Long before Antonia Sierra-Martinez knew the term “promotora de salud,” she knew what it meant to show up when somebody needed help.
She grew up in Santa María, a small farming community in Guanajuato, Mexico. There, her mother, with a young Sierra-Martinez in tow, went from house to house, helping neighbors with whatever they needed.
The mother-daughter duo helped older neighbors with their gardens and daily chores, and they even administered injections and provided medical advice.
“Siento que yo empecé como promotora, aunque no sabía que era una promotora – I feel I started as a promotora, even though I didn’t know what a promotora was,” Sierra-Martinez said in Spanish.
The promotora title, with a meaning similar to liaison, came years later, after she practiced law and worked in community programs in Mexico. That was before she moved to California to start over in agriculture.
In the Central Valley, that title of promotora, for example, translates to the work of helping someone affected by cancer understand where to turn for care, connecting a pregnant woman with diapers or food, or helping a family find counseling, health care or another service, Sierra-Martinez said.
Promotoras don’t all do the same work. Their training and experience can vary across healthcare, education, mental health and other community needs. Some develop deeper knowledge than others in certain topics.
The U.S. Bureau of Labor Statistics counted more than 8,700 people in California as community health workers in May 2023. But that title doesn’t fully capture the role promotoras play in their communities, according to experts in the field.
The role of promotoras
Sergio Aguilar-Gaxiola, founder and director of the Center for Reducing Health Disparities at UC Davis, knows the work of promotoras well, since he’s worked with them for more than 40 years.
“Promotoras are a crucial workforce supporting health promotion, resource navigation, and dissemination of evidence-based health information across diverse communities,” he said. “Promotoras can reduce the barriers to health education, health promotion, and services that are common for native-born and immigrant communities.”
On any given day, promotoras may help someone understand a cancer diagnosis, apply for a health program, or find a clinic.
The next day, they may help a parent navigate the school system, connect a family to food, explain a government program, or help someone who’s overwhelmed figure out which problem to address first.
Most of these services do not take place in an office or clinic. Rather, they take place in churches, schools, residents’ living rooms, and even during spontaneous conversations in grocery store aisles.
The work often starts with a problem close to home. For Carmen, whom the Merced FOCUS is identifying only by her first name for safety reasons, it began with her children’s school in Dos Palos.
“Yo veía que en la escuela de mis hijos el agua salía amarilla – I saw that the water at my children’s school was yellow,” said Carmen, who immigrated with her family to the U.S. in 1999.
Parents in Dos Palos continued to press for safe drinking water at the school, and Carmen said the effort eventually helped secure funding for a water purification system.
“It took about five or six years to have that,” Carmen said. “But being persistent is something that has to be done.”
Migrant education programs gave Carmen a better understanding of the school system, and she later became a facilitator for the Parent Institute for Quality Education (PIQE), a civic education program for parents.
Among the parents who learned from Carmen was Anabel Serna, who arrived in Merced in the early 2000s with a young son and faced challenges navigating the school system.
“Yo pensaba que nada más era mandar a los niños a la escuela como allá y se iban a encargar de todo – I thought it was just sending the kids to school like back home, and they would take care of everything,” Serna said in Spanish. “But when I got involved, I said, ‘No. I’m going to start doing what Carmen is doing.’”
Now a promotora coordinator for Cultiva Central Valley, Serna followed in Carmen’s footsteps, serving as a PIQE facilitator for six years before working with organizations focused on healthcare, housing, mental health, elections and the census.
“You realize you can’t focus on just one problem because there are many,” Serna said, explaining that many promotoras follow the same pattern. “Promotoras are the heart of everything that happens in the community. They are experts.”
That community knowledge is also what makes promotoras valuable to researchers and health systems trying to reach people they have struggled to serve. For about seven years, UC Davis researcher Carlos Castañeda has worked with promotoras to deliver cancer information and research to Latino and other underserved communities.
“They are the most effective way for us to have a close and positive interaction with the community,” Castañeda said, adding that hospitals need promotoras to get that information out. “They are trusted members of the community.”
The flow of information also moves back to universities and health systems because promotoras bring residents’ concerns back to researchers, ultimately shaping what information and training gets developed, Castañeda said.
“We include a module of mental health on training and resources because the community was asking for this,” Castañeda said.
COVID-19 made the work more visible
When COVID-19 reached the Central Valley, promotoras stepped up to respond to a new set of problems.
They delivered supplies, explained public health information, helped residents find testing and vaccines and carried questions from their communities back to health officials and researchers.
The pandemic was when Sierra-Martinez first learned there was a name for the kind of community work she had done for most of her life.
After operations stopped at California Special Foods, the chocolate plant where she worked, an acquaintance active in the community asked Sierra-Martinez to help distribute food. She told Sierra-Martinez to post on a community social media page and ask families who needed groceries to send her a private message with the number of food boxes they needed. The food was brought to Sierra-Martinez’s home, where residents picked it up at scheduled times.
“We distributed about 250 food boxes here in the community,” Sierra-Martinez said.
Later, the same acquaintance told her that a promotora was needed to deliver supplies to people quarantined with COVID-19. The work required training through the Merced County Public Health Department.
“If I can help, let’s go,” Sierra-Martinez remembered saying.
After receiving training, Sierra-Martinez began delivering masks, food and other supplies. As the pandemic dragged on, her responsibilities expanded to include organizing clinics, sharing health information and coordinating with other promotoras.
Promotoras realized many of them heard similar fears and questions circulating in the community, Serna said, and people relied on responses and information from doctors and researchers.
A 2024 American Journal of Public Health report documented similar work across California through the California Alliance Against COVID-19, which included 540 promotoras and community health workers.
In Merced, the Alliance team created a vaccine appointment hotline in Spanish, Punjabi, Hmong and English. Central Valley teams also hosted online health talks where community members, many of them farmworkers, could ask questions to Spanish-speaking doctors.
Across the state, promotoras and community health workers reached more than 127,000 people through health fairs and educational outreach and more than 432,000 accounts through messaging apps such as WhatsApp, the report noted.
As schools closed and classes moved online, PIQE asked facilitators to call families and find out what they needed. The calls pulled Carmen beyond the education work she focused on before the pandemic, as parents described job losses, housing problems and children struggling with isolation and mental health.
“I cried,” Carmen said. “I cried.”
From Dos Palos, Carmen began working with leaders in other rural communities, distributing food and creating WhatsApp groups to share information directly with families. She also became involved in efforts to improve internet access and provide devices to students who suddenly depended on technology to attend school.
“I feel that before the pandemic, promotoras were situated in one area, focused on one system,” Carmen said. “But after the pandemic, we saw the need for promotoras not only to focus on one thing, but on different things.”
The pandemic also helped build more formal networks around the promotora work. Valley Onward emerged in 2020 after the Building Healthy Communities initiative ended, according to Isai Garnica-Palma, the organization’s assistant director.
One of the nonprofit’s early opportunities came through a $5,000 Sierra Health Foundation grant, which the organization used to provide stipends to promotoras who helped educate neighbors about masking, social distancing, and other COVID-19 information.
As more funding became available, the effort expanded into vaccine clinics and outreach across Merced County.
Valley Onward’s staff and network helped lead 34 vaccine clinics and connect more than 5,000 people with vaccinations, Garnica-Palma said, while also pushing to bring services to smaller communities such as Delhi, Livingston, Gustine and Winton.
California’s response also shifted toward working directly with community organizations and promotoras, Aguilar-Gaxiola said.
“Things started to get better once the state rectified that,” Aguilar-Gaxiola said.
Hospitals, universities and nonprofits relied more on promotoras, but the work still was often tied to short-term grants, stipends and unpaid hours.
Recognition and pay
That gap between the work being asked of promotoras and the actual time they are paid for shows up in ordinary visits.
Two recent home visits on Sierra-Martinez’s schedule show how quickly paid hours can fall short of the time the work requires.
Each visit was supposed to last about 45 minutes. After accounting for travel time and needs that arose during the visits, Sierra-Martinez left home around 11 a.m. and returned around 4 p.m. She was paid for about 90 minutes.
“A lot of it is volunteer work,” she said.
Home visits can also run longer than scheduled because one question often leads to another, Sierra-Martinez said, especially when families are dealing with several needs at once.
“I think what we need most today is a little more support, more backing for the work we do,” she said.
“I feel the work we do is very important and essential, because there are people who don’t trust, or don’t even feel safe, going into the health care system. Through a promotora, they can get the service they need.”
Antonia Sierra-Martinez, promotora in Merced County
Years of community work often means giving more time than a program or paycheck covers, Carmen said.
Her husband sometimes jokes about the unpaid work she does.
“He tells me, ‘You prefer to work where they don’t pay you than go work somewhere they pay you,’” Carmen said.
That unpaid time can stretch longer than anticipated because residents may need repeated conversations before they trust information or decide to act, she said.
“I’m there every day, bringing them information and staying on top of it,” Carmen said.
The U.S. Bureau of Labor Statistics reported a national mean annual wage of $52,610 in May 2023 for community health workers, an occupational category that’s broader than what promotoras do. Serna said that figure does not match what she sees among promotoras in the area.
“All the promotoras I know make less than $22 an hour,” she said.
Most work part time, Serna said, often across several projects or organizations, because they do not have a permanent job.
“Of the 20 or 25 I know who have years of experience, none are employed permanently or for 40 hours,” she said.
Serna said some of the higher-paid community health worker positions go to people who were already working full time before receiving the additional title or certification.
“Those salaries are from workers who were already in 40-hour positions and were also certified as promotoras,” she said.
More training and certifications don’t always translate into paid work, Serna said. Some promotoras have years of experience in their communities, but they still face employment barriers tied to formal credentials and immigration status.
“Hire them based on merit, not whether they have documents,” Serna said. “They are leaving out the people who are actually working outside, who know the problems, who are experts, who have the empathy and who can do this work better.”
Much of the work still happens outside scheduled hours, with residents approaching promotoras at stores, schools and community events, or even contacting them at home. That work can also include gas costs, the use of their own vehicles, and time spent preparing for meetings or events.
“We don’t stop being promotoras. We’re promotoras 24 hours a day.”
Anabel Serna, promotora in Merced County
That unpaid time is part of why Serna pushes back on the idea that commitment to the community should substitute for compensation.
“It’s fine that we get satisfaction,” Serna said. “But we eat too. We spend money on gas.”
Unstable jobs, delayed payments, Social Security documentation requirements and a lack of institutional recognition were among the barriers identified in the American Journal of Public Health study. The authors recommended fair compensation rates, timely payment and fewer documentation barriers for workers with different immigration statuses.
At Valley Onward, Garnica-Palma said the organization is trying to create more stable pathways for promotoras to turn community experience into paid work beyond a single grant or program.
“We’re trying to create a pipeline for them to be able to find opportunities outside of just Valley Onward,” he said. “You have to understand that this is a job that is marketable.”
One problem is convincing funders to pay for the labor itself. Organizations applying for grants must make the case that promotoras’ wages are worth supporting, even when projects rely on their outreach.
“The mere fact that I’m having to justify that and convince people that this is something worth investing in,” Garnica-Palma said, “that tends to be a problem for us.”
A cooperative model now under development with UC Merced could allow promotoras with different areas of expertise to pursue contracts together. Part of the goal, Garnica-Palma said, is to help workers understand how outreach is priced and whether a contract covers their actual time and expenses.
“It’s work, at the end of the day, that they’re doing,” he said, “and making sure that people are getting compensated accordingly, that they’re not being taken advantage of by entities or people that are trying to contract them for services.”
Medi-Cal may offer another possible path. California allows certain community health worker services to qualify for reimbursement. Garnica-Palma said Valley Onward has been working with United Way and Central California Alliance for Health to understand how that system could be used locally.
The long-term goal would be to receive reimbursement for eligible services promotoras already provide and use that money to employ workers more consistently, instead of relying only on temporary contracts and volunteer labor.
“We see this as job opportunities,” Garnica-Palma said.
Training programs can also help promotoras carry their experience beyond a single university project by providing certificates they can use when applying for other positions, said Castañeda, the UC Davis researcher.
“That training was designed for them to be employable,” he said, speaking about a combination of UC Merced’s promotora/ Community Health Worker certification and Valley Onward’s promotora pipeline and leadership development. “What we do is prepare them, so they can do a great job with anyone else who needs them.”
As promotoras become more mainstream in health-related fields, Aguilar-Gaxiola hopes that recognition also includes fair wages for their work.
“My hope, at least in California, is that compensation happens, regardless of the immigration status that the promotoras have,” he said.
The next generation
The people entering community promotora work now are learning from women who spent years building those relationships.
After watching her mother advocate for students during school meetings, 21-year-old Nataly Lopez began working as a promotora in May.
“She’s doing something good for me, not just for me, but for every student here on campus,” Lopez said. “Because that’s what promotoras do. They’re focusing on the whole community.”
The work already felt familiar when she joined.
“I feel like I already had that in me,” Lopez said. “Now, I’m able to speak. Before, I was able to see, to see and observe. Now, I’m able to join.”
In her first few months doing the work herself, Lopez has helped families learn about programs that help with their kids’ education.
“We know what’s happening, we know how to utilize these apps,” Lopez said, noting how younger promotoras’ experience with technology opens new ways to communicate.
At 20, Ashe Aguirre has spent about a year and a half involved in community work through Cultiva Central Valley while studying social work and participating in youth organizing.
Already, Aguirre has felt the mental and emotional toll.
Burnout was also documented during the statewide AJPH study. Some programs held weekly or biweekly debriefings, peer-support sessions and healing circles to help promotoras and community health workers deal with stress and COVID-related trauma.
“There have been times when I did feel like I was gonna give up,” Aguirre said, explaining how the experience made him more comfortable taking on a leadership role. “Sometimes it feels like things are going slow, and you do get burnt out sometimes.”
Part of continuing the work, Aguirre said, has been learning to recognize when he needs to stop, rather than treating every community problem as something he can solve himself.
“The difficult part is not realizing when you do need a break and not overworking yourself,” Aguirre said. “It gets really hard sometimes when you feel like a lot of people aren’t paying attention to what’s going on in the community.”
For Carmen, the veteran promotora, building more community leaders matters more than receiving recognition, especially if that support can help other residents learn how to advocate for their communities.
“My daughter tells me, ‘Mom, they want to recognize you,’” Carmen said. “No, mija. You tell them I don’t want recognition. I want them to help other people so they can start doing this, too.”
For her, spreading knowledge also spreads responsibility among more people, rather than expecting one promotora to meet the needs of an entire community.
“If you’re in a community of 100 people, and there’s only one promotora, imagine, she’ll go crazy,” Carmen said. “But if there are 10 promotoras, and those 10 encourage another 10, then that community is going to fill up with people who lead.”