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Community health workers promote perceived social support among Latino men: Respaldo

Promotores or community health workers are trusted community members who offer information and support to marginalized groups in society. Latinx immigrants in new growth communities or emerging communities (areas with a small yet growing Latinx population) confront many challenges in their settling processes. De la Mano con la Salud was a community-based participatory project that trained Latino immigrant men as promotores. Promotores recruited 182 Latino immigrant men helped them to attain their own goals, connected them with health and social services and connected them to the larger community. We present data from 23 in-depth interviews with project participants conducted after six months of enrollment. Qualitative analysis confirmed participants’ vulnerabilities and showed that promotores addressed many of the health, legal, and occupational needs of participants. Emerging themes showed that 1) participants had a thirst for a united Latinx community; and 2) felt that promotores had their back (respaldo). The need for community may reflect the current invisibility of this Latinx population, as well as the desires for recognition and ethnic identity affirmation. Respaldo strongly resembles perceived social support, which is the kind of support most associated with health outcomes. Future research can determine what intervention components best foster respaldo.


Introduction
Latino immigrant men confront a myriad of challenges in the U.S., especially in areas with a low proportion of Latinx. We present evidence that male promotores (community health workers) can foster social support and provide a targeted relief to those challenges, especially in emerging destinations.
There is a sustained trend within the United States for Latinx to move into areas where they have not traditionally settled, known as emerging Latinx communities (ELC), emerging destinations, or non-traditional destinations, among other names ( Documet et al., 2019 a;Frey, 2015 ;Jacquez et al., 2015 ;Nathenson et al., 2016 ). Latinx in ELC tend to depend on small support networks that often consist of other Latinx ( Barrington et al., 2018 ;Hill et al., 2019 ). This situation reflects the isolation of Latinx in ELC and suggests that expanding the number of other Latinx with whom they interact would be beneficial. In ELC, there are typically few services that are culturally tailored to Latinx; social support is low, isolation is frequent, and Latinx tend to be uninformed about their health service options and rights ( Documet et al., 2013 ;Jacquez et al., 2015 ;Nathenson et al., 2016 ). Efforts by individual providers fall short to address these needs ( Lanesskog et al., 2015 ). Organized social relationships, especially peer support are a way to address these issues, yet are often incipient or non-existent in ELC ( Vaughn et al., 2016 ). the cultural similarities that they share with the participants, which positions them as ideal candidates to communicate with socially isolated or marginalized populations who often mistrust and fear the health system ( Fisher et al., 2014 ;Kim et al., 2016 ). Promotores have worked for many years in Latin America and among Latinx in the United States addressing health concerns ranging from cancer control to stress ( Ayala et al., 2010 ;Jacquez et al., 2019 ;Kim et al., 2016 ) . The promotores' effectiveness is based on the social support they provide to their communities.
Social support is a function of social relationships and consists of intentional assistance exchanged through social relationships and interpersonal transactions ( House, 1981 ). Both the structure of social relationships (interconnections among individuals) and their function prevent mortality and enhance other health outcomes ( Holt-Lunstad et al., 2010 ). The social support individuals believe is available to them, also called perceived social support, is often the support that is associated with better health, and not, as one would expect, the actual help somebody receives ( Cohen, 2004 ;Haber et al., 2007 ;Holt-Lunstad et al., 2010 ;Luszczynska et al., 2007 ). One way of characterizing social support is by its type. Emotional support includes expressions of empathy, trust and caring. Affective support relates to expressions of love. Instrumental support is tangible aid or services. Informational support includes education and tips to obtain resources. Appraisal support is information that is useful for self-evaluation, such as feedback ( House, 1981 ).
Most promotores interventions have historically relied on female promotoras. Explicitly male-to-male promotores interventions have been condition-specific. For example, in Connecticut, promotores organized groups of men who had sex with men for training on sexual identity, AIDS prevention and referrals ( Singer et al., 1996 ). In North Carolina, several interventions relied on promotores to conduct volunteer outreach to achieve HIV prevention education and behavior modification ( Rhodes et al., 2017 ;Rhodes et al., 2009Rhodes et al., , 2006Rhodes et al., , 2016Rhodes et al., 2011 ). Another intervention trained men to facilitate participatory, nondirective groups with farm workers around intimate partner violence in four states ( Nelson et al., 2011 ). In Washington State, male and female promotores delivered an intervention to reduce alcohol consumption among Latino day laborers . In Florida promotores encouraged eyewear protection use among citrus migrant workers ( Monaghan et al., 2011 ). None of these interventions measured social support as a variable nor explored it qualitatively and only the North Carolina interventions have been in an ELC.
Current scholars recognize not only the existence of several forms of masculine behaviors -masculinities, but also that masculinities are not static; rather they are created and re-created constantly ( Pascoe, 2020 ;Walter et al., 2004 ). Migration shapes how men perceive themselves and behave. For example, the same person who is perceived by his family, his country and himself as a brave strong man who migrates to support his family finds himself in the US at the bottom of the social ladder, facing racism and having to behave in a submissive way ( Hirsch et al., 2009 ;Walter et al., 2004 ;Wilson et al., 2010 ). Latino men's upbringing often involves them assuming and performing "strong " and "macho " roles, which consequently leaves them with little room to accept other masculinities without significant inner conflict ( Wilson et al., 2010 ). Similar patterns emerge within first-generation Latino immigrant men in the US. However, the literature shows that cultural aspects of machismo such as the need to be able to work, can be used by health providers to help men to seek medical and preventive care ( Sobralske, 2006 ).
To address the concerns of Latino immigrant men living in Allegheny County, we developed a community-based participatory project, De La Mano con La Salud (Lend a hand to Health). In this innovative project, all promotores and all participants were Latino immigrant men living in an ELC. In relation to this work, we have published the process evaluation ( Documet et al., 2017 ), the baseline quantitative analysis ( Documet et al., 2019 ), the outcomes quantitative analysis ( Documet et al., 2019 ), and a qualitative article highlighting the perception of promotores themselves about the project and their work ( Macia et al., 2016 ). Here we present the perspectives of participants in De La Mano con La Salud, exploring specifically their accounts and perceptions of social support.

Setting
Allegheny County, where the study took place, is an ELC. In 2012, Latinx comprised only 2% of the population, and in 2019 it comprised 2.3% ( U.S. Census Bureau, 2020 ). However, from 2000 to 2010, the Latinx population increased by 71% ( U.S. Census Bureau, 2010 ). In 2010, males comprised about 50% of the Latinx community, with a mean age of 27. The median household Latinx income was lower than the general population ($41,490 vs. $51,366) ( U.S. Census Bureau, 2010 ). Their countries of origin were diverse, with the largest proportion of Latinx being Mexican in 2010 ( U.S. Census Bureau, 2010 ). This community was and still is scattered throughout the county, with no single concentration in one neighborhood. Community organizations report that in recent years, there is an increase of Central American and Venezuelan immigrants as well as in the number of Latinx whose primary language is an indigenous one.

The intervention
The Latino Engagement Group for Salud (LEGS), a coalition of community members, researchers and health and social service providers designed De la Mano con la Salud. The Latino men in the LEGS coalition, which included construction, landscaping, and restaurant workers, specified that De la Mano con la Salud was to be holistic, as opposed to focusing on a single disease. During the intervention, the LEGS coalition met regularly to oversee the program's implementation as well as to suggest and approve changes. For example, the coalition decided that it was inappropriate that the promotor job description asked for "high school. " Instead, they decided that it should ask for "ability to read and write. " This decision enabled us to hire two promotores who had not finished high school. Eleven Latinx men were trained as promotores and seven stayed until the completion of the project . Between November 2011 and June 2012, promotores recruited participants from their own social networks and places where Latinx congregated, such as Latinx grocery stores, churches, and events using flyers and word of mouth. Immigrant men 18 years of age or older who identified themselves as Latino were eligible. Promotores met with participants at their home or at a place convenient to them, such as public libraries and coffee shops. The main purpose was to offer non-directive social support. Non-directive support consists in collaborating with participants to develop solutions to the problems that participants themselves prioritize and has shown to be more effective in promoting health and healthy behaviors than directive support ( Kowitt et al., 2017 ). Promotores used the Wheel of Life ( Byrne, 2005 ), a tool to elicit participants' concerns and priorities by prompting them to discuss several aspects of their lives that the LEGS coalition deemed relevant. Then, promotores assisted participants in developing a plan of action. The plan consisted of goals and activities to attain those goals, as decided by the participant with assistance of the promotor .
Promotores actively listened to participants (emotional support) and depending on the plan of action, referred them to health and social services, connected them to community venues (informational support), or took them to appointments with medical or legal providers (instrumental support). Promotores followed participants' well-being for six months, contacting them at least one time per month in person, and more often by phone. At these opportunities, promotores continued to offer emotional, informational, and instrumental support and provided feedback (appraisal support). In addition, promotores invited participants to eight educational talks and a picnic during the life of the study ( Documet et al., 2017 ). Promotores recruited 182 participants, who were of Mexican (62%), Central American (34%), and of other (4%) origin. Data collection included baseline and 6-month follow up surveys, a short exit survey, and a qualitative interview of a subset of participants. Baseline and outcome results have been described elsewhere ( Documet et al., 2019 ;Documet et al., 2017 ;Documet et al., 2019 ). The University of Pittsburgh's Institutional Review Board approved this study (IRB # PRO09110511).

Data collection and analysis
Here we focus on the 23 qualitative interviews conducted at the end of the project participation (6 months or more from enrollment). We designed an interview guide to elicit the participants' perspectives about the project. We asked: 1) how they enrolled in the promotores ' network; 2) to describe the first promotor visit and the follow-up sessions, 3) if they had discussed the success plan and if it was helpful to set healthy goals, and 4) to provide an overall assessment of the project. Finally, the interviewer asked participants to add anything they wanted to say.
Two male native Spanish speakers conducted the interviews in person, at a place convenient to the participant, such as their homes, or coffee shops. To increase trust, the promotores met the interviewers at their regular bi-weekly meeting and had the opportunity to ask them questions. Then, promotores notified participants via text that the interviewers might contact them. The interviews lasted 30-90 min (average 50 min), and were audio recorded and transcribed in Spanish. Participants' time was compensated with $15.
We selected interviewees trying to achieve maximum variation: participants served by all promotores , from different countries, and age groups ( < 35, > = 35 years of age). We interviewed twenty-three participants. They worked with seven different promotores and ranged in age from 20 to 50 years old ( Table 1 ) . Fourteen were Mexican, seven were Central American, and one was South American. Most interviewees worked in restaurants, cleaning, or construction. Of the fifteen that disclosed their time in the US, eight had been here for more than 5 years.
We analyzed the Spanish transcripts with a mixed deductive and inductive approach using NVivo 10. Predefined codes based on the topics explicitly addressed in the interview guide related to perceptions and evaluation of the project and the impact of the project in their lives. These were complemented with emergent themes. Three researchers (LM, HCR and PID) conducted open coding and developed an initial codebook. Then, we followed an iterative process of coding, assessing reliability and refining the codebook. After, LM, HCR and PID read six transcripts; the codes repeated, and no new codes emerged. We measured intercoder reliability using kappa and defined 0.61 as acceptable. All coders discussed and solved disagreements to finalize the codebook. Subsequently, one author coded all transcripts (HCR). We strived to represent the experiences of participants as authentically as possible. For this, we used the framework method ( Gale et al., 2013 ;Ritchie, 2018 ). Two authors (LM and HCR) developed tables with summaries by participant and categories: client's issues, migration, interaction with and perceptions of the project, community, and support. This structure enabled us to discriminate between overarching issues and those that arose only from a few participants. Three researchers (LM, HCR and PID) individually developed analytic memos for each theme in the table, which they discussed to identify the core themes that are the focus of this manuscript. The LEGS Chair (RB), not a trained researcher, provided verbal feedback on the summary results and on the manuscript draft.
One researcher (PD) translated quotes into English and a bilingual native English speaker unrelated to the project revised them for clarity. Then, another researcher (HCR) back translated the quotes into Spanish. Finally, PD and HCR discussed outstanding differences and reached consensus. All names associated with quotes are pseudonyms.

Results
Participants narrated their experiences of migration and settling in Allegheny County, and with the intervention. We grouped their responses in four overarching themes: 1) experiences of migration and settling; 2) help from the promotores, 3) thirst for community; and 4) respaldo ( "had my back "). The last two are emergent themes.

Experiences of migration and settling
Often, participants narrated coming to the US to help their families and sending most of their income back to their countries to support them. While we did not ask about immigration status, some participants volunteered that they came to the US with temporary work permits, and others that they were undocumented. Some lived with their families, but more often they lived in houses or apartments with other Latinx men who were not relatives. Almost all participants said that their main reason to migrate to the US was to escape poverty, violence, or both. According to participants, exhaustion and unhealthy lifestyles required them to access health care services. However, they said accessing such services was hard due to legal status, elevated costs, fear, language barriers, lack of time, and not knowing how to access health services. It was common to hear about their hesitation to attend health care visits especially because of costs and losing paid hours, and their difficulty with making appointments at the time the services were open. Sometimes, they said, they just preferred to wait and visit the doctor in their home countries.

Almost until now, I have always told [the promotor] that because I work in construction and [at the clinic] they only are open from Monday to Friday, that is why I have not gone. Roberto
The first bill of $ 1560 arrived. Then, I tell my brother, if I go again they will charge me more. I tell him, no, that's okay, no more. Diego It does not matter the immigration status. Because many times there are things, and you, as a Latino, do not know. The moment that anything happens to you, you don't know where to turn. Gabriel

Help from promotores
The participants said the De la Mano con la Salud was unique and useful, and expected it to last longer and include more participants.

A program, above all, for the Hispanics who do not have documents here, for those of us who do not have resources, or for those of us who do not know English. Ramiro
Most participants said the program helped them access health care services, many for the first time in years. Participants appreciated support from promotores, including interpretation in medical and dental care and other sorts of appointments, help with bills and legal referrals, and translation of documents. They also appreciated promotores followup sessions that enabled them to embrace healthier habits and medical care as an option. Participants credited promotores with helping them find employment, which had been the main reason to migrate for them. Participants spoke often about isolation. They said that they felt lonely, sad, stressed, and had difficulty connecting with others because of heavy work and because Spanish was rarely spoken in Allegheny County, there were no Latinx neighborhoods and few gathering opportunities. It was common to hear their social contacts were constrained to their flat and work mates.

I have gone to the clinic, and every time I had an appointment, I saw my discount. I have gone to make sure of my medical condition and now
One participant summarized the situation by comparing Allegheny County with other parts of the US.
There are quite a few Latinos but not the same as other states. They are few and far between; there are Hispanics here but they are few and far between. Pedro Participants said they wanted to have access to a community where they could belong. They expressed the need to have a social network to provide help and support, especially in difficult moments. Many participants expressed the desire to see a stronger and more united Latinx community. However, two participants said that people worked on their own, with no interest to create a stronger community, and one mentioned the need of local leaders with the potential to unite all Latinx under one umbrella.

Respaldo
Participants said that having someone reliable, bilingual, and with good information and knowledge about the city was helpful, a "respaldo, " which literally means "someone has your back. " They reported special appreciation for the opportunity to call a promotor to ask for information or just chat. They said that the promotor was there for them.

Uh-huh, the communication with [promotor], I feel it's like support. Because when I think, "If I can't handle this, " he says, "whatever you need, give me a call. If you need to go somewhere even for a job interview and if you see that you cannot understand, call me and if I can, I will help you, or find a way to help you. " [He is] looking out for me. Ramiro
In addition, almost all participants mentioned feeling good because the promotores invited them to meetings and gatherings via text message and phone calls. They said that these invitations were opportunities to meet others and that even if they were often unable to attend, it was nice to know somebody was thinking of them. Participants said that promotores were a medium to reach other people.
[Promotor] talks to me, invites me to meetings, migration seminars, seminars about this, meetings at the University for events of different types, or festivals or something else to, to integrate me more into the Hispanic society. David Well, I have someone to talk with like this. So, more communication with people who come to help you and explain to you how the city works; how it is outside, not just being locked in at work and at home. One feels freer, right? That now, well, they tell you that if this happens to you, you know where to go, or if you see something like that or if you feel bad, you know what to do. At first, one thinks, better one stays at home so as not to get into trouble and, uhm, so yes. Diego [Promotor] has always said, "Do not hesitate to call, if we can do something then it is done. " Roberto

Discussion
Consistent with the literature ( Nathenson et al., 2016 ;Valenzuela et al., 2013 ), we found that Latinx immigrants in this ELC experienced social isolation, lack of social support and lack of information. The life situations participants described were also consistent with what we found earlier in an assessment of the health of Latino men in the same area ( Documet et al., 2013 ). Other literature confirms that Latinx leave their countries seeking to economically support their families or flee violence ( Chavez, 2013 ). The immigration experience engenders stressors, including discrimination, loneliness, and low social support ( Cobb et al., 2016 ;Documet et al., 2013 ;Haimueller and Hiscox, 2010 ;Winkelman et al., 2013 ). The life constraints and challenges of Latino immigrant men explain why participants saw promotores as helpful not only in navigating the health system, but also in obtaining jobs and legal help, establishing connections with the community, and brainstorming personal decisions. This last point validates the LEGS coalition's insistence that De la Mano con la Salud be a holistic intervention.
One of the reasons that the provision of social support and connections is extremely relevant in ELC is that in these places, Latinx have small personal networks consisting of other isolated Latinx ( Barrington et al., 2018 ). Promotores appear to have been able to expand participants' social networks through information about community venues (e.g., churches, places where Latinx played soccer) and invitations to public events and social gatherings. By decreasing loneliness and providing connections with a broader group, social support ultimately can enhance health ( Cohen, 2004 ). It connects individuals to a network of resources, equipping them to confront their health problems and can foster healthy behaviors by protecting against stressors and increasing coping resources ( Cohen, 2004 ).
For the working-class Latino immigrant men in this study, living in an area with a scattered Latinx population, isolation was experienced deeply. Participants expressed the need to belong to a community. A similar thirst for community appeared in a PhotoVoice project with members of the same population ( Ruiz Sánchez et al., 2018 ), confirming this finding. It is also likely that the community's invisibility contributed to the feeling that there was no Latinx community.
Allegheny County has seen a rapid increase in its Latino population in the last decades promoted by the demand for cheap labor in the service and construction sectors. The area has seen the emergence of Latino grocery shops and other businesses as well as organizations to support Latino immigrants. However, despite the growth and diversification of their community, Latinx remain invisible to the general public and sometimes to themselves. For example, a recent report on gender and race inequality focuses on Black and White individuals, grouping Latinx with others ( Howell et al., 2019 ). While the report provides invaluable information about Black residents, inequalities among Latinx are not discussed. It is likely that the absence of specific Latinx neighborhoods contributes to this perception. The intentional targeting of Latinx in this study breaks with the Black and White dichotomy, offering needed services and at the same time acknowledging the existence of this community. The need for a cohesive community might also reflect a desire for stronger ethnic identity. Ethnic identity promotes mental health among immigrants ( Espinosa et al., 2018 ).
Respaldo in Spanish refers to support, having someone to hold your back, and guarantee. The perception of participants that the promotores were a "respaldo " available in case of need clearly resembles the definition of perceived social support: they were sure promotores would respond to them quickly if called, take time to listen to them and address their problems, and give them accurate and timely information on how to access health care and other services. As said in the introduction, it is perceived support, rather than received support, that has a greater influence on individuals health and well-being ( Haber et al., 2007 ). Interestingly, in our exploration of promotores perspectives, we found that they were committed to fulfill the needs of participants, even though sometimes promotores saw these actions exceeding their primary roles ( Macia et al., 2016 ).
The emerging theme of respaldo highlights the importance of perceived social support and shows that male promotores can generate such support. Respaldo also raises new research questions related to masculinities among immigrants opening a window to their vulnerabilities and needs ( Charsley and Wray, 2015 ). Studies like ours have found that men are willing to take care of themselves and of other men, because they want to be healthy to be able to keep providing to their families ( Sobralske, 2006 ), as it happens in Malawi ( Chikovore et al., 2015 ). It is important to acknowledge that the potential menaces that sickness pose to working, and the non-paid time that seeking health care entails, put men in conflict with their desire to be healthy and be effective providers. Some related questions worth exploring in a subsequent study are for example: What is the role of conventional masculinity in shaping the structure and roles of social support networks? How do immigrant men include caretaking as part of their masculinity? To what degree the "solutions " for isolation participants gave, such as drinking alcohol or working more time, are the results of a gamut of solutions narrowed by traditional conceptions of masculinity?
This study exemplifies how Latino men can fulfill the role of promotor role, as shown in the growing literature on the topic. It also dispels the notion that the job of promotor is not suited for men because it is perceived as a volunteer or low wage job ( Villa-Torres et al., 2015 ). More importantly, it also illustrates how Latino men's wellbeing can be enhanced through improving their social support, particularly their perceived social support, and networks.

Strengths and limitations
We were able to reach an underserved community that is often unheard. The participatory nature of the project and the identity of promotores, who were themselves from the community facilitated reaching Latinos, reflecting the literature ( Fisher et al., 2014 ;Rhodes et al., 2018 ). Regarding Latinx, specifically, including Latino men, Rhodes explains that trust built over time and an institution that has a good reputation in the community are crucial to enroll study participants ( Rhodes et al., 2018 ). The time investment in developing the trusting relationships suggests that a longer intervention, probably 9-12 months would cement the positive changes obtained and probably yield improved results regarding respaldo . This emerging theme warrants intentional exploration to document exactly what actions of promotore s are best at resulting in perceived social support, thus informing new interventions.
A limitation of this study is that our team did not speak indigenous languages. This precluded us from interviewing any of the participants who spoke mainly Quiche or Capchi (Guatemalan languages that one of the promotores spoke). This was a small number of participants, but we believe they could have provided a unique and important perspective, especially considering the increase of indigenous language speakers community leaders reported. The LEGS coalition designed De La Mano con la Salud to deliberately offer non-directive support, that among received support is the most useful ( Harber et al., 2005 ;Stewart et al., 2012 ), and can be delivered by peer supporters ( Kowitt et al., 2017 ). We did not, however, explore the type of support participants received qualitatively nor quantitatively, which constitutes a limitation. Future research should consider measuring the type of support received. Finally, this was an intervention at the individual level. As such, it cannot solve the problems for which structural interventions are needed. However, creating connections not only improves current lives and wellbeing, but plants the seed of relationships that can inspire community organization. In addition, the LEGS coalition did engage in advocacy, yet not as part of the research study.

Implications and conclusions
Future research should deliberately explore respaldo or perceived social support, as well as the characteristics of perceived support (directive or non-directive). In addition, a qualitative study focusing on how masculinities affect Latino immigrant men's responses to the challenges of immigration and settling in an ELC is needed. In each case, including participants and staff who speak indigenous languages would provide a richer picture of the immigrant Latinx population, especially those who face additional changes.
In summary, we present evidence that male promotores can increase connections and perceived social support among Latino immigrant men, which in turn has the potential to increase their material and psychological health.

Declaration of Competing Interest
None.