On Wednesday night, about 15 students sat in a classroom on the West Side.
The group shared stories of medical discrimination, and not knowing whether they could question their doctors, or not knowing what questions to ask.
The students were undergoing training to become community health workers, or “promotores,” across the South Texas area. The health literacy project called Health Confianza, Spanish for health confidence or trust, launched in 2020 in response to the COVID-19 pandemic.
A partnership between UT Health San Antonio, the City of San Antonio Metropolitan Health District and The University of Texas at San Antonio, Health Confianza is funded through a three-year, $3 million grant from the U.S. Department of Health and Human Services and Health Resources and Services Administration. The grant covers tuition and stipends for students enrolled through Health Confianza, which works with the South Central Area Health Education Center, the Alamo Colleges District and others to enroll students into community health worker certification courses.
The group aims to train 275 people across 38 South Texas rural counties from Brownsville to Laredo to become promotores and help rebuild trust in socioeconomically disadvantaged communities within three years.
On San Antonio’s South, East and West sides, lower access to health services, lower educational attainment, lower income and multigenerational households have been “baked into the community,” said Jason Rosenfeld, director for global health education with the Charles E. Cheever Jr. Center for Medical Humanities and Ethics at UT Health San Antonio.
Those factors, along with other social determinants of health, have a huge impact on health outcomes in local neighborhoods, he added.
Universities, public health agencies, and nonprofits can become certified to offer the trainings. In San Antonio, two more organizations that received HRSA grants to train community health workers will join the list of programs already training community health workers, or promotores.
YWCA San Antonio, a multicultural women’s organization, and Form Communities, a mental health nonprofit, also each got $3 million over three years.
The YWCA will offer paid training, educational coaching and case management for local women to become community health workers. Form Communities will also train community health workers, focused on helping people in the community navigate their mental health challenges.
Community health workers are not volunteers. As trained professionals certified by the state, they can be hired by hospitals, nonprofit and community organizations and public health agencies, among others. People already in the health care industry can enroll in the program to gain another certification.
According to May 2021 data, most recent available according to the U.S. Bureau of Labor Statistics, there are 4,850 community health workers in Texas with a mean annual salary of $42,220.
The San Antonio Community Health Workers Association, one of about 12 health worker groups in the state, has 310 members, said Guadalupe Cornejo, the association’s lead organizer and instructor for the program at Northwest Vista College.
Rosenfeld said promotores working alongside people in the community to help change their health will be the key to disrupting the disparities that make up for the 20-year difference in life expectancy between Southside communities and Northside communities.
“Everyone should feel they have an advocate to turn to say, ‘I don’t understand what this doctor is telling me. I don’t understand what these medicines are,'” said Siria Arriaga, a student attending the Health Confianza program to be a community advocate. “I think a lot of people are afraid to do that pushback to the doctors — they’re afraid to ask those questions. Unfortunately, their health suffers from it.”
Arriaga’s own personal experiences stirred her passion for wanting to help people navigate the health care system. Her daughter underwent a liver transplant in 1998 and again in 2018, and recently, her mother-in-law’s Alzheimer’s diagnosis made her feel confused and lost in the hospital system.
At the time, Arriaga was handed a four-inch binder of everything to know about transplants. Overwhelmed, she became her daughter’s advocate, reading and learning about available resources.
When her mother-in-law’s diagnosis progressed, Arriaga, without realizing it, was again playing the role of a promotora.
Arriaga was accepted into the program two days after her mother-in-law’s death and attended her first day of class last Wednesday. Classes are held twice weekly in the evenings at Alamo Colleges’ Westside Education & Training Center.
When the program concludes, she and her peers will be trained to connect people in their community to preventive, curative and recovery services for COVID-19, mental health and chronic diseases such as diabetes.
Studies show community health workers are essential to lowering the rate of hospital readmissions, and for helping people maintain and reduce their risk factors for chronic diseases like diabetes and obesity.
Those improvements in outcomes are due to the cultural and linguistic skills the promotores have that help tailor strategies to each person’s cultural context and needs, Rosenfeld said.
“It’s one thing to say, ‘You need to go eat healthy fruits and vegetables,’ but if I don’t have access to those in my neighborhood, then what am I supposed to do?” he said. “Community health workers can help people design strategies to either identify resources that they didn’t know exist or find ways to tweak what they already knew to make their food and their nutritional habits a little bit better.”
In September, UT Health San Antonio published a study that showed one-third of 986 patients achieved long-term self-care for their Type 2 diabetes after building trusting relationships with community health workers.
The promotores program is an alternative to health workshops, during which people come to a group setting to discuss health. Many of those sorts of events are held during the day and aren’t an option for those who don’t have transportation or the time to attend.
With that in mind, the first goal of promotores is to build relationships, according to author of the study and UT Health San Antonio assistant professor Carolina Gonzalez Schlenker. That takes understanding.
At the primary care clinic at University Health’s Robert B. Green Campus in San Antonio on the West Side, Gonzalez Schlenker said doctors primarily see patients from zip codes in San Antonio that have lower life expectancy rates and high poverty rates.
“There’s a lot of uncertainty in their lives, there’s a lot of unpredictability, just with their basic needs, they usually are juggling things that are basic in their survival,” she said. “They often won’t take diabetes as a priority.”
Those who need help from promotores include patients who show up with an uncontrolled diagnosis they are already aware of but not proactively addressing. The next step, Gonzalez Schlenker said, is to connect with the patient.
“We go knock at your door, listen and sit in the kitchens and they move at the pace of trust building,” she said. “They find the person, they listen in from that listening, they understand.”
At Wednesday’s workshop, students learned that it’s during those sessions that patients often vent about misinformation, trust and the confusion of navigating the health care system, and ask the questions they don’t feel comfortable asking physicians.
Gonzales Schlenker used a metaphor: Imagine you get in a car, but it’s not going anywhere because you have a flat tire. Yes, you’re sitting in the driver’s seat, but it’s not moving. The promotora knocks on your window and says, “Can I get in with you?” She then sits down and says, “OK, let’s take care of your diabetes. You’re the driver. I’m in the passenger’s seat. Where do you want to go?”
Approaching those conversations non-judgmentally is key, she added.
“They need to listen attentively. They need to be there with the patient. That’s what triggers the trust,” Gonzales Schlenker said. “And then there’s a point in where the patient says, ‘You know what? I’m turning the car on. Let’s pump that tire, and let’s fill the gas tank. And let’s go.’”
Any U.S. resident over 18 with a high school diploma or GED is eligible to become a promotor, and can apply for the program. Tuition for the biweekly trainings are covered by the grant and stipends are available.