Integration of creative expression into community-based participatory research and health promotion with Native Americans

Honoring our teachings: children's storybooks as indigenous public health practice

Introduction

American Indian and Alaska Native (AIAN) communities continue to flourish and innovate in the face of the COVID-19 pandemic. Storytelling is an important tradition for AIAN communities that can function as an intervention modality. To support the needs of AIAN children and caregivers, we (a collaborative workgroup of Indigenous health researchers) developed a culturally grounded storybook that provides pandemic-related public health guidance and mental health coping strategies woven with Inter-Tribal values and teachings.

Methods

A collaborative workgroup, representing diverse tribal affiliations, met via four virtual meetings in early 2021 to discuss evolving COVID-19 pandemic public health guidance, community experiences and responses to emerging challenges, and how to ground the story in shared AIAN cultural strengths. We developed and distributed a brief survey for caregivers to evaluate the resulting book.

Results

The workgroup iteratively reviewed versions of the storyline until reaching a consensus on the final text. An AI artist from the workgroup created illustrations to accompany the text. The resulting book, titled Our Smallest Warriors, Our Strongest Medicine: Honoring Our Teachings during COVID-19 contains 46 pages of text and full-color illustrations. An online toolkit including coloring pages, traditional language activities, and caregiver resources accompanies the book. We printed and distributed 50,024 physical copies of the book and a free online version remains available. An online survey completed by N = 34 caregivers who read the book with their child(ren) showed strong satisfaction with the book and interest in future books.

Discussion

The development of this storybook provides insights for creative dissemination of future public health initiatives, especially those geared toward AIAN communities. The positive reception and widespread interest in the storybook illustrate how braiding AIAN cultural teachings with public health guidance can be an effective way to disseminate health information. This storybook highlights the importance of storytelling as an immersive learning experience through which caregivers and children connect to family, community, culture, and public health guidance. Culturally grounded public health interventions can be effective and powerful in uplifting AIAN cultural values and promoting health and well-being for present and future generations.

Can 'life writing' be therapeutic in response to trauma? An exploratory research project in Medical Humanities in South Africa

The therapeutic benefit of expressive writing has been well researched in the Global North but there is no literature from the Global South. Potentially healing interventions need to be investigated in different contexts, particularly where there is a need to build social cohesion. South Africa has a violent past and is a highly stressed society. An exploration of self-reports by a diverse group of South Africans on the effects of life writing on their health and well-being was conducted using qualitative methods. Twenty members of a writing collective, the Life Righting Collective (LRC: www.liferighting.co.za), were purposively sampled and interviewed by medical students as part of a Medical Humanities special study module. Five major interconnected themes emerged. The LRC as a specific intervention was central to the benefits described. The findings of this study indicated that life writing is a useful non-medical, cost-efficient method to improve resilience to trauma, as well as improving the psychological well-being of the participants. In addition, participants reported positive experiences regarding personal development, overall wellness and mental health, and that life writing can engender a sense of community. Resource-constrained countries in the Global South, like South Africa, where there have been historical and ongoing multiple traumas, need interventions for healing and wellness that are low cost and can be replicated.

From Empathy to Action: Design Thinking as a Catalyst for Community-Based Participatory Research in Dementia Caregiving

This article delves into the understudied realm of investigating the potential benefits of integrating design thinking into community-based participatory research within the context of culturally diverse dementia caregivers. Following the Double-Diamond process model, we conducted a series of workshops with 15 family caregivers of dementia patients from three distinct communities (multi-racial, Black, and Latino ethnicity) to gain insights into their daily experiences and co-create interventions that could address their pressing challenges. The research question for this study aimed to explore the potential benefits of design thinking in community-based research on dementia caregiving. Our findings contribute to the health design community by demonstrating the potential of design thinking to 1) uncover common and distinct challenges in diverse communities, 2) translate findings into actionable solutions, and 3) design tailored interventions that are responsive to the context-specific needs of the community. Our study leads us to conclude that the integration of design thinking as a catalyst in community-based participatory research has the potential to amplify the identification of nuanced and previously unexamined challenges through empathetic exploration, and to propose innovative interventions that are more amenable to uptake and acceptance within the community.

Engaging with 'less affluent' communities for food system transformation: a community food researcher model (FoodSEqual project)

The UK food system is distorted by inequalities in access, failing the people most in need, yet it should provide access to safe, nutritious affordable food for all citizens. Dietary patterns are associated with socio-demographic characteristics, with high levels of diet-related disease mortality attributed to poor dietary habits. Disadvantaged UK communities face urgent public health challenges, yet are often treated as powerless recipients of dietary and health initiatives. The need for food system transformation has been illustrated within recent UK government policy drivers and research funding. The Food Systems Equality project is a research consortium that aims to 'co-produce healthy and sustainable food systems for disadvantaged communities'. The project focusses on innovating food products, supply chains and policies, placing communities at the centre of the change. Tackling the above issues requires new ways of working. Creative approaches in food research are known to empower a wider range of individuals to share their 'lived food experience' narratives, building relationships and corroborating co-production philosophies, thus promoting social justice, and challenging more traditional positivist/reductionist 'biomedical' approaches for nutrition and food studies. This review paper critiques the use of community-centric approaches for food system transformation, focusing on one, a community food researcher model() as an exemplar, to highlight their utility in advocating with rather than for less affluent communities. The potential for creative methods to lead to more equitable and lasting solutions for food system transformation is appraised, consolidating the need for community-driven systemic change to foster more progressive and inclusive approaches to strengthen social capital. The paper closes with practice insights and critical considerations offering recommendations for readers, researchers, and practitioners, enabling them to better understand and apply similar approaches.

Healthy Environments: Understanding Perceptions of Underrepresented Communities in the United Kingdom

A healthy environment has been defined by global health organisations as one that is safe, supportive of healthy lifestyles, and free of hazards. Such definitions disregard the complexity of what it means for an environment to be perceived as 'healthy'-such as the mental, not just physical, health effects on citizens. This study aimed to understand the attributes that underrepresented groups of the United Kingdom (UK) public assign to healthy environments-an important step for directing public policy and actions to create environments that are inclusive of all citizens. This co-created study involved 95 participants from underrepresented communities in 10 separate focus groups, each facilitated by a community member. Thematic analyses highlighted five key attributes of a healthy environment: sounds and sights, accessibility, safety, familiarity and mental health and wellbeing. This study draws a picture of key attributes underrepresented groups of the UK public assign to healthy environments that is richer than that drawn by existing definitions. These findings illustrate the importance of hearing diverse voices when directing research, policy, and actions that attempt to develop healthy environments for all.

Using Community-Academic Partnerships and a Creative Expression Contest to Engage Youth in the Development of Communication Materials for Promoting Behaviors That Prevent COVID-19

Youth can transmit COVID-19 to adults, but few communication materials exist for engaging youth in COVID-19 prevention behaviors. We describe the process of leveraging a community-academic partnership in a rapid response initiative to engage youth in a contest (i.e., Youth-Led Creative Expression Contest to Prevent COVID-19 across Texas) to develop creative public health messaging centered on the prevention of COVID-19 transmission and infection for their peers. Core activities included developing a request for applications that solicited submission of creative expression materials promoting the use of COVID-19 prevention behaviors (mask-wearing, social distancing, handwashing, not touching the face) from Texas youth in elementary, middle, and/or high school; sending the request for applications to 48 organizations in Austin, Brownsville, Dallas, El Paso, Houston, and San Antonio in summer 2020; and recruiting a youth advisory board to score submissions and award prizes. We report on youth engagement in the COVID communication contest across Texas and use statistics (chi-square and t-tests) to characterize and compare youth participants and their creative expression artwork. The contest resulted in 3,003 website views and 34 submissions eligible for scoring. Each submission averaged >2 prevention behaviors. On average, winning submissions included a higher number of prevention behaviors than nonwinning submissions. The prevention behavior "not touching the face" was included more often in winning submissions than nonwinning submissions. Elementary school children were less likely to include a mask in their submission compared with older youth. Existing community-academic networks can engage youth in the development of geographically and age-tailored communication materials.

Participatory food events as collaborative public engagement opportunities

There is an urgent need to ‘get creative’ with the way we tackle social and nutritional inequalities. The Food as a Lifestyle Motivator (FLM) project has explored the use of creative participatory approaches to engage ‘harder to reach’ communities in dialogues to improve their well-being and life skills. Preliminary findings have confirmed that food can be a powerful catalyst for social inclusion with the potential to empower ‘marginalised’ individuals. Part of this exploratory study has involved two participatory food events (November 2015 and November 2016) run in a local day centre for drug and alcohol rehabilitation. The aim of these events was to bring together key stakeholders (from the service user and provider communities) to exchange food-based knowledge, using collaborative and co-creative participatory approaches. Following ethical clearance, a range of data were collected at the events to assess their ‘social impact’. These consisted of (1) audio interviews (service providers and users), (2) oral surveys (service users and key workers) and (3) observations of social cooking and eating engagement, and creative visual arts (photography, collage, food games and quizzes). In this article, we detail how the range of creative approaches used has successfully engaged individuals (average attendance: n = 80, service users: n = 32) to participate in these food-themed events. We reflect on the overarching themes from data capture of the social and therapeutic aspects of food (activities). We also reflect on the collation (and curation) of findings, systematically critiquing the approaches used, including consideration of ethics, and drivers for engagement. Finally, we consider how the utility of such creative approaches can optimise public engagement activities, not only to enhance research impact but also to inform collaborative developments with and between service users, service providers and other stakeholders, with the potential to lead to transformative food-related changes.

Yes We Can: Eating Healthy on a Limited Budget

OBJECTIVE

This study determined how people who live in low-income households can consume an affordable, nutritious diet.

DESIGN

A community-based participatory research (CBPR) project was completed that developed and priced 2 weeks of healthy menus that met US Department of Agriculture Dietary Guidelines for Americans. Prices were collected from a market basket survey of 13 stores in the city of Chico during October, 2010. Initial menu development began in 2011-2012. Menus were reviewed in 2017 and reflect current guidelines.

SETTING

Chico, CA.

MAIN OUTCOME MEASURES

Macro dietary objectives including the caloric content and servings of fat, sugar, whole grains, and fruits and vegetables. The cost of purchasing the market basket of goods for a family of 4 that achieved those objectives was determined.

RESULTS

The 2 weeks of menus all met dietary objectives on average. The daily cost varied from $19 to $31 when food was purchased from a bulk supermarket, with an average daily cost of $25. Average monthly cost was $756 in 2010 dollars, or $838 in 2015 dollars.

CONCLUSIONS AND IMPLICATIONS

People living in low-income households can afford to eat healthily. Using CBPR principles, daily targets, and technical support, public health partners can partner with community members for member-defined solutions that are affordable and meet dietary guidelines. Access to stores that sell low-price bulk items is important to being able to afford a healthy diet.

Grandmother and health care professional breastfeeding perspectives provide opportunities for health promotion in an American Indian community

RATIONALE

While breastfeeding is well recognized as beneficial, rates of breastfeeding among American Indian women are below average and contribute to health inequities. Culturally specific approaches to breastfeeding research are called for to inform appropriate interventions in American Indian communities. Specifically, a grandmother's role in breastfeeding promotion is of great import particularly in American Indian (AI) groups, although is an understudied topic to date.

OBJECTIVE

This research seeks to fill a prominent literature gap by utilizing a grounded theory and community-based research approach to inform breastfeeding practices from the voices of grandmothers and health care professionals in a rural AI community in the United States.

METHODS

A community-based approach guided the research process. Convenience and snowball sampling was used to recruit for semi-structured and follow up member checking interviews with AI grandmothers (n = 27) and health care professionals (n = 7). Qualitative data were transcribed, characterized into meaning units, and coded by a review panel. Data were reconciled for discrepancies among reviewers, organized thematically, and used to generate community-specific breastfeeding constructs.

RESULTS

Three major themes emerged, each with relevant subthemes: (1) importance of breastfeeding; (2) attachment, bonding, and passing on knowledge; and (3) overburdened health care system. Multiple subthemes represent stressors and impact breastfeeding knowledge, translation, and practice within this community including formula beliefs, historical traumas, societal pressures, mistrust, and substance abuse.

CONCLUSIONS

Interventions designed to raise breastfeeding rates in the study site community would ideally be grounded in tribal resources and involve a collaborative approach that engages the greater community, grandmothers, health care professionals, and scientific partners with varying skills. More research is needed to determine stressors and any potential impact on infant feeding practices among other AI groups. Application of the research approach presented here to other AI communities may be beneficial for understanding opportunities and challenges to breastfeeding practices.

Planting Healthy Roots: Using Documentary Film to Evaluate and Disseminate Community-Based Participatory Research

Documentary filmmaking approaches incorporating community engagement and awareness raising strategies may be a promising approach to evaluate community-based participatory research. The study purpose was 2-fold: (1) to evaluate a documentary film featuring the formation and implementation of a farmers' market and (2) to assess whether the film affected awareness regarding food access issues in a food-desert community with high rates of obesity. The coalition model of filmmaking, a model consistent with a community-based participatory research (CBPR) approach, and personal stories, community profiles, and expert interviews were used to develop a documentary film (Planting Healthy Roots). The evaluation demonstrated high levels of approval and satisfaction with the film and CBPR essence of the film. The documentary film aligned with a CBPR approach to document, evaluate, and disseminate research processes and outcomes.

Promoting Culturally Respectful Cancer Education Through Digital Storytelling

Cancer is the leading cause of mortality among Alaska Native people. Over half of Alaska Native people live in rural communities where specially trained community members called Community Health Aides/Practitioners (CHA/Ps) provide health care. In response to CHA/Ps' expressed desire to learn more about cancer, four 5-day cancer education and digital storytelling courses were provided in 2014. Throughout each course, participants explored cancer information, reflected on their personal experiences, and envisioned how they might apply their knowledge within their communities. Each course participant also created a personal and authentic digital story, a methodology increasingly embraced by Indigenous communities as a way to combine storytelling traditions with modern technology to promote both individual and community health. Opportunities to learn of CHA/Ps' experiences with cancer and digital storytelling included a 3-page end-of-course written evaluation, a weekly story-showing log kept for 4 weeks post-course, a group teleconference held 1-2 weeks post-course, and a survey administered 6 months post-course. Participants described digital storytelling as a culturally respectful way to support cancer awareness and education. Participants described the process of creating digital stories as supporting knowledge acquisition, encouraging personal reflection, and sparking a desire to engage in cancer risk reduction activities for themselves and with their families and patients. As a result of creating a personalized digital story, CHA/Ps reported feeling differently about cancer, noting an increase in cancer knowledge and comfort to talk about cancer with clients and family. Indigenous digital stories have potential for broad use as a culturally appropriate health messaging tool.

Digital storytelling: an innovative tool for practice, education, and research

Digital storytelling is a method of using storytelling, group work, and modern technology to facilitate the creation of 2-3 minute multi-media video clips to convey personal or community stories. Digital storytelling is being used within the health care field; however, there has been limited documentation of its application within occupational therapy. This paper introduces digital storytelling and proposes how it can be applied in occupational therapy clinical practice, education, and research. The ethical and methodological challenges in relation to using the method are also discussed.

Using Research Poetics “Responsibly”: Applications for Health Promotion Research

Research poetics, a form of arts-based research methods, has been underutilized in the field of health promotion. Poetic methods have most commonly been used as a form of re/presentation of the lived experience in qualitative research. For the community-engaged researcher, re/presenting findings through poetry offers unique opportunities for engaging the reader and reaching diverse communities. However, this approach also has implications as an analytic method and allows the analyst to have a more meaningful and personal engagement with participants' stories. Perhaps most importantly, this approach acknowledges and brings to the forefront the co-construction of qualitative findings and de-centers the authority of the researcher by preserving and promoting the participant's voice. Using examples from the authors' own research, this article describes opportunities for incorporating research poetics into health promotion research and argues for its applicability for community-engaged health promotion researchers.

Figurative language can give shape to the difficult and the painful. It can make visible and “felt” that which is invisible and “unfeelable.” Imagery, more than anything else, can take us out of our own existence and let us stand in the condition of another instance, or another life. It can make the subject of the poem, whatever it is, as intimate as honey—or ashes—in the mouth. Use it responsibly [1, p. 108].

Building research capacity with members of underserved American Indian/Alaskan Native communities: training in research ethics and the protection of human subjects

OBJECTIVE

To develop a research ethics training course for American Indian/Alaskan Native health clinic staff and community researchers who would be conducting human subjects research.

METHOD

Community-based participatory research methods were used in facilitated discussions of research ethics centered around topics included in the Collaborative Institutional Training Initiative research ethics course.

RESULTS

The community-based participatory research approach allowed all partners to jointly develop a research ethics training program that was relevant for American Indian/Alaskan Native communities. All community and clinic partners were able to pass the Collaborative Institutional Training Initiative course they were required to pass so that they could be certified to conduct research with human subjects on federally funded projects. In addition, the training sessions provided a foundation for increased community oversight of research.

CONCLUSIONS

By using a collaborative process to engage community partners in research ethics discussions, rather than either an asynchronous online or a lecture/presentation format, resulted in significant mutual learning about research ethics and community concerns about research. This approach requires university researchers to invest time in learning about the communities in which they will be working prior to the training.

Adapting Western research methods to indigenous ways of knowing

Indigenous communities have long experienced exploitation by researchers and increasingly require participatory and decolonizing research processes. We present a case study of an intervention research project to exemplify a clash between Western research methodologies and Indigenous methodologies and how we attempted reconciliation. We then provide implications for future research based on lessons learned from Native American community partners who voiced concern over methods of Western deductive qualitative analysis. Decolonizing research requires constant reflective attention and action, and there is an absence of published guidance for this process. Continued exploration is needed for implementing Indigenous methods alone or in conjunction with appropriate Western methods when conducting research in Indigenous communities. Currently, examples of Indigenous methods and theories are not widely available in academic texts or published articles, and are often not perceived as valid.

Building partnerships in community-based participatory research: budgetary and other cost considerations

Community-based participatory research (CBPR) is an important framework for partnering with communities to reduce health disparities. Working in partnership with community incurs additional costs, some that can be represented in a budget summary page and others that are tied to the competing demands placed on community and academic partners. These cost considerations can inform development of community-academic partnerships. We calculated costs from a case study based on an ongoing CBPR project involving a Community Planning Group (CPG) of community co-researchers in rural Alaska and a bicultural liaison group who help bridge communication between CPG and academic co-researchers. Budget considerations specific to CBPR include travel and other communication-related costs, compensation for community partners, and food served at meetings. We also identified sources of competing demands for community and academic partners. Our findings can inform budget discussions in community-academic partnerships. Discussions of competing demands on community partners' time can help plan timelines for CBPR projects. Our findings may also inform discussions about tenure and promotion policies that may represent barriers to participation in CBPR for academic researchers.

Social media, digital video and health promotion in a culturally and linguistically diverse Australia

Participatory processes are effective for digital video production that promotes health and wellbeing with communities from diverse cultural and linguistic backgrounds, including migrants and refugees. Social media platforms YouTube, Vimeo, Flickr and others demonstrate potential for extending and enhancing this production approach. However, differences within and between communities in terms of their quality of participation online suggest that social media risk becoming exclusive online environments and a barrier to health and wellbeing promotion. This article examines the literature and recent research and practice in Australia to identify opportunities and challenges when using social media with communities from diverse cultural and linguistic backgrounds. It proposes a hybrid approach for digital video production that integrates 'online' and 'offline' participation and engages with the differences between migrants and refugees to support more inclusive health and wellbeing promotion using digital technology.