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Working Alongside Us: Promotores de Salud Becoming Integral Partners for the U.S. Health Care System

Friday, February 14, 2020   (0 Comments)
Posted by: Crysta Maniscalco
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Written By: Alejandra Ferris, MA & Ruth Zúñiga, PhD

School of Graduate Psychology, Pacific University, Oregon

www. Pacific.edu/sgp

 

Alejandra Ferris and Ruth Zuniga will be presenting at the Western Forum for Migrant and Community Health in Sacramento on February 20th.

 

Promotores de salud (promotores), also known as community health workers, or lay health workers, are front line individuals whose roles respond to the disparities and exclusions that exist within health care systems (Early, Burke-Winkelmann, & Joshi, 2016). They are an asset in health care systems because they are trusted community members who have an unusually close understanding of the community they serve and can be a link between health care providers and systems, social services, and the community. Promotores have a personal commitment of service to their community and are recognized as natural helpers across the world (Stacciarini et al., 2012). They have experience-based expertise that allows them to establish rapport and trust from hard to reach populations. They can elicit responses from patients regarding symptomology as well as providing comprehension of communication from providers. Furthermore, they hold similar experiences and direct personal understanding of their community’s cultures, beliefs, norms, behaviors, and values (Martinez, 2015). In general, promotores facilitate access to services and improve the quality and cultural competency of service delivery (American Public Health Association, 2009). Though the work of promotores is not something new, very few healthcare centers and health partners know of their origins or the impact of their work. This paper presents the history of the promotores, the evolution of their responsibilities within health systems, and their impact on underserved and diverse communities.

 

 

 

 

The history of promotores is rooted in Latin America during the 1960s and 1970s and spread across the continent shortly thereafter. In the U.S., promotores’ work first began receiving attention with the passage of the Migrant Act of 1962 and, shortly thereafter, the creation of the Indian Health Service’s Community Health Representative program in 1968. This formal endorsement by the U.S. government facilitated the expansion of healthcare to underserved populations which included Native Americans as well as Latin American migrant workers. Previously, working as a lay health advisor, as it was more commonly referred to at the time, was an entry level position for career development. Over time, their roles continued to expand and, by 1994, the U.S. Centers for Disease Control and Prevention [CDC] further defined the lay health advisor role to include providing informal community-based health related services, as well as bridging health providers and persons in underserved communities (Ayala, Vazquez, Earp, Elder, & Cherrington, 2010). Additional recognition of community health workers came in 2005, when President Bush signed into law the National Patient Navigation Act which sought to establish more patient navigator programs across the country (Westrasmus, Pineda-Reyes, Tamez, & Westfall, 2012). In 2009, promotores were formally recognized by the U.S. Department of Labor’s Office of Management and Budget through provision of an occupational classification that placed them within the realm of community health and social services (Stacciarini et al., 2012). Then, the Affordable Care Act, signed into law by President Obama in 2010, authorized the advancement of community health workers to provide culturally and linguistically competent care. By 2011, the U.S. Department of Health and Human Services [HHS] Office of Minority Health’s [OMH] announcement of incorporating promotores de salud as part of their Action Plan to Reduce Racial and Ethnic Health Disparities further expanded the reach of their work, particularly to the Latinx population. Special attention was given to strengthening outreach and education for health services, as well as increasing insurance coverage to underserved populations, who may be underserved as a result of logistical barriers (e.g., lack of transportation) as well as systemic barriers (e.g., lack of providers) (U.S. Department of Health & Human Services Office of Minority Health, 2016; U.S. Department of Health & Human Services the Office of Minority Health, 2011). In the U.S., the work done by promotores continues to be acknowledged by the CDC, the National Institute of Health, and the American Medical Association to address ethnic health disparities and to improve patients’ outcomes (Stacciarini et al., 2012; American Medical Association, 2020).

 

On an international level, the World Health Organization [WHO] acknowledges community health workers as a vital part of primary care and have released guidelines that provide recommendations on how to best integrate them into the general health system and existing community structures. The guidelines intend to provide specific recommendations based on the literature available through identification of contextual elements that can influence policy development and implementation. The guidelines also suggest the tools needed to create and implement community health worker programs and acknowledges the need to assess priority evidence gaps that require further study. In an effort to address a health workforce shortage, maldistribution of resources, and performance challenges, WHO urges national health systems to adopt an approach that takes into consideration health system capacities and projected population increases by deploying community health worker programs (WHO, 2018).

 

Thanks to the changes in legislation, changes in health care, increased number of disparities in underserved communities, and increased recognition of promotores’ work, their roles have evolved across health systems. Promotores’ roles and responsibilities moved from including core roles related to cultural mediation, informal counseling and support, health education, to patient navigation, advocacy, and direct service provision. Promotores also are becoming more integrated into general health and behavioral health interventions which include health education, chronic disease self-management, diet and exercise, tobacco cessation, stress management, and referral to mental health services (Volkmann & Castañares, 2011). Additionally, they are now also supporting other determinants of health such as housing, education, employment, and food or income insecurities that may impact patients access to care or disease management (Belcazar et al., 2011). Numerous studies over the last decade demonstrate that promotores help improve patients’ outcomes, such as diabetes, cardiovascular disease, and depression, and help reduce costs to healthcare systems (Laderman & Mate, 2016). For example, studies show that including promotores to the care team reduces health care costs, with the health care settings saving $2.30 for every $1 it invests in promotores (Findley, Matos, Hicks, Chang & Reich, 2014).

 

Originally envisioned as integral members of the national health care teams working to meet the needs of underserved populations, promotores are in a unique position to help fill the gaps of inequitable service delivery. Promotores can intervene with underserved population and migrant communities because typically they are community members that are similar to their patients. In addition, their knowledge of the culture, geography, history of country of origin of their patients, awareness and understanding of immigration and documentation issues, and an ability to emphasize leadership, activism, and advocacy, contributes to their impact (Manetta, Stephens, Rea, & Vega, 2007).

 

The practice of working with promotores has evolved to becoming a critical part of a health care team, especially for migrant communities, as promotores help patients address social determinants that others in health care settings are unable to address due to lack of expertise,

time, and/or resources. Additionally, they are able to establish trusting relationships and address barriers in culturally and linguistically appropriate ways. With the increased recognition afforded to community health workers worldwide, it is upon us as healthcare providers to tap into our local grassroots organizations housing the promotores. In collaboration with them, the goal of reducing health care disparities and improve service delivery to marginalized and especially migrant communities is made feasible. If we are committed to ensuring access for all, promotores are a necessary tool and resource for providers to partner with.

 

About the Writers

 

 

Alejandra Ferris, MA, is a third year doctoral-level student at Pacific University's School of Graduate Psychology. Her studies are health-focused and she is a member of "Sabiduria" Pacific University's Latino Psychology Emphasis. She has worked with Dr. Ruth Zuniga and Providence Community Health to develop a curriculum for emotional health and wellness trainings aimed at promotores de salud in the Latinx community to help increase their knowledge of mental health and culturally appropriate resources as well as promote the reduction of stigma. Originally from Venezuela and raised in Miami, FL, Alejandra is passionate about reducing health disparities in the Latinx community.

 

 

 

Dr. Ruth Zúñiga is a professor, licensed psychologist and the director of the Sabiduría: Latinx psychology emphasis at the School of Graduate Psychology at Pacific University in Oregon. She is also a clinical supervisor at the Pacific Psychology and Comprehensive Health Clinic, an agency focused on serving the mental health needs of immigrant and Latinx community. Her research and practice focus on integrated health care, diabetes management, cultural resiliency, cultural adaptation of mindfulness, and rural, community and Latinx psychology and mental health. Dr. Zúñiga has been serving, teaching, researching the subjects of Latinx mental health and has been working with the Latinx community for over 10 years in trauma, chronic disease management, and overall mental health concerns.

 

 

 

References

  1. American Public Health Association. (2009). Support for community health workers to increase health acces to reduce health inequities [Policy brief]. Retrieved from http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/09/14/19/support-for-community-health-workers-to-increase-health-access-and-to-reduce-health-inequities
  2. Ayala, G. X., Vazquez, L., Earp, J. A., Elder, J. P., & Cherrington, A. (2010). Outcome effectiveness of the lay health advisor model among Latinos in the United States: An examination by role. Health Education Research, 25, 815–840. http://dx.doi.org/10.1093/her/cyq035
  3. Belcazar, H., Rosenthal E. L., Brownstein J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health 101(12), 2199-2203
  4. Early, J. O., Burke-Winkelmann, S., & Joshi, A. (2016). On the front lines of prevention: Promotores de salud and their role in improving primary care for Latina women, families, and communities. Global Journal of Health Education and Promotion, 17(2), 55–86. http://dx.doi.org/10.18666/GJHEP-2016-V17-I12-7130
  5. Findley, S., Matos, S., Hicks, A., Chang, J. & Reich, D. (2014). Community health workers integration into the health care team accomplishes the triple aim in a patient-centered medical home: A Bronx tale. Journal of Ambulatory Care Management, 37(1), 82-91. 10.1097/JAC.0000000000000011
  6. Henry, T. A. (2020, January 6). How community health workers can help improve outcomes, cut costs. Retrieved February 7, 2020, from https://www.ama-assn.org/practice-management/payment-delivery-models/how-community-health-workers-can-help-improve-outcomes?fbclid=IwAR3XkxUAZxDEn0_KwSBdTgy91_SZ7wrm0CX9oFQrxmgfdyaRvlM_HL_a5Nw
  7. Laderman, M. & Mate, K. (2015). Community health workers for patients with medical and behavioral health needs- Challenges and opportunities. Healthcare, 4(2016), 145-147. http://dx.doi.org/10.1016/jjhdsi.2015.07.007
  8. Manetta, A., Stephens, F., Rea, J., & Vega, C. (2007). Addressing health care needs of the Latino community: One medical school’s approach. Academic Medicine, 82(12), 1145–1151.
  9. Martinez, G. (2015). Stories from the field: My experience as a promotora de salud. Journal of Ambulatory Care Management, 38(3), 209-210. DOI 10.1097/JAC.0000000000000094
  10. Stacciarini, J.-M. R., Rosa, A., Ortiz, M., Munari, D. B., Uicab, G., & Balam, M. (2012). Promotoras in mental health: A review of English, Spanish, and Portuguese literature. Family & Community Health: The Journal of Health Promotion & Maintenance, 35, 92–102. http://dx.doi.org/10.1097/FCH.0b013e3182464f65
  11. U.S. Department of Health & Human Services Office of Minority Health. (2016, Sept 29). HHS Promotores de Salud Initiative. Retrieved from https://minorityhealth.hhs.gov/omh/content.aspx?ID=8929
  12. U.S. Department of Health & Human Services Office of Minority Health. (2011, May 18). HHS announces promotores de salud initiative. States News Services. Retrieved from http://link.galegroup.com/apps/doc/A256724669/AONE?u=s8865459&sid=AONE&xid=cbda20fe
  13. Volkmann, K., & Castañares, T. (2011). Clinical community health workers linchpin of the medical home. Journal of Ambulatory Care Management, 34(3), 221–223. http://dx.doi.org/10.1097/JAC.0b013e31821cb559
  14. WestRasmus, E. K., Pineda-Reyes, F., Tamez, M., & Westfall, J. M. (2012). Promotores de salud and community health worker: An annotated bibliography. Family & Community Health: The Journal of Health Promotion & Maintenance, 35, 172–182. http://dx.doi.org/10.1097/FCH.0b013e31824991d2
  15. World Health Organization. (2018). WHO guideline on health policy and system support to optimize community health worker programmes (ISBN 978-92-4-155036-9). Geneva: Author.

 

 

 

 

 

 

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