respectively. The author also says that the hermeneutic problem begins where linguistics stops, that is, uncovering in the literary work traits of non-descriptive reference, non-utilitarian communication and non-narcissistic reflexivity. Hermeneutics would be the hinge between the (internal) configuration of a work and the (external) refiguration of life (Ricoeur, 2006).

The fragility of the link between two ontologically distinct worlds, the “imaginary world of the text and the actual world of readers”, highlights the paradox that “the more readers become unfulfilled in reading, the more profound and far-reaching will be the work’s influence on their social reality”. The author concludes: “Is it not the least figurative style of painting that has the greatest chance of changing our vision of the world?” (Ricoeur, 2019, p. 309).

The more one delves into Ricoeur's work, the more one is led to move away from any merely instrumental intention regarding the narratives applied to health actions, as the focus is placed on the comprehensive dimension of the reading process, which escapes to any possibility of an a priori closure of meaning. And it is from this very perspective of openness of meaning that the relationship between narrative and Care, including health education, is perceived.

According to Ayres (2004; 2014), the idea of Care can be understood in contrast to that of treatment due to the distinct way in which the two inseparable poles of all healthcare practice are articulated: practical success and technical achievement. Treatment, as traditionally understood, designates technical interventions focused on purposes that have been well established and generally validated by both health professionals, patients and the population, which include: losing weight, controlling cholesterol, correcting a deviated nasal septum, etc. - purposes dependent on an arsenal of knowledge taken from biomedical sciences, diagnosis and treatment technologies, as well as means that can “measure” the achievement of pre-established purposes. The practical pole is here unduly subsumed to the technical dimension, as if technologies could be universal and timeless (Mendes-Gonçalves, 2017), as if the combination of purposes and certain techniques could guarantee their final purpose of promoting health or controlling illness.

In turn, the (technical and ethical) proposal developed by the Care framework aims to rescue the practical dimension of health actions, that is, to look for the concrete possibilities of any technical intervention to respond to the legitimate aspirations of the subjects faced by the sense of illness and find ways to help them deal with it in their daily life. With the conceptual framework of Care, the practical-moral dimension involved in health care is highlighted, allowed by the encounter between subjects, from which the triggered knowledge (technical and non-technical) and actions can be agreed upon and put into practice.

Based on this concern of moving away from unilaterally defined purposes and following the Ricoeurian line of thought, the reader's encounter with the text, within the scope of its application in the field of health, deserves to be apprehended and developed on foundations that go beyond the traditional prescriptive vocation of health education and the type of objective (product) it has pursued, based on a strict scope of technical achievements. The type of purpose aimed at diabetes education is associated here with that which sees health assistance as Care, targeting the health experiences of individuals and groups dynamically inserted in multiple contexts and lifestyles (Ayres, 2004). It is believed that the narratives, both those produced by these individuals and groups and those received by them in our educational actions, can provide both the expression of their singularities and interests and the recognition of material and existential obstacles to good living, as well as the possibilities to respond to these obstacles.

By localizing diabetes education in the field of Care, the role of narratives in pedagogical practices is also repositioned, as a merely instrumental and moralizing use of them is rejected, thus reinforcing their intersubjective character. In these terms, the use of narratives would provide a reflective and critical examination of the obstacles to health care by raising questions about the subjects involved and the meanings of their life stories and experiences of living with diabetes.

Narrating experiences is like building a mosaic of existence; The pieces can be arranged in different ways, leading to the creation of a work made up of multiple colors, sizes, shapes and arrangements. Narratives frame experiences, but do not imprison them. Thus, they can be configured and told in different ways, for example, the experience of being diagnosed with diabetes can be a traumatic event, with deleterious consequences for life. But it can also be seen as a positive event, as an organizing element of life: “a trauma that brought early discipline and responsibility” (Villas-Boas, 2015, p. 27). Experiences expand knowledge about oneself and the disease and, consequently, about ways of dealing with the different situations imposed by diabetes.

Following this line of thought, Cyrino (2009) evokes the valorization of knowledge acquired from the experience of those living with diabetes, not as a way of opposing technical-scientific knowledge, nor to examine the patients' perceptions on the illness individually. The author sees the knowledge derived from experience as bridges that can strengthen the dialogue between expert subjects and patient subjects, exploring other possibilities of recognizing, providing and sharing this knowledge based on a self-reflective examination.

Narratives, as a way of configuring experiences, favor this critical and reflective examination of self-knowledge through a process of interpretation. Ricoeur develops this process of self-understanding through narrative in terms of the narrative identity, the destination of the proposed theoretical-conceptual framework and the main “effect” that the text could provide to the reader-student.

It starts with the premise that, even if we are not the direct authors of the stories we read, we can “apply to ourselves the stories we receive from our culture and, thus, experience the different roles assumed by our favorite characters in the stories we appreciate”. (Ricoeur, 2006, p. 22).

Ricoeur (2019) clarifies that the term identity is taken as a practical category, in the sense that “talking about the identity of an individual or a community is answering the question: who did such an action? Who is its agent, its author?” (p. 418). When designating the subject of the action through a proper name, a question about the permanence of this subject throughout his or her life arises. As this question can only be answered by localizing the action in time, space and within the scope of a plot (a meaning for the action) that involves other settings and characters, this who identity is substantively narrative.

The Ricoeurian construct of narrative identity is especially interesting for reflecting on the use of narratives in prevention and care related to conditions such as diabetes. The emergence of a narrative identity provided by and through the encounter between a text and its reader is a reflective process, combining learning and innovation.

On the one hand, the “fate”, “destiny” and actions of the characters in the texts can be accepted within the limits of a substantialized or formal identity, such as “the diabetic”, leading to a process of self-identification, self-reproduction, where he/she is seen as self-identical, substantialized and immutable over time, a process that Ricoeur calls idem-identity. Such a situation can lead to and crystallize feelings such as guilt due to a lack of control over food or behaviors such as social isolation, to avoid events where the snacks available are restricted to “non-diabetic individuals”. On the other hand, these ideas of “fate”, “destiny” and actions can be thematized, questioned and compared with the reader's ways of life, giving rise to the dynamic construction of the “self”, related to the ipse-identity. The ipse-identity belongs to the action domain, assuming, as previously seen, an agent - author, actor and reader. An interactive game of actions takes shape, which encourages unfamiliarity, problematization and the possibilities of reconfiguring stories, a moment in which “reading becomes a provocation to be and act differently” (Ricoeur, 2019, p. 423). The list of “experiential knowledge” enunciated by Cyrino (2019) and based on testimonies from people with diabetes show examples of actions to be taken in the face of problematic issues such as knowing how to share the restrictions of this condition with friends instead of relying on isolation and feelings of victimization.

The author points out that the narrative, although considered a category of action, may involve an exercise of imagination, more than of will (estase). But reading can also be a moment of allusion, “when reading becomes a provocation to be and act differently” (p. 423). This allusion only turns into action through a decision, highlighting ethical responsibility as the supreme factor of ipseity.

The ethical intentionality underlying the narrative identity coincides with the search for a fulfilled life, which the author aligns with the horizon of a good life with and for others in fair institutions (Ricoeur, 2006, p. 176). Based on this understanding, the intrinsically interactive nature of narratives stands out, as it regulates the horizon of the good life and shapes the notion of an ethical and political subject, in terms of Aristotelian phronesis, as an expression of practical wisdom capable of considering the universality of values focused on human actions and, at the same time, the uniqueness of situations. Just as telling stories is not a neutral action, every narrated action involves some type of judgment from the readers.

The story is not confined solely to the mind of its author (the romantic fallacy of the primacy of the author's original intentions). Nor is it confined to the mind of its reader. Nor to the narrated actions of its actors. The story exists in the interactive game between them all [...]. For this reason, the narrative is an open invitation to ethical and poetic responsiveness. (Kearney, 2012, p. 429).

In the horizon of the good life, not restricted to technical achievements, narratives can encourage self-understanding as a reconfiguration of the storyline and people’s own stories in the health education process.

Convergences between “Pauls”, by way of conclusion

Without intending to examine the convergences between the works of Paulo Freire and Paul Ricoeur, the similarities set out in this study aim solely to highlight the possibilities of promoting health education based on critical pedagogy, through narratives.

Even considering the possible distinctions regarding the epistemological bases that guide each of the proposals, both authors share views on the ethical horizons focused on human possibilities, which include hope, dialogue, praxis, with emphasis on the ability to act and the sense of emancipation.

Although neither Freire nor Ricoeur directly approached the pedagogical role of narratives, the idea of reading the world draws attention, establishing a relationship between language and reality, placing the reading of the word as always preceded by the reading of the world and by its infinite openness to resignification.

[...] the reading of the word is not only preceded by the reading of the world, but by a certain way of “writing” or “rewriting” it, that is, of transforming it through our conscious practice. (Freire, 1989, p. 13).

By highlighting language in terms of understanding the world, the text reaches up to the level of the world - the world of the text, or the text of the world. This world can only be understood if it is read, and hence the importance of the act of reading, not as a mere literal translation of signs, but as an act of interpretation of this world. This interpretative process, whose readings create different possibilities of re-readings, implies an active relationship involving alterity and dialogism.

Narratives provide an opportunity for distancing from situations that are often incorporated into everyday life and not thematized to the extent that, upon entering the stories, student-readers can agree, disagree with the plots, empathize or not with the characters, thus providing reactions of conformity or strangeness in the face of situations, ultimately problematizing the courses of actions.

Narratives take on a mediating role, allowing a certain “application” of the text to life, however, not in the sense of simple transpositions of stories into life, but by creating other configurations through an interpretative process that highlights self-interpretation.

Under the critical pedagogical horizon, stories would not have the instrumental and moral nature of influencing behaviors or lifestyles - they would actually promote their problematization, within the limits of what the reader may recognize as obstacles to health, in a game between identities and alterities instigated by an interpretative process which can culminate in the reconfiguration of these stories.

We must not ignore the fact that, in the dispute between pedagogical approaches that reproduce hierarchical relationships of power and knowledge in health and those that seek more horizontal interactions, the primacy of technoscientific/biomedical rationality and its discourses of truth have tipped the balance in favor of the former. But from a critical perspective, our immaturity in incorporating other types of logic that deviate from the transmissional and vertical model that affects communications and health education (Teixeira, 1997) is also noteworthy. Popular health education, perhaps one of the most democratic and inclusive proposals in the field of health education has shown its potential but has also been the target of interpretations and practices merely disguised under its scope, being far from fully showing its source of participation and engagement.

Another trap or illusion that falls on critical pedagogical and communicational initiatives is that their implementation is eagerly awaited by their recipients, in theory, tired of being saturated with explanatory booklets and lectures that oscillate between technical jargon, which is difficult to understand for the non-specialized audience, and the use of communication that is often considered too childish for an adult audience. But it is important to consider that as much as health professionals were “socialized” into traditional pedagogical practices based on the transmission of content, so was the population. Breaking with this logic is not a simple matter, requiring more than the will of the subjects. How many times have we become impatient when faced with a problematizing approach? How many times have we preferred to be “Paulo Freire’s recipients”, that is, passive repositories of a “ready-made” knowledge, ultimately cultivating our alienation?

Therefore, by seeking other pedagogical alternatives for health education, we expect nothing but to contribute to valuing people's concrete experiences, as well as the projects that guide our ways of being and living in the world. Perhaps blood insulin levels will fail to reach the desired levels after choosing an intervention that uses this type of reference, but we hope that people can, for example, consciously decide whether to adhere to physical exercise programs based on an examination in which the sense of personal will is compared to other conditions that facilitate or hinder such practice. And that they can, if necessary, build strategies to raise personal and collective resources to claim their right to have a space for this practice in their neighborhood.

Seeking horizontal interaction between educators and students, promoting health actions within the framework of Care, thus integrating technical achievement and practical success, exploring narratives as a hermeneutic resource, thus abandoning instrumental pretensions in favor of reflective and dialogical potentials and, finally, radically assuming the ipse-identity of the subjects with whom we work in healthcare - that is, knowing that their character must be always reconstructed based on actions and intersubjectivity: these are all counterfactual proposals, utopic in the best sense of the term. It consists, therefore, of a learning process that daily puts us to the test when we encounter each co-worker, assist each health service user, and interact with each member of the community.¹

Referências

• ANDERSON, R. M., FUNNEL, M. M. Patient empowerment: Reflections on the challenge of fostering the adoption of a new paradigm. Patient Educ Couns., v. 57, n. 2, p. 153-157, 2005.
• AYRES, J. R. C. M. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde Soc., v. 3, n. 13, p. 16-29, 2004.
• AYRES, J. R. C. M. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: CEPESC; UERJ/IMS; ABRASCO, 2009. 284p.
• AYRES, J. R.C. M. Vulnerabilidade, Direitos Humanos e Cuidado: aportes conceituais. In: BARROS, S.; CAMPOS, P. F. DE S.; FERNANDES, J. J. S. (Eds.). Atenção à Saúde de Populações Vulneráveis. Barueri: Manole, 2014. p. 1-25.
• BECKER, F. Modelos Pedagógicos e Modelos Epistemológicos. Educação e Construção do Conhecimento. Porto Alegre: Artmed, 2001. p. 15-32.
• BERBEL, N. A. N. A problematização e a aprendizagem baseada em problemas: diferentes termos ou diferentes caminhos? Interface comum. saúde educ., v. 2, n. 2, p. 139-154, fev. 1998.
• BORDENAVE, J. E. D. La transferencia de tecnologia apropiada al pequeño agricultor. Revista Interamericana de Educação de Adultos, v.3, n. 1-2, p. 19-26, 1983.
• BROOM, D.; WHITTAKER A. Controlling diabetes, controlling diabetics: moral language in the management of diabetes type 2. Soc Sci Med, v. 58, n. 11, p. 2371-2382, 2004.
• CARO-BAUTISTA, J. et al. Impact of self-care programmes in type 2 diabetes mellitus population in primary health care: Systematic review and meta-analysis. J Clin Nurs, v. 29, n. 9-10, p. 1457-1476, 2020.
• CENTERS FOR DISEASE CONTROL AND PREVENTION. National Diabetes Education Program. NDEP Webinar Series. Atlanta: CDC, 2013. Disponível em: http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/diabetes/ndep/training-tech-assistance/webinars.html#socialMediaShareContainer Acesso em: 5 jan. 2022.
  » http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/diabetes/ndep/training-tech-assistance/webinars.html#socialMediaShareContainer
• CENTERS FOR DISEASE CONTROL AND PREVENTION. Do it for them! But for you too. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2017.
• CHARON, R. et al. The principles and practice of Narrative Medicine. Oxford, UK: Oxford University Press, 2016.
• CYRINO, A. P.; SCHRAIBER, L. B.; TEIXEIRA, R. R. Education for type 2 diabetes mellitus self-care: from compliance to empowerment. Interface comun. saúde educ., v. 13, n. 30, p. 93-106, 2009.
• CYRINO, A. P. Entre a ciência e a experiência. Uma cartografia do autocuidado no diabetes. São Paulo: Ed. UNESP, 2009.
• FERNANDES, I. A pertinência da Medicina Narrativa na prática clínica. Revista Portuguesa de Medicina Geral e Familiar, v. 5, n. 30, p. 289-290, out. 2014.
• FRANK, A. The wounded storyteller. Body, illness and ethics. Chicago: The University of Chicago Press, 1995.
• FREIRE, P. A importância do ato de ler: em três artigos que se completam. São Paulo: Autores Associados: Cortez, 1989.
• FREIRE, P. Pedagogia do oprimido. 62. ed. Rio de Janeiro: Paz e Terra, 2016.
• FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. 17 ed. São Paulo: Paz e Terra, 2001, 165p.
• FUNNEL, M. M. et al. Empowerment: An Idea Whose Time Has Come in Diabetes Education. Diabetes Educ., v. 17, n. 1, p. 37-41, 1991.
• GADAMER, H. G. Verdade e Método I: traços fundamentais de uma hermenêutica filosófica. 6 ed. Petrópolis: Vozes, 2004. 631p.
• GODDU, A. P.; RAFFEL, K. E.; PEEK, M. E. A story of change: The influence of narrative on African-Americans with diabetes. Patient Educ Couns, v. 98, n. 8, p. 1017-1024, 2015.
• GRONDIN, J. Paul Ricoeur. São Paulo: Edições Loyola, 2015.
• IRONSIDE, P. M. Using narrative pedagogy: learning and practising interpretive thinking. J Adv Nurs, v. 55, n. 4, p. 478-486, 2006.
• KEARNEY, R. Narrativa. Educ. Real. v. 37, n.2, p. 409-438, 2012.
• LAMANNA, J. et al. Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature. Diabetes Educ, v. 45, n. 4, p. 349-369, 2019.
• LIPSEY, A. F.; WATERMAN, A. D.; WOOD, E. H.; BALLIET, W. Evaluation of first-person storytelling on changing health-related attitudes, knowledge, behaviors, and outcomes: A scoping review. Patient Educ Couns, v. 103, n. 10, p. 1922-1934, 2020.
• MCBAIN, H. et al. Self-management interventions for type 2 diabetes in adult people with severe mental illness. Cochrane Database Syst Rev, v. 4, 2016.
• MENDES-GONÇALVES, R. B. Práticas de saúde e tecnologia: contribuição para a reflexão teórica. In: MENDES-GONÇALVES, R. B.; AYRES, J. R. C. M.; SANTOS, L. (Orgs.). Saúde, sociedade e história. São Paulo: Hucitec; Porto Alegre: Rede Unida, 2017, p. 192-250.
• MONTEIRO, P. H. N.; DONATO, A. F. Contribuições teórico-práticas do campo da educação para as ações de prevenção em DST/AIDS. In: PAIVA, V.; PUPO, L. R.; SEFFNER, F. (Eds.). Vulnerabilidade e direitos humanos - prevenção e promoção da saúde: pluralidade e vozes e inovação de práticas. Curitiba: Juruá, 2012. p. 77-111.
• O'DONNELL, M. et al. Assessing the effectiveness of a goal-setting session as part of a structured group self-management education programme for people with type 2 diabetes. Patient Educ Couns, v. 101, n. 12, p. 2125-2133, 2018.
• RICOEUR, P. O si mesmo como um outro. Campinas: Papirus, 1991.
• RICOEUR, P. Del texto a la acción. Ensayos de hermenéutica II. Mexico: Fondo de Cultura Económico, 2001.
• RICOEUR, P. La vida: um relato em busca de narrador. Ágora: Papeles de Filosofia, v. 25, n. 2, p. 9-22, 2006.
• RICOEUR, P. O problema da hermenéutica. In: RICOEUR, P. Escritos e conferências 2: hermenéutica. São Paulo: Loyola, 2011, p. 15-68.
• RICOEUR, P. Tempo e Narrativa III. O tempo narrado. São Paulo: Martins Fontes, 2019.
• SILVA, C. M. C. Educação em Saúde: uma reflexão histórica de suas práticas. Ciência e Saúde Coletiva, v. 15, n. 5, p. 2539-2550, 2010.
• TEIXEIRA, R. R. Modelos comunicacionais e práticas de saúde. Interface - Comunicação, Saúde, Educação, v. 1, n. 1, p. 7-40, 1997.
• VILLAS-BOAS, D; DEMIER, F.; MATTOS, R. Dado Villa-Lobos: memórias de um legionário. Rio de Janeiro: Mauad X, 2015.
• VITALE, M. X. U. C et al. Impact of diabetes education teams in primary care on processes of care indicators. Prim Care Diabetes, v. 14, n. 2, p. 111-118, 2020.

• 1
  N.E.K. and Silva: article design and writing. J.R.C.M. Ayres: critical review of the content and approval of the final version of the article.

Editor:

Jane Russo

Publication Dates

• Publication in this collection
  04 Oct 2024
• Date of issue
  2024

History

• Received
  15 Jan 2022
• Reviewed
  10 Mar 2023
• Accepted
  04 Feb 2024