GENERATIONS – Journal of the American Society on Aging

While the Healthy Fit approach was some- what conventional in terms of CHW roles, it shows how these roles can be culturally adapted in specific settings. The CHWs in Healthy Fit were known as promotores de salud , a common title in Hispanic/Latino communities. But the history of promotores in the United States and in Latin America shows an emphasis on “commu- nity transformation,” an empowerment model driven by a community’s internal priorities and resources rather than the goals of healthcare institutions (Visión y Compromiso, 2016). Pro- motores fall under the umbrella term of CHW because they derive their effectiveness and much of their value system from lived experience, which they share with the community they serve. In the case of Healthy Fit, the promotores were not operating under a true community transformation model, but were engaged in recruitment, health education, referral to com- munity resources, and social support for life- style changes aimed at improving health status. They had latitude to design word-of-mouth recruitment and telephone follow-up in ways that would be considered acceptable to local community norms, which include elements of Mexican-origin culture, but are specific to the local community. This tailored aspect of “cul- tural humility” is a strength of CHWs with locally rooted experience; knowledge of the fun- damentals of Mexican culture does not guaran- tee success in specific communities. One culturally specific feature of Healthy Fit was the use of fotonovelas, which typically are short graphic novels with photos rather than illustrations, as education tools. The Healthy Fit fotonovelas were used to send positive mes- sages or cautionary tales on health issues, with characters who physically resembled commu- nity members. The CDC recommends and has produced fotonovelas for educational strategies with Hispanic-Latino communities (CDC, 2015). In addition to its emphasis on physical activ- ity to prevent and reduce obesity as a contribut- ing factor in diabetes and cardiovascular disease,

Healthy Fit also encouraged routine screen- ing for various forms of cancer, and achieved increases in screening rates for the study partici- pants. Of those found to be “behind” in schedul- ing recommended screenings for breast, cervical, and colon cancers, 45 percent, 32 percent, and 20 percent, respectively, received recommended screenings as a result of the promotores’ inter- vention (Brown et al., 2018). The promotores’ cultural awareness and relationship capabilities were likely crucial in this aspect of the project, because many in such populations are reluctant to be screened due to established belief systems, some of them cul- turally based. Such belief systems include fatal- ism, faith-based practices, and a mistrust of healthcare institutions. For this project, special arrangements also were often necessary to pro- vide access to clinical services needed by large numbers (80 percent) of uninsured or underin- sured participants (in many cases this was due to these participants’ undocumented sta- tus). These specific arrangements included vouchers for free services provided by the local health department. Analysis These three initiatives all are successful on some level, and provide examples of the broad range of CHW activities related to chronic disease. Spec- trum Health is an example of a long-standing commitment to CHWs as a responsive approach to community needs. Spectrum executives credit the “high-touch” approach of CHWs—enabled by their embeddedness in the community—with achieving advances in patient self-management and adherence to treatment, as well as amelio- ration of patient stress associated with social determinants of health. Spectrum’s commitment has gone beyond inclusion of CHWs in externally funded posi- tions to integrating some CHW staff into the system’s core budget (twenty-seven positions in summer 2018) and to leadership in statewide pol- icy and standardization of the workforce across

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