Marilu* is not a licensed therapist. She isn’t a doctor. But to many of the men in her Philadelphia community, she’s the only person they truly trust with their pain.

As a promotora — a lay health worker who helps Latino families connect to support systems — Marilu has become an unofficial first responder for Spanish-speaking Philadelphians who are suffering from mental health challenges. Men who have never spoken about their emotions before, who have been taught from childhood that showing sadness is a weakness, now come to her in silence.

As deep as their pain is, they don’t want their wives or children to see them cry, even as they cry out for help.

“They break down,” says Marilu. “They cry, they let out all their pain, everything. And then they ask me, ‘Tell me if I’m OK, because my family can’t see me like this; I can’t let them see me like this.’”

In Latino culture, machismo still casts a long shadow. From a young age, Latino boys are taught not to show vulnerability, to stay strong at all costs.

“There’s this deep stigma,” Marilu says. “Men shouldn’t cry, shouldn’t look weak, shouldn’t appear fragile.”

But slowly, Marilu says, something is changing.

“Lately, we’re getting there,” she adds. “Men are opening up. In secret. But it’s a start.”

It’s an important step forward toward reducing mental health stigma in Philadelphia’s Latino communities, made possible in large part by a unique and impactful initiative organized by Drexel’s Dana and David Dornsife School of Public Health.

The CRiSOL Mente program, a community multi-level intervention aimed at improving mental health among Latinos, leverages the power of trusted community members like Marilu to bridge the gap between underserved populations and mental health services.

Promotoras are carefully chosen from the communities in need and receive hundreds of hours of training in mental health support, community outreach, screening, patient advocacy, and grief and crisis counseling. Drexel and its nonprofit partners — most notably, the Philadelphia AIDS Consortium and the Esperanza Health Center, along with a coalition formed and led by the Drexel team called the Latino Health Collective — connect them to culturally appropriate care and resources, all of which they leverage to help their communities and create better health outcomes.

The results have been remarkable.

Emerging from Crisis

The program evolved from an original iteration of CRiSOL that launched in 2019, just months before COVID-19 laid bare longstanding disparities in health care access across the United States. In Latino communities, the unfolding pandemic had a disproportionate impact, not just in terms of infections and fatalities, but also in its psychological toll.

Isolation, job loss, food insecurity and the trauma of losing loved ones posed a mental health burden that many Latino families were ill-equipped to address. Today, the challenges are different but just as urgent, as immigrants also contend with fears of potentially losing their lawful status or seeing friends or relatives deported.

CRiSOL, which stands for Comunidades Resilientes, Sostenibles y Organizados for Lideres (“Cultivating Resilient and Strong Opinion Leaders”), arrived just in time, quickly adapting to help Philadelphia’s Latino communities cope.

“I prioritze this. And that’s not because anyone is telling me I have to. The promotoras know they can call on me at any time — and they have. If they need me, I’m always there.”

—Claudia Zumaeta-Castillo
CRiSOL Program Coordinator

In 2022, the program was rebooted as a five-year, federally funded community intervention focused on mental health, CRiSOL Mente, under the guidance of Ana Martínez-Donate, a professor of community health and prevention in Drexel’s Dornsife School of Public Health whose work centers on improving health outcomes among immigrant and underserved populations.

Helping to helm CRiSOL Mente is Mariana Lazo, MD, a research professor at the Dornsife School of Public Health. With a medical degree from Universidad La Salle in Mexico City and advanced degrees in epidemiology from Johns Hopkins University, Lazo brings a wealth of experience in the implementation of interventions and the study of health disparities.

Martínez-Donate and Lazo envisioned a three-pronged approach: placing lay health workers on the front lines of the fight for better health by embedding them in both Latino communities and in health clinics across Philadelphia; breaking down stigma through public outreach campaigns including radio segments, informational sessions and community events; and partnering with Latino-serving organizations to strengthen their role in addressing mental health needs.

While the program engages on multiple levels, each essential to its success, the Latino lay health workers are the bedrock on which it is built. By serving as bridges between the clinical and community worlds, these workers conduct outreach and education that help to connect people to care even if they are reluctant to reach out. Some parlay their training into full-time jobs with nonprofit partners, where their experience boosts the organizations’ capacity to reach those in need.

Lazo is deeply committed to the community volunteer model as a means of establishing trust.

“A lot of the people that we are targeting in this effort are immigrants … and that makes them especially hard to reach,” she says. “The lay health workers are influencers or leaders in their community and also know a lot about those communities. This model not only creates greater capacity to address these mental health issues, but it also helps us address the social and economic issues that we know underlie all of these conditions.”

Her Silent Crisis

While machismo teaches men to suppress emotion, Latina women face a different kind of silence — rooted in the cultural expectation that they must be selfless and composed.

The concept of marianismo, drawn from the Catholic ideal of the Virgin Mary, holds that women should be morally virtuous, spiritually resilient and endlessly giving. This value system, in combination with a traditional emphasis on family privacy, means women’s mental health struggles often stay hidden, unspoken or are absorbed quietly in service of others.

For first-generation Latinas especially, the pressure to succeed in a new country while preserving cultural roots can create a relentless psychological tug-of-war. Expected to be caregivers, cultural translators, emotional anchors and economic providers, many shoulder the invisible weight of keeping their families afloat — often without acknowledging their own needs.

“Talking about mental health in the community is not easy, since there is so much stigma that the topic cannot be discussed,” says Zulma, a promotora who has worked with CRiSOL since the first program cycle in 2019. She says her passion for the work is tied in part to the fact that both her family and friends have been directly helped by it. “Due to beliefs, cultures and religion, it is very difficult [to address] … All of this affects well-being: Emotionally, socially, psychologically.”

These expectations exact a high emotional toll. Only about 35% of Latinas with mental health issues receive treatment, compared to nearly 50% of non-Hispanic white women, according to the National Alliance on Mental Illness. Untreated mental illness ripples out across families, schools and workplaces. Studies have linked mental distress among Latinas to higher rates of suicide attempts, especially among young women. The Centers for Disease Control and Prevention reports that Latina adolescents are more likely than their white or Black peers to seriously consider or attempt suicide.

By offering listening and support, CRiSOL Mente offers something radical: the idea that caring for others can begin with caring for yourself.

New Challenges

Philadelphia is home to an estimated 47,000 undocumented immigrants, according to Migration Policy Institute, and recent efforts to tighten federal immigration enforcement have put many Latinos on alert, regardless of their immigration status.

“Nowadays, if you do not have a work permit, if your legal status is not in order, a person cannot get a job elsewhere, cannot financially support their family, has to build their life in this country, and also has to take care of their family back home,” Marilu says. “Many have gone or come to this country paying a lot of money to arrive. They have that debt pending in their country. Added to that is the distancing or family separation. On top of that, there is that feeling of persecution where one does not know when a person will be deported or not; it becomes even more difficult. The person no longer feels stable. The person no longer feels safe.”

Although health care providers generally aren’t required to report immigration status, many immigrants still see the system as risky terrain. Inconsistent policies and mistrust of institutions leave many hesitant to seek care, even when they need it most.

“Our promotoras have such big hearts, and they want to help their peers. They have seen people struggle, and they understand how much the community needs them.”

—Mariana Lazo, MD
Research Professor

In the face of numerous challenges, the program has nonetheless succeeded in completing hundreds of individual interventions that otherwise may never have happened, Lazo says. That’s because of the promotoras.

To identify promotoras, the program organizers took a grassroots approach, tapping into existing networks. Potential promotoras were referred through a patchwork of channels: fliers, radio shows, social media and referrals from earlier Drexel programs. Most candidates were interviewed by academic and clinical teams to ensure they were a good fit.

They were all, Lazo says, “connected to other Latino immigrants, perceived as trustworthy, comfortable talking to other members of the community, and highly motivated to be an agent of change in their community.”

In its current program iteration, CRiSOL Mente has trained 10 promotoras, providing more than 130 hours of hands-on and virtual trainings, plus more than 100 additional hours of “booster sessions,” which provided the promotoras the opportunity to report back on their outreach efforts, get feedback from program leadership — and, by extension, build confidence for future interventions.

The impact of that investment speaks volumes. Over just two years, promotoras have screened more than 800 individuals for mental health concerns — none of whom had received mental health care in the past year. Nearly half were ultimately connected with clinical support, receiving free care for six months in their preferred language.

As the program enters the final year of its current NIH grant, Lazo says, the team’s goal is to reach at least 200 more individuals in need. That effort relies not only on training but also on the dedication of promotoras.

For many, this work is more than a job. Claudia Zumaeta-Castillo, a CRiSOL Mente program coordinator who helps train and support the promotoras, says the work is so special to her that she often finds herself putting it first — including ahead of her dissertation.

“I prioritize this,” she says. “And that’s not because anyone is telling me I have to. It’s just that this is the work that I really like. I’ve seen this program grow from what it was to what it is, and sometimes that means being available 24-7. The promotoras know they can call me at any time — and they have. If they need me, I’m always there.”

Marilu has an “all-hours” ethic when it comes to being available to community members in need.

“It could be in the afternoon, it could be a Saturday, a Sunday, an emergency,” she says. “They don’t know that I have specific hours; they call me at any time, so I always try to be available for them and be able to help them at all times. That’s my job, to bring benefits so that the community can have a better quality of life through these benefits, through these care services.”

Talk to anyone involved in the program and you’ll hear their enthusiasm — they believe they’re making meaningful, lasting progress. Barriers are coming down, men are opening up, and conversations once unthinkable are finally happening.

“I am hoping that other organizations see the value of community health workers and embrace this model,” says Lazo. “There is so much commitment. Our promotoras have such big hearts, and they want to help their peers. They have seen people struggle, and they understand how much the community needs them. They very much want to help others. …If you hire a community health worker, they will make it happen.”

*Promotoras’ last names have been withheld.