(Photo by iStock/Hiraman)
Care workers, from community health promoters to family caregivers, are a backbone of the US economy. With compassion and humanity, they take care of our children, parents, and communities; but they often work outside of health care systems and without the workplace supports they need to thrive.
In 2020, Children’s Hospital Los Angeles (CHLA) set out to engage promoters—individuals who serve as liaisons between providers and community members—onto their care teams, as a way to address the hospital’s disconnection from Spanish-speaking families. They partnered with Para Los Niños’ Community Transformation Collective (CTC), a nonprofit serving the Los Angeles community with decades of experience in training and deploying promoters. Integrating promoters into the hospital created a bridge of trust between CHLA and the Spanish-speaking community. Within the first year, referral rates increased from 26 percent to 85 percent, with promoters successfully connecting families to resources such as housing and food support, removing systemic barriers to improved health and well-being.
The CHLA and CTC team made progress toward the integration of this new workforce, but improvements were still needed. To equitably support promoters means not just hiring them but also shifting power by working in partnership with them to understand and remove systemic barriers so that workplace policies and practices are designed to meet their needs. Our organization, Health Leads, partnered with CTC to develop an institutional assessment tool to support that power-shifting process. Utilizing our innovation process, we collaborated to research, design, and test the assessment tool in partnership with promoters, CTC, and CHLA.
At this critical moment in the United States and around the world, as economic and political instability threatens the work, livelihood, and well-being of Black, Latinx, and other workers of color, institutions and policies need to be reimagined and restructured to meet their needs. For organizations that want to support the integration of care workers or other workforces who are often marginalized by structural and systemic barriers, we arrived at four principles that may help you design your own assessment tool to support their equitable inclusion in workplace policies and practices.
Understand the Systems and Their Exclusion of Workers
We conducted a landscape scan to understand the history of the promoter workforce (commonly known by their Spanish-language name, promotoras) and their marginalization, working in the health care field but often outside of its structural supports and protections. The promoter model began as a grassroots effort in Latin America in the 1960s, shifting power to communities by training and educating local women on health to then bring that knowledge, awareness, and advocacy back to their isolated communities. They often bridged the gaps to health and social service systems caused by a lack of government investment.
Their work represents a popular adage that still resonates throughout Latin America and its diaspora: “Solo el pueblo salva el pueblo,” meaning “Only the community can save the community.” The initial prevalence of promoters in the United States came during WWII with an influx of Mexican agricultural workers. To this day, they are primarily trained, hired, and deployed by community-based nonprofit organizations, sitting outside of health care institutions to support communities. Often monolingual, Spanish-speaking women, they give their time, connection, and commitment in exchange for low wages or a small stipend. Many nonprofits struggle to offer consistent and sufficient compensation due to the unstable nature of funding for these jobs—primarily grant-based and short-term.
As promoter models proliferate in American health care, tools have been developed to evaluate the effectiveness of promoters, but a tool to evaluate an institution’s integration of this workforce has never been created. Thus, failures in performance are attributed to the perceived ineffectiveness of the workforce and not institutional and systemic failures that may impede the promoters’ ability to perform their job effectively. The need for an institutional assessment created an opportunity for the CTC team to collaborate with CHLA to develop a novel tool that evaluates an institution’s performance while elevating the internal changes needed to strengthen their support of promoters. At the same time, they also sought the ability to signal to policy makers the legislative and regulatory changes needed that sit outside of the institution's control.
Use a Community-Centered Design Process
Effectively creating system change, and ensuring the process is equitable, demands that affected communities—with their lived experience and culturally affirming approach—have power from the start. We conducted interviews with promoters to understand the problem that needed to be addressed from their perspective. We heard from promoters about some of the barriers faced and how they often opened doors for themselves. These insights led to a problem statement that centered their experience: “Promoters who are working with health care institutions have struggled to be integrated in inclusive and equitable ways due to systemic racism in workplace policies and practices.”
By centering the expertise of workers, organizations and institutions can authentically and accurately understand the barriers that exist for workers and their families. Through a community-centered design workshop, the CTC team, along with promoters, developed a prototype of the assessment tool. Having promoters at the table ensured their experience and knowledge informed the design of the tool, including the specific metrics that needed to be assessed and the workplace policies and practices necessary to ensure their equitable integration. Each of the 25 metrics—such as recruitment, payment accessibility, and work culture of trust and safety—is scored based on how well aligned that workplace policy or practice is to inclusive integration of non-English-speaking promoters. Knowing the importance of institutional buy-in and partnership, the team also intentionally designed the tool to create transparency and accountability through a reinforcing and aspirational, not punitive, lens. The score ranges from “Not Yet Aligned” to “Fully Aligned,” with the tool providing awareness of performance and an understanding of levers for change for institutions to advance their alignment.
Ensure Institutional Performance Is Transparent and Accountable to Community
In the design workshop, the CTC team and the promoters also recognized the importance of the institution’s administrative staff and promoters working collaboratively to score the institution. Shifting power comes not just through the design of the tool itself, but the recognition of whose experience, participation, and voice should be essential to the assessment. The CTC and CHLA teams worked collaboratively to test the tool and collect feedback to understand its effectiveness and strengthen its design. To do this in a way that ensured the agency of promoters, the tool and feedback form were translated into Spanish and an interpreter was present. This process allowed promoters to share their perspective and expertise while scoring confidently and accurately.
Ensuring community has power to influence, or in this case, to assess, the institution cedes power in a way that can effectively drive changes. Working side-by-side to assess the institution also ensured collective awareness of the institution’s performance, built trust, and created accountability with a shared understanding of where critical work is still needed. Without community voice, perspective, and experience, institutions have a limited understanding of where they stand and the progress needed. Working together provides accountability internally and externally to strengthen the workplace to inclusively support workers and the communities they serve.
Promote Ongoing Refinement and Adaptation
We ran two rounds of testing as an opportunity for cross-dialogue between promoters and institutions. Feedback gathered through the testing process allowed for the refinement of the tool to ensure it effectively supports promoters and the hospital. This included a recognition that the tool needed to use more simple, accessible, and non-technical language to be linguistically and culturally accessible.
At the same time, the team recognized how far they have come with their integration since the launch of their program in 2020, the improvements that are still needed, and that changes in the social, economic, and political environments impact both community needs and workplace policies and practices. Creating space and time for ongoing reflection and adaptation means existing solutions can be modified to ensure they continue to support the community and new innovative solutions can be developed when needed.
Conclusion
By collaborating with promoters toward integration into the hospital care team and assessing institutional performance in support of this workforce, the CHLA and CTC partnership exemplifies how shifting power to community can drive meaningful changes to address the health disparities experienced by under-resourced children and families. Because of their inclusive approach to integrating promoters and adapting workplace policies and practices in their support, families experienced more patient-centric care management. They more consistently attended their appointments and followed through on treatment, improving their health and strengthening the trust between community and institution.
Veronica Corona, a health promoter at CHLA, reflected on her experience, “I visualize[d] the power-shift, that change of connection, that trusting connection between community and hospital. Our community is working together with the hospital, and if the community can walk hand in hand with other institutions, that would be my dream.”
Truly innovative solutions that transform institutions and systems to work for isolated and excluded communities come from centering their needs throughout the research, design, implementation, and evaluation processes. In this moment in our country, investment in a community-driven research and development process and the creation of tools co-designed by workers—to assess their employers, institutions, or sectors—is imperative to ensuring all our workers and their families can thrive. Sharing power to drive meaningful systemic change supports not only their health, well-being, and dignity, but a United States with an inclusive economy for shared prosperity.
Read more stories by Sarika Abbi-Patel & Arantxa Sanchez-Cruz.