Veronica in 7 de mayo
The purpose of the Choluteca Health Promotor program is to develop a sustainable community health worker (promotora in Spanish) model to establish a health education program for Honduras. One barrier experienced by the Choluteca Health Promoter program that needs to be addressed is to provide effective, lasting health education to the communities in southern Honduras, where the vast majority of community members are under-educated. 

A theoretical and conceptual model of learning that addresses the challenges and variables experienced by the Choluteca Health Promoter program is needed to guide Honduran health promoters in the development of teaching and learning activities in the Honduran communities. 

Health promotion has been defined by the World Health Organization as “the process of enabling people to increase control over, and to improve, their health” (World Health Organization, 1997). As a process, health promotion is not a means to an end, but an activity “directed towards enabling people to take action” (World Health Organization, 1997). Health promotion is done with people and not to them (World Health Organization, 1997). A theoretical and conceptual model of learning that addresses the Choluteca regional health challenges and variables is needed to guide Honduran health promotors in the development of teaching and learning activities in the Honduran communities. Health promotion has been defined by the World Health Organization as “the process of enabling people to increase control over, and to improve, their health” (World Health Organization, 1997). As a process, health promotion is not a means to an end,but an activity “directed towards enabling people to take action” (World Health Organization, 1997). Health promotion is done with people and not to them (World Health Organization, 1997). 

The health promoter model has been applied in the United States and Latin America to reach Hispanic communities in particular. It has been used widely in rural communities to improve the health of migrant and seasonal farm workers and their families.Additionally, "in rural border communities, promotoras often conduct environmental health and home assessments, and deliver education about environmental health hazards” (U.S. Department of Health and Human Services,Health Resources and Services, 2011). Health Promoters have been found to have a positive effect on impacting health outcomes by building partnerships and coalitions in communities (Balcásar, Alvarado, Cauntu, Pedregon, & Fulwood, 2009). "Apart from serving as effective conduits for health education dissemination and outreach work, promotores can also serve as researchers, carrying out research functions such as project conceptualization, assessment tool development, data collection, and information analysis. Promotores should not merely be asked for assistance with data collection but should be part of the entire research process from conception to dissemination" (Nelson et al, 2011, p. 

The community health promotora performs many different roles in the community. Squires and O’Brien (2012) found that promotoras filled a primary role of imparting knowledge to other community members. Secondary aspects of their role included providing support to others in the community and serving as “trusted advisers to community members” (Squires & O’Brien, 2012). 

The promotora model is one of several options to consider when involving Community Health Workers in meeting the health care needs of a community. “Promotoras”, a Spanish term for lay community health educators (Bush, 2014), are typically trusted members of the community where they work. As members of the community, the promotoras share many of the same characteristics of other members of the community. Promotoras often “provide culturally appropriate services and serve as a patient advocate, educator, mentor, outreach worker, and translator. They are often the bridge between the diverse populations they serve and the health care system” (U.S. Department of Health and Human Services, Health Resources and Services, 2011). Community health promotoras have had a vital role in health care in the United States since the 1960’s. Among their many titles, they are also known as community health workers/educators, navigators and lay health advisors (Crider, 2010). 

“Participatory education is a collective effort in which the participants are committed to building a just society through individual and socioeconomic transformation and ending domination through changing power relations. As educators and students work toward building a just society, participants share, create, analyze, and act on their knowledge and experiences” (Campbell & Burnaby, 2005, p. 1). According to Sauvé, participatory education involves “the enabling of a group of people to name their world, recognize their potential to create experience, and begin working to fulfill that potential, as individuals and communities. It is learning to see new, more life-giving choices and developing confidence and skills to act on them” (Sauvé, 2005, p. 17). 

Participatory education has its roots in the popular education model promoted by Paulo Freire (Campbell & Burnaby, 2005. p. 1), a Brazilian educator who spent much of his life teaching literacy programs among the poor peasants of his country. Although Friere’s work in literacy was done in Latin America, his pedagogical approach has been adapted to other contextual situations, including education in North America.  

Freire (1970) felt that much of the traditional educational system suffered from “narration sickness” (Freire, 1970, location 977), where the teacher narrated information, and the student became a passive listening object. The narration was often lifeless rote, predictable information, or else the information that was being presented did not relate to the student’s own experience. Freire (1970) termed this type of teaching as the banking educational method in which the teacher viewed students as vessels which they were charged with filling with memorized information. According to Freire, under the banking system teachers and students are viewed as opposites. Knowledge is viewed as a gift which is given by the teacher to those who are ignorant. Freire believed that for education to be successful, it is necessary for teachers and students to become collaborators who both simultaneously become teachers and students (Freire, 1970, location 991). Under the banking system of education, students are not encouraged to become critical thinkers or to develop any cognitive skills. Their creative powers are not developed and they become limited in making world transforming contributions (Freire, 1970). 

Freire likened the use of slogans, monologues or communiqués, over the use of dialogue, as simply a useless attempt to liberate the oppressed through the use of tools that are only really suitable for domestication. One of the concepts utilized by Freire in the participatory education model was that of active problem-posing dialogue. The educator who promotes problem-posing reflections relevant to their learner’s world is inviting them to become co-investigators in the learning process (Freire, 1970, location1134). Authentic thinking can only occur through communication. Too often, the poor were treated as objects that needed to be saved, thus turning them into masses susceptible to manipulation. According to Freire, dialogue is essential in helping to create critical thinking skills (Freire, 1970, location 865).  

In the participatory model, dialogue alone is not sufficient. According to Freire, dialogue must be followed by reflection which in turn should lead to action (praxis). However, action alone without true reflection leads only to activism (Freire, 1970, Chapter3, paragraph 3).

Teacher-Student interaction

The monologue or lecture is the traditional form of teaching where the instructor does all of the talking. Freire viewed “liberation dialogue” as more than a technique for the teacher to get desired results or as a tactic which was to be used in order to manipulate students in an attempt to make turn them into friends with the teacher. Freire emphasizes that dialogue is necessary for “knowing that we know” and separates humans from animals which also have the capacity to know and to communicate with each other. Humans also know that we don’t know, and through the dialogue of reflective, dialogue between the student and teacher may result in action to critically transform reality (Shor, & Freire, 1987, p. 13) 

Freire viewed knowledge as a social event which involves an individual dimension. “Dialogue seals the relationship between the cognitive subjects, the subjects who know, and who try to know.” Dialogue helps break down the perception of knowledge as domination, where the teacher is viewed as the owner of knowledge, and from a position of authority, graciously doles out knowledge to the student (Shor, & Freire, 1987, p. 14). 

Freire wrote that critical consciousness referred “to learning to perceive social, political, and economic contradictions, and to take action against the oppressive elements of reality” (Freire, 1973, introduction, Kindle). 

While many of the health problems that individuals encounter arise as a result of the individual choices that they have personally made, there are many other contributing health risk factors that are not within the individual’s ability to change. People can be taught which choices they can change in order to contribute to an improvement of their health (Israel, Checkoway, Schulz, & Zimmerman, 1994). 

There are many other environmental and social issues beyond the individual’s control that may be affecting their health. Teaching in the traditional sense, or individual changes in life style choices are often not sufficient to make the changes needed in community health care. Israel et al. (1994) suggest a model for participatory community empowerment.  

Community empowerment for improving health contrasts with other health models which place emphasis on the treatment of a person’s illnesses. Empowerment of a community “refers to the ability of people to gain understanding and control over personal, social, economic, and political forces” for the purpose of implementing improvements in their particular situation (Israel, Checkoway, Schulz, & Zimmerman, 1994, p.152).  

Community empowerment can take place on three levels. At the individual, personal level, empowerment means taking control over one’s own personal efficacy and competence, creating a sense of mastery and control in a person’s life, and participating in the process of influencing community institutions and community decisions (Israel, Checkoway, Schulz, &Zimmerman, 1994).  

At the organizational level, empowerment means creating a democratic management style where members collaborate and share information and power. By encouraging the organizational democratic process and involving individual participation, the organization also becomes empowered and has increased opportunity to influence the larger community (Israel, Checkoway,Schulz, & Zimmerman, 1994). 

The empowered community is one where individuals and organizations work together using their combined skills and resources to meet the collective needs within the community. Just as with the empowered organization, an empowered community has a better opportunity of influencing the larger society (Israel, Checkoway, Schulz, & Zimmerman, 1994).  

Israel et al. (1994) note that Freire’s concept of conscientization describes the possibility of empowerment across all three levels of empowerment within the community. Through dialogue, reflection, and action, social change can take place (Israel, Checkoway, Schulz, & Zimmerman, 1994). Community empowerment at all three community levels, with the individual, the organization, and across the community, may lead to success in overcoming the barriers to real health care reform (Wallerstein, & Bernstein, 1994).  

“The three-phase model of critical pedagogy based on the writings of Freire consists in: listening and naming; dialogue and reflection; the promoting of transformative social action” (Matthews, 2014, p. 602). The listening and naming phase helps focus on the issues that learners face and facilitates a problem-posing approach to health education. During the naming phase, educators spend time in the community helping community members identify issues of concern (Matthews, 2014). 

The dialogue and reflection phase helps learners confront those problems of inequality that they encounter and then suggest their own options for helping resolve those problems. The SHOWed model may be effectively used to encourage dialogue. Learners can be encouraged to talk about what they: 
    What is Happening? 
    How does this issue relate to Our lives? 
    Why does the problem exist? 
    How can the person become Empowered? 

The last phase, or action phase (praxis) of the Freire model of critical pedagogy involves the promotion of transformative social action. During this phase, learners and facilitators work together to understand how power works in society and to determine the areas that they have the power to transform (Matthews, 2014).  

Participatory health promotion practices have been found to be effective in cooperative extension education. Participatory learning allows extension educators to build on community experience. Community dialogue encourages members to be subjects of their own learning. Networking becomes a collective effort in gathering and sharing information (Gillis & English, 2001). 

Participatory education techniques may be successfully incorporated with the Choluteca community health education program using the promotora model. The success of the project will depend on the participation of key members within the community and with educators from outside the community. Buy-in is needed from community leaders and community members. This health education initiative is different from past projects. By being a participatory education initiative, the community has the major portion of the responsibility deciding which Local community health promotors will be valuable in identifying persistent issues, such as diabetes, problems with parasites, and malnutrition. Health promotors are strategically located in the community with an opportunity to encourage moral and spiritual transformation of individual lives, as well as impacting the world view of the entire community, and even of the southern region of Honduras and beyond.  

One of the primary roles of the health promotor is to engage neighbors in dialogue which identifies problems and suggests solutions that can be provided by community members themselves. It is anticipated that there will be an increased awareness of the range of needs that exist, but also a desire to meet those needs.


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