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. But she had heard rumors that the vaccines could kill people or were meant to wipe out chronic disease patients like her. 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. Known as America’s winter salad bowl and located near the border with Mexico, its residents are largely Mexican and Mexican-American farmworkers and their families who toil in the region’s $3.2 billion agricultural industry. For more than a decade, the group members—mostly Latinos with diabetes and hypertension—have met to learn about these chronic diseases and other health conditions prevalent in the community, while sharing food, laughs, tears, and a feeling 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. The knowledge they provide is very important, she says. “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. In practice, however, healthcare managers may sometimes not understand who promotoras are, what they do, and they may not be used properly, she says.
The pandemic began to change that. Over the last two years, the federal government has increasingly invested in promotoras and other community health workers by funding states and counties to hire them or supporting them through nonprofit organizations and clinics, says Jill Guernsey de Zapien, a community-based public health expert at the University of Arizona.
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. “These systems started seeing the value of community health workers in ways they haven’t before,” Sabo says. “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. “There were a million barriers to healthcare because the medical system was not interested in providing them with care,” she says. 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 from the migrant farmworker community to provide basic healthcare information and serve as a link between the American health 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. She trained eight migrant farmworker women for six months to be community health leaders and deliver the curriculum with the necessary cultural sensitivity. “The response was unbelievable,” she says. “[Pregnant] women showed up for the classes with their partners, with their mothers.” The promotoras were also helping pregnant women set up appointments and sometimes accompanying them to hospitals.
But the promotoras were not always treated with respect. “One time we were told we were a bunch of gossiping women thinking we can be doctors,” says Emma Torres, a former migrant farmworker and a promotora on the project. 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’ve connected patients to healthcare providers, prepared them for hospital visits, coordinated transportation, and spoken with providers to explain their client’s situation. And there’s some evidence of 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 Galván 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 afraid.” She and her colleagues used the phone calls as an opportunity to also talk about disease symptoms; the latest CDC guidelines on masking, isolation and quarantining; and resources people could access.
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. “A lot of them didn’t want to test because if they were positive, they would be asked to stay at home and they weren’t going to be paid,” Torres says. Others were hesitant to provide personal information to health authorities. So promotoras arrived at the border at 2 a.m.—when large numbers of migrant farmworkers line up daily for hours to cross from Mexico into Arizona—and helped set up a testing site.
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.
As COVID-19 vaccines arrived, the work of promotoras became more crucial. “One of the worst things that happened during the pandemic was the misinformation that we had to counter and fight back,” Castro says. From microchips in vaccines to their cancer-causing potential, vaccine skepticism and mistrust was particularly high among Hispanics. Promotoras were often the first point of contact at vaccination sites, giving people information in Spanish, making them feel comfortable, and answering 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. “The promotoras were instrumental in making that happen,” she says. Among other efforts, they filmed themselves getting vaccinated and distributed the video through their social channels, which built credibility.
In North Carolina, promotoras advised health department officials on where and when to set up vaccination sites. “They let us know, this church would be great on Sunday, where they’re going to have a cookout, so why don’t you bring vaccinators here,” says John Resendes, data analytics and innovations manager at North Carolina’s Office of Rural Health. “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. “If it wasn’t for the promotoras, there would be nobody else to let me know what’s going on,” says Velazquez, who attended the meeting.
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’re raising awareness about lingering symptoms, urging people to seek diagnosis, and linking them to federal disability programs if eligible for financial assistance. Promotoras are also helping researchers increase Latino representation in clinical trials like RECOVER that aim to understand, treat, and prevent long 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.