They’re called by different names: community health workers… promotoras… health advocates… pomoshniks… peer counselors.
By any name, or in any language, these health workers reach into ethnic communities to help underserved Californians navigate the confusing maelstrom of healthcare delivery.
California’s stew pot of ethnicities – Latino, Hmong, Russian and beyond – has made these workers an effective force for improving care in hard-to-reach areas.
Although used sparingly around the state, reform in 2014 under the federal Affordable Care Act provides incentives to utilize more of these workers – commonly referred to as the “promotora” or health promoter model.
Planned Parenthood of Los Angeles has used promotoras since 1990, and now has 52 working at 17 health centers throughout the county.
Though the organization focuses on reproductive health, promotoras offer help ranging from physical and mental health to family issues.
Celinda Vazquez, vice president of public affairs for the organization, says that promotoras advise women on sexually transmitted diseases and pregnancy, but also other health concerns: asthma, diabetes, obesity, cancer screenings, substance abuse, and prevention. Interpersonal issues such as domestic violence, self-esteem, or parent-child communication are also addressed.
“We absolutely know that the promotora model is highly successful,” says Vazquez. “It’s a creative, innovative way to reach folks that are underserved.”
A former promotora herself, Claudia Estrada-Powell says that promotoras are often critical resources for families. Some women don’t get simple yet effective screenings such as pap smears or mammograms, and a promotora can help initiate the process.
“It is life-changing for many of the women,” says Estrada-Powell, public affairs specialist for the LA Planned Parenthood. “The program can empower women to advocate for themselves and their families.”
The promotoras initially receive more than 200 hours of training. Once in the field, they typically help clients at their homes, yet also connect in other locations where they can conduct outreach, such as schools, churches, even foreign consulates.
Barriers to good health in ethnic communities are vast. They include lack of healthcare coverage, poor language skills, poverty, fear, and an inability to navigate “the system.”
Assistance is offered anywhere needed: finding healthcare coverage, filling out applications, translating, or finding the right physician.
“The sheer diversity of California alone is a significant barrier,” says Laura Hardcastle, deputy director of the state’s Office of Multicultural Health. “Every single population has its own set of distinct issues.”
Today’s catchphrase for ethnic health outreach is “cultural competence.” Community health workers must be fluent not only in the given language of the community, but its cultural nuances.
“It takes time, sensitivity and respect,” says Glenna Trochet, recently retired public health officer for Sacramento County.
Translating materials into different languages requires trained medical translators, yet scientific terms may not always exist in another language. Issues of informed consent, even sickness itself, may differ drastically.
Many Hmong immigrants, for example, still actively practice shamanism and animism. Trochet recounts the story of a Hmong patient who received a prescription, but instead of swallowing the pills, placed the drug vial on her altar at home.
Even minimal contact with a community health worker can have a significant health impact.
“An average of 10 hours of intervention per patient can significantly increase healthcare access, including preventative care,” reports The Effectiveness of a Promotora Health Education Model for Improving Latino Health Care Access in California’s Central Valley authored by the Central Valley Health Policy Institute and others.
In 2007, the institute worked with the public health department at California State University Fresno to train 14 promotoras, who then helped more than 300 low-income Fresno county residents access local health services and programs.
“They trust her,” said the institute’s Alicia Gonzalez, a research assistant, of the largely female profession. “They’re not ashamed to share that (private) piece of information with her.”
During the study, the institute found a number of undocumented workers needing similar guidance, and with the financial assistance of Kaiser Permanente, began a second program that helped over 100 undocumented workers (with at least one U.S.-born child) access services.
The goal of the institute’s work is to create an official community health worker curriculum at Fresno State and neighboring College of the Sequoias.
“The health professional shortage is a major issue in California, especially in the San Joaquin Valley,” says Gonzalez.
Historically, community health workers date back to China during its Cultural Revolution, into Mexico and throughout Latin America.
In the United States, The Indian Health Service adopted the model in the 1970s.
Today, this “community health representative” is a staple in Native American life, says James Crouch, executive director of the California Rural Indian Health Board.
There are about 38 community health representatives – all of them Native American – serving 31 tribal and urban health programs in California.
Crouch says despite financial constraints during the past 15 years, the program has been “maintained at a high level” as these workers have moved into larger health education roles – prevention and chronic disease management.
“We’ve been doing health navigation similar to the promotoras for a long time,” says Pa Koua Vang, interim executive director for the Hmong Women Heritage Association in Sacramento, which has the state’s second largest Hmong community behind Fresno.
“A lot of our elders were directly affected by the (Vietnam) war,” says Vang, citing PTSD and anxiety. Today’s economic woes have added depression to the mounting list of mental woes.
The Hmong association currently offers two health programs supported by “peer partners.” The first focuses on mental health and assists 100 people at a time with five staff. The second is the aptly titled Health Navigator Program, aiming to help 55 people in its first year.
San Francisco has always been a popular destination for immigrants. In the 1970s and 1980s there was a huge influx of southeast Asians, followed in the next decade by citizens escaping communist or fallen regimes.
While the speed of Russian immigrants has slowed, they once represented one of the fastest-growing communities in the Bay Area, according to a report by the city’s Department of Public Health.
The report calls for further outreach to Russians, a community it terms hard-working, resourceful, and resilient. Many fled their homeland because of anti-Semitism, social or economic upheaval.
Ground zero for the city’s immigrant population is the Newcomers Health Program and its Refugee Medical Clinic, based at San Francisco General Hospital.
“We used to see thousands (of patients) a year” says Patricia Erwin, director, Health Education Programs for the city’s Community Health Promotion and Prevention Section. But slowing immigration trends and the high cost of living in San Francisco have reduced those numbers, forcing many newcomers to outlying areas such as Daly City.
For years “pomoshniks” have served the city’s Russian community, and at one time the Newcomers Health Program employed five of them. Today, the program has seven outreach staff who speak 11 languages. Only one speaks Russian.
Olga Radom worked as a pomoshnik for more than 10 years at the Refugee Medical Clinic during the 1990s.
“At that time there were a lot of newcomers,” says Radom, citing immigrants from Russia, Ukraine, Moldova, and Uzbekistan.
The main concern?
“Depression of course,” says Radom.
Physical illnesses ranged from diabetes to heart disease and “anything related to smoking… when you immigrate, quit smoking is not a first priority, right?”
She says her biggest success as a pomoshnik was creating a support group for depressed Russian women.
Today, pomoshniks are also being used in the city’s “Let’s Be Healthy” wellness program targeting Russian-speaking immigrants.
In some communities where resources are more readily available, the community health worker model is less popular. One of these is San Francisco’s Chinatown.
“They are not into this kind of model,” says Pauline Ong, community relations specialist for San Franscico Health Plan, which represents many low-income families. “I think it’s a cultural thing.”
Ong says Chinatown already has two health centers that meet the needs of most local residents, even for those who may live elsewhere.
“Most of their activities are in Chinatown,” adds Ong. “It’s easy to get resources in the Chinatown area.”
Still, one local Bay Area organization is trying out the community health worker model. The Chinese Lay Worker Project is an experimental program to train health educators in colon cancer prevention. Operated by the NICOS Chinese Health Coalition, the program will test the effectiveness of this outreach model in the Chinese community, says Kent Woo, executive director of the coalition.
Even in non-immigrant communities outreach workers often prove beneficial.
Black Women for Wellness is a small, LA-based organization that targets the African-American community.
“We do peer education training,” says Denise Lamb, program coordinator. “It’s like the domino effect. We train them and they go out and educate someone else.”
The wellness organization delivers a wide range of health education services such as “Black Going Green” (environmental health), “Kitchen Diva” (healthy nutrition), “Sisters in Control” (reproductive health) and “Keep in Touch” (breast health).
Yet because most community health workers are supported by grants or public funds, this means they are often at risk during a questionable economy.
“It seems like policymakers are always looking to cut social service programs and health programs that these communities really depend on to get by,” says Sadio Woods, community liaison for the south LA-focused Community Health Councils. “And it happens every year.”
A new program in the state’s Maternal, Child and Adolsescent Health department uses community health workers for home visitations, with funding provided by the Affordable Care Act.
Kaiser Permanente has funded several programs to support promotoras. In Alameda county, a promotora traveled door-to-door to start the Caminatas de Salud walking club to help reduce heart disease, high blood pressure, and diabetes. The health giant’s Community Benefit Program funded the walking club through the Tiburcio Vasquez Health Center, which operates eight health centers and community clients.
“You can’t even quantify the role” that these workers play, says Woods.
“Promotoras are really like miracle workers,” says Vasquez.