Community health workers and promotores de salud: a tiered framework for infectious disease prevention and care among California agricultural workers.

Agricultural workers in the United States face a disproportionate burden of infectious diseases, including tuberculosis, HIV, coccidioidomycosis, viral hepatitis, and COVID-19, driven by occupational exposures, crowded housing, poverty, and limited healthcare access. Despite this burden, farmworkers have among the lowest rates of healthcare utilization of any US working population, and traditional clinic-based delivery models are poorly suited to the realities of agricultural labor. Community health workers (CHWs), known as promotores de salud in Latino communities, offer a well-established strategy for bridging this gap through shared language, culture, and lived experience with the communities they serve. This mini-review synthesizes evidence on CHW and promotora interventions for infectious disease prevention and care among agricultural workers, with particular attention to California's farmworker communities. Available evidence supports CHW roles in COVID-19 vaccination and outreach, tuberculosis treatment adherence through community-based directly observed therapy, HIV prevention and pre-exposure prophylaxis (PrEP) navigation, and hepatitis screening and linkage to care. However, existing programs have largely operated in isolation, and, to our knowledge, no CHW intervention for coccidioidomycosis has been developed despite its importance as an occupational infectious disease in California. To address this fragmentation, we propose a three-tiered framework that extends CHW roles from community-based prevention and early recognition to screening, linkage, and treatment support, and ultimately to formal integration with healthcare and public health systems. Implementing this framework will require infectious disease-specific training in the languages of the communities served, sustainable financing, and rigorous evaluation of an integrated cross-disease CHW model in California's agricultural communities.