Introduction

Latinos and Latinas (or Latinx, the gender-inclusive term used in this study) living in the United States have been one of the country’s largest and fastest growing ethnic groups for decades. As of 2018, over 18% of the U.S. population self-identified as Latinx, with projections estimated to reach 28% by 2060 (U.S. Census Bureau, 2018). A number of factors complicate their access to health and social services, particularly for those who live in low-income conditions and are first generation arrivals: low English proficiency (Pérez-Escamilla, Garcia, & Song, 2010), lack of familiarity with the U.S. healthcare system (Escare & Kapur, 2006), cost of services (Shattell, Hamilton, Starr, Jenkins, & Hinderliter, 2008), high rates of poverty and lack of health insurance (U.S. Census Bureau, 2017), a shortage of bilingual and culturally informed providers (Shattell et al., 2008), and few linguistically and culturally adapted materials (Wilkin & Ball-Rokeach, 2011). Such barriers contribute to significant health disparities and exact an economic burden on individuals and communities (Fiscella, Franks, Doescher, & Saver, 2002; LaVeist, Gaskin, & Richard, 2011).

In response to such disparities, scholars, practitioners, and advocates have emphasized the value of community-based participatory research (CBPR). Focusing on the community, CBPR highlights and further develops the strengths and capacities of all collaborative partners (Israel, Schulz, Parker, & Becker, 1998). The community health worker (CHW) model is an example of CBPR, with supporting national and international research dating back to the 1950s (Lehmann & Sanders, 2007). CHWs develop trusting, supportive relationships with fellow community members. They educate their peers, provide referrals to health and social services, support navigating systems of care, and serve as change agents (American Public Health Association, 2017).

CHWs can enhance community engagement, as well as participation and retention in health programs, resulting in enhanced well-being, particularly in under-resourced and marginalized communities. CHW scholarship within Latinx communities supports this claim, noting positive outcomes associated with, for example, enhanced cancer screening and prevention (Nuño, Martinez, Harris, & García, 2011), chronic disease prevention (Keller, Fleury, Perez, Belyea, & Castro, 2011), leadership development (Serrata, Hernandez-Martinez, & Macias, 2016), and heightened social capital (Farquhar, Michael, & Wiggins, 2005).

Research about the development of CHW programs is, however, scarce. What exists is generally limited to descriptions of promotora recruitment and training as part of the research methodology (Villalta et al., 2019) or aggregated reflections of program managers (Koskan, Hilfinger Messias, Friedman, Brandt & Walsemann, 2013). Attuned to this gap, some scholars have developed evaluative frameworks to inform process evaluations and fidelity to “participatory” partnerships. In a Brazilian CHW program focused on HIV prevention, Pinto et al. (2011) developed a 4-step “International Participatory Research Framework” to guide development and assessment of participatory partnerships. The authors suggested: “By moving beyond a set of [CBPR] principles and by standardizing procedures for forging partnerships, the scientific basis of participatory research will gain further support” (p. 436). Thus, understanding the context, identifying collaborative partners, obtaining support from community gatekeepers, and aligning expertise with community needs supports the development of collaboratively-identified research objectives and the building of community capacity.

The current study contributes to this nascent body of scholarship by applying a CBPR conceptual model as an organizing framework to describe the development of Lazos Hispanos (Hispanic Links), a CHW program launched in 2017 to enhance the health and well-being of Latinx members living in low-income communities.

Theoretical Framework for the Development of Lazos Hispanos

The CBPR conceptual model proposed by Wallerstein et al. (2008), and later refined by Kastelic, Wallerstein, Duran, and Oetzel (2018) informed the development of Lazos Hispanos. The model identifies four processes or dimensions that influence each other and impact community research. First, context refers to the multiple dimensions that influence a community, such as social characteristics (e.g., location, culture, racism, economy, education), political and policy influences, perceived health, capacity and readiness for change, and history of (mis)trust related to collaboration. Second, partnership refers to individual characteristics, relationships, and partnership processes that influence the commitment to community development and empowerment. Partners can be community organizations, healthcare and service providers, government and non-for-profit agencies, and academic professionals. Third, intervention and research refer to intervention processes (integrate community knowledge, empowering processes, and community involved research) and outputs (culture-centered interventions, partnership synergy, and appropriate research design). The last and fourth dimension is intermediate and long-term outcomes of the community work. Examples of intermediate outcomes are changes in policies, sustained partnerships, shared power, and research productivity. Examples of long-term outcomes are social justice, health equity and community transformation.

The multi-stakeholder evaluation of outputs and intermediate outcomes of Lazos Hispanos, anchored in the third and fourth dimensions of this same model, showed strong fidelity to this CBPR model and positive outcomes for all participants: the promotoras, the service providers, and the community members who received the services (Orpinas, Matthew, Bermúdez, Alvarez-Hernandez, & Calva, 2020).

Current Study

The current study anchors itself in the first and second dimensions of the CBPR model: context and partnership processes. The purpose is to detail the development of Lazos Hispanos, a multisystem, community-based promotora (we use the Spanish feminine term “promotora,” as all were women) program, describe the lessons learned, and provide further support for the application of “process-to-outcome” evaluative frameworks (Stanley et al., 2015).

Method

This case study describes the formative development of a multisystem, community-based promotora program (Yin, 2009), reflective of prior research (Pinto, Bulhoes Da Silva, Penido, & Spector, 2011; Wright et al., 2017). We collected primary and secondary data from the following sources: (1) initial community assessment findings from 370 members of the local Latinx community (Calva, Matthew, & Orpinas, 2019); (2) initial key informant interviews with nine local service providers and three community leaders with extensive experience working with the local Latinx population; (3) individual and group interviews with the founding nine Latina promotoras of Lazos Hispanos; (4) individual interviews with representatives from four primary clinics, three mental health facilities, three women and children advocacy groups, one legal service provider, and one Latinx serving agency holding memorandums of understanding with Lazos Hispanos; and (5) input from the interdisciplinary research team, as reflected in the “development of a multicultural, interdisciplinary research team” section below. The Institutional Review Board (IRB) at the University of Georgia approved all research activities.

We reviewed and summarized the findings from the initial community assessment. A thematic analysis approach was used to examine the initial key informant interviews (Boyatzis, 1998). Heuristic inquiry (Moustakas, 1990; Sultan, 2019) and thematic analysis (Braun & Clarke, 2006) guided the analysis of the semi-structured interviews with promotoras and service providers to examine their experiences and meanings of working with Lazos Hispanos.

Lazos Hispanos: Development Process and Lessons Learned

The description of the process and lessons learned from the development of Lazos Hispanos was anchored in the first two dimensions of the CBPR conceptual model: context and partnership development. For context, we described the community assessment, activities leading to Lazos Hispanos, and characteristics of the community. For partnership development, we discussed three interrelated processes: the development of a multicultural and interdisciplinary research team, the selection and ongoing training of promotoras, and the engagement of community service providers as partners. Table 1 summarizes the lessons learned during this process.

Table 1 Lessons learned from the development of Lazos Hispanos
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Community Context: Community Assessment and Activities Leading to Lazos Hispanos

Lazos Hispanos is situated within a middle-sized city in Georgia. In 2017, the estimates of the size of the Latinx community ranged from 11%, based on the U.S. Census, to 24% based on the number of children enrolled in the local public schools. Almost all Latinx students enrolled in the local school district (92%) qualified for free or reduced-price lunch. A community assessment spearheaded Lazos Hispanos (Calva et al., 2019). Mirroring findings from national research (Escare & Kapur, 2006; Pérez-Escamilla et al., 2010), this assessment identified interrelated barriers to healthcare and social services: insufficient information regarding available services, lack of transportation, prohibitive fees for services, language barriers, and immigration status. By virtue of outreach and engagement, this effort also identified a group of well-respected community leaders and advocates.

Using the findings from the initial community assessment, we obtained funding to assess receptivity to a promotora program. Through key informant interviews with local service providers and community leaders, we explored barriers and promising strategies to provide (or receive) healthcare and social services. Community leaders expressed enthusiasm for the project, particularly given its emphasis on capacity development of existing leaders. Among service providers, two themes emerged: (1) a desire to enhance outreach and services to the local Latinx community, and (2) a stated inability to do so.

Building on nearly 2 years of formative efforts, the research team was well positioned to apply and secure a large University interdisciplinary research seed grant to support program development in 2017. The goal of the program was to enhance the health and well-being of local Latinx through a promotora-researcher model. To achieve this goal, the proposal had four objectives: the promotoras would educate their peers, reinforce primary prevention, provide resources to navigate local systems of care, and advocate for culturally responsive programs and policies.

Concurrently, we partnered with PASOs (http://www.scpasos.org/), a nationally recognized CHW organization serving Latinx communities since 2005 (Matthew et al., 2017). We sought their technical expertise regarding domains critical to the development of the program’s infrastructure: developing a process to select the promotoras, specifying training competencies based on national standards, crafting the Memoranda of Understanding (MOUs) with promotoras and local service providers, and selecting promising data management procedures.

Based on prior experience and challenges noted in the CBPR literature regarding navigating IRB processes (Mikesell, Bromley, & Khodyakov, 2013), we nearly immediately began conversations with the University’s IRB. We collaboratively developed strategies to accommodate an emergent research design, the participation and protection of vulnerable participants, and the involvement of CHWs as promotora-researchers (John et al., 2013). For example, we embedded several confidentiality-related procedures: verbal (vs. signed) consent, de-identified participant codes, and pseudonyms for all promotoras.

Partnership: Development of a Multicultural, Interdisciplinary Research Team

Research team members had different levels and types of involvement and support. This section describes two interrelated research groups. First, the “convening team,” charged with responsibility for day-to-day activities, constituted the core research and outreach group. Second, the “research team,” which included the convening team, was a multicultural and interdisciplinary group of researchers that provided support and consultation on specific issues.

The convening team comprised the project’s four co-principal investigators, one project coordinator, and several research assistants. The majority of the team members were bilingual (Spanish–English), bicultural Latinx, or both. An active cadre of student and community volunteers also participated in the project. The multicultural perspectives of our team informed the research design, data collection, and process of engaging and building relationships with promotoras and community partners. For example, we conducted all training sessions in Spanish, provided near-simultaneous interpretation during service provider gatherings, created data collection instruments in Spanish, developed a culturally responsive promotora training curriculum, and translated service provider documents from English to Spanish.

The larger research team comprised faculty from eight academic programs from the University of Georgia: social work, public health, an institute for leadership, pharmacy, law, family therapy, human development, and counseling psychology. Research team members made valuable contributions to the project. For example, given the rising fear regarding deportation at national, state and community levels, our team’s attorney developed a “know your rights” resource guide and training for the promotoras. Likewise, given calls to (re)center leadership and capacity development within promotora programs and agencies (Farquhar et al., 2005; Matthew et al., 2017), our leadership training expert facilitated 6 months of leadership training (2–3 h per month). Additionally, two of our team’s bilingual and bicultural scholars are licensed practitioners with experience supporting the mental health and well-being of Latinx individuals, couples, and families. They provided 24-h emergency supervision for the promotoras and culturally tailored crisis response protocols.

Our group benefited from and provided mentoring opportunities to those interested in expanding their research and service portfolio to include CBPR. Researchers have expressed concern regarding the lack of professional mentorship and isolation among CBPR scholars (Lowry & Ford-Paz, 2013). Learning with and from a CBPR-informed effort in real time afforded rich opportunities to further develop the craft of designing research approaches attuned to CBPR, developing compelling CBPR funding proposals, and implementing culturally responsive community engagement strategies. These opportunities were open to faculty, academic professionals, promotoras, and graduate and undergraduate students.

Partnership: Selection, Training, and Ongoing Support of Promotora-Researchers

Based on the key informant interviews suggesting a preference to speak with and among women regarding health, we prioritized the initial partnership with female promotoras via a three-phase process. First, we reached out to community leaders to recommend individuals who might be effective in this role (e.g., demonstrated leadership capacity). Second, a bilingual and bicultural research team member contacted all candidates to assess interest and eligibility based on the following inclusion criteria: the candidate self-identified as Latina or Hispana, was 18 years of age or older, resided in the local county, and intended to reside in the county for at least 1 year. If interested and eligible, a member of the research team screened each candidate via a standardized assessment tool of core competencies (e.g., interpersonal and relationship-building, service coordination and navigation, capacity building, advocacy, etc.; Rosenthal, Hush, & Allen, 2016) and behavioral skills (Hobson & Kesic, 2002). These assessments resulted in an overall recommendation to serve in the program. Of the 18 women contacted to determine interest and eligibility, nine committed to participate in the program, given their expressed interest, eligibility, and satisfactory assessment scores.

After the initial selection during the summer of 2017, the promotoras attended a meeting to discuss roles and responsibilities as outlined in a MOU. The MOU served as their official consent form, delineating their involvement (e.g., attend trainings, outreach to at least 10 individuals, abide by code of ethics, etc.) and the benefits of participation (e.g., CHW and leadership training). At this time, the promotoras collectively chose a name for the program that they felt represented program intent and the community—Lazos Hispanos (Hispanic Links)—and discussed ideas for the logo and related color scheme. This energizing and exciting process engaged the promotoras in taking ownership of the project, and later lent them credibility among peers:

… for a while I had been telling [my friends about the project] and they just ignored me. Then, later they saw me with my [branded] shirt and bag, and they said, ‘Oh, wow! I like your shirt! Tell me more about what you’re doing.’

The formal training started in late September 2017. Mindful of common participation barriers, we held all training sessions in locations that were well known to the promotoras, welcoming of Latinx community members, and conveniently located (e.g., Latinx community resource center, a library located within a Latinx enclave). We provided transportation, light breakfast, and lunch at each meeting. Aided by seed funding, the research team subcontracted with PASOs to conduct the initial 24-h promotora training based on nationally recommended core competencies (Rosenthal et al., 2016; U.S. Department of Health and Human Services, 2007) and their extensive experience managing a CHW program. Key topics were qualities and responsibilities of promotoras, code of ethics, security protocols, reflective listening, resource connections, motivational interviewing, and self-care. The Lazos Hispanos research team members led 8 additional hours of training, including a review of crisis intervention protocols, discussion and practice of data collection and management procedures, and completion of the Spanish-language Collaborative IRB Training Initiative (CITI).

Following the initial training, the promotoras attended 4-h monthly team meetings and trainings. Each consisted of a general “check-in” to discuss current progress, submission of data for processing, and content-specific training. Towards the latter, we allocated 6 months to leadership and advocacy training. To provide ongoing support, the project coordinator also contacted each promotora weekly (~ 15 min) to discuss challenges and successes, and monitored (and participated in, as appropriate) a text message group through which the promotoras supported each other.

During the first year of the project, the promotoras received more than 70 h of training and participated in tours of local service providers. Training attendance averaged 80% throughout the first year; competing work and family responsibilities were the most common reasons for missing a session. The promotoras repeatedly commented on the advantages of meeting regularly: “I feel like every time we meet, we learn something new.” Over the course of these trainings, growth in leadership capacities was likewise evidenced by two of the promotora-researchers assuming co-leaderships positions in a local, grassroots Latinx advocacy group.

As shown in Fig. 1, the promotoras were the foundation of the Lazos Hispanos. They were members of the community they serve, but also interacted with service providers, the research team, and possible funders. As promotora-researchers, they kept track of every interaction with members of the community and with service providers. They also provided suggestions to improve the data collection system. The convening team entered the information into a computerized system and regularly provided them summaries of project advances, which generally filled them with pride.

Fig. 1
figure 1

Lazos Hispanos organizational model. The figure displays the Lazos Hispanos program model. The promotoras serve as the foundation, offering connection among the community, service providers, research team, and funders. Likewise, there is bidirectional communication and contact among all levels

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Partnership: Engagement of Community Providers as Collaborative Partners

We invited various health and social service providers to formally collaborate with Lazos Hispanos. At a meeting with each provider, we presented a draft MOU. Three sources informed the development of this MOU: best practices noted within the CBPR literature (Browne et al., 2009), guidance from PASOs, and legal oversight from the University. The MOU delineated the following expectations from each service provider: facilitate a 1-h training for the promotoras to review their services, provide a tour of their facility, address questions and misconceptions about the organization, and complete yearly surveys and interviews to assess changes in organizational policies, procedures, and Latinx population served. In return for their collaboration, the MOU also outlined what community partners could expect from the research team: support the provider’s community outreach events, convene gatherings of service providers and the Lazos Hispanos team (held as a biannual breakfast), and translate one document from English to Spanish to help facilitate service to the Latinx community.

Based on expressed interest, during the first year of the project the team met with 19 local service providers to formalize a collaborative partnership; 12 elected to sign the MOU. The most common reason for not signing the MOU was the large size of the organization, which made them unsure about how to track data or even who should sign the document. The 12 MOU-holders represented a wide array of service specialties: primary medical care clinics, mental healthcare providers, women and children advocacy organizations, legal services, and a local Latinx nonprofit center.

Baseline interviews with MOU-holders explored motivations to join the collaboration. Many noted that community members distrusted the medical and social services, felt insecure about how to access services, had difficulty accessing services due to language barriers, and had limited information about the U.S. healthcare system and insurance programs. These organizations viewed Lazos Hispanos as a promising mechanism to “reach out” to the local Latinx community. Providers expressed that the promotoras could provide a “connecting point” to enhance “visibility” of an “established community network.” A member of a domestic violence prevention agency stated,

…when I heard about this [project] I almost cried because I was so excited, because that is always going to be the way to effect change. It is not going to come from us. I’ve been doing as much as I can for a long time, which has been completely insufficient.

Another partner working at an agency that serves the Latinx community noted the value of “word-of-mouth referrals” from the promotoras to their agency.

Efforts to build relationships among service providers and key community stakeholders (e.g., local government, local and regional foundations, etc.) were not limited to those holding MOUs but also included a large group of “Friends of Lazos Hispanos.” Local agencies were invited to biannual breakfasts; these events provided opportunities for networking and sharing best practices. During this gathering, the research team provided an update based on the data collected (number of hours of training, people contacted, referrals made, and follow-up meetings with community members). The most-impactful section was the interactive question-and-answer session with the promotoras.

These collaborations and an intentional emphasis on building relationships were beneficial in several domains. Tours of the facilities of MOU holders helped address misconceptions and enhanced access. For example, while touring a local mental health service provider, several of the promotoras asked if they would encounter people in “straitjackets” and “in padded rooms,” as this misperception was common in the community. The service provider quickly disabused them and provided a comprehensive tour of the facility, noting comfortably lit rooms and an array of toys and board games for children. While leaving, the promotoras commented on “how important it was to visit,” as they realized the agency’s objective was to prioritize personal and family counseling and treatment, support well-being, and mitigate mental health crises.

The MOU facilitated opportunities to seek collaborative grants to enhance access and culturally responsive care. The existence of our collaborative partnership (via a formal MOU) proved instrumental to one of our partners to obtain funding to hire a bilingual staff member to enhance outreach to the Latinx community. Lastly, these partnerships and efforts to build relationships in the community spawned invitations to serve in various advocacy roles. For example, several bilingual and bicultural members of our research team were invited to serve on community advisory and visioning boards, and the promotoras were encouraged to advocate on behalf of their community by presenting on culturally responsive practices to various local, governmental and professional organizations.

Conclusion

Emerging from nearly three years of formative research and relationship-building efforts, Lazos Hispanos successfully developed a multisystem, community-based promotoras program. The team built upon existing relationships to forge a multicultural, interdisciplinary research team, recruit and provide over 70 h of training to nine promotoras, and engage 12 community providers as formal collaborative partners. This study addresses a gap in the literature concerning a lack of information on the formative development of community-based CHW programs by applying a “process-to-outcome” CBPR conceptual model to identify lessons learned with respect to community context and partnership development (Kastelic et al., 2018; Stanley et al., 2015; Wallerstein et al., 2008).

A focus on context was critical in the development of Lazos Hispanos. For example, the initial community assessment (Calva et al., 2019) allowed for an in-depth understanding of the impact of interrelated social characteristics (e.g., language proficiency, education level, health insurance coverage, socioeconomic status) on health status and access to services. Key informant interviews with community leaders and service providers allowed us to explore capacity and readiness for change, as well as the history of mistrust among the local community and “outside” collaborators (Kastelic et al., 2018; Wallerstein et al., 2008). As suggested by Pinto et al. (2011), attention to the development of culturally responsive, collaborative partnerships in these ways fosters the development of “collaborative research aims” and “community capacity development” (p. 438), within CBPR generally and CHW programs specifically. Indeed, these efforts proved critical in the initial selection of the CHW model to enhance access to health and social services, the formation of an interdisciplinary research team, the identification of research and community collaborators, the identification of specific training needs among the promotoras, and the attainment of seed funding.

Our focus on partnership development significantly enhanced program commitment and capacity development among all involved: interdisciplinary research team members, promotoras, community participants, and local service providers. The development and nurturance of these partnerships was the fruit of a considerable investment of time. Lazos Hispanos emerged after years of formative research and collaborative efforts. During the initial program planning phase, we allocated time and resources to collaborate with the Institutional Review Board (in pursuit of IRB approval), cultivated a partnership with an aspirational community-based CHW organization, formed a multicultural and interdisciplinary research team, provided ongoing training for promotoras, and fostered collaboration with community provider-partners. As suggested by Trickett (2009), we worked against a common practice in community-based programming and intervention that sees collaboration “…as a tactic or necessary strategy for accomplishing the intervention.” Rather, we “…conceptualized [collaboration] as part of the intervention paradigm itself” (p. 264).

Partnering with a successful promotoras program (PASOs) to share best practices and receive support was instrumental in the successful launch of Lazos Hispanos, likely saving untold amounts of time and additional resources. The development of a multicultural, interdisciplinary team expanded the scope and content of culturally responsive research and community practice and facilitated enriching mentoring and professional development opportunities among faculty, staff, students, and promotoras. The recruitment and ongoing training of promotoras supported retention, enhanced health and social service access, and fostered the development of community advocates, thus (re)centering social justice advocacy as a central component to and benefit of CHW programs (Lehmann & Sanders, 2007). These elements, combined with ongoing collaborative partnerships among local service providers, fostered the development of a community-embedded, culturally responsive, health-supportive infrastructure. The lessons learned during this process, as detailed in Table 1, can be a resource for researchers and communities working together to promote social justice and health equity.