Promotoras, Community Health Workers Rule!

From the community, trusted, lived experience, life literate, bridging, valued & valuable. Russell Bennett shares his experience with Promotores and Promotoras.

Proem

I was the first male public health nurse in Western Massachusetts in 1976. It was also my first professional nursing job. I had a walking route in inner-city Holyoke caring for people with physical disabilities. Many people had bed sores. At most I could see people weekly, but they needed much more help than their families could provide, if they had families. I noticed one of the churches sent parishioners to help out with meals. I quickly realized that I could teach these few local dedicated churchgoers in the neighborhood to help the bed-bound people with dressing changes as long as I provided the materials and checked regularly. I didn’t know it at the time, but I was supporting community health workers. Many years later, when working with peer support in mental health and substance use recovery, I learned about the professionalism of these dedicated people with lived experience. The professionalism came from lived experience plus communication and connection skills, and critical and systems thinking. During my work in acute medical settings (inpatient, emergency, intensive care), I tried to incorporate more lived experience professionals without much success. Some of my studies to obtain a Master’s in Public Health included community health workers. Call them peer professionals, community health workers (CHWs), or Promotoras (Health Promoters). I see similarities. Note: As I understand it, the work is Promocion de Salud, Health Promotion. I will alternate between Promotores and Promotoras, but mostly use Promotoras and the initials CHW, Community Health Workers. Honor the Caregivers, Help the Helpers.

Introducing Russell Bennett

I’m delighted to have Russell Bennett as my guest today. Russell Bennett is a Strategy and Marketing Consultant at the Institute for Healthcare Advancement (IHA). Russ consultants with organizations in the health sector, focusing on strategy, marketing, and health literacy. He is based in California and works nationally and in Mexico. Having been raised in Mexico and lived there for 30 years, he is bilingual and bicultural and has served diverse populations at the US-Mexico border. He is attuned to the unique learning and communication needs of many people. Russ was the founding Executive Director of the US Mexico Border Health Commission over twenty years ago, and he has worked in the government, corporate, and non-profit sectors. He also founded Latino Health Solutions at United Healthcare, a major health insurance company, and has worked to improve the Social Determinants of Health in several states.

Health Hats: Russ, thanks for joining me. I'm delighted to have you. I'm very excited about this episode and having a chance to talk with you. Why don't we start with you introducing yourself and telling us about you and whatever it is you'd like to share about yourself and your work.

Russell Bennett: Thank you very much, Danny, and thanks for inviting me to your podcast. I've listened to quite a few of them, as I've told you. And I'm impressed with what you're doing. I have been in healthcare for 25, maybe closer to 30 years. I am bilingual and bicultural. I was raised in Mexico, and I've worked at the border and around the country for many years, working in government health care, corporate healthcare, and non-profit. I'm committed to the concept of health literacy and helping people understand and navigate the healthcare system in a way that will be better for them. We have a complicated healthcare system in the United States, and we've no need to go into that, but it can be so much better for people if they understand their healthcare needs and the resources that they can find in the system. So, in addition to health literacy, I'm interested in the social determinants of health, and suffice it to say if I can be of service to people, if I can help, I'm pleased to do that.

Community Health Workers, Promotoras. PotAto, potahto?

Health Hats: Oddly enough, I don't want to talk to you too much about health literacy, directly, but rather indirectly. What interested me when I learned about some of the work you do is your work with community health workers. I wonder if you could tell us a little bit about what is a community health worker.

Russell Bennett:  I'm going to make a little bit of a distinction between a community health worker and a Promotor, the Spanish word for health promoter. And most of them being women, they're called Promotoras, even though there are some men. A CHW is a person who is not necessarily licensed, although in some States, they are and they provide health information. They're a bridge between the health professionals, the doctors, the nurses, the hospitals, and community members. What happens is that CHWs are mostly in organizational settings, and Promotoras or Promotores are primarily in community settings. Sometimes they're the same people. A CHW is a Promotora. Sometimes they're two different ones. But the importance of a community health worker and Promotor - I will use the same term now for both of them now that we've talked a little bit about the distinction of where they work - is that they usually come from the community that they are addressing. So, when they talk to a family, the family will trust in what they're saying more than they might trust a white coat, medical professional who has their best interest in mind and has wonderful academic education. Still, they may not have the ability to translate their learning into the needs of that person. And as you said, indirectly, we're talking about health literacy because the CHW or Promotora is a bridge between the level of health literacy of the medical professional and the community member's health literacy.

Health Hats: I have several thoughts. First, in my world, as I’ve come up in healthcare, I've had considerable experience in behavioral health. That's where I learned to think about lived experience, that people have lived experience. People with lived experience have life expertise and life literacy. And clinicians and the licensed white coats, as you described them...

Russell Bennett: Whitecoat is not pejorative. That is someone I would be very proud to be one. I never got there.

Health Hats: Thank you. But I think that bridge, we call it health literacy, right? I like how you’re talking about the various abilities people have in talking about and understanding health. Some people have more expertise in medicine, and the formal medical part of health, and some people have more expertise in life, the community, the day-to-day aspect of health. It's all needed. It's all of a package. You've worked in different types of settings. Do you think that there's a difference in the approach, say, in this country, to community health workers and Sub-Saharan Africa or Mexico or rural Mexico? What's the difference in that?

Russell Bennett:  So, the difference is interesting. I hope we'll have a chance to discuss applying some of that here in the US. CHWs outside the US are often utilized in a much broader capacity than we use them in the US. They vaccinate. They extend the professional caregiver or the health professional. They extend that ability further into the community. They have a lot of respect for them. There are government programs in Mexico, for example, that utilize CHWs to provide health services. That's something that, although we're beginning to do in the US and a few States and we can talk a little bit about what Arizona is doing, for example, we haven't fully explored or used the potential of the Promotoras and the CHW in the US, but we could.

Community Health Resources and CHWs for vaccination

Health Hats: Yesterday, I was listening to somebody talking about vaccination and that for this country to get to 75%, 80% vaccination rate, we're going to have to use community health workers. They're going to have to train people. I appreciate that. I'm a nurse, and I feel like I have a skillset, but I have very few sets in my toolkit that I needed to have a degree to learn. Like one of those skills, five of those skills, can be taught to anybody. As a direct care nurse, I was always thinking about who comes to visit or who's at home with that person and what skills I have, can I teach? Because they're with the person who is not feeling well, way more than we're going to be with them. And it's just interesting in this country that we don't do that very much. And I think it's a part of it is a factor of the density of healthcare workers, across the nation, across the world. So that areas that systematically have less density, we'll use more community health workers.

Russell Bennett: That's true. They get filled up. For example, in Alaska, community health workers and the Indian nation community call them community health resources, CHRs. In Alaska, they're authorized and trained to vaccinate. For the same reason, you're saying that the number of health workers, especially in rural areas, is fewer and further between. And they have been successful with that. For example, I work with an Arizona program, the Regional Border Health Clinics, and they have trained community health workers to draw blood. For blood samples, for blood tests and they say that they can train a capable community health worker in two weeks to do it with all the requirements that we have in the US for drawing blood appropriately and safely. And they could train vaccination CHWs to do vaccination in less than two weeks. And the point that our new government wants to get a hundred million vaccinations done in a hundred days, I think CHWs could have an important role in getting that done.

In Promotoras we trust

Health Hats: I had a project once in Nigeria - I didn't go to Nigeria - community health workers were doing prenatal care. I want to talk more about was this question of trust. I imagine that the confluence of the community health worker, health literacy, life literacy, trust, access all fit together. Can you say a little more about your experience with that?

Russell Bennett: Sure. When I look at the overall community health worker, Promotora role they're patient advocates. They're educators. They become mentors to the families and the young people in the family there, of course, outreach workers. And in many cases, they're translators. And when I say translators, they're not just translating the language. In other words, translating what the healthcare professional says in English to Somali or Spanish or, whatever. They're also translating conceptually. It's like when we talk about translation of basic research into usable life into reality. So, all of those roles allow them to create trust. Often when a Promotora is recruited, the clinics that recruit them, the organizations such as Vision Y Compromiso in California - vision and commitment is what it means in English. They will go into communities and look for the highly visible, maybe the activists, maybe the opinion leaders, the people who others in the community are already going to, for their opinion. They're already going to these folks to help them interpret what the latest news is. One of the very interesting experiences with Promotoras and community health workers in the past year was getting out the vote, educating people that their vote counts. Another was on the census, educating people on the importance of being counted, the importance of filling out the forms, or answering the door when someone came to them no matter their immigration status. And I think the Promotora as a leader within the community can provide information, whether it's on the census, whether it's on vaccination, whether it's on COVID. All of these things, if we make an effort and the government makes an effort to get them the resources, get them the training, and get them the messages they need to provide. And pay them to do it. Exactly. They will be an effective way of reaching those, as we call them hard-to-reach units or family units or communities.

Health Hats: So interesting. If you were on President Biden's COVID Response Advisory Board, what would you recommend? I think you've started to answer that question already. What else would you, how else would you use community health workers in this COVID response, wherever it is, whether it's this country or another country?

Local Health Departments and Promotoras

Russell Bennett: In this country, one of the important things is to get approval from local health departments to vaccinate because vaccination is not authorized if the local health department doesn't manage it. That's the way it should be. But the local health departments are authorizing fire departments. They're authorizing EMT and others, and they're overseeing that vaccination. I don't see why they can't train and authorize the Promotoras as an extension. One of the things, for example, that Promotoras are doing is when you have drive-through screenings and they're waiting in line. They come after a while, they come up to the tent and get a nose swab or whatever the test is that they're going to get, Promotoras can do all the preliminary steps, even if they are not trained and authorized to do the nose swab. As the car drives up, they're doing the screening. They're helping fill out the form. They're helping the person know what's going to happen when they get to the tent. And they're building that trust. We're back to the expression or the importance of trust. They're building that trust so that when the person comes into the tent and gets their screen or test. There's less fear. There's more acceptance and understanding. They've been able to answer the question of when the report will come back. The results will come back, but it means if they get a positive result and what they have to do, so they're doing some training and education and maybe life literacy, as you're saying, as they are for that half-hour or time that they're spending in line. And I hope it's only a half-hour before they get to this.

Health Hats: And it seems like they could also be doing contact tracing.

Russell Bennett: They could also be doing contact tracing. It seems that we've allowed the contact tracing situation to get so out of hand with so many infections. If we had been doing contact tracing starting in February of last year, we could have a much better handle on it. And at this point, that's more difficult, but yes, the core, we’re talking about the importance I think of CHWs, not only in this pandemic but in future health needs. And the other thing is if a test is positive, then the patient needs counseling, and they need someone to mobilize the resources to address the housing, the food, the other social determinants of health. Because I think if someone tells you or me that we need to stick close to our house for 14 days and we can't go to the other end of the house or see our family, we're still going to eat a couple of times a day. We're still going to be able to live in our home. But what about the people who live a couple of families to a house or a room? What about the people who really cannot isolate, or if they isolate, they're not going to earn for those two weeks? So, our country has resources for that, but to mobilize them, there needs to be a bridge to get those resources from the government, from the churches, and from whoever is providing.

Win-win for doctors, nurses, and CHWs

Health Hats:  In your experience, what's been the range of responses that you faced from licensed professionals, being comfortable with community health workers?

Russell Bennett: That's a great question. There have been cases where at the beginning, the licensed professional denigrates or even or just doesn't feel that the non-licensed professional is going to be able to help. But in every case that I have seen, once you get them working together - it's not like I've gotten them working together. Still, the clinics like the one in Yuma and Somerton in Arizona, the groups in California, groups in Texas, once you get the CHWs working with the licensed professionals, the doctors begin to realize that you have fewer no shows to medical visits because the Promotoras are either picking them up and driving them to the clinic or encouraging them and showing them why they need to be at the visit. Maybe the Promotoras provides childcare for the woman who otherwise would not be able to go into a visit. So, the bottom line is that by creating this understanding, everybody has a role; you create a lot of unity. You create a lot of good energy. And synergy. And you create a lot of value for the health system, but also the health professionals. The group in Arizona did a program with United Healthcare a few years back where they proved improved health outcomes and saved about a million dollars over six months because people were coming to their visits, they were doing their follow-up. They were complying with medical instructions. There’s only 50% of medication adherence in our country, or compliance with medication adherence is fulfilled. If you can raise it from that 50%, people need an understanding that the doctor is not just giving them a medication because he or she thinks it's the right thing, but because it's going to cure them. And suppose they have the assistance of someone that they trust. In that case, the patient will often reduce readmissions, so there's a whole series of things that they'll reduce the use of emergency rooms and the inappropriate use of emergency services. It helps that synergy helps to stabilize the use of resources within the healthcare system.

Investing in CHW Research

Health Hats: I want to ask you one more thing. If you could control research dollars, what kind of research about community health workers would you like to see that would help you in your work or help spread community health workers' valued use?

Russell Bennett:  I think it builds on what we were saying. Not enough research has been done into the things that we were talking about right now into how that synergy works and the savings that we can create for the healthcare system by educating and using by training them. And I think that some of that research budget needs to go directly to the community organizations. We often send research money, or the government and the grantmaking organizations send the money to a university because they require that there be at least a Doctor of Public Health to manage the program. Still, the money might stay at the university. And very little of it gets to the community organization, producing the data, and training the people. Suppose we flip that model on its head, and we give the money to the organizations such as Vision Y Compromiso in California or the regional border program in Arizona. In that case, if we provide them with the research money, they can then hire a Doctor of Public Health or even partner with a university to analyze the data. But they are the ones that are creating the data, and it would not only raise the value of the research and real on the ground research, but it will also raise their own, empower them and raise their profile within their community for their satisfaction as well.

Farm Workers

Health Hats: Russ, what should we have talked about that we didn't?

Russell Bennett: Gosh, we’ve talked about so much. One of the things is helping them work with farmworkers. Farmworkers seasonally are sometimes bused into communities, and the farm companies or cooperatives will rent or buy an unused hotel or motel to house them. If they can incorporate - and in some places in Arizona, for example, they do - if they can incorporate to help in educating the farmworkers about proper sanitation, proper care during the COVID pandemic. That's just one of the many places where you can use Promotoras that they are used in some States, but not necessarily all across. So one of the other things that perhaps we could address is picking the successful CHW and Promotoras deployment models and taking those models nationally in Texas or Chicago, what's done in Arizona. For years, there's been an annual conference. And they share best practices, but to get significant organizations such as the government, maybe PCORI, involved in some of these conferences and picking the cause that are patient-centered interventions, where if you see that it's successful in one place, then duplicated where it could be. So those are some of the things.

Health Hats: Thank you. I appreciate your taking the time. This has been fascinating.

Russell Bennett: Thank you for inviting me.

Health Hats: My pleasure.

Reflection

Promotores, Promotoras, Community Health Workers, Peer Support Professionals. How can we manage COVID-19 prevention, acute and chronic, physical and emotional care in our communities without them? I don’t see it. Our licensed professionals are burning out at an alarming rate. We tend to think of CHWs in developing countries, not here. But look around. Not only do we have care and treatment deserts in urban and rural regions right now, but those deserts are also growing larger every day. Look around you, it could be your block or your neck of the woods. We need the remaining licensed professionals in acute care settings, so we need to extend their reach. Communities are rich with bright, skilled, passionate, unemployed neighbors who need work. As Russ said, highly visible, maybe the activists, maybe the opinion leaders, the people who others in the community are already going to, for their opinion. A perfect storm and opportunity. Are we resourceful and proud enough to fund and create armies of Promotoras and CHWs? I hope so. See the show notes for more information about Community Health Workers in Alaska, Arizona, California, and Texas. Honor the Caregivers. Help the Helpers.