This page provides a selected list of current articles from the research literature of interest to stakeholders in the Promotor(a) or Community Health Worker Training and Certification Program. A promotora/community health worker is defined here as a person who, with or without compensation:
provides cultural mediation between their communities and health and human service systems;
provides informal counseling and social support;
provides culturally and linguistically appropriate health education;
advocates for individual and community needs;
assures people get the services they need;
builds individual and community capacity;
or provides referral and follow-up services.
For further information on the following articles contact the Medical and Research Library at firstname.lastname@example.org or call 512-776-7559. For further information on promotoras/es and community health workers in Texas, contact email@example.com; call 512-776-3500, or visit the Promotor(a) or Community Health Worker Training and Certification Program website, part of the Office of Title V and Family Health, at http://www.dshs.state.tx.us/mch/chw.shtm.
External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may also not be accessible to people with disabilities. The links were working at the time they were created.
Selected Current Journal Articles and Reports
[See a more comprehensive bibliography of articles on community health workers.]
Arredondo E, et al. Advocating for environmental changes to increase access to park: engaging promotoras and youth leaders. Health Promot Pract. 2013 Jan 29. [Epub ahead of print]
Access to physical activity opportunities are limited in underserved communities. Community-based programs can increase promotoras and youth leaders' capacity to advocate for built environmental changes. Promotoras and youth leaders were trained on walkability assessment, park audits, and advocacy. The youth and promotoras from one church located adjacent to a park implemented a community survey, conducted walk audits, and engaged in consciousness-raising activities about environmental factors that affect communities. They also mobilized community members to advocate for a nearby park. Advocacy tactics included attending and making presentations at the City Council, planning meetings, organizing health fairs, and speaking to community members. The following changes were made at the park: removed overgrown plants, relocated storage container, increased park security (i.e., lighting, fencing), improved safety (i.e., covered sewer drain, sand lot removed), enhanced amenities (i.e., drinking fountain, bathroom, benches, tables), improved pedestrian safety in park (i.e., leveled the old and added new walking paths), and improved children's play area (i.e., new play equipment, fencing). The current program highlights factors that contributed to park changes and challenges in increasing access to parks. Furthermore, the current study notes steps that other programs can take to make environmental changes.
Casper JM, Harrolle MG. Perceptions of constraints to leisure time physical activity among Latinos in Wake County, North Carolina. Am J Health Promot. Vol. 27(3):139-42 (Jan 2013).
Purpose: Examine and compare constraints to physical activity (PA) among Latinos based on age, gender, income, and self-reported leisure time PA (LTPA). Design: Cross-sectional survey. Partnered with a North Carolina nonprofit advocacy organization who recruited community leaders (promotores) to administer the survey to Latino constituents. Setting: Latino communities in Wake County, North Carolina. Subjects: Respondents (N = 457) were mostly women (58%), with a mean age of 34 years (SD = 11), low income (70% < $39K/year); 78% were born outside the United States, with a majority from Mexico (52%). Measures: Sociodemographics; Stanford Brief PA Survey; constraints on PA were measured with 20 items assessing seven constructs (accessibility, facilities, knowledge, partners, psychologic, safety, and time). Analysis: Descriptive statistics, reliability analysis, confirmatory factor analysis, t-tests, and analysis of variance. Results: Half of the sample was inactive. Eighty-one percent indicated that they would like to be more active and perceived lack of accessibility, partners, and knowledge of PA resources as the most constraining factors. Respondents in low-income categories cited significantly higher psychological and accessibility constraints. Inactive LTPA respondents perceived significantly higher constraints overall, with knowledge and accessibility having the largest effect sizes. No differences were found based on age and gender. Conclusions: This study highlighted that among Latinos, there may be an opportunity to increase activity levels by targeting knowledge about PA resources, increasing access to opportunities for PA, and enhancing the social environment for PA. Such efforts that target these constraints to increase PA may ultimately improve health.
Ferrer RL, et al. Advanced primary care in San Antonio: linking practice and community strategies to improve health. J Am Board Fam Med. Vol. 26(3):288-98 (May-Jun 2013).
Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.
Hawkins J, Kieffer EC, Sinco B, Spencer M, Anderson M, Rosland AM. Does Gender Influence Participation?: Predictors of Participation in a Community Health Worker Diabetes Management Intervention With African American and Latino Adults. Diabetes Educ. 2013 Jul 16. [Epub ahead of print]
The purpose of the study was to determine the effects of gender on participation in a community-based, culturally tailored diabetes lifestyle intervention, led by trained community health workers (CHW) and conducted with African Americans and Latinos with type 2 diabetes. This study utilized data collected from 180 participants. Multivariable binary and cumulative logistic regression models were used to analyze associations between gender and race/ethnicity with study completion and participation in 3 aspects of the intervention: group classes, CHW home visits, and CHW-accompanied doctor visits. Among Latinos, men were less likely than women to complete the study, attend group classes, and complete CHW home visits. There were no gender differences in participation seen among African Americans. Diabetes management interventions may need to adapt their designs to optimize retention and participation of Latino men. Among African American men, the CHW model may be promising. Reasons for low participation among Latino men should receive more study. Future studies should assess whether similar findings apply in other communities and populations.
Hernandez MY, Organista KC. Entertainment-Education? A Fotonovela? A New Strategy to Improve Depression Literacy and Help-Seeking Behaviors in At-Risk Immigrant Latinas. Am J Community Psychol. 2013 Aug 2. [Epub ahead of print]
Research shows high risk for depression among immigrant Latinas known to increase during the acculturation process. Several barriers such as stigma and low health literacy result in an under-utilization of needed treatment among these women. In response, this study replicated the effectiveness of a Spanish language fotonovela, a form of Entertainment-Education (E-E), designed to increase depression literacy, decrease stigma, and increase help-seeking knowledge and behavior in Latinos. Specifically, this study evaluated a fotonovela delivered in a multifaceted approach to health education used by promotoras. A pretest-posttest randomized control group experimental design with 142 immigrant Latinas at risk for depression was employed. Results indicate significant posttest improvements in depression knowledge, self-efficacy to identify the need for treatment, and decreased stigma in experimental as compared to control group participants. Findings support the application of E-E health literacy tools such as fotonovelas, delivered in multifaceted approaches to health education used by promotoras, to Latinas at risk for mental health concerns.
Islam NS, Zanowiak JM, Wyatt LC, Chun K, Lee L, Kwon SC, Trinh-Shevrin C. A Randomized-Controlled, Pilot Intervention on Diabetes Prevention and Healthy Lifestyles in the New York City Korean Community. J Community Health. 2013 Jun 28. [Epub ahead of print]
Asian Americans experience diabetes at a higher rate than non-Hispanic whites. Diabetes prevention programs using lifestyle interventions have been shown to produce beneficial results, yet there have been no culturally-tailored programs for diabetes prevention in the Korean community. We explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve health behaviors and promote diabetes prevention among Korean Americans using a randomized controlled trial. Between 2011 and 2012, a total of 48 Korean Americans at risk for diabetes living in New York City (NYC) participated in the intervention. Participants were allocated to treatment or control groups. A community-based participatory research approach guided development of the intervention, which consisted of 6 workshops held by CHWs on diabetes prevention, nutrition, physical activity, diabetes complications, stress and family support, and access to health care. Changes over 6 months were examined for clinical measurements (weight, BMI, waist circumference, blood pressure, glucose, and cholesterol); health behaviors (physical activity, nutrition, food behaviors, diabetes knowledge, self-efficacy, and mental health); and health access (insurance and self-reported health). In this small pilot study, changes were seen in weight, waist circumference, diastolic blood pressure, physical activity nutrition, diabetes knowledge, and mental health. Qualitative findings provide additional contextual information that inform ways in which CHWs may influence health outcomes. These findings demonstrate that a diabetes prevention program can be successful among a Korean American population in NYC, and important insight is provided for ways that programs can be tailored to meet the needs of vulnerable populations.
Kenya S, et al. Using community health workers to improve clinical outcomes among people living with HIV: a randomized controlled trial. AIDS Behavior. 2013 Mar 21. [Epub ahead of print]
AIDS-related mortality remains a leading cause of preventable death among African-Americans. We sought to determine if community health workers could improve clinical outcomes among vulnerable African-Americans living with HIV in Miami, Florida. We recruited 91 medically indigent persons with HIV viral loads ≥1,000 and/or a CD4 cell count ≤350. Patients were randomized to a community health worker (CHW) intervention or control group. Viral load and CD4 cell count data were abstracted from electronic medical records. At 12 months, the mean VL in the intervention group was log 0.9 copies/μL lower than the control group. The CD4 counts were not significantly different among the groups. Compared to the control group, patients randomized to CHWs experienced statistically significant improvements in HIV viral load. Larger multi-site studies of longer duration are needed to determine whether CHWs should be incorporated into standard treatment models for vulnerable populations living with HIV..
Koskan AM, et al. Program planners' perspectives of promotora roles, recruitment, and selection. Ethnicity & Health. 2012 Oct 8. [Epub ahead of print]
Objective. Program planners work with promotoras (the Spanish term for female community health workers) to reduce health disparities among underserved populations. Based on the Role-Outcomes Linkage Evaluation Model for Community Health Workers (ROLES) conceptual model, we explored how program planners conceptualized the promotora role and the approaches and strategies they used to recruit, select, and sustain promotoras. Design. We conducted semi-structured, in-depth interviews with a purposive convenience sample of 24 program planners, program coordinators, promotora recruiters, research principal investigators, and other individuals who worked closely with promotoras on United States-based health programs for Hispanic women (ages 18 and older). Results. Planners conceptualized the promotora role based on their personal experiences and their understanding of the underlying philosophical tenets of the promotora approach. Recruitment and selection methods reflected planners' conceptualizations and experiences of promotoras as paid staff or volunteers. Participants described a variety of program planning and implementation methods. They focused on sustainability of the programs, the intended health behavior changes or activities, and the individual promotoras. Conclusion. To strengthen health programs employing the promotora delivery model, job descriptions should delineate role expectations and boundaries and better guide promotora evaluations. We suggest including additional components such as information on funding sources, program type and delivery, and sustainability outcomes to enhance the ROLES conceptual model. The expanded model can be used to guide program planners in the planning, implementing, and evaluating of promotora health programs.
Koskan AM, et al. Preparing promotoras to deliver health programs for Hispanic communities: training processes and curricula. Health Promotion & Practice. 2012 Sep 14. [Epub ahead of print]
Training is an essential component of health programs that incorporate promotoras de salud (the Spanish term for community health workers) in the delivery of health education and behavioral interventions to Hispanics. During training sessions, promotoras are exposed to information and skill-building activities they need to implement the health programs. This analysis was one component of a broader study which explored program planners' approaches to recruiting and training promotoras to deliver and sustain health promotion programs for Hispanic women. The purpose of this study was to examine promotora-curriculum and training processes used to prepare promotoras to deliver health programs. The authors examined transcripts of 12 in-depth interviews with program planners and conducted a content analysis of seven different training materials used in their respective promotora programs. Interview themes and narratives included program planners' varying conceptualizations of promotora-training, including their personal definitions of "training the trainer," the practice of training a cadre of promotoras before selecting those best fit for the program, and the importance of providing goal-directed, in-depth training and supervision for promotoras. The content analysis revealed a variety of strategies used to make the training materials interactive and culturally competent. Study implications describe the importance of planners' provision of ongoing, goal-directed, and supervised training using both appropriate language and interactive methods to engage and teach promotoras.
Koskan A, et al. Sustainability of promotora initiatives: program planners' perspectives. J Public Health Manag Pract. 2013 Jan 3. [Epub ahead of print]
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 10 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 health care systems at local, state, and national levels.
Krantz MJ, et al. Effectiveness of a Community Health Worker Cardiovascular Risk Reduction Program in Public Health and Health Care Settings. American Journal of Public Health. Vol. 103(1):e19-e27 (Jan. 2013).
Objectives: We evaluated whether a program to prevent coronary heart disease (CHD) with community health workers (CHWs) would improve CHD risk in public health and health care settings. Methods: The CHWs provided point-of-service screening, education, and care coordination to residents in 34 primarily rural Colorado counties. The CHWs utilized motivational interviewing and navigated those at risk for CHD into medical care and lifestyle resources. A software application generated a real-time 10-year Framingham Risk Score (FRS) and guideline-based health recommendations while supporting longitudinal caseload tracking. We used multiple linear regression analysis to determine factors associated with changes in FRS. Results: From 2010 to 2011, among 4743 participants at risk for CHD, 53.5% received medical or lifestyle referrals and 698 were retested 3 or more months after screening. We observed statistically significant improvements in diet, weight, blood pressure, lipids, and FRS with the greatest effects among those with uncontrolled risk factors. Successful phone interaction by the CHW led to lower FRS at retests (P = .04). Conclusions: A CHW-based program within public health and health care settings improved CHD risk. Further exploration of factors related to improved outcomes is needed.
Quandt SA, et al. Evaluating the Effectiveness of a Lay Health Promoter-Led, Community-Based Participatory Pesticide Safety Intervention With Farmworker Families. Health Promotion & Practice. 2012 Oct 17. [Epub ahead of print]
Pesticide safety training is mandated for migrant and seasonal farmworkers. However, none is required for family members, who implement home sanitation to protect against pesticide exposure and need to control pests in substandard housing. Controlled studies have demonstrated the efficacy of pesticide education programs for farmworker families, but no carefully evaluated demonstration projects have shown effectiveness in public health settings. This project evaluates a lay health promoter program to improve pesticide-related knowledge and practices. Promotoras from six agencies recruited families with children to deliver a six-lesson, in-home, culturally and educationally appropriate curriculum. Independently conducted pre- and posttests evaluated changes in knowledge and practices. Adults in 610 families completed the study. Most were from Mexico, with low levels of formal education. Significant improvements in knowledge were observed for all six lessons. Significant improvements were observed in practices related to para-occupational exposure and residential pest control. Lay health promoters with limited training and supervision can have significant impacts on families' knowledge and practices. They represent a workforce increasingly recognized as a force for reducing health disparities by providing culturally appropriate health education and other services. This study adds to the literature by demonstrating their effectiveness in a public health setting with rigorous evaluation.
Sabo S, et al. Predictors and a framework for fostering community advocacy as a community health worker core function to eliminate health disparities. Am J Public Health. 2013 May 16. [Epub ahead of print]
Objectives. Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. Methods. We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. Results. CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. Conclusions. The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity.
Salant T, et al. Lessons in translation: insights from a collaboration integrating community health workers into diabetes care. Journal of Ambulatory Care Management. Vol. 36(2):156-65 (April 2013).
Beginning in 2007, a community health center and a community health worker organization collaborated on a community health worker initiative to improve diabetes outcomes among underserved communities. Despite a shared vision, the initiative ended prematurely because of a number of unexpected collaborative challenges. This article describes the results of a qualitative investigation into these challenges. Through examples, we show how our collaborative difficulties were due to 3 interacting influences: logistics, participation, and institutional culture. We argue for the importance of institutional cultural competency in health care collaborations and provide recommendations for future collaborations that takes into account these 3 overarching influences.
Singh, P, Chokshi, DA. Community health workers--a local solution to a global problem. N Engl J Med. 2013;369(10):894-6.
St John JA, et al. Empowerment of promotoras as promotora-researchers in the Comidas Saludables & Gente Sana en las Colonias del Sur de Tejas (Healthy Food and Healthy People in South Texas Colonias) Program. The Journal of Primary Prevention. 2013 Feb 13. [Epub ahead of print]
Promotoras are trusted members of underserved, at-risk Hispanic communities experiencing social and health inequities. As promotora-researchers, promotoras have the unique ability and opportunity not only to provide outreach and education but also to be actively engaged in conducting research in their communities and serve as a cultural bridge between the community and researchers. In this article, we present a case study of personal and collective empowerment of six promotora-researchers who participated in seven community-based participatory research projects. Data sources included debriefing interviews with the promotora-researchers, milestone tracking and documentation completed during and after each study, and observations by the principal investigator and project managers regarding the role of the promotora-researchers in these studies. We qualitatively analyzed the data to identify the processes and decisions that were developed and implemented in a series of projects, which resulted in promotora-researcher empowerment. We found that active engagement empowered promotora-researchers personally and collectively in all phases of the research study. Common elements that contributed to the empowerment of promotora-researchers were valuing promotora-researchers' input, enabling promotora-researchers to acquire and utilize new skills, and allowing promotora-researchers to serve as both researchers and traditional promotoras. Together, these elements enabled them to more fully participate in research projects, while allowing them to identify and address needs within their own communities.
Swartz A. Legacy, Legitimacy, and Possibility: An Exploration of Community Health Worker Experience across the Generations in Khayelitsha, South Africa. Med Anthropol Q. 2013 Jun 26. [Epub ahead of print]
In South Africa, the response to HIV and TB epidemics is complex, varied, and contextually defined. "Task-shifting" and a movement toward a decentralized model of care have led to an increased reliance on community health workers (CHWs) providing health care services to residents of impoverished, peri-urban areas. Public health policy tends to present CHWs as a homogeneous group, with little attention paid to the nuances of experience, motivation, and understanding, which distinguish these care workers from one another and from other kinds of health workers. An exploration of the layered meanings of providing community health care services under financially, politically, and socially difficult conditions reveals clear distinctions of experience across the generations. Many older CHWs say that ubuntu, a notion of shared African humanity, is being "killed off" by the younger generation, whereas younger CHWs often describe older women as being "jealous" of the opportunities that this younger generation has for education, training, and employment. The structure of the South African health system, past and present responses to disease epidemics, and the legacy of apartheid's structural violence have amplified these generational differences among CHWs. Using ethnographic data collected from approximately 20 CHWS in a peri-urban settlement in Cape Town, South Africa, I explore how CHWs experience and understand legitimacy in the moral economy of care. A call for closer attention to the experiences of CHWs is critical when designing public health policies for the delivery of health care services in impoverished communities in South Africa.
Tran AN, et al. Evaluation of Amigas Latinas Motivando el Alma (ALMA): A Pilot Promotora Intervention Focused on Stress and Coping Among Immigrant Latinas. Journal of Immigrant and Minority Health. 2012 Nov 2. [Epub ahead of print]
Recent immigrant Latinas are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. This study evaluated Amigas Latinas Motivando el Alma, a promotora intervention to reduce stress and promote health and coping among recent immigrant Latinas. Using a pre- and post-test design, we evaluated mental health outcomes, specifically, in promotoras. Promotoras' knowledge levels related to role of promotora and stress management increased, depressive symptoms and stress levels decreased, and coping responses and perceived social support increased as well. Results suggest that promotora programs may be an effective way to improve mental health in recent immigrant Latinas.
Vincent D, et al. Challenges and success of recruiting and retention for a culturally tailored diabetes prevention program for adults of Mexican descent. The Diabetes Educator. 2013 Feb 25. [Epub ahead of print]
Purpose: The purpose of this article is to describe methods used to recruit and retain high-risk, Spanish-speaking adults of Mexican origin in a randomized clinical trial that adapts Diabetes Prevention Program (DPP) content into a community-based, culturally tailored intervention. Methods: Multiple passive and active recruitment strategies were analyzed for effectiveness in reaching the recruitment goal. Of 91 potential participants assessed for eligibility, 58 participated in the study, with 38 in the intervention and 20 in the attention control group. The American Diabetes Association Risk Assessment Questionnaire, body mass index, and casual capillary blood glucose measures were used to determine eligibility. Results: The recruitment goal of 50 individuals was met. Healthy living diabetes prevention presentations conducted at churches were the most successful recruiting strategy. The retention goal of 20 individuals was met for the intervention group. Weekly reminder calls were made by the promotora to each intervention participant, and homework assignments were successful in facilitating participant engagement. Conclusions: A community advisory board made significant and crucial contributions to the recruitment strategies and refinement of the intervention. Results support the feasibility of adapting the DPP into a community-based intervention for reaching adults of Mexican origin at high risk for developing diabetes