Promotoras: A community model with heart — and teeth - Generocity Philly

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Jun. 10, 2020 1:06 pm

Promotoras: A community model with heart — and teeth

The first of a five-part look at whether the distinctive Latinx immigrant community health and advocacy model will survive — or thrive — in the time of COVID-19.

Promotoras at Puentes de Salud in 2013.

(Photo courtesy of Matthew O'Brien)

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If 16% of all Latinxs living in the U.S. lack health insurance, 42% don’t regularly see a healthcare provider or doctor, and a general mistrust of medical professionals is commonplace, how do you make sure that the most marginalized members of that demographic have access to health and wellness efforts?

Promotoras are one way Latinx communities self-ensure that immigrant, working-class and non English-speaking folks in their neighborhoods aren’t shut out.

Promotoras are community health workers who perform outreach on a multitude of levels; making house calls, hosting events and classes, and sometimes creating gathering spaces that build community beyond health questions.

Latinxs traditionally face several health barriers in America, including distrust, lack of transportation and lack of insurance, according to CREA Results, a Latinx research and resource center.

A lack of Spanish-speaking healthcare providers is also a huge obstacle for Latinx communities, said Allison Squires, an associate professor of nursing at New York University who co-authored a study on promotoras.

“We do not have enough Spanish-speaking healthcare providers in the U.S., period,” Squires said. “One of the key things that promotoras bring is those language and cultural interpretation skills.”

Most promotoras are long-standing members of their communities and are respected prior to becoming community health workers —which eliminates the need for them to build trust the way outside healthcare providers may have to. They are also located within their community and provide health and wellness information for free, or at a reduced rate, making their services accessible for people who may not have access otherwise — like undocumented immigrants who are ineligible for Medicaid or insurance under the Affordable Care Act.

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Promotoras help people in their community stay up-to-date on medication, make sure they’re going to their appointments and answer specific questions about treatment.

“They are very helpful for doing what I would call triage monitoring,” Squires said. “That gives promotoras a cultural entrée that many professional health workers might not have.”

The California public health organization Visión y Compromiso describes promotoras as providing “servicio de corazón,” or heartfelt service, a characteristic which the organization says sets them apart from outside healthcare resources. The National Latina Institute for Reproductive Health writes that promotoras are friendly, good listeners and people who like people.

Matthew O’Brien, associate professor of medicine and preventative medicine at Northwestern University, said because promotoras have good social skills and cultural understanding, they are often able to help people in ways conventional healthcare providers cannot.

“As a doctor, I’ve got seven minutes with that person,” he said. “Promotoras are part of the communities that they serve and they really understand the issues in the community. It’s just a more caring, personal type of relationship.”

Promotoras also act as activists for more and better resources for the populations they serve and provide information about how to contact lawmakers and politicians.

“A lot of the people who gravitate toward this role are already community leaders and have a lot of connections in nonprofit organizations,” O’Brien said. “It’s naturally a group of people who are really passionate about improving their community and many of them are also interested in change at a higher policy level.”

“That’s one thing I love about the promotora model,” O’Brien added. “It’s not relying on the doctor and it’s not relying on the ivory tower health system. It’s actually empowering communities to address their own health problems.”

From Latin America to U.S. Latinx communities

The promotora model has been a staple in Latin America since the 1950s, where it originated as a way for women to get information about reproductive health from other women they trusted, according to NLIRH.

In the 1980s and ‘90s, many Latin American countries were coming out of civil wars and other conflicts. This unrest led to a lack of stability in many countries, a state in which promotoras and other community-based healthcare initiatives thrived, said Steven Larson, an associate professor of emergency medicine at the University of Pennsylvania who studies health in Latin American communities.

A gathering of “popular legal promotoras” in the municipality of Hortolândia in the state of São Paulo, Brazil. The promotora model in this instance focuses on women providing guidance on justice and legal issues in the community. (Photo by Ana Perugini, CC BY-NC-SA 2.0)

“You had these Western trained doctors and nurses and healthcare providers, who had no resources,” he said. “It’s obviously unsafe, because it’s a war and these guys are on the front lines. What they had to do was stop the conventional, Western way of thinking about healthcare, and retrace steps back to basics.”

Now, promotoras are a near ubiquitous part of the Latin American healthcare system, said O’Brien, who co-authored the study with Squires when he was a professor at Temple University. In lower-income areas investing in doctors is expensive, so countries like Cuba hire promotoras, who have been found to be extremely effective alternatives to conventional, more expensive healthcare.

As early as the 1960s, promotoras began working in the United States, where they shared information about liver disease, asthma, diabetes and other health problems Latinx people face at a high rate, as well as general and reproductive health.

The impact of the original reproductive health promotoras is still felt today. In the United States, about 80 percent of community health workers are women, and, though other communities use similar models, about one-third of community health workers are Latinx, according to NLIRH. Planned Parenthood also continues this work with its own promotoras program, which trains promotoras across the country.

The 1980s brought an influx of Mexican agriculture workers to the United States, and a period of economic prosperity in the United States in the ‘90s expanded the need for labor in urban areas for restaurant work and other low paying jobs, Larson said.

“That’s the Latinx community we take care of,” added Larson, who is also the executive director of Puentes de Salud. “That’s where the promotoras come in.”

Their role, he said, is really valuable.

In early days, the promotora model spread through Texas and the West Coast, primarily serving migrant farmworkers and cities with large Latinx populations, but today promotoras are active in all 50 states and Washington D.C.

Now, promotoras are used to ease other information barriers in Latinx communities, like Santa Ana College in California, which uses promotoras to help parents prepare their children for higher education.

Gauging the effectiveness of the model

There has been significant research on the impact of promotoras in Latin America and beyond.

Promotoras in Georgia improved access to health services for 75 percent of the people they interacted with, and healthcare providers reported they were able to give better service due to the promotoras’ efforts, a University of Georgia study found.

The model is also recognized by the CDC as an effective way to spread health information to Latinx communities.

In Arizona, a survey of Latinx parents who attended a promotora-led workshop on alcohol abuse showed parents understood the consequences of alcohol use better and appreciated the cultural understanding of promotoras. This survey was used to recommend better funding for promotoras and more promotora training.

“There’s really a good evidence base that these types of programs work, and the model really does have teeth,” O’Brien said.

The model is also recognized by the Centers for Disease Control and Protection as an effective way to spread health information to Latinx communities. The CDC includes promotoras in at least 10 health initiatives that seek to educate the Latinx community living in the United States on issues like the Zika virus, cervical cancer and high cholesterol, and advocates for the use of promotoras to spread health information across the country.

Promotoras have been especially effective acting as a bridge to the healthcare system, Squires added.

“When it’s done well, promotoras are part of the healthcare team,” she said. “The key thing is that they are integrated into the community health team overall that includes professionals and administrators and patient advocates.”

Promotoras in Philadelphia

More than 15 percent of Philadelphia’s population is Latinx and at least 150,000 Philadelphians speak Spanish, according to the U.S. Census. That number is growing, and more than a third of immigrants living in the city are from Central or South America, according to the Pew Charitable Trusts.

A number of local organizations employ the promotora model. The Alzheimer’s Association’s Delaware Valley chapter, which has regional offices in Southeastern Pennsylvania, Delaware and South Jersey, has volunteer promotoras doing educational outreach about the high risk of dementia in elderly Latinxs.

In this five-part, bilingual series, Generocity will look at two Philadelphia organizations that use the promotora model: Puentes de Salud, the community organization co-founded by Larson and O’Brien that provides health and education resources for South Philadelphia’s large Latinx population, and the New Sanctuary Movement of Philadelphia, a nonprofit that aims to improve community and resources for Philadelphia immigrants and uses the promotora model to develop leadership and advocate on community justice issues rather than health concerns.

New Sanctuary Movement’s promotores (spelled with an ‘e’ for gender inclusivity) are in their second year of justice-centered work. (Graphic from the New Sanctuary Movement blog)

This five-part series will examine, in particular, how these organizations are pivoting to adapt to the specific impacts of the COVID-19 pandemic on the communities they serve; how the promotoras are being deployed and to what effect; as well as the ways technology is being incorporated into the promotoras’ practices.

In addition, the series will examine how Philadelphia foundations and funding sources have responded to, and measured the community impact and effectiveness of, the local promotora model.

At the conclusion of the series, we will look at other community-based models that, while similar in intent to the promotora model, have emerged from distinct cultural traditions and been shaped by the specific needs and cultural dynamics of their respective immigrant communities (African, Asian) in the Philadelphia area.

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