Contributions from popular education in health to structural competency training: An experience from Chile

ABSTRACT

Structural competency is used to train health professionals on how social, political, and economic dynamics create conditions that negatively impact a population’s health. In the Global South, this approach has historical roots in social movements, popular education, social medicine, and human rights. In 1982, during a time of extreme poverty, inequality, and violence under the Chilean military dictatorship, Educación Popular en Salud (EPES), developed a programme for training community health promoters to address common illnesses and analyse the underlying causes of poor health. In 2010, EPES began using the same model to train international and Chilean health professionals. The approach advanced four competencies. Evaluations show that training contributes to transforming health professionals’ mindsets and leads them to question their practices. However, educating practitioners does not change the underlying structures that generate poor health. This article examines the intersection between EPES’ competencies and the structural competency framework, highlighting two major contributions of EPES to structural competency: a methodology that narrows the gap between a theoretical analysis of social determinants of health and implementing action plans; and organic long-term links with social movements that strengthen collective action in poor neighbourhoods to advance social justice.

KEYWORDS:

• Popular education
• structural competency
• social determinants of health
• gender
• community health promoters

Introduction

The term ‘structural competency’ has been used to describe recent efforts to educate students and practitioners in health fields about the social, political, and economic structures that create states of health and an uneven distribution of disease (Harvey et al., 2020; Metzl & Hansen, 2014; Metzl & Roberts, 2014; Neff et al., 2020). In parts of the Global South, where the term ‘structural competency’ is largely unknown, the recognition of structural factors underlying poor health outcomes has deep roots in social movement struggles (Breilh, 2011), popular education, Latin American social medicine, and international human rights principles that far predate recent trends.

EPES (Educación Popular en Salud; Popular Education in Health) began developing its unique approach to teaching the structures underlying health four decades ago. EPES was founded in 1982 as a project of the Evangelical Lutheran Church in Chile,¹ in response to the needs of impoverished communities. Under the military dictatorship, these populations were reeling from unemployment, dismantling of public health and social security systems, and loss of rights won in previous decades. EPES generated a health promotion programme in shantytowns in Santiago and Concepción, where it formed health groups, composed mainly of women. The health promoters came to understand health as a right, not a privilege, and to see health not just as the absence of sickness, but as a state of wellness. They were challenged to view living conditions and the structures behind them as causal factors in their health status. And they grew as leaders and decision-makers in movements for social change.

Beginning in 2010, EPES expanded its educational work to train Chilean and international health professionals in the structural underpinnings of health. These trainings contributed to participants questioning assumptions about their practices and led to transformation in their mindsets.

Drawing from EPES’ decades of experience promoting popular education in health, this article examines the intersection between EPES’ competencies and the structural competency framework, and how EPES’ approach can enhance structural competency training for health professionals. Although EPES has not previously used the term structural competency, we find it valuable to engage with the concept as part of this theme issue. Four of the authors of this article are long-time health educators at EPES, joined by an international scholar who has previously published about EPES (Paley, 2001).

Historical/political context

Already developing for decades, Latin American social medicine thrived in Chile during the 1930s with the leadership of then-Minister of Health Dr. Salvador Allende, whose book La realidad médico-social chilena (The Chilean Medical-Social Reality) (Allende, 1939) highlighted how poverty alleviation could improve health outcomes (Waitzkin 2005; Waitzkin et al., 2001). In the 1960s and early 1970s, Chile went through a period of social mobilisation toward building a more democratic and inclusive society. As Allende became president (1970-1973), redistribution policies and provision of social services helped improve living conditions, particularly among the poor (EPES, 2013; Salazar & Pinto, 2002). Chile’s health budget grew by 27.99% between 1971 and 1972 (Llanos, 2013). One of the most emblematic public policies of the Popular Unity government, the ‘Half a Liter of Milk’ programme, benefited thousands of children as well as pregnant and nursing women. The number of people benefiting from complementary feeding programmes rose from 650,000 to 3,600,000 between 1970 and 1973, helping to reduce malnutrition in the country (Ramírez, 2019). Between 1970 and 1973, overall mortality declined from 8.6 to 8.1 and infant mortality declined from 79.3 to 65.1 per thousand inhabitants (Molina, 2007).

In 1973, a violent US-backed coup imposed a military dictatorship that unleashed market-oriented forces and ended the solidarity orientation of health and social welfare institutions (Molina, 2007). Public expenditure declined steadily and dramatically between 1974 and 1980, with public social spending dropping ‘from 20% of GNP in the second half of the 60s, to 16% in the latter part of that period.’ (Arellano, 1988, p. 46). As public spending decreased, social services were privatised, resulting in a drastic reduction in state provision of health care, education, housing, and public works (Goyenechea, 2019). These free-market macroeconomic and public policy changes imposed by the dictatorship led to severe deterioration in living conditions and increased infectious diseases among the poor.

The military government carried out the economic transformation by violently overpowering popular demands. It dismantled the elected political system, closed channels for citizen participation, prohibited political activity, and repressed social movements. Brutal human rights violations subjected dissidents – including leaders and practitioners of solidarity-oriented and social medicine (Comisión de Solidaridad con Médicos Objeto de Represión, 1993; Waitzkin et al., 2001) – to internal displacement, incarceration, exile, torture, disappearance, and death (Detzner, 1987).

Training community health groups

In this context, EPES began training community health promoters in 1982. The founding team developed a strategy, methodologies, and a curriculum that adapted popular education principles to health. In recruiting people to become health promoters, EPES prioritised poblaciones² where community organising persisted despite intense repression. EPES staff visited community-led soup kitchens, day care centres, church groups, and human rights solidarity organisations, where (mainly) women were collectively taking action for resistance and survival. EPES workers invited those they met to sign up, and subsequently interviewed them in their homes to build trust. Later they held educational sessions in places considered safe and welcoming within the community. The EPES team viewed its health promotion work as a way to support rebuilding the social fabric; amid scarcity, fear, and violence, it was defending life and dignity.

For EPES, health problems were a social and political issue, so the health promoters’ role was not to cure illness but to do preventive and educational work. As EPES considered health a human right, the role of health promoters was not to deliver services but to organise to defend health rights. Because poor people's own knowledge was valued, health promoters analysed their communities’ needs, established priorities, developed work plans, carried out campaigns, and conducted evaluations. Community-based participatory action research was an important approach for doing this work (Norambuena & López, 1998; Ortiz & Borjas, 2008; Wallerstein & Duran, 2006). With the goal of transforming reality through collective action, EPES focused on training health groups to become autonomous organisations and connect to broader struggles (Calvin & Grandon, 1995). EPES worked with the health teams to analyse obstacles to exercising the right to health and see that change can be achieved through organising.

These roles differed from what health institutions and policy makers expected health promoters to do. Following the 1990 transition to elected civilian government, there was much talk of participation, but its meaning varied greatly (Paley, 2001). In some cases, officials touted a concept of self-care, emphasising personal hygiene to prevent disease. During the 1991 cholera outbreak, for example, the government's public service messages urged people to boil water and wash their hands, ignoring the reality that residents might not have cooking fuel or running water. EPES emphasised broader structural issues of inequality leading to the spread of disease: garbage dumps, insufficient sewage systems, malnutrition, inadequate income, and lack of medical care.

In other cases, health promoters were viewed as intermediaries assigned to ensure that local people implemented programmes designed elsewhere rather than as facilitators of programmes emanating from communities’ needs and articulated demands. An illustration of this technocratic model is the August 1993 Pap smear campaign in El Bosque municipality. With a history of popular education, participating in networks, presenting at conferences, conducting surveys, and running campaigns, the EPES-trained Renato Castillo Health Group³ had identified its goals for the year related to women's health, including education and action for health rights. When approached to collaborate with the Pap smear campaign, the group agreed, expecting to engage in dialogue, planning, and setting priorities according to community needs.

Instead, group members found that health officials expected them to comply with programme decisions made elsewhere: to find locations for conducting Pap smears, recruit women to have the exams, and prepare lunch for staff performing the tests. The EPES-trained health promoters saw this as reducing them to domestic workers and offloading costs that public funds should bear. Confronted with limited roles that ignored the importance of community participation in defining their health concerns (and solutions), the Renato Castillo health promoters began organising meetings with women in the community to bolster local women's health organisations. Although some of the health group's activities resembled those of the institutional programme, a key difference was using the Pap smear campaign as a way of organising and engaging women in a more critical reflection on their broader health concerns (Anderson et al., 1994). As health promoters took on these pro-active decision-making roles, their leadership, self-esteem, power, and fulfilment were transformed. Quotes from the women themselves expressing their growth are in the book that we collectively produced called Monitoras de Salud: Trayectorias de Participación (Health Promotors: Trajectories of Participation) (Calvin & Grandon, 1995).

While structural competency is now emerging as a concept in health professional education, it draws on a long legacy of community health theory (Werner & Bower, 1982) aligned with the activist training model that EPES has been applying for 40 years.

EPES conceptual framework

EPES’ work draws on various sources, including Latin American social medicine, liberation theology, public policy, and social movements. Four influences – popular education, human rights, primary health care and health promotion, and gender – have been bedrocks of EPES’ practice over the years.

Popular education

EPES is deeply influenced by the work of Brazilian educator Paulo Freire, whose seminal book Pedagogy of the Oppressed was written in 1967–1968 during his exile in Chile (Bresnahan, 2012; Holst, 2006). Popular education values everyone’s knowledge, respects people’s own understanding of their health, and engages people in a continuous learning process (Freire, 1968/2005; Jara, 2010). It honours community wisdom, including ancestral values. This emphasis contrasts with the hegemonic view of education that only values formal schooling. Freire holds that knowledge is not neutral; to choose neutrality is to reproduce the status quo and side with the dominant powers (Freire, 1968/2005; Freire, 1996). Praxis – in which theory and action inform each other – generates a process of organising for change. According to Schugurensky (2000), popular education involves an ‘explicit political commitment to work with the poor and the marginalised and to assist social movements in fostering progressive social and economic change.’ The goal of popular education is to understand the world to transform it; to collectively build a more democratic and just society.

EPES’ approach often clashes with the reductionism inherent in the biomedical model of health, insofar as it establishes biological and technical criteria for risk factors without considering the social, economic, and political implications of the way health care is organised, the conditions in which people live, or the type of actions proposed for care (Cuadrado, 2015; Morales-Borrero et al., 2013).

EPES’ training begins with critical reflection to seek the causes of locally defined problems and needs. A key exercise is a game in which the question ‘But why … ?’ is asked repeatedly (Werner & Bower, 1982). EPES calls this activity ‘the causes of the causes’ (see also Braveman & Gottlieb, 2014; Marmot, 2017). For example, a community member identifies a problem, such as her child not having enough to eat. The question is asked, ‘But why doesn’t this child have enough to eat?’ The mother might answer, ‘Because her dad is unemployed.’ ‘But why is her dad unemployed?’ She might respond, ‘Because the factory closed.’ ‘But why did the factory close?’ This might lead to recognising structural factors such as imports from other countries. And to continue the inquiry: ‘But why are there imports from other countries?’ ‘Due to government policy.’ And so on.

This critical thinking exercise deepens people’s understanding by starting with their lived realities and facilitating recognition that health problems affecting their families and communities stem from living and working conditions, the social determinants of health.⁴ It also shows the much broader causes, the structural determinants of health,⁵ and fosters awareness that these conditions are related to deeply unjust power structures.

Popular education’s participatory processes enable people to better understand the multiple ways they and their communities experience inequalities resulting from the intersection of structures that generate social hierarchies by class, gender, race, and other factors. The next step is to realise that these can be changed. As Freire says, ‘In problem-posing education, people develop their power to perceive critically the way they exist in the world … they come to see the world not as a static reality, but as a reality in process, in transformation.’ (Freire, 1968/2005, p. 96). Hence, EPES approaches health education from an emancipatory perspective – promoting organisation and collective action to improve community health.

Health as a human right

In 1948, the United Nations adopted the Universal Declaration of Human Rights, stating in Article 25, ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.’ (United Nations, 1948).

The World Health Organisation reaffirmed the fundamental right to health in the Preamble to its Constitution, where it defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ (World Health Organization, 1946, p. 100).

These international statements and subsequent human rights covenants that enshrine the right to health in international law (Labonté & Ruckert, 2019) undergird EPES’ stance that health is a right, not a privilege, and that the role of health promoters is to defend that right against free market forces, authoritarian government, and reductionist biomedical models that undermine it.

Primary health care and health promotion

The 1978 Alma Ata Conference (World Health Organization, 1978) – a landmark international event that identified health as a key element in countries’ development – asserted that fulfilling the right to health requires intervention by many social and economic sectors.

The Declaration forged at the Alma Ata conference established international promotion of comprehensive primary health care as the best way to provide health services to meet the health needs of impoverished populations. Rather than centring health care on medical professionals treating sick people in hospitals, the model involves training community health workers in prevention with responsibilities extending to collective actions to improve people’s living and working conditions (Labonté et al., 2017). Most notably, the Declaration conceptualised people as agents of change and decision-makers in their well-being, stating ‘people have the right and duty to participate individually and collectively in the planning and implementation of their health care.’ (World Health Organization, 1978).

Subsequently, the 1986 Ottawa Charter (arising from the first World Conference for Health Promotion) affirmed that health requires socially structured ‘prerequisites for health’: peace, education, housing, nutrition, income, a stable ecosystem, sustainable resources, social justice, and equity. It defined health promotion as a process of ‘enabling people to increase control over and to improve their health.’ (World Health Organization, 1986).

Both the Alma-Ata Declaration and the Ottawa Charter advance the belief that institutional systems must expand the ways they function to support the active participation of people in designing public health policy.

Although the concepts posed by Alma Ata emphasised the value of prevention and health promotion, its implementation often situated community health promoters in the role of subordinates to professional teams usually headed by doctors and nurses oriented toward individual and biomedical health care. As mentioned above, EPES’ model is antithetical to this technocratic approach and instead trains health groups that are independent organisations capable of analysing problems in their communities and making collective decisions about how to address them.

Gender

EPES works mainly with women and considers gender a determinant of health, recognising that gender inequality increases when gender discrimination intersects with the experience of living in poverty. Women continue to be responsible for sustaining most ‘activities and practices necessary for daily survival of people … ’ (Rodríguez, 2015, p. 34), such as feeding families, raising children, caring for sick relatives, and more. However, this work is taken for granted, ignored, and devalued, despite being vital for well-being and health (Provoste, 2012), perpetuating the idea that women possess greater caregiving abilities and capacity for domestic work. When institutional health care systems fail to recognise how gender hierarchies structure health inequities, they reproduce inequities rather than reduce them.

Methods

Methodology of organising and implementing the curriculum

Having spent decades challenging the dominance of the biomedical model, grounding processes in people’s knowledge, coordinating with social movements, understanding health as a right, and emphasising the social determinants of health, EPES decided to bring its principles to broader audiences within and beyond Chile. In 2010, EPES launched the International Training Course on Popular Education: Participatory and Community Strategies in Health (known as the International School, or Escuela). It was based on the health promoter training programme EPES had implemented since its founding. Held annually in Santiago and Concepción, the course explores participatory strategies and methodologies for health promotion in local communities. Initially a 2-week course, it was later shortened to 11 days. Some 225 health care workers and activists from 27 countries have participated since it began 13 years ago. The tuition for the International School is usually paid by the participant or their institution. However, EPES works to obtain donations to support the participation of community activists and leaders who lack the means to cover course expenses.

Initially, the Chilean Ministry of Health sent professional staff to the International School to learn popular education and participatory approaches to health. Later, various health departments and the National Disability Service (SENADIS) contracted EPES to organise training for their workers. To meet this need, EPES adapted the curriculum, shortening it to five days. Since 2014, EPES has held 23 of these courses, called Participatory and Community Strategies in Health, for primary health care workers in Chile. A total of 745 people have participated. All EPES courses for primary health care workers are paid for by the public health services, and in some cases are mandatory for employees. This reflects the high regard officials have for the course content and methodology.

Summary of course curriculum

The courses for public health workers in Chile seek to strengthen, foster, and expand a right-to-health perspective. They offer a unique opportunity for health workers to understand the influence of social determinants of health in people’s lives, through access to perspectives of local health groups. And they open a space for reflection on how to integrate these perspectives into the public health system.

In this article, we describe the curriculum and results of the national course. The course consists of 35 h structured into 12 sessions over 5 days. There are eight theoretical/practical sessions, as well as three sessions in the community where participants interact with an EPES-trained health group or other community organisation. In these on-site sessions, participants learn how to plan, implement, and evaluate an action in the neighbourhood where the community group lives. The remaining three-hour session is for self-evaluation and programme evaluation.

EPES Course Curriculum.

1. Introduction to popular education: Principles and methodologies (2 h)

2. Popular education and social determinants of health (2 h)

3. Exploring designs: Participatory needs assessment (3 h)

4. On-site Session 1: Becoming acquainted with the neighbourhood (3 h)

5. Perspectives and tools for promoting health (4 h)

6. Applying what is learned: Designing a work plan for specific neighbourhoods (4 h)

7. On-site Session 2: Reviewing and recognising steps in designing an action plan (3 h)

8. Learning about health through play (2 h)

9. Production of community action materials (4 h)

10. On-site Session 3: Carrying out a community action (3 h)

11. Exploring methodologies: Participatory evaluation (2 h)

12. Final session and evaluation (3 h)

The course equips participants with methodological tools for carrying out participatory assessments and for planning together with the community (EPES & Ministerio de Salud [MINSAL], 2016). The tools challenge participants to recognise that every action for health must focus on people’s needs, starting from the community’s own knowledge and actions. Part of what makes this effective is the link between theory and practice. For example, in a training session on designing a workplan, participants in small groups put in order a series of cards with the steps of participatory planning and explain their process in the plenary, where they get feedback and learn from other groups. The theoretical-practical sessions prepare participants for subsequent experiences in the community.

Experiential learning gives participants the opportunity to analyse their practices and to design health promotion strategies that will improve people’s lives. All sessions include interactive exercises and reflection to create a climate conducive to learning about social context and how it impacts health.

Competencies

The courses for primary health care workers include activities designed to strengthen four competencies aimed at helping participants move beyond a biomedical model toward an analysis of structural conditions influencing health outcomes. They also bolster participants’ abilities to confront challenges faced by health systems in addressing health inequities.

Competency 1: Reflect on and propose interventions that incorporate a structural framework for health problems.

Officially, a social determinants focus is part of the conceptual framework of health promotion strategies in Chile’s primary health model (MINSAL, 2018; MINSAL & Organización Panamericana de la Salud [OPS], 2012). In practice, however, medical care is prioritised over health promotion in allocating human and financial resources. EPES’ courses for health care workers convey the social determinants of health approach by pointing to living conditions that impact a population’s health. Methodologies based on Freire’s concept of codes (drawings, photos, skits, or videos that reflect generative themes) (Hope & Timmel, 1986) help participants strengthen this first competency.

EPES developed a series of drawings to generate collective analysis of underlying determinants of poor health. Participants working in small groups look at a drawing depicting a health issue in a low-income community and answer a series of questions (Figure 1) (produced for EPES by Francisco Ramos). One drawing, for example, shows an overweight child sitting at a computer, snacking on french fries and drinking soda. Other details show the exterior of the rundown apartment building, with street vendors selling junk food, while in the background signs advertise fast food from transnational corporations. The questions posed to the group are: What problem does this child have? What are its causes? What could a group of community health promoters do to address this situation?

Figure 1. Generative Drawing.

This methodology challenges participants not only to recognise individual-level changes to encourage health but also to identify and respond to structural factors that promote poor health. This approach seeks to generate solidarity and understanding, and challenges health workers to act at both micro and macro levels.

Rather than health workers responding to a child’s weight problem with advice on what to eat, how to exercise, and other individual-level behaviour changes, the group analysis of the picture has them discuss what food is available in the neighbourhood and what conditions exist for getting exercise. They also recognise the importance of challenging the role of the international food industry and its influence over unhealthy food habits. This discussion prompts participants to consider alternative strategies for promoting health, such as working with local residents and organisations to collectively address the structural factors that can foster positive health results for this child and their community.

Competency 2: Identify how social, political, and economic structures generate and maintain health inequities.

One of the sessions is a group exercise called the Power Walk, adapted by many organisations. It helps groups identify and reflect on political, economic, social, and environmental differences shaping inequalities and health outcomes. Participants form a row along one wall. Each person draws from a bag a piece of paper describing a character (keeping it private) with varying power and social privilege: indigenous woman, bus driver, immigrant woman, senator, doctor, farmworker, etc. A facilitator reads affirmations aloud, and participants are asked to take one step forward for each affirmation that applies:

1. Everyone in my household has their own bed.

2. If I get sick, I know I will have access to health care and needed medications in a timely fashion.

3. I have access to at least two healthy meals every day.

4. I can go out without fearing discrimination.

5. My family has access to clean water.

6. I have adequate time and space for exercising every day.

7. I know my contributions will be well received at school meetings or public events.

The statements can be adapted to the objectives of each group. Facilitators read twenty affirmations and then ask the people who have moved the farthest to state who they are and why they are in front. Those who have moved the least are asked to share their thoughts about why they have taken so few steps.

Afterwards, the group reflects on key questions: Why are some ahead and others behind? How did people feel when they advanced and others did not? How did people who did not advance feel? How do the distances between people reflect social inequalities? Which people are most likely to have access to health care? What role does gender play in whether people advance? Finally, the group reflects on how a social determinants of health approach can help us better understand patients and the community.

Competency 3: Create and implement a work plan in cooperation with local organisations.

One unique aspect of the course is that community health promoters trained by EPES help design, teach, and contribute to ongoing curriculum improvements. From their holistic perspective connecting health to living conditions, the health promoters lead course participants in three on-site sessions in the neighbourhoods where they live and carry out their community health work.

In the first on-site session, participants learn about health promoters’ stories and work experiences. Then participants are divided into small groups and, guided by health promoters, walk through the neighbourhood with a printed observation checklist. They are asked to reflect on the conditions of sidewalks, housing, green spaces, and garbage, and are asked to find a health clinic, a school, a mural about health, and so on. Back in the community centre, each group shares what they have observed. Based on their walk and reflection, the group develops an analysis of health problems that might be present and brainstorms actions they could take during the course to address one structural issue facing the community. During the second on-site session, participants choose an issue that affects the community and design an action to be implemented that reflects what they observed during the previous session's walk. Together with the health promoters, they develop a simple work plan (problem, objectives, activities, responsibilities, resources needed, evaluation). In the process, health promoters offer feedback and suggestions based on their community experience. Participants gain experience developing materials needed for their action plan.

During the third on-site session, the action is implemented in a public space (usually in an open market, clinic waiting room, or street), accompanied by the health promoters. For example, one group performed a skit in the open market about the right to live in a clean community, and surveyed shoppers about their concerns and proposals for addressing garbage. Another group had a stand in the open market in which they denounced the high sugar, sodium, and fat content of ultra-processed food industry products, while offering samples of healthy, low-cost recipes.

This activity challenges participants to look at and respond to structural issues that shape health. In the afternoon, each group presents its assessment and community action to the other participants and the health groups. In the plenary session, participants evaluate to what extent the groups managed to integrate a social determinants of health perspective into their work. They also offer suggestions and feedback on how the actions could be improved.

On-site sessions with health promoters enable participants to become acquainted with a horizontal and participatory method that acknowledges and validates the voices of non-professionals. The experience leads health care professionals to adapt their messages and methods in culturally appropriate ways that reflect a community's needs.

Competency 4: Question the dominance of the biomedical model and explore other systems of health knowledge rooted in people’s own wisdom and life experience.

EPES’ methodology harnesses community knowledge and voices, building on people's experiences, family traditions, and cultures. This popular education standpoint implies questioning the authority and predominance of technical knowledge in health, a premise ingrained among health care workers whose professional training is fundamentally biomedical. That professional focus often devalues the working-class world, as if living in poverty deprives people of wisdom and knowledge. In EPES’ view, the combination of popular and scientific knowledge can produce social transformation.

This curriculum segment is intended to motivate participants to question power relationships between health care professionals and community members. It enables participants to recognise and value wisdom that health promoters have gained through years of work in their neighbourhoods.

Methodology of evaluating the curriculum

Course evaluation

In alignment with the principles of popular education, EPES engages in an ongoing process of systematization (Antillón, 1995; Torres, 2010) by categorising and ordering information from the formal and participatory course evaluations, with value placed on participants’ voices. This has made it possible to identify what is working well and what needs to be modified to make the curriculum more useful to future participants.

Each course includes two formal evaluations. The first evaluates participants’ involvement in the course: attendance, producing materials, and carrying out a community action. The second evaluation is a questionnaire administered upon completion of the course. Its aim is to compile participants’ views on course content, structure, and methodology. The questionnaire has two sections. The first section evaluates the general course programme and the field work with community groups in the form of two Likert scale questions, followed by two open-ended questions. The second section evaluates participants’ perceptions regarding whether the stated objectives were achieved. For example, ‘I experienced some of the ways in which popular education generates opportunities to recognise the influence of social determinants of health in people’s daily life.’ Subsequently, participants are asked to identify three sessions they liked the most and three sessions of greatest use to them in their jobs. The questionnaire concludes with two open-ended questions for participants to offer general comments and suggestions for improving future courses.

To analyse the data, we employ the SPSS statistical programme for the scales questions, summarise the sessions most valued by participants, and use analysis by categories to systematise responses to open questions.⁶

Results

For this article, we analysed evaluations from 12 of 24 courses, selecting those with similar content and structure (e.g. number of sessions, number of educational hours, evaluation questionnaire used). These courses have included a total of 325 public health workers, mainly from primary health care in four public institutions: three in Santiago (the National Disability Service – SENADIS, the Central Metropolitan Health Service – SSMC, and the North Metropolitan Health Service – SSMN); and one in southern Chile (the Chiloé Health Service – SSChiloé).

Regarding the participants’ perception of whether or not course objectives were met, 96.8% agreed or completely agreed that the objectives had been achieved.

Regarding practical work with community health groups, 87.9% rated the three on-site educational sessions as very good or excellent. The participants stated that this aspect of the programme enabled them to better grasp the reality and health situations affecting the communities and put into practice a popular education and social determinants of health approach.

Participants valued the opportunity to experience popular education methodology in theory and practice. They noted that the course enabled them to see that it is possible to forge horizontal relations based on genuine solidarity through a redistribution of power. This propelled participants to rethink the traditional asymmetrical power relations that are the norm between health workers and communities.

• ‘ … we learned from what they had done, their experiences. Being able to put into practice what we learned with their constructive criticism. […] a very enriching learning experience.’ (SSMC, September 2015)

• ‘ … broaden our outlook, begin to work together with the community and not from the top down, get involved with their problems and feel part of them and thus be able to seek solutions together.’ (SSChiloé, March 2017)

• ‘ … spaces were generated for knowledge, sharing information, achieving mutual learning, brimming with new experiences.’ (SENADIS, June 2018)

• ‘ … it enables us to immediately put into practice the content we studied, as well as visualising even more clearly its importance.’ (SSChiloé, March 2017)

While participants valued practical fieldwork with the community, they expressed surprise at the health groups’ organisational capacity, revealing the verticality of their view. Previously, some participants had regarded local communities as lacking in knowledge – unable to engage in analysis, develop proposals, or implement actions.

• ‘The transparency with which they related to us, the ‘professional’ way they work, that was very serious, and they had good methodological training.’ (SSMN, October 2017)

• ‘The possibility of discovering experiences and knowledge that, for various reasons had been ignored. The women who accompanied us were teachers.’ (SSMN, October 2016)

Participants recognised that the course stimulates critical thinking and generates actions for health promotion work. However, they expressed frustration at being introduced to and becoming excited about methodologies they feel they don’t have the capacity to implement in their professional roles. Therefore, the course creates recognition of structures that sustain inequality, while also shedding light on health professionals’ lack of tools and authority to change the system they are immersed in.

• ‘These courses should be held with the heads [health care facility directors and mayors] so they can understand the issues and not put up so many obstacles that hinder our work.’ (SENADIS, May 2015)

• ‘That the approach seeks not only to understand its reality but to transform it.’ (SSMN, October 2017)

• ‘It was a week of profound reflection on issues that it's often not possible to have amid our everyday activities.’ (SSMC, April 2016)

Participants were also asked which educational sessions they liked best and which could have the greatest benefit for their work. The sessions most lauded by participants were: ‘Exploring designs: Participatory needs assessment’, ‘Learn about health through play’ (which uses EPES’ educational games), and ‘Exploring methodologies: Participatory evaluation’. These sessions offer concrete tools to carry out health promotion work and are easily reproducible at low cost. This underscores the need for health workers to gain practical skills and knowledge for working in the community; it highlights the need for them to apply the social determinants of health approach to professional practice.

• ‘I leave with the desire and ideas to undertake community work that is more fun without losing track of its purpose. I see my neighbourhood in all its dimensions and feel capable of recognising and incorporating psychosocial aspects into this work.’ (SSMN, October 2017)

• ‘ … it has been an enriching experience to become acquainted with community work as a vibrant practice that can have a high impact at the local level. I leave here happy and grateful for the experience with colleagues and the community groups we shared.’ (SENADIS, October 2014)

• ‘The methodology and hands-on experiences are the best ways to learn and understand the topics covered.’ (SENADIS, May 2015)

• ‘This experience has been transformative and has renewed my love of this profession. I would like more colleagues to be able to participate.’ (SSMN, October 2017)

• ‘Wonderful to understand other perspectives, the flexibility of the processes, although no less serious. Find an appropriate way, validate knowledge, horizontality, methodologies, learn by doing, super … all excellent!’ (SSChiloé, March 2017)

Regarding the overall view of the course, participants noted that five days of training is a short period for the complexity of the issues and diverse tools that are shared. They suggest extending the course, especially the field work with the community.

• ‘Although the methodology is very important for the learning process, I needed more time to carry out our field work. One hour to produce everything that we needed was very little.’ (SENADIS, June 2018)

• ‘Increase the times for planning and carrying out the community action.’ (SSMN, October 2017)

• ‘Continue deepening the theoretical-political aspects that underpin popular education, understanding the need to deepen those themes with the teams [staff of public health clinics], using the methodology.’ (SSMN, Oct, 2017)

Based on participants’ suggestions and opinions in their evaluations, as well as observations of the educational process, the following new sessions and content were incorporated in the most recent courses: ‘Participatory planning for health promotion work’ and ‘Perspectives and tools that highlight communication’.

Discussion

EPES’ courses offer a theoretical and methodological contribution to health practitioners’ understanding of the social determinants of health. They provide participants an opportunity to get out of their workplaces and go to low-income neighbourhoods – not as professionals providing services in a top-down manner, but as collaborators with EPES-trained health promoters to analyse and address issues in their communities. The experience has the potential to reorient the conceptual framework through which they view health problems and interventions.

While overall course evaluations were very positive, a factor that limits the training’s potential for impact is that participants often do not hold decision-making positions in health services and therefore are unable to implement some important aspects of what they have learned. For that reason, EPES often encourages clinics to send two employees to the training, so that together they might have more leverage in their organisations. Additionally, budgetary constraints and decisions mean that practitioners often don’t have time or materials allocated for community work.

Even if people with decision-making power attend EPES trainings, there are aspects of broader structures they do not have the power to control. These include factors such as international trade agreements, escalating prices for essential medications, and reduced funding for public health systems, all of which create the conditions affecting people’s health and wellbeing. Therefore, while evaluations show that training contributes to transforming health professionals’ mindsets and leads them to question their practices, educating practitioners does not change the underlying structures that generate poor health.

Intersection between EPES’ courses and structural competency

Literature on structural competency defines its core competencies in various ways (e.g. Metzl & Hansen, 2014). In this article we engage with a piece (Harvey et al., 2020, p. 1) that describes five competencies for global health education. We analyse the ways in which those competencies overlap with and/or complement the four competencies of EPES’ training courses, summarised in three common themes. (Table 1).

Table 1. Intersection between structural competency framework and EPES training.

Common Theme	Structural Competencies	EPES Competencies
How Structures Impact Health	(1) describe the role of social structures in the production and maintenance of inequalities in health at the international level	(2) identify how social, political, and economic structures generate and maintain health inequities (4) question the dominance of the biomedical model and explore other systems of health knowledge rooted in people’s own wisdom and life experience.
	(2) identify the ways structural inequalities are naturalised within the health field globally
	(3) discuss the impact of structures on global health practice.
Structural Interventions	(4) recognise structural interventions for addressing global inequities in health	(1) reflect on and propose interventions that incorporate a structural framework for health problems
Importance of Horizontal Relationships	(5) apply the concept of humility in the context of global health.	(3) discuss, create, and implement a work plan in cooperation with local organisations (4) question the dominance of the biomedical model and explore other systems of health knowledge rooted in people’s own wisdom and life experience.

How structures impact health

Both approaches question the dominance of the biomedical model in individualising disease and the narrative that naturalises biomedicine. Structural competency proposes an educational strategy for clinical training that helps reveal the reductionist nature of the biomedical framework. It puts more of an emphasis than EPES’ courses do on analysing the processes through which structural inequities come to be taken-for-granted.

Structural competency for global health education, as explained by Harvey et al. (2020), brings greater visibility and recognition of colonialism and racism as broad sociocultural factors affecting the institutional structures that sustain inequities in health. It also incorporates a broad view of international economic organisations and humanitarian aid agencies, which frequently represent the interests of industrialised countries while failing to respect the traditions, wisdom, and experiences of Global South communities.

In comparison, EPES’ courses are more proximate to lived experience, for example by highlighting access to schooling or clean water in the Power Walk. Nonetheless, the global context has always been present in EPES’ health promoter and health worker training. For example, in Figure 1, health workers are encouraged to look at the structural factors influencing the health of the overweight child in front of the computer, including international factors such as the impact of the fast-food industry. However, EPES’ training courses emphasise policies and practices that public health and community health workers can aspire to influence locally.

Structural interventions

Both approaches emphasise collective action. Structural competency identifies five levels of intervention: individual, clinical, community, national, and international. EPES courses focus primarily on individual and community levels. EPES’ broader work has encompassed national networks and policy, for example a successful campaign to impact Chile’s tobacco law (Chile Libre de Tabaco, n.d.). EPES has also participated in international networks such as ACT Alliance and the People’s Health Movement (People’s Health Assembly 2, 2005). EPES’ approach to intervention involves praxis, the interplay of critical reflection and action in working with social movements to promote justice. EPES develops materials that health workers and community health promoters can easily use – such as educational board, card, and domino games; generative theme drawings; and flyers. The games convey EPES’ conceptual framework (popular education, human rights, primary health care and health promotion, gender).

Importance of horizontal relationships

Structural competency uses the term humility, which appears to assume that the professional has more power than the patient and needs to engage in power-sharing. EPES sees people in communities as leaders and protagonists and honours their knowledge.

Overall, a major contribution of EPES’ training to structural competency is its methodology. EPES’ educational materials narrow the gap between a theoretical analysis and implementation of a social determinants of health framework, because they foster critical thinking and reflection concerning the context in which people live and conditions that affect health. EPES’ approach goes far beyond biomedical conceptions that reduce interventions to individual risk factors by contributing concrete participatory assessment and planning tools to undertake actions. Another major contribution is that EPES begins from a key principle of popular education: the importance of building horizontal relationships where everyone learns and everyone teaches. On-site sessions in EPES courses are led by health promoters, who guide participants in assessing community problems, developing action plans, and implementing them. Seeing organisations as the driving force of change, EPES creates organic, long-term links with social movements to strengthen collective action in poor neighbourhoods and to advance social justice.

Conclusion

In conclusion, by combining theoretical and experiential approaches to understanding popular education and the social determinants of health, EPES’ training model contributes a unique curriculum that equips participants to identify the role of structural factors in individual and community health, and to work collectively with local groups to address those factors.

We would like to see education on this topic be part of formal degree programmes, not only for doctors, but also for physicians’ assistants, nurse practitioners, and allied health workers, as well as government officials, clergy, and others in positions of power who make decisions impacting public health. Moreover, we recommend that the lenses of gender, human rights, and social determinants of health be addressed not just as elective or specialised courses, but mandatory across the curriculum in health-related fields. We believe this approach would strengthen structural competency training programmes and therefore more effectively promote justice in health.

Acknowledgments

The authors appreciate the excellent suggestions from the reviewers, as well as pivotal guidance from Carlos Piñones and Joel Ferrall. We are especially grateful for insightful feedback from Ronald Labonté, Christina Mills, Kathleen Vickery, and Claudia Guerra. Thanks go as well to our EPES colleague Jorge Olivares for his collaboration with the bibliography and to Maxine Lowy for translation from Spanish to English. Our deepest gratitude goes to the health promoters for sharing their experiences and vision as course teachers and inspiring us to contribute to building a society with greater justice and equity in health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Notes

1 EPES became an independent foundation in 2001.

2 Poblaciones are poor communities located on the margins of the city, where there are fewer resources, and which are regarded with less prestige.

3 Renato Castillo was a human rights activist who went into exile; the health group took on his name when he died to honor him and his sister, who was an original staff member of EPES.

4 While we are aware of and appreciate literature discussing the ‘social determination’ of health approach (Breilh, 2021; Harvey el. al., 2022), we have historically used the concept ‘social determinants’ in our work, so are using that term in this paper.

5 According to Harvey et. al. (2020), ‘the “structural determinants of health,” … refers to the policies, systems, and institutions that give rise to the conditions that constitute the social determinants of health. If the social determinants of health refer to “the conditions in which people are born, grow, live, work and age” (WHO About Social Determinants of Health, n.d.)—such as poverty, homelessness, unemployment, and inaccessible healthcare services—the structural determinants of health call for a more explicit analysis of the systems, policies, institutions, and social forces that shape—and unequally impose—those pathogenic social conditions.’

6 Our course evaluations are at the equivalent of an exempt level from ethics review because the subjects cannot be readily identified and any disclosure of responses outside of the research would not reasonably place the subject at risk.