Promotores as Researchers: Expanding the Promotor Role in Community-Based Research

Abstract

The community health worker, known as promotor in the Hispanic community, is an accepted member of the public health team whose core role is that of bridging target communities with health services. However, the promotor’s role in research has not been considered a core function of their work. This article will present the promotor in the additional role of researcher, as conceived by the Migrant Clinicians Network for the Hombres Unidos Contra La Violencia Familiar (Men United Against Family Violence) sexual violence/intimate partner violence project. The Hombres Unidos project used promotores as survey facilitators, gathering male Hispanic farmworkers’ perspectives on the sensitive topic of sexual violence and intimate partner violence. This article demonstrates that when trained, the promotores’ linguistic and cultural competence make them a valuable addition to the research team, especially when collecting sensitive information.

The use of the lay health worker in the delivery of health care services in the United States has undergone changes in recent decades. During the 1960s, community health workers (CHWs) were involved in responding to the health needs of the poor in both urban and rural settings without a specific framework for their utilization (Health Resources and Services Administration, 2007). Since 1990, CHW utilization has become widespread at both the state and federal level, with both public and private entities integrating CHWs into projects to combat a myriad of health topics from tuberculosis prevention (Heath, 1967, Lewy, Ricardo, Forges, & Nelson, 2008), migrant farmworker pesticide exposure risk (Liebman, Juarez, Leyva, & Corona, 2007), and HIV/AIDS prevention (Martin et al., 2005) via outreach and health promotion. Within the Spanish-speaking community, these CHWs are called promotores. In this article, we will focus on promotores, since the intervention described served a Spanish-speaking community; however, the terms community health worker or promotor can be used interchangeably.

Traditionally, promotores are engaged in (one of) several core roles: cultural mediation between communities and health systems, informal counselors or social support, providers of culturally appropriate health education, advocates for individual’s and community’s needs, facilitators of services for the poor, individual and community capacity builders, or providers of direct services (Rosenthal et al., 1998). Apart from serving as effective conduits for health education dissemination and outreach work, promotores can also serve as researchers, carrying out research functions such as project conceptualization, assessment tool development, data collection, and information analysis. Promotores should not merely be asked for assistance with data collection but should be part of the entire research process from conception to dissemination.

The Hombres Unidos Contra la Violencia Familiar (Men United Against Family Violence) project, a sexual violence and intimate partner violence primary prevention program, engaged Hispanic promotores in a culturally relevant model in a Hispanic migrant community with the aim of positively affecting knowledge, attitudes, beliefs, and behaviors of program participants. The promotores were not employed in their traditional role but rather served as integral members of the research team. What follows is a description of the Hombres Unidos Contra la Violencia Familiar project and a discussion of the integral role that promotores played within this project.

PROJECT OVERVIEW

In 2007, the Migrant Clinicians Network (MCN) partnered with the Centers for Disease Control and Prevention (CDC) to develop an intervention specific to migrant farmworker populations in order to reduce the incidence of sexual violence and intimate partner violence (SV/IPV) in migrant communities. The program was carried out in five sites in Colorado, Connecticut, Pennsylvania, Illinois, and Florida. Promotores were included to implement health outreach as well as facilitate the project’s research aims. The program’s secondary aim was to transition several of the participating promotores into a role as facilitators of male-only violence prevention workshops.

Migrant Clinicians Network

Organized as a not-for-profit governed by a national board of clinicians, MCN promotes and sustains its mission through training, education, research, and program development. Operated by a diverse staff with clinical, cultural, and technical expertise, MCN serves clinicians and communities in the United States, Mexico, and sites around the world. Founded as a network focused on the health of America’s migrant farmworkers, MCN has retained service to this special population as a core value while also acknowledging its leadership and responsibility in assisting the health of other mobile, poor, and culturally displaced populations. Initially limited to federally funded migrant and community health centers, MCN has expanded over its 25-year history to include health departments, universities, medical centers, and private practices in its scope of work. MCN’s interdisciplinary focus includes

• primary, secondary, and tertiary oral, physical, and mental health care access,

• quality improvement of health care programs serving the mobile poor,

• occupational and environmental health,

• preventive health, such as in immunization care and cancer screening,

• family violence prevention and intervention,

• research safety and justice as it affects the mobile poor,

• capacity building for health centers and communities,

• health education and training,

• professional development across all clinician disciplines,

• cultural competency training, and

• direct technical assistance to organizations and communities serving the mobile poor.

Rationale and Novel Approach

The Hombres Unidos Contra la Violencia Familiar project in the migrant farmworker community is one of many interventions that have been part of MCN’s SV/IPV initiative, which began in 1994. MCN formed the Practice-Based Research Network on Domestic Violence and Migrant Farmworkers (PBRN), which gathered and analyzed domestic violence data during 1994–1997 from 1,001 migrant women via health professional-administered surveys. The statistical analysis of the surveys revealed that 20% of the women sampled reported being a victim of domestic violence within the previous year (Van Hightower & Gorton, 1999; Van High tower, Gorton, & DeMoss, 2000). Additionally, in 1998, MCN research with migrant farmworker women in Texas, entitled No hay mal que por bien no venga (Every Cloud has a Silver Lining), found that 53% of the woman surveyed reported experiencing abuse in the previous year (Van Hightower & Dorsey, 2001). With the goal of decreasing this statistic, MCN researched how to address domestic violence from the male perspective in the farmworker community from 1995 to 1998. MCN partnered with the State of Wisconsin to conduct focus groups with males. The results provided a template for an intervention strategy targeting farm working men, while providing clinicians with recommendations for discussing issues of domestic violence with farmworkers (Koroscik & Rodriguez, 1994).

Many others have designed IPV interventions targeting men. Called “batterer intervention programs,” these programs specifically provide therapeutic educational programs for groups of men who batter (Gondolf, 2002; Rooney & Hanson, 2001). Although these programs provide valuable services, the Hombres Unidos Contra la Violencia Familiar project did not specifically target men who committed acts of intimate partner violence. This novel intervention is instead designed for all men in the community, acknowledging the power of direct intervention for offenders and indirect intervention for bystanders. Also, unlike most SV/IPV intervention programs, the project used a Freirian collective discussion model (Freire, 1978, 1992). In this tradition, men were not told they were “wrong” to commit acts of violence by a teacher, but rather, the group received education on the topic of SV/IPV through engaging in dialogue and learning from each other.

METHODS

Collectively, the studies conducted by MCN in 1994–1997, led to the Hombres Unidos Contra la Violencia Familiar project, which aimed to assess and analyze knowledge, attitudes, beliefs, and behaviors related to the prevention of SV/IPV. After the assessment, a culturally appropriate educational program administered by males was developed and implemented with the goal of decreasing SV/IPV within the Hispanic migrant and recent immigrant community. The focus of this article is on promotores’ work in the initial phase of the project. The intervention developed from the results of this study is discussed elsewhere (Nelson et al., in press).

A Leadership Consortium composed of professionals with expertise in SV/IPV was created to develop an assessment tool. Concurrently, an advisory committee comprised of promotores and several site coordinators provided consultation regarding the development of the assessment tool. The Leadership Consortium and the Advisory Committee also collaborated on the survey questions and conceptualized the execution of the survey within the target population.

A 3-part, 45-question survey to measure a prospective respondent’s knowledge, attitudes, beliefs, and behaviors (KABB) regarding SV/IPV was developed in partnership by the research team. After receiving consent and collecting demographic information, the SV/IPV KABB used close-ended questions to assess a participant’s attitudes and past behaviors as related to sexual violence and imitate partner violence.

The Unique Role of Promotores

From the beginning, both the Leadership Consortium and the Advisory Committee believed that the promotores based in the five farmworker communities would be uniquely equipped to facilitate the survey within the target community. Partner organizations understood that discussion regarding domestic violence among males was sensitive and required cultural competency beyond external health professionals’ expertise; therefore, promotores, once trained, would be integral to both the data collection and the consequent interventions among the targeted community.

Since promotores are customarily recruited from the community being served, they are theorized to provide a level of “indigenousness” that outside health professionals may not be able to offer (Giblin, 1989). Promotores’ indigenous qualities include language skills, both verbal and nonverbal, understanding the target community’s health barriers and perceptions, empathy, and a desire to improve the health indicators in their community. In many cases, as a consequence of their inclusion in the community, a promotor may have experienced the same health realities as those they are attempting to assist.

Recruiting Promotores

Promotores were recruited through site coordinators at all five sites based on the following characteristics: dual cultural competency, leadership-trust bond, caring for the community and homogeneity to the population.

According to the site coordinators, promotores had to be culturally competent and able to operate in the Spanish-speaking community, while also understanding the intricacies of the English-speaking community. This allowed community members to be comfortable when interacting with the promotor; however, it also allowed the promotores to be able to communicate effectively with site coordinators. Also, the promotors’ cultural competency was an essential component of the process of survey refinement. After the piloting of the survey, the promotores stated that several of the questions were confusing to the participants because of the use of formal Spanish. This led to the changing of some of the phrasing of the assessment tool.

All site coordinators believed that the promotores had to be seen as trusted figures or leaders within the farmworking community. The leadership-trust bond was theorized to aid in the gathering of valid and truthful data from participants.

[Promotores] have to be highly regarded by their peers, not so much a higher level of education, status or in the pecking order in the worksite, it’s really people that they trust, value and are viewed a leaders—quietly or at the forefront. When you think of the vulnerability in the population—whether it’s immigration status or acculturation issues—people know each other’s secrets, especially when living in a barracks with other guys. Everyone else knows everyone’s business, so the more you trust the person or leader, the more honest you’ll be. (Site Coordinator)

Each site coordinator referenced that a successful promotor and the promotores in this intervention, deeply care[d] for the health status of their respective communities. Site coordinators believed that many of the promotores demonstrated an interest in improving the health of their community and peers. “They had to be highly regarded by their peer group because of their keen interest: in the health and wellness in all permutations within their community” (Site Coordinator).

Finally, site coordinators shared that promotores had to uniquely understand the health and well-being of their farmworking community, plus have experienced “their own demons and come through it,” to be a successful promotor (Site Coordinator). They believed that if a promotor had already faced adversity they would be able to guide individuals through similar adversity successfully.

Training Promotores

To minimize interviewer bias and aid in the uniformity of the information collected from the five sites, promotores were trained in survey administration and surveying techniques via telephone conferences with MCN staff. Promotores received an overview of the MCN organization, the purpose of the program and the intent of the survey. The MCN trainer reviewed survey topics such as eligibility requirements, participant recruitment, obtaining informed consent, and appropriate sites to conduct the surveys to protect the respondent’s privacy and maintain confidentiality. The sessions also discussed how promotores could avoid interviewer bias during the surveying process while effectively probing respondents for clarifications of their answers. To provide the promotor with additional practical training and a method of survey refinement, the promotores were required to pilot one survey in Spanish and provide verbal and written feedback to MCN. Table 1 contains an outline of promotor training, which was done over the phone.

TABLE 1.

Promotor Training Outline

What is Migrant Clinicians Network (MCN)? The purpose of the survey Participating sites Interviewer responsibilities MCN responsibilities How to conduct surveys Consent Screening questions Survey General advice Maintaining confidentiality Avoiding bias How to probe Cases of abuse: What to do? Questions and answers

Promotor feedback raised issues related to the length of time needed to conduct a survey and the appropriateness of the questions. The comments from the pilot survey feedback were reviewed and approved by both the Leadership Consortium and Advisory Committee and the survey instrument was amended.

Implementing the Study

Following the demographic questions were 22 yes/no questions about respondents’ own beliefs relating to appropriate behavior in male-female relationships, beliefs among men they know and questions about the problems of violence against women and rape in the community. Ten survey items elicited personal beliefs about appropriate behavior in relationships (Table 2). These 10 questions were grouped to create a Relationship Behavior Belief Scale (RBBS), which generated scores of the respondent’s level of disapproval of violent behaviors by men against women. A high score indicates high disapproval whereas a low score indicates approval of violent behaviors. Desirable answers were scored with a 3, undecided responses were scored with a 2, and undesirable responses were scored with a 1.

TABLE 2.

Relationship Behavior Belief Scale (RBBS)

Do you think men should make the decisions in a relationship? Do you think a man has the right to control who his partner can see? Do you think a relationship between a man and a woman should be equal? Do you think it is okay for a man to insult his partner? Do you think it is okay for a man to hit his partner? Do you think that when a man hits his partner, it is often her fault for provoking it? Do you think that it is okay to make unwanted sexual comments to a woman? Do you think that women have the right to say “no” if they don’t want to have sex with their partner? Do you think that when a man rapes a woman, it can be her fault? Do you think most women who report they have been raped are telling the truth?

KABB SURVEY RESULTS

Demographics of Respondents

Respondents were mostly younger than 45 years (83%) with a median age of 32 years. The oldest respondent was 65 years old and the youngest was 18 years old. A total of 90% were born in Mexico and about 5%(n = 15) were born in Puerto Rico with the rest originating from six other Latin American countries. The average number of years of education for the group was 6 years. Fewer than 7% (n = 16) had attended at least 12 years of school and 12% (n = 28) had no schooling. About half (51%) attended between 5 and 10 years of school.

Most of the respondents had resided in the United States for a number of years. The mean of the total years (counting all trips) they had resided in the United States was 8.6 years with the respondent with the shortest stay being less than 3 months and the one with the longest stay being 33 years. About a quarter (24.5%) had been in the country 3 years or fewer and about 30% had been in the United States for 10 or more years.

The men were asked about the type of work they had been engaged in during the past 12 months (Table 3). Most (85%) were involved in agriculture. The next three most common types of work were construction (28%), landscaping (27%), and packing (20%). About half of the respondents had been involved with only one type of work in the past 12 months (53%) with 20% being involved with two types of work, 14% three types of work, and 11% four or more types. Five respondents did not respond to this question.

TABLE 3.

Type of Work in the Past 12 Months

Type of Work	n	Percentage
Agricultural	212	85
Construction	69	28
Landscaping	66	27
Packing	49	20
Livestock	29	12
Factory work	15	6
Service industry	15	6
Dairy	5	2
Other (mechanic)	1	<1
No response	5	2

Relationship Behavior Relief Scale

Ten survey items elicited personal beliefs about appropriate behavior in relationships. These 10 questions were grouped to create a Relationship Behavior Belief Scale (RBBS), which generated scores of the respondent’s level of disapproval of violent behaviors by men against women. A high score indicates high disapproval whereas a low score indicates approval of violent behaviors. The mean score was 24.87 with a median of 26. The lowest score was 10 and the highest 30. Scores for this sample of respondents were skewed to the right (desirable answers). Cronbach’s alpha for the 10 items in the RBBS was .760 indicating strong reliability for this scale.

Multivariate analysis of variance using the general linear model and the least significant difference procedures found significant differences in RBBS mean scores by state (Table 4). Overall, differences by state were statistically significant at p < .001 (f= 33.64, df = 4). Colorado and Illinois respondents were not found to have significantly different mean scores from one another but were significantly different from the rest of the states (p < .001). Pennsylvania and Connecticut also were not different from one another but were significantly different from the other three states (p < .001). The mean score of the Florida sample was found to be significantly lower than all other states (p < .001) indicating less disapproval of violent attitudes and behaviors of men against women.

TABLE 4.

Descriptive Statistics for the Relationship Behavior Belief Scale by State

State	Mean	Standard Deviation	n
Colorado	27.5510	2.69306	49
Illinois	27.5625	2.33299	48
Pennsylvania	24.8696	4.14519	46
Connecticut	23.8261	3.68965	46
Florida	20.5510	4.31113	49
Total	24.8739	4.37977	238

Causes of Violence Against Women

Four questions were about beliefs about causes of violence against women (Table 5). An equal number of respondents (45%) believed that “when a man hits his partner, it is usually because he is drunk” as those who did not believe this, whereas 9% were undecided about this cause. Nearly one third (31%) of respondents agreed that “when a man hits his partner, it is often her fault” whereas 55% did not think this was true and 14% were undecided. One third (33%) believed that Latino men are more abusive than other men whereas 54% disagreed with this idea and 13% were undecided. Most respondents (66%) thought that “rape is caused by uncontrollable sexual desire,” whereas 23% disagreed with this statement and 11% were undecided.

TABLE 5.

Causes of Violence Against Women

Do you think that when a man hits his partner, it is usually because he is drunk? Do you think that when a man hits his partner, it is often her fault for provoking it? Do you think that Latino men are more abusive than other men? Do you think that rape is caused by uncontrollable sexual desire?

Acceptance of Violence by Men in the Community

Two questions assessed perceptions of the acceptance of violence by men in the community (Table 6). Two thirds of respondents said that most men they know do not “believe it is okay for a man to hit his partner” whereas 28% said the men they know do believe this.

TABLE 6.

Acceptance of Violence by Men in the Community

Do you think that most men you know believe it is wrong for a man to hit his partner? Do you think that most men you know believe women have the right to say “no” if they don’t want to have sex with their partner?

On the question of whether a woman has the right to say “no” to sex with their partner, 83% of respondents thought a women had that right, but only 55% said that most men they know believe that way. In total, 13% said that they themselves do not believe a woman has a right to say “no,” and 35% of these men said the men they know do not believe a woman can say “no.”

Two thirds of respondents thought that partner abuse was a “big problem” in their community and nearly as many (60%) thought the same of rape. Overall, 10% were undecided on the first question and 13% on the second.

DISCUSSION

KAAB Results

The SV/IPV prevention project, through the use of promotores as survey collectors, interviewed 250 male farmworkers. Because of the nomadic nature of seasonal farm work, the number of captured responses was encouraging. Although not the purpose of this article, this is an important opportunity to point out that the majority of men who took the survey believed SV/IPV to be a “big problem” in their communities. This is consistent with our earlier findings from women’s interviews (Van Hightower et al., 2000; Van Hightower & Dorsey, 2001; Van Hightower & Gorton, 1999). Little work has been done on SV/IPV among farmworker and other low-wage immigrant worker communities. Health care and social service providers should consider this and screen for SV/IPV during routine care and interactions with all women, including this population. Further research needs to be done on how best to address this problem in a culturally sensitive way among immigrant workers.

Promotores’ Roles

Without the trusted and skilled promotores, the sensitive nature of a variety of survey items may have led participants to engage in impression management behaviors (Helfritz et al., 2006) to limit disclosure or deemphasize the number of potential violence acts committed. However, as demonstrated by the SV/IPV KABB findings, participants seemed to openly communicate with the promotores during their interviews, providing a level of intimacy that may not have been realized by a non-farm working or American-born surveyor. Each promoter successfully completed the full 45-question survey tool with 50 participants. The high completion rate Illustrates the effectiveness of the promotor in data collection, since guarded information such as attitudes about sexual violence or past incidences of intimate partner violence would have been difficult to collect without culturally competent and community-trusted interviewers.

The trust and familiarly that the promotores had among the target community aided in participant recruitment and data collection. Research by Kiffin-Petersen (2003) concluded that participant distrust in their surveyor influenced their willingness to disclose important personal information. Also, trust in the surveyor was a significant predictor of the frequency with which participants chose the neutral option on the Likert-type scale. Although most of the KABB questions featured dichotomous responses, honest responses, and complete surveys about past SV/IPV experiences may have been gathered because participants believed they could trust the surveyor, an individual who shared the same farm work and cultural background.

Although the promotores spoke Spanish, the native language of the majority of the participants, linguistic competency was only partially involved in the successfulness of the surveying component. Other factors such as trust, cultural awareness, and “indigenousness” aided the promotores in collecting the data. However, as noted earlier, language competency was essential in reconstructing the survey’s colloquial language. Because of the linguistic and regional differences between the survey creators and target community, the survey needed refinement. The refinement of the survey instrument was important since each survey question aimed to elicit intimate answers regarding a specific construct; thus refinement could not change the essence of the variable that the initial phraseology attempted to capture.

It is important to note that the promotores were involved in multiple steps of the research process, including instrument refinement, participant recruitment, data collection, and intervention development/implementation (described elsewhere).

Ethical Issues

Several ethical issues arose during the Hombres Unidos study. Of particular concern was how confidentiality of sensitive data could be maintained when members of the community would be the ones collecting the data. It seems that the very same strength of “indigenousness,” could also be a liability when it came to ensuring the confidentiality of participants. Surprisingly, there is very little literature on this topic, even as community-based research gains popularity. In our experience, it is important for the entire research team, including community partners, to talk frequently and honestly about confidentiality and other ethical issues as they arise during the course of the study. All the promotores in this study were well trained in issues of confidentiality and the candid responses from participants are a testament to the level of trust that was given to them by their communities.

Promotores gave all participants a National Domestic Violence Hotline card and explained to each participant that the hotline was open 24 hours/day, could provide direct connection to local resources, would speak Spanish, and would be confidential. All promotores were familiar with local domestic violence resources as well and were well prepared to refer participants if necessary.

Limitations

Without comparison data, we are unable to definitively show whether the inclusion of promotores made a significant difference in the quality of data gathered. Our impressions are based on the CHW literature, observations of promotores during training, survey development, survey implementation, intervention, and findings from site coordinator interviews. One small pilot study by Brugge et al. (2010) found no differences between the data collected by graduate students versus data collected by community members from a public housing development in Boston. Although we are unable to provide this same kind of comparison data, we believe the promotores’ ability to complete 250 surveys is testament to their ability to collect sensitive and guarded information, which might have been difficult for alternate data collectors. We did not debrief with respondents about the influence the interviewer had on how they answered sensitive questions.

CONCLUSION

Although promotores have not traditionally been in the role of researcher, this project demonstrates that they can be very important members of the research team. Their intimate knowledge of the community allows them to provide valuable feedback from project conception, to implementation, analysis of results and translation into intervention and practice. Promotores provide an invaluable resource to further understand the issues and behaviors of the Spanish-speaking farmworker community.

The Hombres Unidos Contra La Violencia Familiar research staff, as well as the five partner organizations involved, relied on both the promotores’ analysis and evaluation of the SV/IPV KABB survey tool and their ability to carry out the survey within the migrant farmworker communities. Though the Hombres Unidos project did not initially envision the promotores involved in the project as researchers, the project was clear about the characteristics that would enable promotores to contribute to the research process. As demonstrated through the collection of sensitive data and the comments of the participating site coordinators, the characteristics that allowed promotores access to this targeted population are the same characteristics that allow them to be effective in community-based health research.

The historic role of the promotor in community projects and interventions in the United States has led to the entrenchment of their responsibilities (Rosenthal et al., 1998). Lacking in the traditional description is their role as researchers, a task that should be considered since they are well qualified for this position. Numerous studies have used promotores as health educators and outreach workers because of their language skills, homogeneity, and the leadership roles that they play within their community, yet it is also these skills that make promotores excellent researchers.

These results clearly show that promotores can not only fulfill the role of health educator but that they are also an integral part of the community-based research team. Promotores should be recognized as bridges to the collection and interpretation of community perspectives, which will be used to influence education and interventions to strengthen the well-being of Hispanic farmworker communities. This article describes how, when trained, the promotores’ linguistic and cultural competence can make them a valuable addition to the research team, especially when collecting sensitive information.