Local Heroes: Promotores de Salud

The Promotores de Salud pilot program is now halfway through its 6-month contract with Mendocino County and non-profit Nuestra Allianza de Willits. Late last year, this small-but-mighty group of Willits-based Latino/a leaders hit the ground running, and for the last 3 months have been conducting COVID outreach, vaccine advocacy, supporting basic needs to ensure well-being for their community while helping close the equity gaps widened by the pandemic.

Over the last year, regions around the country have experienced large disparities in COVID-19 infections between white communities and communities of color. The cases among Latinx communities have been disproportionate to their overall share of the population. As of February 17^th, Latinos made up 39.3% of California’s population, yet represented 55.2% of COVID-19 cases. In Mendocino County, Latinos comprise 27.1% of the population and 50.3% of COVID-19 cases.

Much of this disparity is due to socio-economic factors and systemic racism. In 2019, Latinos made up 41.5% of California’s essential workforce, making them more vulnerable to COVID infections and less likely to have paid sick leave benefits and a living wage.[i] Additionally, many undocumented workers do not have adequate health and safety protections from their employers. Factors such as the affordable housing crisis across the county has forced many low and medium income families into multi-generational housing, increasing risk of transmission. In addition, Latinos are less likely to have health insurance.[ii]

However, one of the major contributors to this disparity is the trivialization of and inattention to comprehensive, Spanish language information and outreach to the Latinx community. Accurate information, including prevention and early intervention messages, about COVID-19 did not get to non-English speaking populations in timely, culturally, and linguistically competent ways. Governmental organizations that held the information did not have or assign culturally and linguistically competent employees to translate and relay information through appropriate or trusted communication channels.

While there have been strides to remedy this on a local level, gaps in outreach persist, as well as language hurdles, and technological challenges that exclude many Latinos in Mendocino County, particularly mono-lingual and/or undocumented individuals, from crucial health information and care.

“There are sensible ways we can help people, but the largest challenges we face are systemic barriers,” said Laura Diamondstone, Promotores de Salud Project Epidemiologist and Evaluator.

The Promotores de Salud is an evidence-based best practice implemented throughout the country to bridge Latinx and Spanish-speaking communities with the healthcare system. This model works to improve the health of Latinx populations and dissolve barriers to information, resources, and services, particularly for non-English speaking or monolingual communities. It is important that promotores do not just speak Spanish, but that they are also members of the populations they serve, sharing the same social, cultural, and economic characteristics which enable them to easily build trust and provide culturally appropriate services and healthcare information.

Promotores can have a specific focus or target populations[iii] within the Latinx community or work generally to promote resources and services available for all groups. They can take on many roles including patient advocate, educator, mentor, outreach worker and translator.

The Willits Promotores set out to disseminate information on COVID-19, how to stay safe and protect others, and resources available for those impacted by COVID, working off a unique database called Aislamiento y Cuarentena Indicaciones, consejos y recursos  that includes eligibility basics, documentation required and bilingual contacts for resources offered in the community Understanding that nobody is a monolith, the Promotores deploy various communication strategies using all channels at their fingertips to reach community members without smartphones, internet accesses, social media, or email addresses, as well as those that are monolingual, documented, and undocumented.  

However, very quickly their work expanded from prevention and outreach into the clinical realm. A grant from The Community Foundation of Mendocino enabled the health workers to support those affected by COVID-19 in a new way, by delivering food and supplies during their check-ins with families in quarantine.

“This is why this program works so well under a community-based organization such as Nuestra Alianza de Willits—nothing can be really planned and you have to move fast when things shift and change, and you have to be really flexible,” said Daimondstone.

This sort of agility has been crucial to navigating the vaccine distribution system in our county. Last minute clinic announcements through social media and online registries such as Vaccinate Mendocino and MyTurn have left many eligible people without internet to fall through the cracks. Additionally, of the multiple registries currently active in the county, not one meets all the needs of the diverse Latinx community. For instance, a registry offered in Spanish may require an email address to sign up, inadvertently excluding those without internet. While another list that may allow for multiple people to register under one email address, may not offer a Spanish language method to sign up for a vaccine once.

“We can’t get people into the system even for notifications,” said Diamondstone. “It requires us to be monitoring every registry and contact them specifically. It’s not a unique frustration [to Mendocino County].”

To combat this, the Promotores are compiling their own list of individuals interested in getting vaccinated, and partnering with local advocates in the community to reach out quickly after a vaccine event is announce to book an appointment them on their behalf. However, this is just part of the battle.

While it is important to prevent line jumping, ridged employment documentation requirements at industry-specific vaccination events can frequently exclude eligible people. The Promotores have advocated for a change in the eligibility language promoted by the County and have recently received some movement on this. Yet the Promotores are also attempting another top-down approach: outreach to employers with large Latinx and/or undocumented workforces to encourage them to facilitate vaccinations for their employees.

Last week, the Promotores registered employees from 15 different businesses in Willits and are currently working on a letter to employers offering their support in the vaccine registration process, that will remind them that by supporting their employees to get vaccinated they are protecting their business and saving money in the long-term. The health workers are also visiting farm managers to speak with them directly about taking a more active role.

“They are saying to them, ‘If it comes through you, then the vaccine administrators know your employees are essential workers, rather than the workers trying to do it individually,' ” said Diamondstone.

So far, two restaurant owners among the many contacted, were uncooperative and expressed no interest in assisting their employees with vaccinations, but overall, the response has been favorable. The Promotores are now discussing ways to assist workers whose employers are unsupportive.

With the rollout of the COVID-19 immunizations throughout the country, a new wave of skepticism around vaccines has emerged, with many professionals zeroing in on the attitudes prevalent in of communities of color. According to the KFF COVID-19 Vaccine Monitor ‘s Health Tracking Poll, just 16% of Latino/a adults were “very confident” the vaccine development process was taking their needs into account (compared with 11% of Black adults).

However, Graciela Botello, Coordinator for the Promotores de Salud, does not notice an overwhelming amount of apprehension within the community she serves, and asserts that vaccine hesitancy is not exclusive to the Latinx community. The KFF poll supports her observations, reporting that the same number of white adults (27%) and Latino adults (27%) would “probably not” or “definitely not” get the vaccine.[iv]  The vaccine is new, and naturally myths and misinformation will spread among all groups. However, as the country progresses further in the rollout, there has been an uptick in vaccine willingness among all racial and ethnic groups, particularly among Black, Latino/a, and white populations.[v]

Botello believes the trust the Promotores have built in a short time has helped their efforts in encouraging local Latinos to get vaccinated.

“In general, I think that many people in our local Latino community are feeling more encouraged to get the vaccine precisely because many of us have lost loved ones to COVID-19 or because we know people who were seriously ill with it,” said Botello through a translator[vi]. “I also believe that the fact that we are a small community where we all know each other helps us push each other to get vaccinated.”

The team is addressing issues of vaccine myths and misinformation with posts and public discussions and is  creating a video that tackles common misinformation with themes salient to their community. As integral members of the communities they serve, the Promotores are in touch with how to impact hearts and minds and can deeply empathize with issues facing their peers, having often shared similar lived experiences interacting with the healthcare system. This is what makes them so effective. The grassroots nature of the promotores model enables outreach to be flexible, responsive, culturally appropriate, and deeply personal.

 “I love my community and find pleasure in work that is by the community and for the community,” said Botello. “The Promotores gave me the opportunity to do just that.”

Program Evaluator Laura Diamondstone says that in doing this work she has learned to have a much more empathetic understanding of what everyone is going through. While her frustrations with local vaccine distribution and outreach persist, she has a better grasp on why organizations and agencies may have difficulty meeting certain requests right now. However, she strongly believes COVID-19 has exposed the need for a shift in the way organizations conduct outreach in the future.

“Everyone addressing public well-being has to think through not just who are the people most at risk, but how do we get information to the hardest to reach first,” said Diamondstone.  “If you start from there and work backwards, you first put the energy where it is hardest . Then the easy part comes afterwards and there will be more equity with information distribution from the get-go.”

The contract for the Promotores de Salud Pilot Program ends in June of this year. Coordinators are in search of additional funding streams to continue their work and grow as a trusted organization serving as an intermediary between health services, social services and the community. With adequate financial support, the program could scale to other communities in Mendocino County.

“Our community more than ever is in need of these vital services, especially as we will be dealing with the social and economic effects that we’ve inherited from this pandemic for a really long time” said Botello. “I would also like to continue increasing individual and community capacity about general health awareness.”

Promotores de Salud Resources and Information

February 2021 Update:  Promotores de Salud --Nuestra Alianza de Willits

20^th Confrencia Binacional de Promotores- Fortaleciendo el trabajo communitario

Rural Health Information Hub: Promotores de Salud Evidence-Based Toolkit

[i] https://milkeninstitute.org/sites/default/files/reports-pdf/InaVulnerableState.pdf

[ii] SARS-CoV-2 Positivity Rate for Latinos in the Baltimore–Washington, DC Region | Health Disparities | JAMA | JAMA Network

[iii] For example, the  Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care program in Mariposa County, AZ; or the Salud es Vida Cervical Cancer Education program in rural southern Georgia 

[iv] This poll collected data from Nov 30-Dec 8, while vaccine rollout was in very early stages. Other studies point to a more favorable shift in vaccine acceptance as rollout progresses.

[v] https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

[vi] A special thank you to Promotora Keily Becerra for her translation assistance.