Elsevier

Health Policy

Volume 82, Issue 2, July 2007, Pages 153-166
Health Policy

Promotor(a)s, the organizations in which they work, and an emerging paradox: How organizational structure and scope impact promotor(a)s’ work

https://doi.org/10.1016/j.healthpol.2006.09.002Get rights and content

Abstract

Objective

To analyze how organizational structures and scope (geographic and programmatic) generate dissonance between the organization and its workers, creating a paradox with policy implications for access to health care in hard-to-reach populations. The workers are lay community health workers called promotor(a)s. The organizations are community based organizations in which the promotor(a)s work, either as volunteers, part-time or as full-time wage staff.

Method

Ethnographic study of 12 organizations and their promotor(a)s. Data gathering included interviews with organization directors, promotor(a)s, service providers working with the organizations, and community residents served by the organizations and workers. In addition, promotor(a)s were observed in the course of their work. Sampling was a non-probability, snowball procedure for identifying the organizations and the workers within them.

Results

A paradox is emerging between (a) promotor(a)s who perceive their work to be locally focused and tightly integrated with the communities they serve and live in, and (b) the employing organizations that are expanding in geographical and programmatic scope because the work promotor(a)s do is in increasing demand by agencies and funding sources external to the communities served. The paradox potentially threatens to undermine and transform the work and working environment of the promotor(a)s. The challenge is to find a balance that will sustain a workable and working relationship among the organization, the workers, and the communities served.

Conclusion

Care is needed in setting out policies that translate the paradox into greater congruence among organization, workers and communities. Policy needs discussed focus on (a) worker training, (b) worker employment and deployment, and (c) funding source recognition of the paradox.

Introduction

This paper analyzes how organizational structures and scope generate dissonance between the organization and its workers, creating a paradox with policy implications for access to health care in hard-to-reach populations. The workers are lay community health workers called promotor(a)s.2 Promotor(a)3 is the Spanish term for a lay community educator and outreach worker used widely in Mexico and the U.S.–Mexico border [17], [18], [19]. The organizations are community based organizations in which the promotor(a)s work, either as volunteers, part-time or as full-time wage staff.

Analytical attention is focused on organizational structures because in all of the literature describing and evaluating the work of promotor(a)s none focuses on the organizational structures in which they work, a major flaw in a literature about a growing para-profession and its impacts on access to health care. This lack of attention to organizational ecology is brought home by a recent comprehensive review of 43 studies of lay community health workers [20], not one of which analyzes the organizational ecology of lay health workers’ work and how it affects the way they carry out their work.

The organizations in this study are located in unincorporated communities along the Mexico–U.S. border called colonias. Although colonia is a Spanish word related to community or neighborhood, the term has a specific along the U.S.–Mexico border. The Texas Secretary of State's description is fitting for all colonias on the border: “… colonia refers to an unincorporated settlement along the Texas–Mexico border that may lack basic water and sewer systems, electricity, paved roads, and safe and sanitary housing. Most colonias are outside city limits or in isolated areas of the county. Many have a very limited property tax base…” [21]. Colonias’ residents are primarily immigrants, many of which have low education levels and live in poor economic conditions and precarious life circumstances. Approximately 2000 colonias with a collective population of 500,000+ are located on the Texas–Mexico border alone.

Geographically isolated from services (health, human and public), colonias also lack—in varying degrees—physical infrastructure (waste water treatment, sewer lines, hard surfaces roads, water, and in some cases electricity); formal political structures (city government); economic infrastructure (only randomly dispersed micro-enterprises can be identified); social infrastructure (in a few colonias there will be a community center owned and operated by the county or school district and in many are found one or more small religious institutions). The one stable and strong social institution in colonias is the family.

Promotor(a)s live in one or another of these colonias. Traditionally, they are indigenous to the specific communities in which they work, often volunteer workers, with their work focused almost exclusively on the needs and assets within their own community.

Following a discussion of the research design and methodology in part one, part two analyzes the ways in which promotor(a)s perceive their work and its relationship to community. Next, part three analyzes the shape and diversity of organizational structures in which promotor(a)s work, showing that as the organizations become more extensive and formal, they change promotor(a)s’ relationships to the people they serve and challenge the traditional ways in which they relate to the residents and communities they serve. Incongruities arise and part four analyzes an emerging paradox for promotor(a)s and the organizations in which they work and its implications for access to health care.

Section snippets

Part one: research design

Twelve organizations participated in this study, six in the Lower Rio Grande Valley, Texas, and six along the border in southern New Mexico. The research methodology is qualitative and ethnographic, combining semi-structured individual interviews, observations, and focus-group interviews.

Part two: domains of work and practice as perceived by promotor(a)s

The work of promotor(a)s is built on two philosophical cornerstones – they perceive themselves as having a symbiotic connection with a particular community in which they work, and the work they do is understood to be fundamentally holistic. Five domains of promotor(a)s’ work were found; these domains and their specific manifestations are understood by promotor(a)s as an integrated “whole”. “[They] are community members who work almost exclusively in community settings and serve as connectors

Part three: the organizational context for promotor(a)s’ work

Promotor(a)s often work within and through some form of structure, but traditionally structures that are local and minimally formal. With little supra-local and formal organization, the work of promotor(a)s exists in the symbiotic interface of promotor(a)s, any organizational structure in which they work, and the community in which they live and work. Organizations rely fundamentally on the promotor(a)s’ knowledge of community, their rootedness in community, and their strong commitment to

The disconnect between perceptions of practices and organizational structures

We can now be more precise about the emerging paradox confronting traditional promotor(a)s’ practices and the growth and development of organizations that hire them with different types of embeddedness. Promotor(a)s in organizations like A and G are the organization-directing it, setting policy and designing program, implementing program and policy-oriented holistically to the organization and the community; they are primarily horizontally integrated socially, functionally and culturally. Any

Acknowledgement

Data is from the study of promotor(a)s and their organizations funded by grant no. 5U1CRH00033 through the Office of Rural Health Policy, Health Resources and Services Administration (HRSA), US Department of Health and Human Services. Data collection was performed through the Southwest Rural Health Research Center (SWRHRC); Catherine Hawes, Ph.D., Senior Investigator and Director of SWRHRC; Marlynn May, Ph.D., Principal Investigator.

References (25)

  • D.E. Bender et al.

    Bridging the gap: the village health worker as the cornerstone of the primary health care model

    Social Science and Medicine

    (1987)
  • D. Bell

    Diagnosis of malaria in a remote area of the Philippinese: comparison of techniques and their acceptance by health workers and the community

    Bull WHO

    (2001)
  • J.M. Kelly et al.

    Community health worker performance in the management of multiple childhood illness: Siaya District, Kenya

    AJPH

    (1997–2001)
  • J.K. Hubbard

    Social networks and social support: implications for natural helper and community level interventions

    Health Education Quarterly

    (1985)
  • E.L. Rosenthal

    The final report of the National Community Health Advisor Study: a policy project of the Annie E. Casey Foundation

    (1998)
  • M.J. Ro et al.

    Community health workers and community voices: promoting good health

    (2003)
  • M. Sanchez-Bane et al.

    Community-based health promotion and community health advisors: prevention works when they do it

  • HRSA

    Directory of HRSA's Community Health Workers (CHWs) Programs

    (2002)
  • M.L. May et al.

    Community health workers and their organizations in colonias on the U.S.–Mexico border, an exploratory study

    (2002)
  • G. Ballester

    Community health workers: essential to improving health in Massachusetts

    (2005)
  • CDC

    Community Health Workers/Promotores de Salud: Critical Connections in Communities

    (2004)
  • A. Witmer et al.

    Community health workers: integral members of the health care work force

    American Journal of Public Health

    (1995)
  • Cited by (17)

    • Boundary spanning practices of community connectors for engaging ‘hardly reached’ people in health services

      2019, Social Science and Medicine
      Citation Excerpt :

      While we have further advanced understanding of the roles and characteristics of connectors, there are elements of collaboration between health services and connectors that require further exploration. Two of the main issues in this relationship identified by previous studies relate to payment (South et al., 2014) and tensions from contradictory expectations from the community and health organisations (May and Contreras, 2007). A further issue that has not been extensively explored is the risk of connectors becoming institutionalised and therefore losing their defining feature of being connected to the community.

    • "Community ambassadors" for South Asian elder immigrants: Late-life acculturation and the roles of community health workers

      2012, Social Science and Medicine
      Citation Excerpt :

      This multifaceted definition represents the breadth of CHW roles – and, in doing so, also helps to explain why the parameters of CHW roles frequently confuse clients, partnering organizations, and CHWs themselves. Although existing literature has repeatedly considered CHW roles in functional terms – core duties, boundaries of social and political advocacy, and so forth (Farquhar et al., 2008; Rosenthal, Wiggins, Ingram, Mayfield-Johnson, & Guernsey De Zapien, 2011) – there remains what May and Contreras (2007, p. 154) identified as a lack of focus on “organizational ecology of lay health workers' work and how it affects the way they carry out their work.” Professional status, relations to client expectations, compensation, and other role-defining parameters have been raised by authors on the CHW role, but seldom addressed in ecologic context.

    View all citing articles on Scopus
    1

    Tel.: +1 813 974 3623.

    View full text