Promotoras Voice Their Challenges in Fulfilling Their Role as Community Health Workers

Setting

Lazos Hispanos is a community-based participatory research program that started in 2017 to respond to the challenges faced by members of the Latinx community in the Southeastern part of the United States: high cost of services, fears related to the immigration status of family members, restricted transportation, limited English language skills, and lack of awareness of free or low-cost community services (Calva et al., 2020). To address these problems, volunteer promotoras were invited to participated in the program. They served as a bridge between community members and social and health service providers in the community, without focusing on any specific disease or social condition. Their main role was to contact members of their communities and offer their support to connect them with needed services. During their first year of the program, the promotoras completed 78 hours of training related to competencies for CHWs: community leadership, effective communication, empowerment, group dynamics, conflict management, and goal and boundary setting (Matthew et al., 2020; Rosenthal et al., 2016).

Theoretical Background

This study is framed by two theoretical frameworks: intersectionality and resilience. Intersectionality examines how multiple levels of oppression interact and how the structural systems of privilege and oppression (e.g., sexism, racism, classism) at the societal-level support inequality (Bowleg, 2012; Collins & Bilge, 2016). In their work, promotoras faced unique and frequently overlapping challenges related to gender (being a woman), ethnicity (being Latina), income (living in low socioeconomic conditions), immigration (having family members with different immigration status), and geography (residing in a state that does not support immigrants or low-income individuals; having family members dispersed between the United States and their country of origin). Intersectionality is particularly relevant for historically marginalized groups, such as Latinas living in the United States, who hold multiple minoritized status (Anzaldúa, 2012). The interviewers, mindful of these complex and challenging intersections, were also trained in a Latinx family resilience framework (Bermúdez & Mancini, 2013). This integrated framework is informed by Walsh’s (2003) family resiliency model and Cardoso and Thompson’s (2010) systematic review of common themes of resilience among Latinx immigrant families. The framework encourages scholars and practitioners to evaluate context from an intersectional lens, as well as amplify strengths and cultural values, despite risks and challenges.

Sample and Procedures

Nine promotoras were initially invited to participate in Lazos Hispanos. At the end of the first year, four promotoras left the program due to family or work commitments. Bilingual and bicultural members of the research team conducted two semistructured group interviews in Spanish (60–90 minutes each) with the remaining five promotoras. We conducted two group interviews to accommodate their schedules and to provide an opportunity for them to exchange ideas and thus provide richer responses. The interviews were informed by heuristic inquiry, a qualitative research methodology aimed at discovering and understanding a particular phenomenon of human experience based on a purposive sample (Moustakas, 1990). According to Sultan (2019), this intuitive methodology embraces individuality within the framework of relationship and collaboration. These data were collected as part of a larger study describing the outcomes of the first year of Lazos Hispanos (Orpinas et al., 2020). The promotoras discussed their perspectives on the challenges of being a promotora (“What challenges have you faced as a promotora when working with community participants?”), as well as possible solutions (“How could we help mitigate or solve this challenge?”). The interviews were audiotaped and transcribed.

Data Analysis

Two bilingual and bicultural researchers used thematic analysis to interpret findings (Braun & Clarke, 2006). Based on the original transcripts in Spanish, we used line-by-line coding to identify meaningful concepts and themes. We examined contextual factors that reflect intersectional identities and discussed each concept and each theme until we reached a consensus on the number of themes and their names. After summarizing the themes from the interviews, we discussed the results with the promotoras as a form of member checking to ensure the accuracy of the findings (Lincoln & Guba, 1985). We integrated their feedback into the final analysis. The university’s institutional review board approved all research procedures.

Balancing Work and Family Responsibilities Was a Challenge

Although the promotoras found their work rewarding, having multiple demands on their time was stressful. Particularly complicated was balancing the labor demands of home and volunteering as a promotora, both unpaid roles. Seeing other promotoras positively managing stress, being married to someone who supports them, and having children who were proud of their work was fundamental to cope with the stress.

Power Imbalance With Men Affected Their Professional Work

The promotoras stated that others’ perceptions of their role as women were, at times, a barrier, especially when working with men. They often felt less confident talking with men or offering them guidance or support; some felt that men discounted them as leaders. The promotoras indicated that one point of tension was regarding when and where male participants could contact them, especially at their home. The promotoras also requested specific training on how to set limits, how to talk with men, and how to clarify their role as promotoras. They suggested additional interactive role playing to help them address some of the gender-based challenges. Finally, they highlighted that their affiliation with Lazos Hispanos and the university helped them leverage their power, not only with their male participants but also with professionals and service providers in the community.

Promotoras Needed Strategies to Set Boundaries and Handle the Emotional Impact of Hearing Participants’ Problems

Listening to the problems of community members affected the promotoras emotionally in several ways. First, some promotoras were experiencing similar situations to those of their participants. For example, concerns about immigration raids and oppressive policies affected the entire community, including the promotoras and their families. One promotora expressed the challenge of setting boundaries with a participant who reminded her of a violent situation that she had experienced. Second, the promotoras reported difficulties dealing with participants who were experiencing intimate partner violence and substance use. Even though the promotoras had access to multiple resources, it was hard for them to hear the intense and complicated family situations of some participants. Third, some participants would call them late at night to share their struggles, making the promotoras feel that their personal time was invaded. Hence, they had to learn how to set limits and to decompress to secure their self-care.

Language Barriers Limited the Breadth of Their Work

Some promotoras had limited English language skills. Thus, when agencies did not have Spanish-speaking staff, they felt frustrated and thought that the agency staff did not care for the Latinx community. They also noted, however, that not all Spanish-speaking staff were helpful or supportive of the Latinx community. Most important, language limitations eroded their self-confidence. They discussed the need to take English classes but recognized that it was not always a realistic option given the lack of transportation and the limitations of time. Another strategy was having a list of common English terms for specific situations with participants.

Lack of Cultural Understanding Limited Effective Interactions With Some Health Care Providers

The promotoras commented on the perception of community members that some health care providers devalued certain beliefs, customs, or child-rearing practices. In consequence, some feared rejection or discrimination when going to health care appointments. Promotoras saw their job as particularly important in this aspect, as they can educate the community about spaces where Latinx individuals are welcome, and they can inform providers on how to serve better the Latinx community.

Feeling Disheartened by the Cultural Beliefs of Some Latinx Participants

The promotoras expressed some frustration with community members who do not understand the benefit of preventive care, and instead wait until they experience acute symptoms to seek help for physical, dental, or mental health problems. In addition to preventive care, the promotoras recognized that community members had difficulty talking about sexuality with their children, a topic that requires having factual knowledge and understanding of cultural values. They also saw the problems related to domestic violence in the community and feared its impact on the children. The promotoras requested more training on these topics.

Lack of Transportation for Themselves and Participants Was a Challenge

Some of the promotoras and some of their participants did not drive. Equally important, most promotoras and participants did not know how to use the public transportation system. Public transportation, however, is not always an option, as it has practical limitations: Traveling by bus inherently takes longer than driving a personal car. With job schedules and family responsibilities competing with health and social services appointments, time is valuable and scarce. In addition, the promotoras found that many of their participants chose not to use buses to avoid stigma and social labels (e.g., poor people can’t afford a car) and perceived unwelcoming “bad looks” from other passengers.

The promotoras of Lazos Hispanos suggested several solutions to address these challenges. First, education: A promotora familiar with the local public transportation system took her colleagues on a tour of several bus lines, teaching them how to purchase tickets, board the bus, and read the schedules and maps. On realizing that relevant materials were only displayed in English, the promotoras advocated the transportation director to facilitate the access to Spanish-language schedules and brochures. Since then, the promotoras have educated their participants on how to use the buses. Second, technology: The promotoras have become skilled at engaging their participants by phone and text messages. They implement the communication skills learned through the monthly training to be as attentive on the phone as if they were meeting participants in person. They encourage participants to call them back if further needs arise while establishing and respecting boundaries. These suggestions addressed not only their participants’ transportation challenges but also their own.

Collecting Data for the Research Aspect of the Program Was a Burden

Three sources of problems with collecting data emerged. First, a practical problem: As the number of participants increased, the promotoras had to carry a large, heavy binder with information about their participants and community resources. They suggested moving into electronic data collection, which also posed challenges with finding and purchasing a user-friendly software and securing the hardware. In addition, a few did not feel comfortable using technology. Second, a confidentiality problem: Many participants did not want to complete an intake questionnaire, given the perceived climate of racial intolerance, xenophobia, and nativism that has recently been heightened in the country. Third, because researchers collect data on numerous behaviors, health problems, and theoretical constructs, surveys can be lengthy. The promotoras suggested reducing the number of questions on the survey (which would limit the its breadth) and providing a monetary incentive to increase the number of participants willing to respond (therefore increasing the reach of their work).

Work–Family Balance

Women are disproportionally and negatively affected by their efforts to manage work and family responsibilities (J. L. Scott et al., 2010). The experience of Latinas may be further compounded by traditional Latinx gender roles and values of marianismo (purity and chastity of the Virgin Mary, who is venerated as a role model) and familismo (strong identification with and protection of the family; Bermúdez & Mancini, 2013; Lucero-Liu & Christensen, 2009). More research is needed to better understand how culture, gender, immigration, and social class affect promotoras’ ability to disrupt power structures while maintaining positive familial and work responsibilities and relationships.

Power Imbalance With Men

Due to patriarchal structures, values, and beliefs, women worldwide continue to experience the harmful effects of power imbalances (Loyd et al., 2009; Parker, 2015). During the training with the promotoras, we discussed strategies to work with everyone in the community. Results from this study highlight the need for culturally and gender-informed training that assist promotoras in setting boundaries and managing their professional and personal roles and contexts.

Emotional Impact of Hearing Participants’ Problems

Vicarious trauma, compassion fatigue, and burnout are common among health care and mental health workers (Beck, 2011; Thompson et al., 2014). Hearing about intense problems is difficult even for trained professionals. The promotoras found it challenging to set boundaries with participants because they felt obligated—at least initially—to be available to them unconditionally. Even though Lazos Hispanos had provided extensive support for handling and referring difficult cases, we realized the need for training in boundary setting and stress management. Using case scenarios, we developed four lessons of 1 hour each to promote positive self-talk, develop strategies to set time limits with participants, discuss the influence of cultural and gender values that challenge their ability to set limits, define professional and personal roles, develop strategies to set reasonable goals with participants, and discuss the advantages and problems of self-disclosure.

Language Barriers

Most CHW programs, to varying degrees, focus on capacity development and empowerment (Plescia et al., 2008), which translates into content-specific knowledge (e.g., diabetes prevention), leadership capacity, and advocacy skills, to name a few. When working with the Latinx community and collaborating with promotoras who may have different levels of English skills, a question emerges: To what extent should the training foster language skills among promotoras to enhance their professional performance and satisfaction?

From a social capital perspective, language is critical. Social capital refers to “features of social organization, such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit” (Putnam, 2000, p. 67). Researchers distinguish three distinct types of social capital: bonding (strong interpersonal connections among like individuals or groups), bridging (weaker ties to heterogenous individuals or groups), and linking (connections to those in positions of power; Gittell & Videl, 1998). Although researchers have explored the role of CHWs in developing community-level social capital (Farquhar et al., 2005), our findings suggest a need for more nuanced attention toward the development of all types of social capital. The promotoras of Lazos Hispanos had strong connections within their communities, arguably fostering bonding social capital. Likewise, they noted consistent challenges in advocating on behalf of their communities, given their lack of English language skills; thus, challenging the development of bridging and linking social capital.

Based on our results, we recommend the inclusion of English-language classes within the overall training. Language training provides an opportunity to move beyond a common tendency to focus on bonding social capital alone, particularly in marginalized communities, and brings critical attention to those skills that foster the development of bridging and linking social capital. Doing so structurally encourages a move beyond “getting by” to “getting ahead,” via access to those in positions of power (Agnitsch et al., 2006; Healy et al., 2004). Without an ability to being understood by those in power, systems-level change and advocacy will remain a challenge.

Lack of Cultural Understanding

Some Latinx individuals feel that service providers discriminate against them (Steinberg et al., 2016). This perception of discrimination may stem from two sources. First, language limitations may result in longer waiting times for services and fewer interventions than those for children of English-speaking parents, as patients must wait for a translator (Connors, 2019). Language barriers may also result in difficulty accessing services. This language barrier could be addressed by increasing the availability of Spanish-speaking and bicultural staff and professionals and providing access to interpretation services. Although this suggestion seems obvious, very few professionals who speak Spanish fluently and understand Latinx cultural values live in this area. At the same time, agency decision makers should continue to adapt their processes and paperwork to meet the needs of Latinx communities, such as having intake forms in Spanish, providing enough space for two last names, translating billing statements, and accepting foreign forms of identification.

Second, health professionals may not understand or value certain cultural practices, which may fall within the general category of complementary and alternative medicine. Doctors have traditionally expressed skepticism toward unconventional practices with unproven evidence of success (Maha & Shaw, 2007). Their views may not be necessarily directed to a specific population; however, the Latinx patients may feel singled out. These barriers could be addressed by a cultural competency training program for service providers to increase understanding and acceptance of cultural practices that may or may not align with Western medical science, but do not pose a threat to patients’ health. Conversely, community members may need more education about the fast pace of the U.S. health care system—which may not provide enough time for health care providers to discuss cultural practices—and understand that the skepticism of health professionals may not necessarily mean to target the Latinx community.

Cultural Beliefs of Some Latinx Participants

Postponing the use of health services could be associated with the traditional cultural value of fatalismo (perceived inability to control certain situations, including the development of a disease, as they are predetermined; Anastasia & Bridges, 2015). Other reasons to postpone making a health appointment are more practical: language barriers, scarce time, lack of transportation, fear of cost, and limited information about where to ask for help (Calva et al., 2020). From the promotoras’ perspective, some community members simply do not know about the importance of early care to prevent or minimize future diseases or where to find low-cost care.

Lack of Transportation

Transportation is a challenge for many Latinx community members. In addition to the high cost of owning a car or simply not knowing how to drive, mobility is often restricted by state policies denying drivers’ licenses to individuals without the required immigration status, and the resulting fear of being arrested, detained, and deported (Klinke & Wallace, 2008). Such policies negatively affect health and well-being by preventing free mobility to, for example, health and social services appointments (Philbin et al., 2018). The promotoras’ suggestions to increase knowledge of public transportation and communicate with participants by phone have been the best strategies to overcome this problem.

Data Collection

A critical principle of community-based participatory research is the balance between action and research (Israel et al., 2018). The action was natural and relatively easy for the promotoras. However, the research was a challenge. The data collected help define areas of need, such as frequent health problems or difficulties accessing certain health providers. This information is crucial for applying for grants, being accountable toward funders, and providing feedback to the promotoras, community agencies, and participants.

Limitations

This qualitative study has some limitations. The number of promotoras who provided their feedback on the challenges they experienced was small. Furthermore, it is possible that the promotoras who left Lazos Hispanos could have encountered different problems. The attrition rate observed during the first year of the program is concerning but not surprising (Nkonki et al., 2011). The promotoras were volunteers and, consistently, the lack of financial compensation has the strongest impact on attrition (Alam et al., 2012; Vareilles et al., 2017). Given that CHW programs are frequently underfunded or involve teams that work with immigrants without work permits, researchers are encouraged to explore innovative means to provide both financial and nonfinancial incentives and recognition. Last, Lazos Hispanos is located in the Southeastern part of the United States, in a state that provides limited or no support to immigrants (Sabia, 2010). Results may be different in states with a larger Latinx community and more resources for this population.

Implications for Practice

CHWs are at the heart of community-based participatory research. As embedded community leaders, they enhance the health and well-being of fellow community members through peer support, education, advocacy, and resource navigation. Framed by an intersectional and Latinx resilience framework, the present study highlights the challenges that Latina promotoras face when working within their community, one that is culturally, politically, and socioeconomically marginalized. Some of their challenges parallel those of working women: balancing work and family responsibilities and perceiving an imbalance of power with men. Others parallel those of mental health workers: managing emotionally difficult situations of participants. Other challenges were specific to immigrants, such as low English proficiency, limited access to transportation, miscommunication with health care providers due to culture and language, and values and circumstances of the Latinx community that stagnate access to health and social services. The final challenge came from being in the field as a researcher, rather than an educator, a role that encompasses new responsibilities. The challenges and practical solutions the promotoras provided in this study help position us and others to not only enhance research and practice but also ensure the well-being and satisfaction of the promotoras themselves.