We recruited a purposeful convenience sample of English-speaking program planners, principal investigators, recruiters, project coordinators, and other individuals with planning roles of U.S.-based promotora-delivered programs which featured information and activities related to obesity-related topics (e.g. nutrition, physical activity) for Hispanic women. The list of potential participants consisted of names identified through professional contacts, the research literature, Internet searches for promotora-delivered evidenced-based interventions, and snowball referrals from other program planners and researchers. We purposefully recruited participants from across the country in order to have participants from various geographic regions and programs serving diverse Hispanic subpopulations. We contacted 65 individuals on the initial contact list by both e-mail and phone. Of these, 25 did not respond, 14 declined because they were not working on obesity-related projects, and 2 declined due to time constraints, resulting in a sample of 24 participants. The Institutional Review Board of the University of South Carolina approved this research study prior to initiation of data collection.

We conducted individual interviews, via telephone, using an open-ended, semi-structured interview guide.³⁶ The interview guide included a section on program characteristics (e.g., program focus, geographic location) and participants’ information (e.g. exact title and role in the health-related intervention). To elicit participants’ perspectives and experiences related to sustainability, we posed a series of open-ended questions in the following domains: promotora role conceptualization, recruitment, selection, training, and sustainability. Table 1 lists the questions specifically related to the sustainability domain. We pilot tested the interview guide with an experienced program planner to ensure that questions were clear and nondirective, modifying ambiguous and unclear questions to elicit more focused responses.³⁷ The choice of in-depth interviews by telephone allowed for a geographically diverse sample.

Data collection occurred between June and September 2010. Participants provided verbal informed consent and permission prior to initiating the audio-recorded telephone interview. Interviews lasted between 30 and 90 minutes (average interview lasted 60 minutes). All interviews were transcribed, and personal and program identifiers were removed from the transcripts.

The purpose of the inductive open-coding process was to identify salient and reoccurring themes and phrases, providing the basis for subsequent development of more selective and focused codes and broader themes and subthemes.³⁸ Data analysis occurred concurrently with data collection, a process designed to enhance the purposive and theoretical sampling processes to lead to the ability to determine saturation.³⁹ Initially, three investigators each independently coded the same three interview transcripts. They then met to discuss individual findings and to compare open codes (e.g., empowerment, advocacy), initial categories by topic domain (e.g., program sustainability), and identify emerging themes (e.g., promotora social mobility). After reaching consensus on an initial set of codes, the first author created an initial codebook using Atlas.TI qualitative data management software⁴⁰ and continued coding the subsequent interviews. As data collection proceeded, we looked for indicators of saturation (i.e., repetition of previously identified codes and themes; lack of emergence of significant new or different codes; fewer variations on the existing themes).⁴¹ For this particular analysis, the investigative team focused on the sustainability domain. This involved a close reading of all transcripts to compare and contrast, expand, merge, and refine the sustainability codes and themes across the entire data set.⁴² All authors participated in refining the analysis and developing the presentation of the findings.

Although all 24 participants reported involvement in program planning activities, they self-identified their primary role in relation to the promotora program as either researcher (n=11), program director (n=7), program coordinator (n=4), or promotora trainer (n=2). The sample included staff from 22 community-based programs located in ten states of five distinct geographic regions - Southwest (n=7), West (n=7), Midwest (n=3), Southeast (n=3), and Northeast (n=2). Participants were associated with community based organizations (CBOs, n=8), universities (n=5), university-CBO collaborations (U-CBO, n=5), federally qualified health centers (FQHC, n=3), hospitals (n=2), and a state-wide government-run public program (n=1). Most of the university-affiliated programs were research initiatives. The specific promotora programs focused on diabetes (n=7), obesity/ weight management (n=6), family health/wellness (n=4), cardiovascular disease (n=3), health literacy (n=1), general women’s health (n=1), and osteoporosis (n=1). The target population of these programs tended to be Hispanic women and their families (n=15) rather than Hispanic women only (n=7). There were an equal number of bilingual (English-Spanish) and Spanish language programs (n=11).

Participants conceptualized sustainability in different ways and at both macros and micro levels (Table 2). They reflected on their own experiences as they identified and described the rationale for using and sustaining the promotora delivery model as well as logistics and barriers. Some participants actually reframed the notion of sustainability in their discussions of promotora career development and trajectories. In the following sections, we present and discuss the evidence supporting each of these themes related to promotora program sustainability. Participants presented diverse views and therefore each of the narrative themes did not necessarily reflect the perspectives of all participants.

Participants’ goals for sustainability focused on the rationale for the need and value of sustaining programs using a promotora-delivery model. This model involved training community leaders who then actively participated in and contributed to programs addressing community health issues. One hospital-based participant noted, “Promotoras are a total strength-based approach to working with people. We are strengthening their skills and supporting them, and then linking them with the resources they need.” Many of these community-based programs empowered Hispanics to become actively involved in their communities and to reach those most in need of healthcare.

Creating a more equitable, cost effective healthcare delivery approach for reaching underserved populations was another reason for sustaining promotora-delivered community-based health programs. Compared to the acute-care, institution-based medical model, community-based models are less expensive and have wider reach, particularly among uninsured populations. Several participants noted the advantages of disseminating health information, preventive health services, disease management, and some medical treatment to the uninsured populations through promotora-led programs over relying on emergency care. One U-CBO-based participant voiced concerns about the high financial costs and inequity within the current medical model and the need for more investment “in community models of care.” Another participant based at a FQHC described the job of being a promotora as empowering limited English proficient Hispanic patients to be able to understand and apply disease prevention and management skills. A hospital-based program planner confirmed the importance of sustaining promotora programs by describing the complex role their promotoras served as health educators, patient navigators, and patient advocates. These promotoras provided direct support to patients as they navigated healthcare services, assisting them in understanding and responding to provider instructions and recommendations, and ensuring they seek further appropriate care.

Participants considered explicit intent to sustain the promotora program as critical. Several indicated program sustainability had been a clear intent prior to program implementation, but there were only two cases in which participants (U-CBO and CBO) reported having actually planned for sustainability prior to initiating the promotora program. In both cases, once the initial program funding ended, the initiatives were transferred to predetermined community stakeholders who assumed the responsibility of continuing the program. In contrast, program planners associated with universities and CBOs working on programs funded through short-term grants noted that the lack of sustainability was directly related to termination of funding and readily acknowledged this lack of guaranteed on-going program funding as the nature of their work. In one example of a promotora program developed as part of a randomized controlled trial, there was never any intent to support an ongoing community health program. This university-based participant noted, “When my research funding is over, and I have a new research grant, I have to switch gears. My new focus is the new program.” Strategies noted among planners involved in grant-funded research projects included short-term extensions for the grant funding, or, more often, simply moving on to other projects. Given this grant-funded context and mindset, one U-CBO based participant recommended that program planners needed to communicate this lack of intent to sustain the program very clearly from the outset to promotoras, program participants, and others involved in the project. “Let them know that you are not looking for something to last long term. Let them know you are looking to advance science.”

The logistics of sustaining promotora health programs was a major concern among these program planners. They identified specific ways in which promotoras contributed to the sustainability of program components and recommended strategies that both promotoras and program planners could employ, such as forming community partnerships and locating program champions. Finally, they considered macro-level approaches to enhance the sustainability of the overall behaviors targeted in the health programs.

Promotoras themselves contributed to program sustainability by continuing to deliver health education in their communities after the program officially ended. One CBO-based participant reported that although the organization was not able to continue providing salary, incentives, or other assistance, they did provide promotoras with the basic resources for the program such as “space, materials, and everything they needed to continue the program.”

Partnering with CBOs was one strategy for continuing promotora programs. A university-based participant described collaborating with other organizations and the development of a community action plan for health program sustainability. Several university and CBO-based participants relied on program champions, community members or professionals who took responsibility for identifying potential funding sources and networked with other community partners and leaders to lobby for space, funding, and other resources. Examples of grass-roots community efforts to sustain and expand promotora programs included the story of a Hispanic woman who, after participating in a promotora-delivered physical activity program, sought additional training to become a promotora. She then organized a cadre of volunteers to lead health education discussion groups and collaborated with community leaders to locate space and resources in which to conduct free exercise classes for other women in her community. A hospital-based participant described how community members worked with promotoras to offer free, weekly support groups in order to continue health education efforts.

Beyond describing sustainability of health programs at individual program levels, participants also discussed sustaining the programs’ results and targeted behavior changes by altering the surrounding macro environment. Promotoras and participants recognized the limitations of promoting lifestyle-behavior changes in communities where the environment was not conducive to enacting positive health behaviors. In some programs, promotoras and community members advocated for environments that supported and/or promoted healthy lifestyles. For example, community members and promotoras associated with the hospital-based program collaborated with their county health department to address how to change the built environment to make it a healthier place for their patients. They advocated for community revitalization initiatives and neighborhood safety enforcement programs to encourage patients to become more physically active in the community.

Funding was the most frequently cited barrier to sustaining the promotora-led health programs. One university-based participant discussed, “When we work with funders, we have to acknowledge that sustainability equals having money. You need money to operate.” Sustained funding was critical for paying promotora salaries or stipends and ensuring other essential program components. At the individual level, promotoras who were salaried depended on the income for themselves and their families. Planners working with programs that did not provide the promotoras a salary understood the need to provide other forms of tangible support such as transportation, reimbursement for gas, and childcare. Other types of incentives included offering career-building opportunities for promotoras, including continuous free health-related trainings, help applying to academic programs, free entrance into conferences, and career-related networking opportunities. These services were offered to promote social mobility for the promotoras.

Another barrier to sustainability was the time required to provide additional promotora training and supervision. Most program planners indicated that the initial promotora training was not sufficient to sustain ongoing health outreach and education within communities, especially after the formal program had ended. A U-CBO based participant believed, “Sustainability is challenging due to the huge time requirements for training and quality assurance.” Program planners had limited time and resources to continue promotora training and supervision to ensure their needs were being met.

The lack of financial and political support for promotora-delivered health prevention programs within the current U.S. healthcare infrastructure was another barrier to sustainability. Participants noted the challenges of an acute-care, institution-based medical model that has not incorporated promotoras as a sustainable component of the healthcare workforce and the need to “figure out how you’re going to sustain them as medical assistants in the healthcare system because for the most part what they do is not billable for reimbursement by Medicaid and Medicare.” Although a few states, including Massachusetts and Minnesota, have instituted policies to reimburse promotoras’ activities through Medicaid, there are no such policies in most states or at the national level. Formal recognition and institutionalized payment would contribute to the sustainability of promotora initiatives, whereas currently most organizations must identify local solutions to sustain the work of promotoras.

Lack of process evaluation and program effectiveness data created other barriers to promotora program sustainability. One U-CBO based program planner noted the challenges of requiring promotoras to document evaluation data. “The type of documentation that we asked of them was really intensive. What we were asking of them was a huge amount of paper work and extensive evaluation, filling out of paperwork was not necessarily the strengths of our promotoras.” Also, without data on the effectiveness of promotora programs, program planners found it difficult to make their case to funders for continued support. One university-based participant described, “I really feel strongly that one of the best ways we sustain promotora research is through some really solid evaluation of interventions. We really need to be doing not only a good measurement of program outcomes but also of describing what the promotoras are doing.”

Promotora attrition was another barrier to program sustainability. The loss of trained promotoras who left the field for different or higher paying positions resulted in the added burden on program planners to recruit and train replacement promotoras. Promotora turnover increased program costs in terms of time, money, and resources.

A few participants reported incidences of promotoras sustaining program components on their own without institutional support, but recognized the lack of documentation regarding these promotora-initiated efforts. Other practice-based participants also noted the need to evaluate how promotoras continue to conduct health education outreach. However, program managers encountered difficulties tracking promotoras’ activities to demonstrate the range and extent of their community outreach. The government-based participant noted, “Maybe we need to find a way to capture the little stories about how promotoras go and talk to people in the grocery stores… They do happen, but these stories are not captured or documented.” Obtaining accurate process evaluation data was difficult because many promotoras were not accustomed to regularly documenting their activities and found the administrative requirements a burden.

An interesting and somewhat unconventional approach to promotora program sustainability was that of fostering individual promotora’s career development. The hospital-based participant believed, “Training and hiring promotoras is the garnering of a beginning of their career ladder.” This notion of individual social and career mobility challenged the conventional definition of program sustainability because it implied increased turnover among promotoras, and therefore could be construed as a barrier to program sustainability. Although promotora longevity with a program had advantages in terms of planning and sustainability, there was the recognition that it could indirectly contribute to limited individual social or professional mobility.

At the level of the individual promotoras, a reframing of sustainability identified by several participants was that consideration of individual promotoras’ social and career mobility was an important factor in and of itself. This alternative notion of sustainability suggests the promotora model may support both individual and community empowerment and growth. For example, promotoras gained knowledge and skills that improved their future employment opportunities. Through their community engagement and outreach, promotoras expanded their social networks, were introduced as community leaders to influential individuals within their communities, and some promotoras received job offers from their new contacts. Participants also reported they had introduced trained promotoras to future employers with the intent of creating opportunities for the promotoras to move on to better paying positions.

Although in the short term it may be more cost and time effective to maintain trained promotoras, participants noted the advantages of continually equipping new, untrained community members to serve as promotoras. This process allowed individuals described as “not hirable” by other organizations to obtain skills that could increase their employability and potentially contribute to their social and economic mobility. Thus, sustaining the ongoing training of new promotoras was a way of helping community members advance their careers and overall social position.