Promotoras de salud: Roles, responsibilities, and contributions in a multisite community-based randomized controlled trial

Promotora* is a commonly used Spanish term for community health worker (CHW), a broad umbrella category of para-professionals who provide health education and outreach services within their own communities (World Health Organization, 1978, 1989). Also called by a plethora of other names (e.g. health advisor, natural helper, peer educator), CHWs are individuals to whom community members regularly turn for information and resources (Guinn, Vincent, Jorgensen, Dugas, & Semper, 2007; Reinschmidt et al., 2006). There is widespread agreement on promotoras’ cultural and linguistic effectiveness in conducting community health education and outreach within U.S. Hispanic communities (Fernandez et al., 2009; Medina, Balcazar, Hollen, Nkhoma, & Soto Mas, 2007; Saad-Harfouche et al., 2011; Waitzkin et al., 2011). By delivering culturally-tailored health education and disseminating information about health and social resources to Hispanics and their families, promotoras serve as bridges between their communities and the formal healthcare system (Forst et al., 2004; Rhodes, Long Foley, Zometa, & Bloom, 2007). Health education, advocacy, emotional support, referral and information support, and community capacity building are common CHW practice domains (Andrews, Felton, Wewers, & Heath, 2004; Koskan, Hilfinger Messias, Friedman, Brandt, & Walsemann, 2012; May & Contreras, 2007; Parra-Medina et al., 2009). In some situations, promotora roles extend beyond delivery of information to include serving as behavioral change agents or health systems navigators (Anders, Balcazar, & Paez, 2006; Waitzkin et al., 2011). Across programs and settings, CHW roles range from unpaid volunteer to salaried paraprofessional (Cherrington et al., 2008; Hinton, Downey, Lisovicz, Mayfield-Johnson, & White-Johnson, 2005). More recent additions to the promotora role repertoire include research-specific activities. The most commonly reported promotora/CHW research role is delivery of interventions through teaching, demonstration, or provision of social support (Larkey, 2006; O’Brien, Squires, Bixby, & Larson, 2009; Pieper, 2008; Strolla, Gans, & Risica, 2006). For example, in one randomized controlled trial (RCT), promotoras implemented a community-based breast and cervical cancer screening intervention, conducting home visits with individual women randomized to the intervention group and helping participants schedule health screenings and medical appointments, in addition to performing research-specific roles of administering informed consent and collecting process evaluation data (Hunter et al., 2004). In another RCT designed to test a promotora-delivered cardiovascular health education program, promotoras also engaged in participant recruitment and retention activities and collected process and outcomes data (Balcazar et al., 2006). Findings from an assessment of promotora involvement in a randomized study of a mental health intervention indicated that although key stakeholders found the promotora-delivered mental health intervention useful and cost-effective in identifying and managing depression, promotora role confusion and blurred boundaries compromised the fidelity of the research design and the ability to implement the intervention as planned (Waitzkin et al., 2011). Despite clear evidence of the benefits of a promotora approach for health promotion in Hispanic communities and indications of increasing involvement in research, we identified several gaps in the literature on promotora involvement in research. These included scant attention to the types of skills and knowledge needed for engagement in the role of community researcher and the lack of evidence of promotora involvement in developing or testing research interventions they deliver. Furthermore, CHW knowledge is rarely systematically documented or integrated into research or program evaluation data (Peacock, Issel, Townsell, Chapple- McGruder, & Handler, 2011). To address knowledge and practice gaps related to promotora research engagement, in this report we examine the promotora research-related roles, responsibilities, and contributions in the context of a multi-site RCT conducted within the framework of community-based participatory research (CBPR; Israel, Schulz, Parker, & Becker, 1998; Minkler & Wallerstein, 2002). We begin with an overview of the contexts, settings, and research process and then provide a more in-depth examination of specific promotora research roles and responsibilities. We then examine variations and differences related to context, sites, settings, and individual promotora characteristics and conclude with a discussion of the benefits, challenges, lessons learned and implications for research and practice.