Amid pandemic uncertainties, Latino immigrants put trust in their ‘promotoras’

For nearly three weeks, Fidelina Velazquez, who has diabetes and high blood pressure, debated whether to get a COVID-19 vaccine. The 59-year-old had been hospitalized for COVID-19 before vaccines were available and didn’t want to get sick again. She had heard rumors about vaccines that could kill people or wipe out chronic diseases patients like hers. To help her decide, Velazquez turned to a trusted source she had relied upon since the pandemic started: her local promotoras or Spanish-speaking community health workers.

With boots on the ground and typically no medical degree, but a strong desire to improve their community’s health, promotoras have been providing culturally appropriate health education, while serving as patient advocates for Latino populations in the United States for decades.

In March 2020, Velazquez joined a health support group run by promotoras at a nonprofit called Campesinos Sin Fronteras in Somerton, a rural, medically underserved, predominantly agricultural town in Arizona’s Yuma County. It is known as America’s winter soup bowl. It is located near Mexico’s border and home to many Mexican-American farmworkers, their families, and the region’s $3.2 million agricultural industry. The group, mainly Latinos living with diabetes and hypertension, has met for more than a decade to share information about chronic diseases in the community. They also share food, laughter, and a sense of solidarity. As the pandemic hit their community, the focus shifted to COVID-19.

“The pandemic motivated me join this group because here the promotoras provide health information,” Velazquez says, noting that it’s in Spanish. Via phone calls, through visits to homes and farms, and in group meetings, they’ve been teaching about COVID-19 using the latest guidelines from the U.S. Centers for Disease Control and Prevention and advising about access medical resources, while battling rampant misinformation and disinformation. She says that the knowledge they share is vital. “It makes me trust that information more.”

In December 2020, when Yuma County became one of the hardest hit parts of the nation as agricultural activity peaked and COVID-19 case numbers soared among migrant farmworkers, promotoras advocated for and helped with testing, and later vaccination efforts, often between 2 a.m. and 5 a.m. when these essential workers line up to commute from Mexico to Arizona’s fields.

“They played a critical role for us during the pandemic,” says Gloria Coronado, health promotions program manager at the Yuma County Public Health Services District. “Them being from the community, their lived experiences, and having that track record of being trusted by the community members makes a big difference in any type of preventative effort, especially during the pandemic.”

But the role of promotoras and other community health workers is often undervalued or underutilized by the mainstream public health system. “There’s 30 to 40 years of scientific evidence that demonstrates that community health workers are highly effective across disease areas, across contexts, across populations,” says Samantha Sabo, a community health scientist at Northern Arizona University. She says that healthcare managers might not know who promotoras are or what they do. They may also not use them properly in practice.

The pandemic began to change that. According to Jill Guernsey de Ziapien, a community-based public healthcare expert at the University of Arizona, the federal government has increased its investment in promotoras and community health workers over the past two years. This includes funding states and counties to hire them, or supporting them through non-profit organizations and clinics.

As some health departments began to notice their inability to reach underserved Latino communities most impacted by COVID-19, they increasingly bolstered their collaborations with promotoras. Sabo states that “these systems began to see the value of community workers in ways that they hadn’t before.” “They were kind of the unsung heroes.”

Establishing promotoras in the U.S.

Promotoras began serving migrant farmworkers as early as the 1960s. But the model is rooted in Latin America, where it has been used since the 1950s to bring healthcare to rural and poor communities.

In Yuma County in the mid-1980s, Guernsey de Zapien noticed that migrant farmworkers often struggled with health issues but had few ties to the community health center, the health department, or other local services. She says that there were a million obstacles to healthcare. The medical system wasn’t interested in providing care. When someone did try to seek medical help, which was often expensive and not geared to Spanish speakers, “they were treated in the most racist fashion at the healthcare facility.”

Inspired by the promotoras model Guernsey de Zapien had seen living in Mexico for 25 years, and the one her colleague had seen in Peru, they replicated the system in Yuma and other regions along the border. The goal was to train trusted members of the migrant farmworker community in basic healthcare information and to act as a link between the American system and the local population.

Her initial surveys in Yuma indicated that pregnant farmworkers were in particular need of healthcare but lacked access to it. With help from four Latino medical students at the University of Arizona, Guernsey de Zapien designed a 13-lesson plan on topics including reproductive health and pregnancy, the need for regular checkups, and where to seek prenatal care. For six months, she trained eight farmworker migrant women to be community leaders and to deliver the curriculum with cultural sensitivity. She says, “The response was incredible.” “Pregnant women showed up to the classes with their partners, their mothers,” she says. The promotoras helped pregnant women make appointments and sometimes accompanied them to hospital.

But the promotoras were not always treated with respect. Emma Torres, a former farmworker in migrant communities and a promotora on this project, says that they were once told that they were gossiping women who thought they could be doctors. She now leads the nonprofit Campesinos Sin Fronteras, which trains and employs promotoras to help farmworkers in Yuma County. “They didn’t believe that we would actually have the ability to reach our own.”

Prevention is better than cure

Over the last 30 years, more trained promotoras have gradually forged deeper connections in their community by sharing information on diabetes and hypertension, respiratory illnesses, and sexually transmitted diseases, along with ways to prevent and manage these and other common chronic health conditions. They have helped patients connect to healthcare providers, prepared them to go to hospital, coordinated transportation and spoken to providers to explain their client’s situation. There is some evidence of their success.

In a 2004 study, researchers documented that those who participated in a promotoras-run diabetes prevention program became more active, consumed fewer sugary beverages, and ate more salads, fruits and vegetables. A 2006 study found that promotoras helped uninsured Hispanic women receive routine preventative screenings from pap smears and mammograms to blood pressure readings and glucose tests. They’ve also assisted those eligible to enroll in medical insurance programs.

Still, it’s a role that’s been less visible and underfunded, says Alma Galvan at the Migrant Clinicians Network, a Texas-headquartered nonprofit that serves the health needs of migrants, immigrants, and asylum seekers. But as COVID-19 began to disproportionately impact Hispanics, promotoras were especially needed to communicate with hard to-reach communities, she says.

The role of promotoras during the COVID-19 pandemic

In the early days of the pandemic, as COVID-19 hit close to home, Campesinos Sin Fronteras promotoras responded quickly. “It was a scary situation,” says Idolina Castro, a former migrant farmworker and a promotora who has worked with the nonprofit for more than 20 years. “People were really scared.” She and her colleagues used the phone call to discuss disease symptoms, the latest CDC guidelines on isolation, masking and quarantining, and the resources that could be accessed.

Via their community radio station called Radio Sin Fonteras, which serves southern Yuma County, promotoras made COVID-19 health announcements in Spanish, interviewed doctors and CDC experts, and answered listeners’ questions. Federico Zamora, a 74-year-old Yuma City resident, says the information the radio station broadcast was important because it addressed his community’s needs and challenges.

When COVID-19 testing became possible, Yuma County’s Public Health Department trained promotoras to collect swab samples as outbreaks rose among farmworkers. Torres says that many of them refused to test because they knew that if they were positive they would be asked to stay home and not be paid. Others were reluctant to give personal information to health authorities. Promotoras were sent to the border at 2 am, when large numbers of migrant farmworkers waited for hours to cross from Mexico to Arizona. They also helped set up a testing station.

In rural parts of North Carolina, they played a key role in connecting Hispanic immigrants sickened with COVID-19, particularly those who were undocumented, to financial aid for rent, food, and other expenses.

Fighting misinformation

As COVID-19 vaccines arrived, the work of promotoras became more crucial. Castro states that “one of the worst things that happened during pandemic was the misinformation we had to counter, and fight back.” Hispanics were particularly skeptical and mistrustful about vaccines, from the microchips in vaccines to the potential for cancer-causing effects. Promotoras were often the first contact at vaccination sites. They provided information in Spanish, made people feel comfortable, and answered any questions.

In West Yellowstone, a rural town in Montana with a small but growing Hispanic population, “we were able to vaccinate over an estimated 80 percent of the people in that community,” says Elizabeth Aghbashian, a health promotion specialist at the Gallatin City-County Health Department. She says that the promotoras were key to making this happen. They also filmed themselves getting vaccinated, and shared the video via their social media channels, which helped build credibility.

In North Carolina, promotoras advised health department officials on where and when to set up vaccination sites. “That was super valuable.” “That was super valuable.”

At a Thursday support group meeting in Somerton in August this year, Castro and her colleagues were helping senior citizens understand the importance of getting a second booster and where to get the shot as Omicron’s highly contagious BA.5 variant rapidly spread. Velazquez, who attended, said that if it weren’t for the promotoras there wouldn’t be anyone else to inform me about what was happening.

Long COVID is now a big part of conversations promotoras are having with their community members, says Floribella Redondo-Martinez, CEO of the Arizona Community Health Workers Association. They raise awareness about lingering symptoms and encourage people to seek diagnosis. If they are eligible for financial assistance, they link them to federal disability programs. Promotoras also help researchers increase Latino participation in clinical trials such as RECOVER, which aim to treat, prevent, and understand long-term COVID.

Since the pandemic started, “we’ve had a lot of money to train and deploy community health workers,” Torres says, “The kind of funding that wasn’t available before.” She hopes, with the growing recognition that promotoras are an essential workforce, that they will continue to be supported.