Sustainability of promotora initiatives: Program planners’ perspectives

Abstract

The use of promotoras de salud is an increasingly widespread delivery approach for community-based health education and promotion programs targeting obesity-related lifestyle behaviors for Hispanic populations. Addressing a gap in the literature, this research examined the sustainability of promotora-led initiatives from the perspectives of those who plan, implement, and evaluate these programs. We conducted 24 in-depth interviews with program planners representing 22 promotora programs focused on Hispanic women’s health in ten states. Findings illustrated program planners’ opinions regarding the components, logistics, and barriers to promotora program sustainability. Several participants challenged the notion of promotora program sustainability by reframing the issue as promoting individual promotoras’ well-being and social mobility rather than maintaining their role in the program over time. Implications for community health planning, management, and policy include developing sustainability strategies during program planning stages and implementation of policies to more effectively integrate promotoras into existing healthcare systems at local, state, and national levels.

There is increasing recognition of the roles and contributions of community health workers (CHWs) in delivering health education and promotion programs and improving access to healthcare resources among marginalized groups.^1–4 Although there is no universally applicable definition of the role, CHWs typically are lay individuals trained to deliver health education and outreach to other members within their community.⁵ The theoretical basis of the CHW delivery model is that direct engagement of community members contributes to community empowerment through processes and activities that raise collective awareness of health and social issues, strengthen the capacity to work together, improve access to primary healthcare services, and enhance health outcomes.^6–10 In the Alma Ata Declaration of 1978, the World Health Organization emphasized the need for community health advisors to deliver primary healthcare to community members.¹¹ Historically, the CHW movement includes promotores de salud¹ (the Spanish term for lay health advisors and educators), who have functioned as integral members of healthcare teams, providing community-based outreach to marginalized populations across Latin America for over four decades. More recently, health program planners in the United States (US) began incorporating promotoras on grant-funded health initiatives, including programs focusing on lifestyle changes to prevent or control obesity among Hispanic women.^12–16

Many researchers and health practitioners view the incorporation of promotoras as a sustainable approach to meeting the health education and outreach needs of a community.^17–18 Promotoras serve as frontline outreach, providing informational (e.g., referral services), tangible (e.g., transportation), and emotional support to participants of their health programs or services.^19–21 Ideally, promotoras live, work, and have existing social connections within the targeted community. For example, promotoras trained in obesity-related health program delivery actively diffuse health information through their social networks, create new communities of practice, and promote and encourage healthy behaviors such as increased physical activity and healthy dietary choices both during and after the intervention.^22,23

Health program sustainability, defined as the “the general phenomenon of program continuation,”^{24, p. 92} requires ongoing provision of resources to continue its implementation within a community.²⁵ Although several conceptual frameworks address the processes of promotora recruitment, selection, training, and evaluation,^26–30 there are few specific recommendations for strategies aimed at ensuring the provision of resources to sustain promotora-delivered programs.^13,31–33 Given the impetus of the U.S. Department of Health and Human Services to increase utilization of promotoras in the delivery of health promotion and education, the lack of evidence related to program sustainability is concerning.³⁴ The perspectives of program planners are integral to the development of strategies and approaches to foster promotora-led program sustainability. The primary purpose of this qualitative descriptive research³⁵ was to explore program planners’ views and experiences regarding sustainability of promotora-delivered obesity-related interventions for Hispanic women.

Methods

Participant Recruitment

We recruited a purposeful convenience sample of English-speaking program planners, principal investigators, recruiters, project coordinators, and other individuals with planning roles of U.S.-based promotora-delivered programs which featured information and activities related to obesity-related topics (e.g. nutrition, physical activity) for Hispanic women. The list of potential participants consisted of names identified through professional contacts, the research literature, Internet searches for promotora-delivered evidenced-based interventions, and snowball referrals from other program planners and researchers. We purposefully recruited participants from across the country in order to have participants from various geographic regions and programs serving diverse Hispanic subpopulations. We contacted 65 individuals on the initial contact list by both e-mail and phone. Of these, 25 did not respond, 14 declined because they were not working on obesity-related projects, and 2 declined due to time constraints, resulting in a sample of 24 participants. The Institutional Review Board of the University of South Carolina approved this research study prior to initiation of data collection.

Interview Guide

We conducted individual interviews, via telephone, using an open-ended, semi-structured interview guide.³⁶ The interview guide included a section on program characteristics (e.g., program focus, geographic location) and participants’ information (e.g. exact title and role in the health-related intervention). To elicit participants’ perspectives and experiences related to sustainability, we posed a series of open-ended questions in the following domains: promotora role conceptualization, recruitment, selection, training, and sustainability. Table 1 lists the questions specifically related to the sustainability domain. We pilot tested the interview guide with an experienced program planner to ensure that questions were clear and nondirective, modifying ambiguous and unclear questions to elicit more focused responses.³⁷ The choice of in-depth interviews by telephone allowed for a geographically diverse sample.

Table 1.

Interview Questions Specifically Related to Sustainability

How does (name of program) define sustajnability? How did you plan for the sustajnability of this program? In what ways did you encourage sustajnability of program activities during promotora training? What resources did you provide promotoras to be able to sustain the program? Did you encourage your promotoras to sustain any program activities at the completion of the program? If so, how? How did you encourage their continuance of program activities? How did you supply them with resources to continue program activities? How did you discuss sustaining the health education component? How do you foresee the promotoms components of (name of program) being sustained in the community?

Data Collection, Analysis, and Interpretation

Data collection occurred between June and September 2010. Participants provided verbal informed consent and permission prior to initiating the audio-recorded telephone interview. Interviews lasted between 30 and 90 minutes (average interview lasted 60 minutes). All interviews were transcribed, and personal and program identifiers were removed from the transcripts.

The purpose of the inductive open-coding process was to identify salient and reoccurring themes and phrases, providing the basis for subsequent development of more selective and focused codes and broader themes and subthemes.³⁸ Data analysis occurred concurrently with data collection, a process designed to enhance the purposive and theoretical sampling processes to lead to the ability to determine saturation.³⁹ Initially, three investigators each independently coded the same three interview transcripts. They then met to discuss individual findings and to compare open codes (e.g., empowerment, advocacy), initial categories by topic domain (e.g., program sustainability), and identify emerging themes (e.g., promotora social mobility). After reaching consensus on an initial set of codes, the first author created an initial codebook using Atlas.TI qualitative data management software⁴⁰ and continued coding the subsequent interviews. As data collection proceeded, we looked for indicators of saturation (i.e., repetition of previously identified codes and themes; lack of emergence of significant new or different codes; fewer variations on the existing themes).⁴¹ For this particular analysis, the investigative team focused on the sustainability domain. This involved a close reading of all transcripts to compare and contrast, expand, merge, and refine the sustainability codes and themes across the entire data set.⁴² All authors participated in refining the analysis and developing the presentation of the findings.

Results

Participants and Program Demographics

Although all 24 participants reported involvement in program planning activities, they self-identified their primary role in relation to the promotora program as either researcher (n=11), program director (n=7), program coordinator (n=4), or promotora trainer (n=2). The sample included staff from 22 community-based programs located in ten states of five distinct geographic regions - Southwest (n=7), West (n=7), Midwest (n=3), Southeast (n=3), and Northeast (n=2). Participants were associated with community based organizations (CBOs, n=8), universities (n=5), university-CBO collaborations (U-CBO, n=5), federally qualified health centers (FQHC, n=3), hospitals (n=2), and a state-wide government-run public program (n=1). Most of the university-affiliated programs were research initiatives. The specific promotora programs focused on diabetes (n=7), obesity/ weight management (n=6), family health/wellness (n=4), cardiovascular disease (n=3), health literacy (n=1), general women’s health (n=1), and osteoporosis (n=1). The target population of these programs tended to be Hispanic women and their families (n=15) rather than Hispanic women only (n=7). There were an equal number of bilingual (English-Spanish) and Spanish language programs (n=11).

Qualitative Findings: Promotora Program Sustainability

Participants conceptualized sustainability in different ways and at both macros and micro levels (Table 2). They reflected on their own experiences as they identified and described the rationale for using and sustaining the promotora delivery model as well as logistics and barriers. Some participants actually reframed the notion of sustainability in their discussions of promotora career development and trajectories. In the following sections, we present and discuss the evidence supporting each of these themes related to promotora program sustainability. Participants presented diverse views and therefore each of the narrative themes did not necessarily reflect the perspectives of all participants.

Table 2.

Planning Promotora-Delivered Programs: Sustainability Themes

Rationale for Sustainability

Prior Intent to Sustain or not to Sustain

Levels of Sustainability

Sustaining health behavior change

Sustaining the promotora activities and program

Sustaining efforts to implement environmental change

Logistics of Sustainability

Forming community partnerships

Identifying program champions

Barriers to Sustainability

Lack of documentation

Limited funding

Promotora attrition

Reframing Sustainability at the Promotora Level

Focus on personal and career development of promotoras

Recommended Actions to Enhance Sustainability

Community Collaborations

Enhanced Evaluation

Ongoing Training

The Rationale for Sustainability

Participants’ goals for sustainability focused on the rationale for the need and value of sustaining programs using a promotora-delivery model. This model involved training community leaders who then actively participated in and contributed to programs addressing community health issues. One hospital-based participant noted, “Promotoras are a total strength-based approach to working with people. We are strengthening their skills and supporting them, and then linking them with the resources they need.” Many of these community-based programs empowered Hispanics to become actively involved in their communities and to reach those most in need of healthcare.

Creating a more equitable, cost effective healthcare delivery approach for reaching underserved populations was another reason for sustaining promotora-delivered community-based health programs. Compared to the acute-care, institution-based medical model, community-based models are less expensive and have wider reach, particularly among uninsured populations. Several participants noted the advantages of disseminating health information, preventive health services, disease management, and some medical treatment to the uninsured populations through promotora-led programs over relying on emergency care. One U-CBO-based participant voiced concerns about the high financial costs and inequity within the current medical model and the need for more investment “in community models of care.” Another participant based at a FQHC described the job of being a promotora as empowering limited English proficient Hispanic patients to be able to understand and apply disease prevention and management skills. A hospital-based program planner confirmed the importance of sustaining promotora programs by describing the complex role their promotoras served as health educators, patient navigators, and patient advocates. These promotoras provided direct support to patients as they navigated healthcare services, assisting them in understanding and responding to provider instructions and recommendations, and ensuring they seek further appropriate care.

Intent to Sustain Promotora Program

Participants considered explicit intent to sustain the promotora program as critical. Several indicated program sustainability had been a clear intent prior to program implementation, but there were only two cases in which participants (U-CBO and CBO) reported having actually planned for sustainability prior to initiating the promotora program. In both cases, once the initial program funding ended, the initiatives were transferred to predetermined community stakeholders who assumed the responsibility of continuing the program. In contrast, program planners associated with universities and CBOs working on programs funded through short-term grants noted that the lack of sustainability was directly related to termination of funding and readily acknowledged this lack of guaranteed on-going program funding as the nature of their work. In one example of a promotora program developed as part of a randomized controlled trial, there was never any intent to support an ongoing community health program. This university-based participant noted, “When my research funding is over, and I have a new research grant, I have to switch gears. My new focus is the new program.” Strategies noted among planners involved in grant-funded research projects included short-term extensions for the grant funding, or, more often, simply moving on to other projects. Given this grant-funded context and mindset, one U-CBO based participant recommended that program planners needed to communicate this lack of intent to sustain the program very clearly from the outset to promotoras, program participants, and others involved in the project. “Let them know that you are not looking for something to last long term. Let them know you are looking to advance science.”

Logistics of Sustaining Promotora-Delivered Programs

The logistics of sustaining promotora health programs was a major concern among these program planners. They identified specific ways in which promotoras contributed to the sustainability of program components and recommended strategies that both promotoras and program planners could employ, such as forming community partnerships and locating program champions. Finally, they considered macro-level approaches to enhance the sustainability of the overall behaviors targeted in the health programs.

Promotoras themselves contributed to program sustainability by continuing to deliver health education in their communities after the program officially ended. One CBO-based participant reported that although the organization was not able to continue providing salary, incentives, or other assistance, they did provide promotoras with the basic resources for the program such as “space, materials, and everything they needed to continue the program.”

Partnering with CBOs was one strategy for continuing promotora programs. A university-based participant described collaborating with other organizations and the development of a community action plan for health program sustainability. Several university and CBO-based participants relied on program champions, community members or professionals who took responsibility for identifying potential funding sources and networked with other community partners and leaders to lobby for space, funding, and other resources. Examples of grass-roots community efforts to sustain and expand promotora programs included the story of a Hispanic woman who, after participating in a promotora-delivered physical activity program, sought additional training to become a promotora. She then organized a cadre of volunteers to lead health education discussion groups and collaborated with community leaders to locate space and resources in which to conduct free exercise classes for other women in her community. A hospital-based participant described how community members worked with promotoras to offer free, weekly support groups in order to continue health education efforts.

Beyond describing sustainability of health programs at individual program levels, participants also discussed sustaining the programs’ results and targeted behavior changes by altering the surrounding macro environment. Promotoras and participants recognized the limitations of promoting lifestyle-behavior changes in communities where the environment was not conducive to enacting positive health behaviors. In some programs, promotoras and community members advocated for environments that supported and/or promoted healthy lifestyles. For example, community members and promotoras associated with the hospital-based program collaborated with their county health department to address how to change the built environment to make it a healthier place for their patients. They advocated for community revitalization initiatives and neighborhood safety enforcement programs to encourage patients to become more physically active in the community.

Barriers to Program Sustainability

Funding was the most frequently cited barrier to sustaining the promotora-led health programs. One university-based participant discussed, “When we work with funders, we have to acknowledge that sustainability equals having money. You need money to operate.” Sustained funding was critical for paying promotora salaries or stipends and ensuring other essential program components. At the individual level, promotoras who were salaried depended on the income for themselves and their families. Planners working with programs that did not provide the promotoras a salary understood the need to provide other forms of tangible support such as transportation, reimbursement for gas, and childcare. Other types of incentives included offering career-building opportunities for promotoras, including continuous free health-related trainings, help applying to academic programs, free entrance into conferences, and career-related networking opportunities. These services were offered to promote social mobility for the promotoras.

Another barrier to sustainability was the time required to provide additional promotora training and supervision. Most program planners indicated that the initial promotora training was not sufficient to sustain ongoing health outreach and education within communities, especially after the formal program had ended. A U-CBO based participant believed, “Sustainability is challenging due to the huge time requirements for training and quality assurance.” Program planners had limited time and resources to continue promotora training and supervision to ensure their needs were being met.

The lack of financial and political support for promotora-delivered health prevention programs within the current U.S. healthcare infrastructure was another barrier to sustainability. Participants noted the challenges of an acute-care, institution-based medical model that has not incorporated promotoras as a sustainable component of the healthcare workforce and the need to “figure out how you’re going to sustain them as medical assistants in the healthcare system because for the most part what they do is not billable for reimbursement by Medicaid and Medicare.” Although a few states, including Massachusetts and Minnesota, have instituted policies to reimburse promotoras’ activities through Medicaid, there are no such policies in most states or at the national level. Formal recognition and institutionalized payment would contribute to the sustainability of promotora initiatives, whereas currently most organizations must identify local solutions to sustain the work of promotoras.

Lack of process evaluation and program effectiveness data created other barriers to promotora program sustainability. One U-CBO based program planner noted the challenges of requiring promotoras to document evaluation data. “The type of documentation that we asked of them was really intensive. What we were asking of them was a huge amount of paper work and extensive evaluation, filling out of paperwork was not necessarily the strengths of our promotoras.” Also, without data on the effectiveness of promotora programs, program planners found it difficult to make their case to funders for continued support. One university-based participant described, “I really feel strongly that one of the best ways we sustain promotora research is through some really solid evaluation of interventions. We really need to be doing not only a good measurement of program outcomes but also of describing what the promotoras are doing.”

Promotora attrition was another barrier to program sustainability. The loss of trained promotoras who left the field for different or higher paying positions resulted in the added burden on program planners to recruit and train replacement promotoras. Promotora turnover increased program costs in terms of time, money, and resources.

Sustainability not documented

A few participants reported incidences of promotoras sustaining program components on their own without institutional support, but recognized the lack of documentation regarding these promotora-initiated efforts. Other practice-based participants also noted the need to evaluate how promotoras continue to conduct health education outreach. However, program managers encountered difficulties tracking promotoras’ activities to demonstrate the range and extent of their community outreach. The government-based participant noted, “Maybe we need to find a way to capture the little stories about how promotoras go and talk to people in the grocery stores… They do happen, but these stories are not captured or documented.” Obtaining accurate process evaluation data was difficult because many promotoras were not accustomed to regularly documenting their activities and found the administrative requirements a burden.

Reframing sustainability

An interesting and somewhat unconventional approach to promotora program sustainability was that of fostering individual promotora’s career development. The hospital-based participant believed, “Training and hiring promotoras is the garnering of a beginning of their career ladder.” This notion of individual social and career mobility challenged the conventional definition of program sustainability because it implied increased turnover among promotoras, and therefore could be construed as a barrier to program sustainability. Although promotora longevity with a program had advantages in terms of planning and sustainability, there was the recognition that it could indirectly contribute to limited individual social or professional mobility.

At the level of the individual promotoras, a reframing of sustainability identified by several participants was that consideration of individual promotoras’ social and career mobility was an important factor in and of itself. This alternative notion of sustainability suggests the promotora model may support both individual and community empowerment and growth. For example, promotoras gained knowledge and skills that improved their future employment opportunities. Through their community engagement and outreach, promotoras expanded their social networks, were introduced as community leaders to influential individuals within their communities, and some promotoras received job offers from their new contacts. Participants also reported they had introduced trained promotoras to future employers with the intent of creating opportunities for the promotoras to move on to better paying positions.

Although in the short term it may be more cost and time effective to maintain trained promotoras, participants noted the advantages of continually equipping new, untrained community members to serve as promotoras. This process allowed individuals described as “not hirable” by other organizations to obtain skills that could increase their employability and potentially contribute to their social and economic mobility. Thus, sustaining the ongoing training of new promotoras was a way of helping community members advance their careers and overall social position.

Discussion and Implications

These program planners grounded their perspectives on promotora program sustainability in their knowledge of local community health initiatives as well as their visions and understanding of the broader U.S. healthcare systems. They highlighted issues of cost-effectiveness, health and social equity, meeting the needs of the medically underserved, and contributing to community empowerment as the basis for sustaining the promotora delivery model. In response to identified logistical challenges and barriers, they offered suggestions to enhance future promotora-delivered interventions and programs.

In discussing their rationale for selecting a promotora approach, participants described the potential for sustaining the promotora delivery model due to the grounding of the model in the community. Strategies identified as having the potential to contribute to sustainability included the identification and mobilization of a community’s pre-existing resources and relationships in the creation of new opportunities for its members to thereby improve population health.⁴² However, participants also identified myriad obstacles to empowering communities to fully take ownership of these programs without the continued assistance of outside organizations and institutions.

The presence of an explicit initial intent to continue promotora programs clearly affects sustainability.²² Future studies, especially those funded by time-sensitive grants, should include program planners’ intentions and plans for sustainability, and researchers/program planners should evaluate these efforts accordingly.^24,44 For example, program planners need to anticipate the methods and resources required for continuing the program, identify aspects of the program amenable to sustainability and describe the duration and extent to which the program is continued.

Our findings identified lack of quality process and outcome evaluation of promotora programs as another barrier to health program sustainability. Evaluation data is needed to create promotora role standards and outcome expectancies which can be used in the development of promotora credentialing programs. There is a growing recognition of the potential that credentialing programs hold in furthering promotora role recognition and sustainability.^45–47 Evaluation data can also be used to demonstrate CHW program effectiveness and, in turn, be used to lobby for further funding.⁴⁸

Lack of continued program funding was the most commonly cited barrier to sustainability in our interview data. Similar to reports from previous research, these program planners described the need for continued funding to provide salaries or incentives to promotoras in order to sustain their employment and continue the health program.²⁷ Further, participants described how health program processes ended after the funding was discontinued.⁴⁹ Because funding is a major component of program sustainability, program planners need to identify ways to build community and organizational capacity to secure ongoing financial resources needed to integrate and sustain CHW programs.²⁴ Building the capacity of promotoras and community participants to apply for community and government grants and other short term funding is one potential strategy, but one which does not address the issue of long-term sustainability. Implementation of policies that lead to training standards and formal incorporation of promotoras and other CHWs into U.S. healthcare systems at the local, state, and federal levels must occur if long-term sustainability and integration is the goal. To date, CHW certification requirements and reimbursement policies exist in several states.^42,50,51 Specifically, Massachusetts and Minnesota implemented a Standard Occupational Category for CHWs that allows for Medicaid service reimbursement.⁵²

Our findings highlighted program planners’ concerns with promoting the well-being and sustainability of the individual promotoras as well as the program, which is a new way to view sustainability in light of intervention research. Participants emphasized the need for continuous funding, training, resources, and either individuals (e.g., program champions) or partnerships to continue to support the program and pay promotoras.^24,26,44 The emphasis of sustaining individual promotoras is related to past research that discussed assisting promotoras in advancing their education and career trajectories through program funding, training, partnerships, and professional networking opportunities as a measure of program sustainability and success.^54,54 This challenges and reframes generalized notions of sustainability. Considering promotora social and economic mobility as a component of sustainability broadens the concept and its applications.

Potential limitations of this research included the small number of program planners interviewed. However, the volume, quality, and consistency of data supporting the various themes support these findings as furthering understanding of diverse program planners’ perspectives on sustainability of promotora initiatives. Selection bias may have occurred due to use of convenience sampling, and our participants may not be representative of all promotora-programs. However, our sampling techniques and telephone interview format allowed us to identify and recruit a diverse sample of program planners from across the country. Despite the advantages, there are limitations to telephone interviews, given the inability of interviewer and research participants to tend to visual cues and body language. Because of the cross-sectional nature of these interviews, and the fact that not all participants had access to or were able to report program and outcome effectiveness data at the time of the interview, we were unable to determine the relationship between prior intent to sustain a program and actual sustainability, or how the effectiveness of a program might impact program sustainability. Finally, the analysis reflects our interpretations of the qualitative data, its meaning, and implications and others may interpret the data differently.

These findings have several implications for the use of promotoras in public health initiatives. Prior to program implementation, planners should collaborate with community partners to develop a sustainability plan that details who and what to sustain and methods to ensure the plan is being followed both during and after the program. They should target the social, physical, and political environments of the community-based program to create an environment more conducive to making sustainable health-behavior changes and for sustaining health programs.⁵⁵ Broader conceptualizations of sustainability may be useful for planners of promotora-delivered health programs. For example, they could take into account ways in which the individual promotoras will be sustained at program completion through continued support (e.g., funding, childcare); finding employment and/or offering educational support; and providing leadership opportunities to continue this work. Planners could also consider methods for improving the evaluation of promotora-delivered programs and the physical and social environments of these programs as components of sustainability.

A growing body of evidence supports the implementation of promotora-delivered interventions in health-related programs as a culturally and linguistically appropriate strategy to improve access to care and health resources, link health institutions and community members and provide services for vulnerable and difficulty-to-reach populations.¹ Program planners and managers spend time, energy, and resources organizing and implementing promotora-delivered programs and interventions aimed at promoting health among underserved populations.¹³ Public health planners, managers, and policy-makers must engage in more concerted efforts to ensure the ongoing evaluation and sustainability of promotora-delivered health education and outreach programs.