Promotoras programs are widely used now and are more common in the health than the education field. The Centers for Disease Control and Prevention have a database of such programs throughout the US that is available on-line. Some of these programs are discussed in this literature review. In looking for ways to continue a relationship with promotoras or animadoras groups in the Valley, the literature can suggest some direction. However, it is essential that any outside group wishing to work with promotoras programs, especially a grassroots one such as ARISE, understands that program direction comes from the women who are the animadoras. Outside attempts to direct the organization would not succeed and are contrary to the foundation of the organization.
     The lay worker programs in the Rio Grande Valley address various social and health issues. For the purposes of this paper, I am looking at only English as a Second Language (ESL) programs and those that are health-oriented.
ARISE is the group that the Colonias project worked with most closely. Its mission is to develop education programs that build capacity in individuals and add a sense of community among the people.  The culture of women that dominate the organization is a striking aspect of the ESL program and other programs at ARISE. Instead of the male-oriented motivation in the workplace, ARISE community members work with a sense of mission that reflects a more female aspect. Sanguinetti (1994) discusses a feminist reflection on empowerment through teaching ESL in Australia. Her paper suggests that empowerment comes from teacher-student solidarity and that a female-centered culture can mediate cultural, class and political differences. It would be interesting to document how the participants feel the ARISE programs influence such differences.
    Many ESL programs now focus on empowerment, like ARISE does, and draw from Freireís model. Wrigley (1993) discusses 11 programs including some that focus on personal growth to those that focus on literacy for social adaptation. The curriculum at ARISE includes both personal growth and empowerment and social adaptation as ends but no formal evaluations have been completed. Faiginís (1985) paper specifically focuses on Freirian principles of designing adult education curriculum. The development and testing of curricula in the Valley might be one area to explore, especially if doctoral students would be interested in combining their dissertation with training new animadoras.

Resources for training programs are a need at ARISE

    The terms promotora, animadora, paraprofessional, community health advisor and lay health advisor are all used throughout the literature and workplace to refer to workers who are indigenous to the community and who serve and train through a community - based organization as opposed to holding a college degree. Community Health Advisors (CHAs) in immigrant communities is becoming more commonplace. Volunteers and encouraging program retention through graduation ceremonies and certificates are also common among the programs (Shimazu, McFarlane, Eng).
Studies have found that using older Hispanic women as nutrition educators is effective (Serrano, Bell). The Abuela Project in Yakima, Washington looked specifically at behavior changes over 6 months and found positive effects in reducing the incidence of salmonella poisoning. This study found older Hispanic women willing to be trained in making pasteurized fresh cheese. After the training, they signed a contract to teach 14 more people about the new method to prevent food poisoning. It would be interesting to use such a model in trying to effect other types of behavior change.
    Baker, et.al. (1997) found that the lay health advisor models provide culturally appropriate, holistic and community centered services that are grounded in local needs as gauged through the input of local members. They found the groups had a positive impact on their communities. The De Madre a Madre program in Houston, whose goal was to reduce low-birth weight babies and reach at-risk mothers, showed promising results after five years. This program has now includes training local women in public speaking, computers, grant writing and leadership skills (McFarlane).
One study looking at the role of lay health promoters found that they are necessary for providing culturally competent care. In spite of efforts to include cultural content into nursing classes, not much progress has been made. It points out that even if such classes were included in nursing schools, thousands of practicing nurses might still lack knowledge for providing culturally competent care. This is the gap that Poss (1999) sees as the niche for lay health promoters. Poss found that of the 269 health care organizations in California that were surveyed, 26% provided lay health promoters or planned to hire them within the next three years. Of the employed health promoters, 55% were paid from ongoing funding and 42% were paid from grants.
    Other studies are more lukewarm on the subject of lay health workers. Korfmacher et.al. (1999) found in comparing a Denver home visitation program for pregnant and parenting women that paraprofessionals had lower outcomes than nurses. Nurses completed more visits and had fewer dropouts than paraprofessionals. One interesting finding was that nurses spent more time on physical health issues during pregnancy and on parenting issues during infancy, whereas Paraprofessionals spent more time on environmental and safety issues. The study does not detail what information the client asked for ­ in the colonias it could very well be that environmental and safety issues are of greater concern. The program Su Casa de Esperanza in Pharr, TX provides a similar service, and following up on questions raised in the Korfmacher study would be useful and interesting.
    Boyer describes in her midwifery program paper her experiences visiting the Holy Family Birth Services near Elsa, TX. The paper describes the program and suggests benefits that could prove useful and necessary for the colonias residents. A definitive evaluation would not only add to the literature but would increase validity of arguments for funding of such programs.
    Eng, et.al. (1997) presented lay health advisor programs as useful as a complement to the more specialized work of health professionals, but not as a stand-alone program, such as some Community Based Organizations (CBOs) use them. This paper suggests lay health advisors should establish meaningful links to service delivery systems. It offers three basic principles of public health practice for lay health advisors: 1) A basic assumption is that a natural resource available in most communities is the existence of social networks through which community members offer and receive social support among one another.  2) The role of the practitioner is to recruit, train, and support community members who can directly reach and offer social support to those in need.  3) The role of the recruited and trained community members is to serve as a bridge between agenciesí formal service delivery system and communitiesí informal social support system.
     The many programs in the Valley that use promotoras de salud are implementing a novel outreach method, and encouraging the participation of members of marginalized communities in mainstream programs. The South Texas Promotoras Organization (STPO) is working toward unifying the efforts of the diverse groups and establishing a communication link. This seems to be successful on some levels, but there is still a lot of work to be done. Accessing one program through a promotora group does not give you access to another. For example, if at Cameron Park you meet with the promotora and are signed up for health services (well-woman exams) through Community-Oriented Primary Care (COPC), you are still perhaps not aware of services that might be free through Planned Parenthood (free birth control pills). For that, you will still have to meet and sign up with the Planned Parenthood promotora. Such challenges are common in our medical care system and are not exclusive to the promotoras programs.
     STPO is also working on creating a standardized certification program for promotoras.  Rosenthal et.al. (1998) overviews this effort and the Report of the National Community Health Advisor Study includes the development of CHA core role and job competency definitions, evaluation strategies, career and field advancement, and integration of CHAs within the changing health care systems which include managed care environments. Such standardization is positive in that it creates more of a "career" feel for some. However, it takes away from the CBOs ability to create a program tailored to their own communities, from training the CHA to providing services to the community.

Recommendations

     The CBOs in the Valley that use promotoras all need practical assistance in grant writing and securing funds to continue with their programs. Most of these programs lack solid evaluation of their programs. As promotoras programs become more common and more competitive, supporting such programs through evaluation over a period of years will be attractive to funding agencies.
     There are many areas, as suggested in preceding pages, where specific evaluations would both benefit the agency and add to the literature about effectiveness of lay worker programs. Linking evaluators to agencies is key. Establishing an office of  "public health and social service practice" in the Valley at one of the universities would benefit any agencies who appeal for help in grant writing or program evaluation and link up graduate students to projects that are reality-based and necessary. The office could serve as a resource for Valley agencies and a conduit for students from across the country that are interested in exploring border issues. A database of projects needed by agencies could be matched to students looking for internships, dissertation or thesis material, or research practice.
     Such an office would offer support when needed by a Valley CBO without the formality or pressure of an on-going alliance. It would also save outside agencies or students from having to approach innumerable CBOs when trying to find an interested party for their new grant or research idea.
Finally, I think such a set up if handled properly, could serve as a point of reference for the Valley CBOs. If the office serves as it should, CBOs will know all parties are acting in good faith. In the past cooperating with outside agencies that did not fulfill their end of the bargain have often hurt CBOs. With this setup, they can dip into the well when they need to, without having to worry that they are dancing with the devil.
 

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Bell, Ryan A.; Hillers, Virginia; Thomas, Theo. The Abuela Project: Safe Cheese Workshops to Reduce the Incidence of Salmonella Typhimurium from Consumption of Raw-Milk Fresh Cheese. American Journal of Public Health. 1999;89:1421-1424.

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McFarlane, J.  De Madres a Madres: An Access Model for Primary Care. American Journal of Public Health. 86(6):879-880, June 1996.

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