When Esperanza Ramirez of Santa Ana pulls you aside in the grocery store and tells you it’s time for a mammogram, you’d better just do what she says. The diminutive 65-year-old has an answer for any excuse you might have to avoid the procedure.

Afraid the mammogram is uncomfortable? Chemotherapy is a lot worse.

You don’t have transportation? Ramirez can get you a ride.

You don’t have money? The mammogram is free.

And so on.

Ramirez is determined to help the women in her largely low-income, immigrant community avoid late detection of breast cancer. And as a promotora (promoter) at Latino Health Access, a nonprofit dedicated to Latino health in Orange County, it’s her job to help.

Promotores are lay people who educate the members of their own communities on preventive practices and connect people to medical services. They are the cornerstone of LHA’s outreach efforts, doing tasks like going door-to-door, approaching people in supermarkets, conducting health classes and babysitting while a parent visits the doctor.

A Community Investment

LHA promotores, also known as community health workers, make contact with some 40,000 people a year. About 4,000 people receive medical and educational services from LHA’s organization annually.

Promotores are LHA staff members and some volunteers. Key programs deal with diabetes prevention and management, obesity, alcoholism, mental health, elder care and women’s health. Promotores are trained in a variety of ways — conferences, online seminars, materials from medical authorities, and meetings with doctors. But in the end, it’s the promotores’ personal touch that differentiates them.

“The medical community doesn’t invest time in building relationships and promotores do,” said America Bracho, LHA founder and a former doctor in rural Venezuela. At LHA, some of the promotores are people who themselves suffered from a malady or dangerous situation and lived through it, making them uniquely credible.

“Say a woman was affected by domestic violence. She survived and now she’s thriving. Who’s going to say she’s not an expert?” Bracho said.

In fact, two of the lead promotores in domestic violence at LHA survived abusive partnerships. Their current efforts for LHA range from leading support groups to accompanying women to court.

Since door-to-door isn’t always a good way to approach domestic violence victims, the promotores also use creative campaigns, such as giving out bags of laundry detergent with a note saying, roughly translated, “Dirty clothes are washed at home but dried out in the sun.”

The idea is to encourage women to stop keeping their dirty laundry (that is, their abuse) a secret. Promotores also hold tortilla giveaways, attaching cards that say that tortillas are part of their culture, but violence is not.

These and other unconventional approaches to health and wellness have proven effective internationally, particularly in developing nations.

Success Internationally

In one famous example, a network of some 40,000 grandmothers became promoters of the use of vitamin A in Nepal, where eye disease had been rampant. Doctors had failed to persuade people to take the remedy. It took women with moral standing in the community to institute vitamin A’s widespread use, greatly reducing illness.

In the U.S., health promoters are more commonly seen in enclaves of ethnic minorities, though they were once deployed in low-income white communities as well, according to Steven Wallace, professor of public health and associate director of the UCLA Center for Health Policy.

“The idea is that the people you are most likely to listen to are people like yourself. They’re able to say things in a way you understand, and because they are from your neighborhood or church, they’re the people you’re more likely to trust as well,” Wallace said.

But do trust and communication come at the price of expertise?

“There’s always a tension,” Wallace said. “Medical care providers are worried about whether the information given by promoters is accurate and useful.”

This concern has led to a push to provide more education and certification to health promoters.

But, Wallace said, “The beauty of lay health promoters is they are people from the community that are grounded there. If you try to upgrade them so they have two years of college-level coursework, you pull them away from the community.”

The program recently made local headlines when members of the Orange County Board of Supervisors expressed concern about awarding a $1.5-million grant to an organization that uses a Spanish word (promotora) in a description of its services.

Yet advocates for the program say the Spanish usage helps to give them legitimacy as community organizers who lead efforts for broader health initiatives such as better parks and school lunches.

Community betterment begins with young people, said promatora Rosario Perez. Over the years, youth initiatives have included leadership development and going door-to-door to teach neighbors about the poison hotline. In Los Angeles, promoters documented housing conditions that were causing children to make repeated trips to hospitals for asthma. Their findings were then used to pressure landlords for improvements, Wallace said.

In Orange County, LHA’s promotores have proven particularly effective in educating the community on mental health and diabetes management, according to local health experts.

“Destigmatizing mental health is one of their best efforts. With diabetes, they’ve done a great job showing that the illness can be prevented, that it’s not a life sentence for you if your parents had it … you can fight it,” said Kim Goll, director of program operations at the Children & Families Commission of Orange County.

But it’s not always easy to sell people on health education and unfamiliar medical procedures, especially when a community faces more immediate concerns about safety, legal status and economic security. So promotores do a lot of coaxing.

Overcoming Hurdles

The women whom Ramirez recruits for mammograms, for example, don’t always believe her when she says the mammogram is free. Some say they’re not overly concerned about breast cancer, because no one in their family has had it. Ramirez responds that Latinas tend to be diagnosed at later stages when breast cancer is harder to treat, which is why the mammogram is crucial.

Other women say their husbands are not comfortable with their wives getting a breast exam, so Ramirez offers to speak to the husbands to assure them of the medical staff’s professionalism. In the end, about 30 percent of women who sign up for mammograms through LHA don’t show up.

“There are numerous barriers, and some people don’t want to come in,” Ramirez explained. Many of the women she is trying to enlist are family caretakers and full-time babysitters, used to meeting others’ needs and not their own. “I tell them, ‘You have to take care of yourself.’ “

Similarly, when it comes to another LHA priority — park space — promotores not only work to obtain resources but urge people to take advantage of them. In June, when Roosevelt Elementary School in Santa Ana unlocked one of its playgrounds for the community to use on weekends, promotores went door-to-door to tell people about the park and encourage them to use it.

But overcoming long-held fears about the safety of parks in gang-infested neighborhoods is a challenge, Perez said.

“Our community is afraid,” she said. “People didn’t always see the benefit; they’re not used to it. But people are using the park more.”

Amy DePaul is a freelance writer and lecturer in the UC Irvine Literary Journalism program. You can reach her directly at depaula@uci.edu

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