Promotores: Vital PRC Partners Promote Nutrition and Physical Activity
In Latino Neighborhoods, Community Health Workers Develop Professional Skills while Assisting PRC Research
In a free community exercise class associated with a study by the San Diego Prevention Research Center (PRC), Lupita Guzman lost 18 pounds in 18 months. The experience inspired her to become a community health worker, or promotora in Latino neighborhoods, for the center’s research project, Familias Sanas y Activas (Healthy and Active Families). Now Ms. Guzman teaches her neighbors how to be fit and healthy, and the PRC assesses how well the promotora-led classes help residents control their weight, blood pressure, and risk of chronic diseases like diabetes.1 Ms. Guzman—who lives in Chula Vista, California—is already convinced of the benefits promotores bring to a neighborhood: residents gain easy access to accurate wellness information and can participate in free, fun exercise.
“When I was taking this exercise class, the promotora leading it encouraged me to become a promotora myself,” she added. “Now I encourage the people in my own class.”
After becoming a promotora, Ms. Guzman became certified to teach aerobic exercise that combines Latin-style music, dance, and other movement.
“We want to give the promotores opportunities to grow, too,” added Carolina Huerta, RN, MPH, research core intervention coordinator for the San Diego PRC. “Once promotores start leading classes, they may want to become certified instructors or trainers. We can help them with some of the requirements in achieving their goals.” –
Through a range of similar relationships with PRCs working in other Latino communities, promotores provide benefits to communities and PRC researchers alike. In return, promotores gain valuable skills and opportunities for career development.
Promotores Assist Researchers
“Promotoras are members of our research team,” said principal investigator Joseph Sharkey, PhD, MPH, RD, at the Texas A&M Health Science Center PRC. “They help identify research questions and develop pilot tests, assist in fact-checking and verification of data, and help make sure our language and approach are correct for a particular community.”
The success of an entire research project often depends on having the promotoras collect the data, Dr. Sharkey said, recalling a recent study of 100 mother-child relationships. Data were collected from 50 mothers and their children four times, and twice from 50 additional mother-child pairs. Because the promotoras had connected with the study participants on a personal level, helping them feel comfortable and engaged in the research, the promotoras were welcomed into participants’ homes, and only three participants dropped out of the research project.
“Promotoras were able to recruit willing participants and keep them involved throughout the study,” said Dr. Sharkey. “And because they were known and accepted by the participants, the promotoras could perform food inventories in participants’ homes, help them with recall surveys of eating habits, and identify other factors that contribute to a community’s access to healthy food, which is a major topic of study at our center.”
“I have always said that being a promotora is not a job—it’s a passion,” added María Dávila-Castillo, a promotora in South Texas who helps the Texas A&M PRC. “I work to give mothers a voice about the health needs of their families, and I let them know that their experiences are important and make these studies possible. In return, the families give me strength and motivation to continue this work.”
Dr. Sharkey emphasizes that promotoras’ feedback helps the researchers shape a study and reveals community conditions. In another study of residents living in US-Mexico border communities, or colonias, of South Texas, the promotoras went door-to-door with a 12-page survey on food access and completed 610 surveys. When the promotoras met with the entire research team to discuss their experiences, Dr. Sharkey learned how serious food insecurity—or having unreliable access to nutritious food—was in the colonias. Some parents said they were not able to feed their children adequately for days at a time, and the promotoras asked to be equipped with emergency food supplies, in case they encounter a family in extreme need. From this project, the researchers found that nearly 80% of participants regularly had experienced food insecurity, and in half the surveyed households, parents had severe difficulty feeding their children. The population in the colonias is rapidly expanding, and the researchers expect food access issues to worsen.2 Gaining this knowledge may influence the researchers’ future activities and help them inform local and federal decision-makers who determine the best ways to offer aid.
Promotoras also bring insights investigators might miss, Dr. Sharkey said. During the study of food access, the promotoras informed the researchers about nontraditional food sources. Some colonia residents buy food at pulgas—or local flea markets, operate small booths in a front yard, or sell items from their homes for a few hours each week.
“We included these sources of food because they were brought to our attention by the promotoras,” said Dr. Sharkey. “The small stores—or tienditas—and pulgas are now part of the overall food access strategies we have been mapping in our research. Much of what we have found was not described in the literature before.”3
Promotores Receive Training
Workplaces using promotores’ services range from medical offices, health-related agencies, and hospitals to community centers and universities. Promotores, whose skills and knowledge determine where they work, must meet any certification requirements established for their area.
In Texas, employers may require promotores certified by the Texas Department of State Health Services (DSHS). The PRC at Texas A&M is certified by DSHS to give this training, and staff often travel to South Texas to offer courses that fit the promotores’ schedules.
For initial certification, promotores must complete 160 total contact hours, including 20 hours in each of eight core competencies: communication, interpersonal relations, service coordination, capacity building, teaching, organization, health knowledge, and advocacy. Promotores who were working before the state established its certification program must have worked 1,000 or more hours as a community health worker (CHW) between 2006 and 2010 to be excused from the initial certification training requirement. Every two years after certification, promotores must earn at least 20 continuing education units (CEUs), at least 10 of which are certified by DSHS.
“The training promotes self-efficacy among both promotores and residents,” said CHW instructor Julie St. John, MA, MPH. “And more and more employers are requiring certification for community health workers, so we are meeting their need as well.”
Ms. St. John estimated the PRC has trained 750 CHWs since 2001 and provided more than 51,000 hours of training. The center also has provided 2,200 DSHS-certified CEUs since it was first authorized to do so in the summer of 2010.
New Training Traditions
In addition to a bilingual Spanish-English certificate program developing for promotores at a local community college, the San Diego PRC has worked with a local agency for the past two years to provide the Adelante Promotores (Community Health Workers Moving Ahead) Conference. In 2011, the center collaborated with additional partners, including the California Department of Public Health-Office of Binational Border Health—and added a second conference day for agency representatives and promotores. The conference was held October 6 and 7, during Binational Health Week and Border Binational Health Week. The conference attracted 230 CHWs and agency representatives as participants. On the first day, a speaker from the U.S. Department of Health and Human Services explained the new national Promotores de Salud Initiative, designed to raise awareness about the benefits of CHWs and support their efforts nationwide. Workshops for CHWs were given on wellness, advocacy, outreach, job search strategies, communication and presentation skills, conflict resolution, prevention and control of chronic diseases, and setting professional goals. On the conference’s second day, agency representatives joined panel discussions and heard presentations by CHWs and by community agencies about how they incorporate promotores into their programs, while CHWs received a three-hour training on mental health.
“Last year, many promotores attending the annual conference told us in their evaluations that they wanted a two-day event and longer workshops to help them develop skills more fully,” said Lisa Hoffman, MA, the San Diego PRC’s managing director and community liaison. “So this year’s conference was broadened to include a second day with an intensive training session for promotores.”
Community Advocacy Training
As part of the research project, Accion Para La Salud (Action for Health), staff at the University of Arizona PRC teach promotores how to work with their communities to change neighborhood environments to promote good health. The center held four workshops with promotores and their supervisors over a one-year period and has continued to give support through technical assistance, advocacy tools, and peer-network support calls. The promotores identify community needs and plan a step-by-step approach to leading community change. To understand the impact of the promotoras' advocacy work, researchers are tracking the changes the promotoras make through their community projects.
“The idea is to give the promotoras additional skills to engage their communities to make change happen,” says project director Maia Ingram, MPH, who also is the deputy director of the Arizona PRC. “These are advocacy projects that the promotoras and their communities develop themselves. They use strategy maps to plan and chart their progress, and we stand by to offer ideas and assistance.”
Alicia Sander is one promotora advocating for change in transportation. In Nogales, Arizona, where she lives and works, bus service is very limited. Ms. Sander is recruiting residents for a campaign and training them to present their case to the city council. Ms. Sander attends city council meetings and is gathering evidence on why expanded bus service is needed.
“We have to know the right way to ask for what we need,” said Ms. Sander, who also works at the Mariposa Community Health Center, teaching clients about diabetes, nutrition, and good health.
In Cochise County, two promotoras working for the health department are building connections between the community hospital’s emergency staff, sheriff’s department, and other local partners to help residents who experience domestic violence find help at a local shelter. The project requires the promotoras to identify all the public services that may refer residents to the shelter, understand referral procedures and eligibility requirements, and know how to arrange transportation and child care for shelter clients.
“The shelter has a great playground, but no one is available to watch the children when mothers need to get to a job interview or another appointment,” said Marilyn Godfrey, an educator and program director at the Cochise County Health Department.
The promotoras approached churches and schools and emphasized the benefits of getting involved.
“Churches may be looking to start new ministries or community outreach projects,” Ms. Godfrey added, “and students planning careers in early childhood development may be looking for work experience. To find the resources we need to be successful, we try to be creative. If we can help promotoras develop the skills they need to become community advocates, they can continue to improve conditions in their neighborhoods.”
Added Interest from CDC
In February 2011, CDC established a work group to identify best practices for using CHWs, find ways to offer support, propose policies that could expand the use of CHWs, and make training available through e-learning formats on a web-based portal.
“Whether you call them promotores, community health workers, lay health workers, or one of the 57 other names for them we have identified, these people have been on the job for decades,” said Bernadette Ford Lattimore, co-leader of the CHW work group. “We want communities to take advantage of the health improvements and cost-effectiveness that community health workers can provide.”
Researchers have shown that CHWs help patients follow their medication regimens.4 Other studies have shown a cut in Medicaid costs when CHWs helped connect residents with local support services.5 Promotores also interact with patients one-on-one and offer health education and supportive services that don’t need a physician’s time. CDC’s CHW work group plans to coordinate effectiveness evaluations of CHWs working in health care systems and participating in community services; then the work group will disseminate the results of these studies.
“Some states are leading the way in creating policies to provide and sustain the services of community health workers,” Ms. Lattimore added. “We want the work group to help this process so more communities can make the most of what CHWs have to offer.”
1. Ayala GX, Elder JP, Patrick K, Arredondo E, Ji M, Marshall S, McKenzie T, Nichols J, Sallis J, Talavera G. Effects of a promotor-based intervention to promote physical activity: Familias Sanas y Activas. American Journal of Public Health 2011;101(12):2261–8. Article available at: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2011.300273 [PDF - 1.26MB]
2. Sharkey JR, Dean WR, Johnson CM. Association of household and community characteristics with adult and child food insecurity among Mexican-origin households in colonias along the Texas-Mexico border. International Journal for Equity in Health 2011;10(1):19.
3. Dean WR, Sharkey JR, St. John J. Pulga (flea market) contributions to the retail food environment of colonias in the South Texas Border Region. Journal of the American Dietetic Association 2011;111(5):705–10.
4. Brownstein JN, Chowdhury FM, Norris SL, Horsley T, Jack L, Zhang X, Satterfield D. Effectiveness of community health workers in the care of people with hypertension. American Journal of Preventive Medicine 2007;32(5):435–47.5. Felix HC, Mays GP, Stewart MK, Cottoms N, Olson M. Medicaid savings resulted when community health workers matched those with needs to home and community care. Health Affairs 2011;30(7);1366–74.