For People Living on the Texas Border, COVID-19 Brings Unique Challenges to Reproductive Health Care

Promotoras are community health workers who usually go door to door and provide essential reproductive health information and access to residents of colonias. But what happens during a pandemic?

[Photo: A woman holds a clipboard as she shows a breast model to another woman.]
During the COVID-19 pandemic, promotoras have found new ways to stay connected with their communities remotely. Courtesy of Access Esperanza Clinics

For continuing coverage of how COVID-19 is affecting reproductive health, check out our Special Report.

For the past 28 years, Dora Proa has visited rural, unincorporated areas along the Texas-Mexico border, going door to door and dropping in at community centers to provide resources on sexual and reproductive health for residents of these colonias.

“It’s a 24/7 job, but I love it,” she said in Spanish (the interview was translated with help from Martha Leos, Access Esperanza Clinics’ education supervisor).

Armed with a breast model, a pouch with sample birth control options, and pamphlets with information on sexually transmitted diseases, cancers, and contraception in both Spanish and English, Proa meets up to 80 people a day in homes, schools, health fairs, and flea markets. Proa serves as a community health worker—or promotora in Spanish—for Access Esperanza Clinics, a reproductive health clinic group with locations throughout Hidalgo County, Texas. Promotora programs allow clinics to make connections with patients in the vastly underserved Rio Grande Valley, which is home to about 900 colonias.

According to a 2015 report, around 500,000 people reside in colonias, geographically isolated, unincorporated, and primarily Latinx communities that are generally concentrated in Texas’ southernmost areas. The colonias often lack running water, electricity, and proper infrastructure, and many are also located in food deserts and medically underserved areas, creating a web of challenges that residents must face when attempting to access general and reproductive health-care services. Heightened border control and lack of public transportation also make this region difficult to traverse, further compounding the obstacles colonia residents face when seeking health care.

As a promotora, Proa serves as a valuable intermediary between clinics and the communities. Her responsibilities include establishing new contacts with residents who need affordable access to screenings, testing, birth control, and other reproductive health-care services. She works alongside other promotoras from other clinics in the region, alerting residents that they can make appointments at their clinics and apply for funding to receive the services free of charge. According to Kathryn Hearn, community services director at Access Esperanza, the clinic’s promotora program engages with around 20,000 people every year.

Amid the COVID-19 pandemic, promotoras have found new ways to stay connected with their communities remotely.

“Our promotoras are still talking to people in the colonias,” said Leos, Access Esperanza’s education supervisor. “They’re making appointments at our clinics, they’re letting them know that it’s important to keep up with their reproductive health, that we’re open, and that we’re following all the [Centers for Disease Control and Prevention] guidelines, and that it’s safe to come to the clinic.”

To help alleviate some stress on colonias residents worried about travel restrictions, Access Esperanza developed a travel letter for patients requiring essential services. Promotoras circulated the letter as an image to patients, so those traveling to the clinic could provide justification for being on the roads with Texas’ stay-at-home orders in place.

Paula Saldaña, lead promotora for Planned Parenthood South Texas’ Habla Con Tu Hermana program, has also found other ways of helping residents in colonias from a distance.

Paula Saldaña. Courtesy of Obed Esquivel.

Using Facebook groups—including one named “Las Super Promotoras” that has over 600 members—WhatsApp, and phone calls, promotoras like Saldaña and Proa are able to continue assisting patients, new and old, in colonias during the health crisis.

Over time, promotoras become well-known figures in colonias, and residents frequently contact them for advice on how to access resources. “People reach out to them after years,” said Mara Posada, director of public affairs at Planned Parenthood South Texas. “They keep their phone number and whenever they need help, they call them. There’s a reason why, even though the promotoras aren’t necessarily in the community right now, they’re still a resource for folks.”

Saldaña has worked as a community health worker for over 20 years in South Texas. At Planned Parenthood’s Brownsville clinic, she conducts educational presentations in rural Texas on reproductive health-care topics, including breast cancer, cervical cancer, birth control options, sexually transmitted infections, HIV/AIDS and stigma, and how to talk to your kids about sex.

The state shutdown that ensued in the wake of the COVID-19 pandemic had a “big impact” on patients who were scheduled for appointments at the clinic, Saldaña said.

In addition to increased sanitation and physical distancing practices, like checking patients in from the parking lot, the clinic suspended routine and preventative health-care services for about a month recently in order to reduce COVID-19 transmission rates. Paused services included standard annual exams—like Pap smears—not scheduled to address any previous issues or complications.

Latinx women have the highest incidence of cervical cancer—a highly fatal yet treatable disease when detected early—compared to other races. “They die from it more frequently because it’s identified further along,” Posada said. “We’ve had women who have not had a Pap test their entire adult life—it’s been 15 to 20 years since they’ve had a test.”

According to data from the U.S. Department of Health and Human Services Office of Minority Health, Latinx women are 40 percent more likely to be diagnosed with and 20 percent more likely to die from cervical cancer, compared to non-Hispanic white women. Pap smears are the most effective way to screen for cervical cancer, but due to barriers like limited access to health care or insurance, lower levels of education, and a lack of Spanish-speaking providers, Latinx women are significantly less likely to get screened.

When clinics began to limit the number of services offered, many patients were forced to postpone already long-overdue Pap smears. “We can hear in their voice the disappointment—because some of them had had years without having a Pap smear exam,” Saldaña said. “And then they were able to finally break so many barriers to get that appointment with us because they met us out in the community.”

However, for the past two weeks, Planned Parenthood South Texas’ clinics have seen a patient volume at over 90 percent.

“At no time did our clinics close or hours change because we know that some health care just can’t wait,” Posada said, clarifying that all services are currently being offered at the clinics.

For some colonias without internet access, information about the pandemic, such as symptoms of COVID-19, testing sites, and social distancing guidelines, can be difficult to access. Nurith Galonsky Pizaña, District 1 City Commissioner of Brownsville, spearheads a program recently enacted to bring critical information to disconnected residents.

Pizaña begins her days at 6:30 a.m. and along with members of the city’s public health department visit over 700 households per day in Brownsville, a low-income city on the lower tip of Texas, delivering informational bags containing census flyers and COVID-19-related information, like locations of drive-thru testing sites.

Although Pizaña’s COVID-19 initiative has yet to coordinate with promotoras, Saldaña is excited at the prospect of partnering on the project. For her and Proa, serving the community is of utmost importance, whether that’s through face-to-face or virtual interaction.

Even within a pandemic, the work of a promotora never ends, Proa said.

“We’ve received all that [promotora] training, and that’s something nobody can take away from me,” she said. “I’m happy to know that I’ve been able to give knowledge to communities who are not aware so they can take care of their own health.”