title: Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression.
abstract: We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.
authors.affiliation: University of New Mexico, Albuquerque, NM 87131, USA. waitzkin@unm.edu
authors.forename: Howard
authors.initials: H
authors.lastname: Waitzkin
authors.forename: Christina
authors.initials: C
authors.lastname: Getrich
authors.forename: Shirley
authors.initials: S
authors.lastname: Heying
authors.forename: Laura
authors.initials: L
authors.lastname: Rodríguez
authors.forename: Anita
authors.initials: A
authors.lastname: Parmar
authors.forename: Cathleen
authors.initials: C
authors.lastname: Willging
authors.forename: Joel
authors.initials: J
authors.lastname: Yager
authors.forename: Richard
authors.initials: R
authors.lastname: Santos
mesh_terms: D000328:Adult; D003151:Community Health Centers / Q000458:organization & administration*; D003150:Community Health Workers; D003156:Community Mental Health Services / Q000458:organization & administration*; D003863:Depression / Q000209:etiology / Q000628:therapy*; D004651:Employment / Q000523:psychology; D005260:Female; D005523:Food Supply / Q000706:statistics & numerical data; D006798:Housing / Q000706:statistics & numerical data; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D009516:New Mexico; D011203:Poverty; D011320:Primary Health Care / Q000458:organization & administration*; D024382:Professional Role; D016896:Treatment Outcome; D014754:Violence / Q000523:psychology