Got Hispanic Clients? Get a Promotora?

Promotora Linda welcomed the ten diabetes self-management members to her class, smiled and asked: "Who can tell me what the pancreas does?” Two hands immediately shot up in the air. Promotora Linda called on a middle-aged heavy-set female, who answered: "The pancreas makes the insulin that keeps your blood sugar down.” Promotora Linda proudly responded: "That is right Maria, and I will now pass around a plastic model of a pancreas.” Similar scenes are taking place throughout the US in ever-growing vulnerable Hispanic communities that are being ravaged by diabetes.

Allied health professionals need to know about the role of promotoras because of the widespread use of promotoras in the US. Furthermore, understanding the role of promotoras will allow allied health professionals to work with promotoras to improve rehabilitative care for Hispanic clients recovering from sequelae of diabetes like blindness, strokes and amputations. Becoming familiar with the attributes or characteristics that define the role of promotoras, like Linda, can allow allied health care professionals to work with promotoras to design and deliver evidence-based, cost-effective, culturally competent care to vulnerable Hispanic communities.

Promotoras, have become key healthcare team members in Hispanic communities because they bring cultural competence to formal healthcare services, like those provided by allied health professionals. Promotoras are indigenous community healthcare workers who link vulnerable Hispanic communities with vital healthcare services to facilitate lifestyle changes. The 2004 Center for Disease Control community health advisor database listed profiles of over 200 programs representing more than 10,000 community health workers. Thirty-eight of these programs are being operated on the US-Mexico border, where the term promotoras, is the preferred way that is used to identify community health advisors or community health workers.

Promotoras impact the health outcomes of vulnerable Hispanic communities by increasing the cultural competence of healthcare services. Promotoras originate from and specifically serve their own Hispanic Spanish-speaking communities. The communities may be rural or urban. A strong sense of interdependence, family values and collectivism prevails in these communities. Promotoras are able to increase the cultural competence of formal health care services through the critical characteristics or attributes that define their role: 1) community co-sanguinity, 2) healthcare bridge, 3) culture broker, 4) appreciation for and involvement with the healthcare system, 5) credibility among the community, and 6) trust.

Community co-sanguinity is the most important characteristic or attribute that defines promotoras. Community co-sanguinity is the non-judgmental sharing of common ties in all dimensions: physical, ethnic, linguistic, cultural, disease process, residence, income, values, and community ownership. Community co-sanguinity is the foundation of the strong bond between promotoras and the community they serve. It is perceived as a dichotomous variable: it is either present or it is not.

Healthcare bridge is another attribute that defines the role of promotoras. Promotoras function as healthcare bridges between a vulnerable Hispanic community and the formal healthcare system to improve health. The awareness of vulnerable Hispanic community healthcare concerns, coupled with an appreciation for the potential benefits of formal healthcare, are pivotal themes in promotora-mediated endeavors. It is the ability and willingness of promotoras to link vulnerable Hispanic community members with the formal healthcare providers that make their role indispensable to society. The act of bridging may take many forms to include: referrals to formal healthcare providers, community member education, follow-up counseling, and role modeling of behavior.

Culture broker is another critical attribute that defines promotoras. Brokerage refers to the process of negotiation between different cultures. This negotiation is critical for positive healthcare outcomes in vulnerable Hispanic communities with a minority of Hispanic providers. The innate cultural knowledge that promotoras provide is negotiated between the vulnerable Hispanic community members and the formal healthcare system providers. Different cultural and professional values are brought to light and acceptable reprioritization is made through promotoras’ first-hand knowledge of community concerns. This is how promotoras, as indigenous community lay workers who serve as cultural bridges between the formal healthcare system and vulnerable Hispanic communities to improve health and hold great promise to ameliorate health disparities like diabetes.

An important attribute that defines the role of promotoras is their appreciation for and involvement with the formal healthcare system. Promotoras value the contribution of the formal healthcare system to the health of vulnerable Hispanic community members. Furthermore, promotoras believe in the benefits of contemporary scientifically-based medicine to include diagnostic tools, medication and procedures that are intended to improve health.

Credibility is another important attribute that defines the role of promotoras. Promotoras are successful in their role by achieving credibility in the eyes of: 1) the formal healthcare providers who service the vulnerable Hispanic community and 2) the vulnerable Hispanic community members. Formal training and certification programs for promotoras increase their credibility in the eyes of the formal healthcare system providers. These certification programs ensure that the information that promotoras share with community members is based on research and is aligned with standards of practice. Formal training and certification programs for promotoras also establish the foundation for much-needed resources for the promotoras within the formal healthcare system. Furthermore, certification programs pave the way for promotoras to be able to clarify their questions and expand their knowledge base in relation to healthcare. In contrast to formal healthcare system providers, community members often do not see formal training and certification programs as a mandatory process for promotoras’ credibility.

Trust is a defining attribute of the role of promotoras that is present in the following dimensions: 1) two-way trust between the promotoras and the formal healthcare system and 2) trust between the vulnerable Hispanic communities and the promotoras. The trust is based on healthcare values and beliefs.

Trust between the formal healthcare system and the promotoras comes from the structured and legitimized training of the promotoras to deliver services that they are trained to offer. The trust also comes from seeing that promotoras are not a threat to authority, but are instead potentially valuable members of the healthcare team who reach out to vulnerable Hispanic communities. The promotoras’ trust for the formal healthcare system is contingent upon evidence that the formal healthcare system genuinely prioritizes the interests of vulnerable communities.

The formal healthcare system must honor all promises that are made to vulnerable Hispanic communities and promotoras, in order for the trust to be established and maintained. It is essential that formal healthcare system providers listen to the concerns that promotoras may raise, as well as include them in community health improvement plans. Formal healthcare system payment for services that are rendered by promotoras demonstrates concrete appreciation for their role as valued employees. This deepens the trust between promotoras and the formal healthcare system providers. Public expressions of respect, by formal healthcare system providers, for the valuable role services that promotoras provide, also deepen the trust between promotoras and the formal healthcare system.

Trust between the promotoras and vulnerable Hispanic communities hinges upon the prolonged physical presence of the promotoras in the communities. The lived-experience of the promotoras, that results from their prolonged physical presence in the vulnerable Hispanic communities, results in many shared moments of common pain and joy. The genuine empathy that promotoras express for the members of vulnerable Hispanic communities translates into trust regarding healthcare issues. The promotoras also earn this trust through their positive role modeling that is often transmitted by word of mouth among members of vulnerable Hispanic communities. Allied health professionals can capitalize on the role of promotoras with its defining characteristics or attributes to achieve optimal health outcomes for their vulnerable Hispanic clients.

The outcomes of collaborating with promotoras are: 1) potential change in the health of vulnerable Hispanic communities and 2) new partnerships between the healthcare system and vulnerable Hispanic communities. The change in the health of vulnerable Hispanic communities can be captured through effective evaluation of the programs that use promotoras, as well as client satisfaction questionnaires and quantitative studies. The partnerships with the formal healthcare system emerge as a result of the empowerment by the formal healthcare system of the promotoras to improve health.

Several steps can be taken by allied health professionals to integrate promotoras into their team. The first step involves analyzing the demographic profile of their clients to identify the need for promotoras. Once the need for promotoras has been validated, allied health professionals need to: 1) develop agency-specific policies and job description for promotoras and 2) contact promoter state-certification programs in their home state to recruit their graduates. The Planned Parenthood "A Guide to Promotora Programs” (2004) is an excellent resource for examining: promotoras roles and functions, examples of successful programs, as well as guidelines for initiating promotoras programs. To date, only Texas, Ohio and Alaska have community health worker or promotora certification programs. However, as the need for promotoras is acknowledged, it is anticipated that more certification programs will be developed.

Promotoras have many implications for allied health professionals as well as all health care providers. Models need to be adapted or synthesized so that they may be used by healthcare providers to identify applicable, mutually beneficial guidelines for the use of promotoras. Interventions need to be developed and tested to maximize the empowerment of promotoras and the vulnerable Hispanic communities they serve. Allied healthcare professionals can and should take an active role in shaping the expanding role of promotoras. This can be done by integrating the definition and role of promotoras into the entry-level curriculum of all healthcare system disciplines and professions. Doing this will acknowledge promotoras as valuable members of the healthcare system team because of the vital bridge they establish between the healthcare system and vulnerable Hispanic communities.


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