Promotoras as Research Partners to Engage Health Disparity Communities

Introduction

There is an urgent need to improve nutritional health in health disparity communities, such as the growing Hispanic and Latino populations. However, efforts focused on complex nutritional health issues, such as obesity and food insecurity, can be more difficult in underserved and at risk communities, such as Mexican-origin residents living in communities along the Texas-Mexico border.^{(blinded for review)} Some of these challenges include:

• Establishing trust and rapport with community residents who are markedly different from the university-based research team;

• Working with communities to recruit from a specified sampling frame and to minimize attrition over the life course of a study;

• Adapting data collection protocol and instruments to culturally appropriate and reliable measures of dietary and environmental exposures;

• Accommodating logistical challenges of study participants (e.g., family, social, employment conflicts, and transportation challenges) in order to acknowledge the time commitment, minimize attrition, and complete timely and comprehensive assessments;

• Capturing contextual factors for understanding food- and health-related behaviors.

Further, it can be quite difficult to conduct research in a way that is both respectful of the community and residents’ norms, values, and traditions, and that possesses the rigor needed for the academy. A community-academic partnership where university-based researchers develop a partnership with promotoras de salud (promotoras) as research collaborators is one way to address these challenges in a culturally-competent manner.

Better than the Alternatives

Promotoras are female community health workers (CHWs) who work in Hispanic and Latino communities.³ Although there is controversy regarding whether promotoras are distinct among CHWs or bring additional skills and experiences compared to CHWs,³ promotoras have an essential role in improving health for priority Hispanic and Latino populations.^4,5 Many promotoras are similar to the residents they serve in ethnicity, language, socioeconomic status, and life experience,^6–9 and function as cultural brokers and health advocates.¹⁰ They often are recruited for leadership skills and trained in health education and advocacy.^5,6,8–11

Promotoras have demonstrated effectiveness in health interventions along the U.S-Mexico border^7,10,12–15 and in border colonias.^16–18 Typically, promotoras are used as a linguistic bridge between Spanish-speaking participants and researchers in recruitment or data collection/intervention activities.^12–19 Exceptions are a few interventions,^7,9,12 and one review¹⁹ that highlight promotoras’ integral role in research. However, promotoras bring additional skills and experiences, such as being role models and community partners,^6,9,19,20 which continue to be overlooked in the literature. Recent papers acknowledge the importance of CHWs in community-academic partnerships²⁰ and the need to increase promotoras’ capacity in research projects,²¹ but the literature lacks publications that describe promotoras as research collaborators in community-academic partnerships. We are not aware of any papers that provide guidance on this kind of community-academic partnership with promotoras and a priority population of Spanish-speaking residents.

In this paper, a promotora is understood to be a female of Hispanic or Latino ancestry, who is from the community, works in the community, and is active in coordinating and ensuring health care services, health promotion and outreach for their community. In addition, the promotoras described here are collaborators in community-based research projects completed in colonias near the Texas-Mexico border.^{(blinded for review)} Given that this research role is not one of the models typically used for CHWs (e.g., grassroots organizational model, lay health advisors model or “natural helper”, and program survival model),³ this paper uses the term promotora-researchers instead of promotoras, to better describe promotoras who are research collaborators in a community-academic partnership.

About the promotora-researchers

To begin with, promotora-researchers must be similar to the priority population of families who participate in research studies. Because of the research focus on Mexican-origin families living in border colonias, project promotora-researchers have been exclusively middle-aged women. As women, they are able to engage and interact with women (and children) in the community, and they are welcomed into the families’ homes, which is essential for completing study activities (e.g., obtaining informed consent, completing surveys, conducting interviews and food recalls). The promotora-researchers are from the communities in which they serve, have lived there for years, and share common ethnicity, perspectives, life experiences, sociocultural values, and native Spanish language (e.g., the vernacular or everyday language of the community). These promotora-researchers have worked in health education or advocacy, or as a health provider (e.g., as a midwife) and been involved with community outreach activities. Individual promotora-researchers range in the years of promotora experience they had before working as research collaborators. In one research project, promotora-researchers served as a promotora between 3–15 years, and three of the four promotora-researchers were certified promotora/community health workers by the Texas DSHS Promotor(a) or Community Health Worker Training and Certification Program.^{(blinded for review)} However, the most important personal characteristic, and the one that the promotora-researchers quickly identify as essential, is that a promotora must have “the heart” and passion for the community.

Also, the promotora-researchers are trusted and considered part of the community by the residents. This is essential for collaboration in a community-academic initiative. Research studies or interventions often only describe using Spanish-speaking promotoras to assist with recruitment or in delivering health education materials.^13–19 In this sense, promotoras are used as only a linguistic bridge. However, the promotoras might not share the perspectives, life experiences, or values of the priority population in the study or intervention. Further, the promotoras might not be considered part of the community by the residents. This can be problematic as it does not appropriately provide the community residents and participants a cultural broker and advocate who can truly give voice to them in interactions with the university.

Selected Examples of Working with Promotoras

Over time, university-based researchers have partnered with a team of promotora-researchers to complete several research projects. Projects have focused on the community and home food environment, food insecurity, dietary patterns and eating behaviors.^{(blinded for review)} Promotora-researchers have been fully involved throughout the project life cycle, from initial conceptualization through pre-planning, pilot testing, data collection, to interpreting and disseminating research findings at scientific conferences, promotora conferences, and workshops.^{(blinded for review)} This is quite different from the way in which most research studies describe using promotoras predominantly as a linguistic bridge. For example, promotora-researchers from the PDPE project were involved with modifying a previous study’s protocol and instruments, pre-planning (including developing training materials and modifications), pre-testing with community residents, training participants on the use of a disposable camera, conducting in-depth and photo-elicitation interviews with participant-mothers, analysis and interpretation of the data, and presentation of findings at an international research conference for nutrition.^{(blinded for review)}

Working with the promotora-researchers as partners improved the PDPE research project. Even though promotora-researchers were trained in explaining the photography activity and leading the photo-elicitation interviews, university-based researchers could not have anticipated having many mothers who had never used a camera (or seen photographs of their family), or never been asked about their everyday decisions and experiences. Mothers broached emotional topics in their interviews, regarding devotion to their children, separation and longing for family members, as well as persistent worries about finances, and health/medical care. Without the promotora-researchers ability to support and encourage the participant-mothers throughout data collection, it is unlikely that the project would have had enough, quality data for analysis. This research also benefited from the promotora-researchers’ self-initiated actions to “win over” the participant-mothers, and help them recognize their own value. Resulting interviews produced rich data that captured the meaning behind mothers’ food choices.

How to Find Promotoras in Communities

In the early days of the collaboration, promotoras were identified by working with community partners in research projects, and asking them to recommend promotoras who were already serving the community as promotoras. However, as the research program in South Texas expanded, additional promotoras were needed who could perform the traditional role of a promotora (acting in the best interest of the participants) in addition to being able to perform the role of a researcher (completing activities in a research study, such as pre-planning, recruitment, data collection). Additional promotoras now are identified in two ways: 1) recommendations from current team promotora-researchers, and 2) promotoras who were familiar with the research program’s work in the community would contact team members with recommendations. Either way, current promotoras conduct initial interviews and recommend candidate promotoras who will fit with the community and with the research program. Team promotoras feel very strongly about protecting the community and are careful in their recommendations. For example, current promotoras are likely to recommend a promotora who is already loved by the community, involved with helping others, and looks to have “the heart” to be a promotora. They also screen for other attributes and skills (e.g., willingness to work in both cultures and learn new things, organization, likeability, professionalism) that allow promotoras to work in mixed methods, community-based research studies. Current promotoras participate not only in the recruitment of new promotoras but also in the interview and training process for newly-hired promotoras.

In Texas, the DSHS Promotor(a) or Community Health Worker Training and Certification Program grants certifications for promotoras, which means that research programs can recruit certified promotoras as collaborators. Currently, the team of promotora-researchers includes only certified promotoras. Although this type of state-level training and certification program is somewhat unique to Texas, and there is no standard, national CHW training program,²⁶ other states have programs to train existing promotoras/CHWs as research collaborators. For instance, several states have promotoras working in Hispanic and Latino communities, and most states have CHWs working in non-Hispanic communities. Training programs and resources, including on-the-job training programs, are available through universities and other direct service agencies.^20,26 Research programs can identify bilingual promotoras who are from priority Hispanic and Latino communities, interested in working as promotoras, and then provide the training and support to facilitate the collaboration.

Training Promotoras as Research Collaborators

All research team members including promotora-researchers complete Collaborative Institutional Training Initiative (CITI) Human Subjects training for social and behavioral research as required by the university’s IRB. During the hiring process, they complete an initial CITI training, as well as other training required by the university’s IRB. Every two years, they complete a CITI refresher training, and renew their Texas DSHS promotora/CHW certificates by completing continuing education and training requirements. Team promotora-researchers also complete project-specific training.

Prior to each research study, university-based researchers and the promotora-researchers work together to understand training needs and make adjustments to the training approach and materials. Each training session is designed to be flexible and accommodate promotora-researchers’ questions and feedback, rather than a final presentation of the study’s protocol and activities. These decisions are intentional in order to build-in another opportunity for collaboration between university-based researchers and promotora-researchers. Further, training sessions are set-up in advance (of recruitment) to allow for additional iterations of protocol or instruments and pre-testing. Without adequate time to complete pre-planning activities, there is insufficient time for collaboration and modification of the study’s protocol and activities. This makes it more difficult for promotoras (to complete research study activities following protocol and within the study timeline) and communities (to feel comfortable participating in the research study and completing the study activities).

For example, a training session was held to prepare for a participant-driven photo-elicitation study.^{(blinded for review)} This half-day, in-person training session was held in the community where the research study would be conducted, led in Spanish, and held in a residence with home-prepared refreshments for breakfast and lunch. The purpose of the training was to present the study, discuss and modify protocol and activities. Training was led by a bilingual, bicultural university-based researcher and supervised by researchers with considerable experience in South Texas, and where one person was a Texas DSHS certified promotora/CHW instructor/trainer with 10 years of experience in training promotoras. Agendas and project materials were brought-in by the university-based researchers, but the training was not formal and rigid. Instead, there were many opportunities to exchange “small talk” (e.g., informal, personal conversations), share stories from the field, and discuss concerns or issues related to the particular project. Training emphasized how to: present the photography activity, teach photography, and facilitate the photo-elicitation interview. Throughout the training, there was active collaboration where protocol and instruments were modified, and ultimately, the fieldwork start date to begin recruitment was delayed to allow for modifications and pre-testing. In addition, promotora-researchers participate in additional training during a project. Additional training opportunities are coordinated as promotora-researchers and university-based researchers communicate about the fieldwork activities and identify gaps in training. Lastly, team promotora-researchers have been involved with peer training locally and nationally. For instance, project promotora-researchers have attended national conferences to discuss and share their work as promotoras and as researchers. Further, they have led sessions at promotora conferences, which provided a unique and beneficial opportunity for the promotora-researchers.

Areas of future research

In summary, there are four advantages to working with promotora-researchers, which are attributed to the roles of: 1) a cultural broker (who navigates the community, the health system, and to an extent, academic environments), 2) a co-resident and community-recognized leader in health promotion and outreach (who acts as an advocate and a resource), 3) a bicultural research collaborator (who can participate in research study activities across cultures, language, and settings), and 4) a voice (who represents the perspectives of community residents). These advantages have resulted in better research: tailoring project training and study protocol to the community, recruiting the priority population of interest, retaining study participants, identifying approaches and language better suited for capturing data related to nutrition and health, and building long-standing relationships between the community and university. In addition, having promotora-researchers as partners in research and outreach empowered them to address important needs in their communities. As an example, they initiated two annual community outreach events for colonia families. These events are coordinated by the research program, with support from the university community, but led on the ground by the promotora-researchers. Each year, promotora-researchers select colonias and families to participate in a summertime back-to-school and Christmas events. The Christmas event provides non-perishable food boxes and children’s gifts delivered during a holiday party in the colonias. In the back-to-school event, promotora-researchers and university-based team members personally deliver backpacks, school supplies, reusable water bottles, and gift certificates for school clothes. Promotora-researchers often bring awareness to a family’s need or a community issue that they address with support of the university-based researchers and community. Recognizing the magnitude of the need throughout the area, promotora-researchers identify different families and colonias for each event.

A community-academic partnership that works with promotora-researchers offers tremendous promise for tackling complex nutrition issues among priority Latino and Hispanic populations. However, future community-based research is needed to provide: university-based researchers with the culturally-situated knowledge to lead projects; promotoras (and promotora-researchers) with the training and support needed to be research collaborators; and to evaluate effectiveness of these community-academic collaborations with promotora-researchers. Specifically, future studies could address:

• What kind of training do promotoras identify as crucial to their roles as collaborators in research projects?

• What components of training contribute to promotoras’ effectiveness in community-academic partnerships?

• How can peer-learning be enhanced within the promotora workforce?