Critical Environmental Injustice: A Case Study Approach to Understanding Disproportionate Exposure to Toxic Emissions

Environmental justice research has focused on the distribution of environmental inequalities, such as proximity to landfills, across the U.S. and globally.

BACKGROUND

Public health research and environmental health research, specifically, have focused on toxic exposure-encompassing individuals or communities that are disproportionately exposed to contaminants that are harmful or potentially harmful to them. Yet, little research has applied critical environmental justice theory-characterized by the idea that marginalized communities need to be treated as indispensable rather than disposable-to the study of toxic exposure. To fill this gap, the current paper offers a case study approach applying critical environmental justice theory to the study of disproportionate and unequal exposure to toxic contaminants.

METHODS

This case study is of Kettleman City, a rural, unincorporated community in the heart of California's Central Valley (USA). This community experiences the co-location of environmental hazards, including residing at the intersection of two major highways and hosting a class I hazardous-waste landfill, which is one of the few licensed to accept PCBs. PCBs are a contaminant that has been linked with several adverse health outcomes, including cancers and low birthweight. Residents may also experience poor air quality from proximity to the highways.

RESULTS

This case highlights the uneven distribution of pollution and environmental degradation that may be shouldered by the community, along with their experiences of adverse health and social impacts. This analysis reveals the importance of incorporating a critical environmental justice perspective to unpack experiences of not only disproportionate exposure but also disproportionate procedural and recognitional inequality.

CONCLUSIONS

This research highlights the untapped potential of environmental justice to catalyze exposure science in challenging the unequal distribution of contaminants.

Participatory Action Research Among People With Serious Mental Illness: A Scoping Review

Participatory action research (PAR) is a research approach that creates spaces for marginalized individuals and communities to be co-researchers to guide relevant social change. While working toward social transformation, all members of the PAR team often experience personal transformation. Engaging people with serious mental illness (PSMI) in PAR helps them to develop skills and build relationships with stakeholders in their communities. It supports positive changes that persist after the completion of the formal research project. With the increasing recognition of PAR's value in PSMI, it is helpful to consider the challenges and advantages of this approach to research with this population. This review aimed at determining how PAR has been conducted with PSMI and at summarizing strategies used to empower PSMI as co-researchers by engaging them in research. This scoping review followed five steps Arkesy and O'Malley (2005) outlined. We charted, collated, and summarized relevant information from 87 studies that met the inclusion criteria. We identified five strategies to empower PSMI through PAR. These are to build capacity, balance power distribution, create collaborative environments, promote peer support, and enhance their engagement as co-researchers. In conclusion, PAR is an efficient research approach to engage PSMI. Further, PSMI who engage in PAR may benefit from strategies for empowerment that meet their unique needs as co-researchers.

Developing STEM Career Identities among Latinx Youths: Collaborative Design, Evaluations, and Adaptations during COVID-19

In response to the low representation of Latinx adults in STEM occupations, this community-based participatory action research study aims to increase the number of middle school youths developing STEM career identities and entering high school with the intention to pursue STEM careers. The students were provided with summer and after-school activities focusing on network science and career development curricula. Using a quasi-experimental pretest-posttest design and career narratives, this study examined the changes in STEM and career self-efficacy, as well as career identity. The results show improvements in self-efficacy, an increased number of youths with intentions of pursuing future STEM career opportunities, and deeper reflections on their talents and skills after program participation. This paper also describes the program development and implementation in detail, as well as the adaptations that resulted from COVID-19, for scholars and educators designing similar programs. This study provides promising evidence for the quality of STEM and career development lessons in supporting the emergence of a STEM career identity and self-efficacy.

Evaluating Human Papillomavirus eHealth in Hmong Adolescents to Promote Vaccinations: Pilot Feasibility Study

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted infection, causing multiple cancers, including cervical, penile, and anal. Infection and subsequent health risks caused by HPV can be diminished by HPV vaccination. Unfortunately, vaccination rates among Hmong Americans are substantially lower than those among other racial and ethnic groups, despite having higher cervical cancer rates than non-Hispanic White women. Such disparities and sparse literature highlight the need for innovative and culturally appropriate educational interventions to improve HPV vaccine rates in Hmong Americans.

OBJECTIVE

We aimed to develop and evaluate the effectiveness and usability of an innovative web-based eHealth educational website, the Hmong Promoting Vaccines website (HmongHPV website), for Hmong-American parents and adolescents to improve their knowledge, self-efficacy, and decision-making capacities to obtain HPV vaccinations.

METHODS

Through social cognitive theory and community-based participatory action research process, we created a theory-driven and culturally and linguistically appropriate website for Hmong parents and adolescents. We conducted a pre-post intervention pilot study to assess the website's effectiveness and usability. Overall, 30 Hmong-American parent and adolescent dyads responded to questions about HPV and HPV vaccine knowledge, self-efficacy, and decision-making at preintervention, 1 week after intervention, and at the 5-week follow-up. Participants responded to survey questions about website content and processes at 1 and 5 weeks, and a subset of 20 dyad participants participated in telephone interviews 6 weeks later. We used paired t tests (2-tailed) to measure the change in knowledge, self-efficacy, and decision-making processes, and used template analysis to identify a priori themes for website usability.

RESULTS

Participants' HPV and HPV vaccine knowledge improved significantly from pre- to postintervention stage and follow-up. Knowledge scores increased from preintervention to 1 week after intervention for both parents (HPV knowledge, P=.01; vaccine knowledge, P=.01) and children (HPV knowledge, P=.01; vaccine knowledge, P<.001), which were sustained at the 5-week follow-up. Parents' average self-efficacy score increased from 21.6 at baseline to 23.9 (P=.007) at post intervention and 23.5 (P=.054) at follow-up. Similar improvements were observed in the teenagers' self-efficacy scores (from 30.3 at baseline to 35.6, P=.009, at post intervention and 35.9, P=.006, at follow-up). Collaborative decision-making between parents and adolescents improved immediately after using the website (P=.002) and at follow-up (P=.02). The interview data also revealed that the website's content was informative and engaging; in particular, participants enjoyed the web-based quizzes and vaccine reminders.

CONCLUSIONS

This theory-driven, community-based participatory action research-designed and culturally and linguistically appropriate educational website was well received. It improved Hmong parents' and adolescents' knowledge, self-efficacy, and decision-making processes regarding HPV vaccination. Future studies should examine the website's impact on HPV vaccine uptake and its potential for broader use across various settings (eg, clinics and schools).

Can Photovoice foster the development of social support?

Photovoice is a participatory, photo-based research method that differs from conventional (non-participatory) research in that the process is meant to be empowering and beneficial. However, empirical research on the Photovoice process remains very limited. Based on feedback from participants who reported Photovoice helped them develop closer relationships, we examine whether engaging in Photovoice fosters social support. Transcripts from a Photovoice study on wellness in mental health Clubhouses (voluntary, community mental health centers) were retrospectively analyzed for instrumental support, appraisal, informational support, and emotional support. Appraisal was the most common form of social support identified, and was primarily expressed through peer praise for photos and insights. Informational support included advice on managing symptoms, promoting wellness, and navigating challenges. Instrumental support was fostered by learning the tangible skill of digital photography and by supporting fellow members with physical or visual limitations to participate in the process. Emotional support was cultivated through encouragement, identification of shared experiences, and connection through humor. In sum, the findings suggest that Photovoice has the potential to foster social support, which may support relational empowerment.

Mobile health technology for hypertension management with Hmong and Latino adults: mixed-methods community-based participatory research

OBJECTIVE

To identify Hmong and Latino adults' perspectives about a mHealth-based care model for hypertension (HTN) management involving blood pressure (BP) self-monitoring, electronic transmission of BP readings, and responsive HTN medication adjustment by a provider team.

DESIGN

We conducted a mixed-methods formative study with 25 Hmong and 25 Latino participants with HTN at an urban federally-qualified health center. We used a tool to assess HTN knowledge and conducted open-ended interviews to identify perspectives about mHealth-based care model.

RESULTS

While most participants agreed that lowering high blood pressure decreased the risk of strokes, heart attacks, and kidney failure, there were gaps in medical knowledge. Three major themes emerged about the mHealth-based care model: (1) Using mHealth technology could be useful, especially if assistance was available to patients with technological challenges; (2) Knowing blood pressures could be helpful, especially to patients who agreed with doctors' medical diagnosis and prescribed treatment; (3) Transmitting blood pressures to the clinic and their responsive actions could feel empowering, and the sense of increased surveillance could feel entrapping. Some people may feel empowered since it could increase patient-provider communication without burden of clinic visits and could increase involvement in BP control for those who agree with the medical model of HTN. However, some people may feel entrapped as it could breach patient privacy, interfere with patients' lifestyle choices, and curtail patient autonomy.

CONCLUSIONS

In general, Hmong and Latino adults responded positively to the empowering aspects of the mHealth-based care model, but expressed caution for those who had limited technological knowledge, who did not agree with the medical model and who may feel entrapped. In a shared decision-making approach with patients and possibly their family members, health care systems and clinicians should explore barriers and potential issues of empowerment and entrapment when offering a mHealth care model in practice.

What Is Not in the Methods Section: Challenges, Successes, and Lessons Learned From Conducting School-Based Interpersonal Violence Prevention Research

Interpersonal violence (IV)-which includes sexual assault, sexual harassment, teen dating violence, bullying, and other forms of violence-among youth (i.e., individuals 18 years of age or younger) is a public health crisis in the United States. As such, preventing IV among youth is a public health priority. Schools are natural settings for IV prevention among youth. However, conducting school-based IV prevention research with youth in school settings is riddled with challenges, and there is little systematic discussion of lessons learned from doing this work. As such, the purpose of this paper is to outline challenges, successes, and lessons learned from conducting school-based IV prevention research, as ascertained by four researchers with over 75 years of collective experience conducting school-based IV prevention research. Specifically, we focus on the importance of researchers (1) doing research on the school/school district prior to reaching out about potential partnerships; (2) establishing relationships with school partners that are characterized by being present, trustworthiness, and respect as well as the prioritization of school partners' ideas over one's research agenda; (3) working collaboratively with school partners to conceptualize and fund school-driven ideas; (4) preparing for pushback, often from parents/caregivers; and (5) embracing reciprocity (i.e., do things to support your school partners that may not directly benefit you). Additional considerations for recruitment, enrollment, and retention; program implementation and data collection; and dissemination are discussed.

Development of an adolescent advisory group to inform sexual and reproductive health research for first- and second-generation immigrant adolescents in Canada: A community-based participatory action research study

BACKGROUND

Despite the growing evidence supporting the benefit of engaging adolescents in research, the active engagement of immigrant adolescents in research is limited. Further, when exploring the sexual and reproductive health (SRH) needs of immigrant adolescents, utilization of adolescent advisory groups is finite. This study aimed to train and evaluate engagement of an adolescent advisory group (AAG) to inform SRH needs of immigrant adolescents in Canada.

METHODS

Using purposive sampling, 13 AAG members were recruited into this study. Members were trained in content related to SRH needs of adolescents and various research methodologies such as conducting a scoping review and qualitative interviews with adolescent participants. After 10 months of member engagement, their experiences were evaluated to identify areas of success and areas for improvement. These data were collected using the Public and Patient Engagement Evaluation Tool, which consisted of a Likert survey and open-ended questions, and analyzed in accordance to the Patient Engagement in Research (PEIR) framework.

FINDINGS

Ten members completed the evaluation survey. Likert survey responses were primarily positive. Majority of members showed positive demonstrations regarding various components of the PEIR framework, including contributions, support, research environment, and feeling valued.

CONCLUSION

Findings illustrated that immigrant AAGs are constructive to informing SRH research. Not only can research teams benefit, but members are also empowered. This study provided the foundation for future immigrant adolescent engagement in research and knowledge translation, and effective means of evaluating engagement by utilizing the PEIR framework.

Photovoice and Instagram as Strategies for Youth Engagement in Disaster Risk Reduction

Community involvement is essential for an all-of-society approach to disaster risk reduction. This requires innovative consultation methods, particularly with youth and during pandemic restrictions. This article outlines methods used for a Photovoice project where we brought together student co-researchers from multiple levels (high school, undergraduate, and graduate health sciences) to explore the topic of youth engagement in disaster risk reduction. Over a two-year period, our team used Photovoice as an arts-based participatory method to collaborate with members of our EnRiCH Youth Research Team. We adapted the protocol to continue our project during the COVID-19 pandemic and presented our work in a Photovoice exhibition using Instagram. This article was written from the perspectives of high school and university students on the project. Our hybrid Photovoice protocol facilitated participation through the pandemic, including a virtual presentation at an international conference and online consultation with the Canadian Red Cross.

Concerted Model of Healthcare for Awá Indigenous of Nariño, Colombia

Indigenous communities in Colombia are facing a critical health situation; alternative health care models based on the vision of the communities themselves are needed. The objective of this research was to create a health care model that decreases health inequities for the Indigenous Awá population of Nariño, Colombia. This study was guided by the paradigm of community-based participatory action research; the process was carried out in 2015 and 2016. The proposed Intercultural Health Care Model is essentially based on health promotion, disease prevention, community empowerment, social participation in health, decentralized health care and coordination between the two medicines (traditional and allopathic). Strategies such as those reported herein, with concerted efforts rather than imposition, maintain human rights and respect for the sovereignty and autonomy of Indigenous people.

"We could see our real selves:" The COVID-19 syndemic and the transition to telehealth for a school-based prevention program for newcomer Latinx immigrant youth

Newcomer Latinx immigrant youths in the United States are currently in a syndemic of increased risk of behavioral health concerns, disparities in access to related services, and are disproportionately impacted by the COVID-19 pandemic. This study used qualitative inquiry to examine the impact that the transition to telehealth had on a school-based group prevention program for immigrant youth, Fuerte, within the context of this syndemic. Data included semi-structured interviews with group leaders, and focus groups with youth program participants. Themes indicated both positive and negative impacts of the transition to telehealth on program component implementation, youth participant engagement, and youth participant social connectedness. Despite the telehealth model, youth participants reported that they felt socially connected to each other through the program. This study's results provide implications for the potential value and drawbacks of a telehealth prevention model for newcomer immigrant youth, as well as deepening understanding of how virtual behavioral health programs may operate in socially isolating contexts around the world.

Barriers and Facilitators to Accessing Digital Health Tools Faced by South Asian Canadians in Surrey, British Columbia: Community-Based Participatory Action Exploration Using Photovoice

BACKGROUND

South Asian community members in Canada experience a higher burden of chronic disease than the general population. Digital health innovations provide a significant opportunity to address various health care challenges such as supporting patients in their disease self-management. However, South Asian community members are less likely to use digital tools for their health and face significant barriers in accessing them because of language or cultural factors.

OBJECTIVE

The aim of this study is to understand the barriers to and facilitators of digital health tool uptake experienced by South Asian community members residing in Canada.

METHODS

This study used a qualitative community-based participatory action research approach. Residents from Surrey, British Columbia, Canada, who spoke 1 of 4 South Asian languages (Hindi, Punjabi, Urdu, or Tamil) were invited to participate in focus group discussions. A subsample of the participants were invited to use photovoice methods in greater depth to explore the research topics.

RESULTS

A total of 197 participants consented to the focus group discussions, with 12 (6.1%) participating in the photovoice phase. The findings revealed several key obstacles (older age, lack of education, and poor digital health literacy) and facilitators (social support from family or community members and positive attitudes toward technology) to using digital health tools.

CONCLUSIONS

The results support the value of using a community-based participatory action research approach and photovoice methods to engage the South Asian community in Canada to better understand digital health competencies and needs. There were several important implications for policy makers and future research, such as continued engagement of community leaders by health care providers and administrators to learn about attitudes and preferences.

A review of current strategies to improve HIV prevention and treatment in sexual and gender minority Latinx (SGML) communities

INTRODUCTION

The HIV epidemic continues to disproportionately impact sexual and gender minority Latinxs (SGML). Several syndemic conditions have been linked with HIV acquisition and transmission among SGML including immigration, discrimination, environmental racism, substance use, and mental health.

AREAS COVERED

We provide a summary of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum among SGML. We also discuss intervention approaches and opportunities that respond at the intersection of HIV and COVID-19 prevention and treatment.

EXPERT OPINION

There is a dire need for the combination of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum. Interventions and combination approaches should be driven by community-based participatory action research. The inclusion of community members in all stages of the research process can assure successful implementation of program activities and deliverables, including the provision of culturally and linguistically appropriate services. Given the current COVID-19 pandemic, which is disproportionately impacting individuals living with HIV and other comorbidities, the elderly, and under-resourced communities with a ferocity not seen in other communities, intervention approaches that respond at the intersection of HIV and COVID-19 prevention and treatment are also urgently needed.

A scoping review of PhotoVoice for people with post-stroke aphasia

BACKGROUND

PhotoVoice is a qualitative research methodology designed to engage and empower marginalized members of a community and/or to understand community needs. PhotoVoice seems aphasia-friendly because it relies on personal photographs to convey opinions regarding prespecified topics. However, PhotoVoice is based on a procedure referred to as the SHOWeD method. Participants are asked to reflect upon their photos by discussing (1) what they See, (2) what is Happening, (3) the relation to Our life, (3) Why the issue or condition exists, and then to (4) explain what can be Done to address the issue(s) at hand. Due to the linguistic demand required to convey complex thoughts and ideas inherent in this methodology, adaptations are likely required to successfully implement with people who have aphasia.

AIMS

A scoping review was conducted to summarize the current literature regarding the use of PhotoVoice with people who have aphasia, to address two questions:(1) Are people with post-stroke aphasia included in PhotoVoice studies?(2) What, if any, modifications are required to address post-stroke aphasia and motor impairments?

MAIN CONTRIBUTION

This scoping review revealed that researchers often exclude people with aphasia from post-stroke PhotoVoice research. Three studies outlined adaptations that allowed successful implementation with people who have post-stroke aphasia.

CONCLUSIONS

Further inquiry regarding how best to adapt PhotoVoice for people with aphasia will facilitate their ability to be included in community-based research. This is an important step in ensuring that all post-stroke stakeholders are involved in projects related to social justice and policy for stroke survivors.

Cultural Connectedness as Obesity Prevention: Indigenous Youth Perspectives on Feast for the Future

OBJECTIVE

To describe a community-based obesity-prevention initiative that promoted cultural connectedness and traditional food revitalization and gained insight into youth participants' perspectives on the program through a photovoice methodology.

METHODS

Photovoice methods were used with fourth- and fifth-grade youths (aged 9-11 years) in the US Southwest who had participated in the Feast for the Future program. A total of 44 youths from 3 communities met for 8-9 sessions; they took photos of current food environments and traditional food systems, and discussed them as well as Feast for the Future and hopes for the future, and then prepared a final presentation. Photovoice sessions were recorded, transcribed verbatim, then open coded using Atlas.ti.

RESULTS

Five common themes emerged: traditional food is farmed or gardened, traditional foods are healthy, Feast for the Future supported positive connections to culture, hope for more farming or gardening for future generations, and store or less nutrient-dense food is unhealthy.

CONCLUSIONS AND IMPLICATIONS

Photovoice can be an effective way to engage Indigenous youths in conversations about their culture and food environments. The findings suggest that attention to revitalizing traditional food systems and supporting cultural connectedness may be an effective approach to obesity prevention in tribal communities, although future research would be needed to assess the impact of the intervention on obesity rates.

Nurturing Meaningful Intergenerational Social Engagements to Support Healthy Brain Aging for Anishinaabe Older Adults

The emergence of Alzheimer's disease and related dementias (ADRD) in Indigenous populations across Canada is of rising concern, as prevalence rates continue to exceed those of non-Indigenous populations. The Intergenerativity Model, guided by Indigenous Ways of Knowing, nurtures a psychosocial approach to promoting healthy brain aging and quality of life. Community-based participatory action methods led by interviews, focus groups, and program observations aid in identifying the barriers to and facilitators of success for intergenerational social engagements in the Anishinaabe community of Wiikwemkoong in northwestern Ontario. A qualitative thematic analysis guides future recommendations for programming opportunities that foster traditional roles of older First Nation adults and support intergenerational relationships. The results of this project elicit culturally appropriate recommendations for community-driven supports that address healthy brain aging. These outcomes are relevant to other Indigenous communities as the framework for determining that culturally appropriate health supports can be adapted to the unique context of many communities.

A Community-Based Participatory Action Research for Roma Health Justice in a Deprived District in Spain

Addressing health disparities and promoting health equity for Roma has been a challenge. The Roma are the largest disadvantaged ethnic minority population in Europe and have been the victims of deep social and economic injustices, institutional discrimination, and structural antigypsyism over many centuries. This has resulted in a much worse health status than their non-Roma counterparts. Current strategies based on ameliorative and top-down approaches to service delivery have resulted in paradoxical effects that solidify health disparities, since they do not effectively address the problems of vulnerable Roma groups. Following a health justice approach, we present a community-based participatory action research case study generated by a community and university partnership intended to address power imbalances and build collaboration among local stakeholders. This case study involved a group of health providers, Roma residents, researchers, Roma community organizations, and other stakeholders in the Poligono Sur, a neighborhood of Seville, Spain. The case study comprises four phases: (1) identifying Roma health assets, (2) empowering Roma community through sociopolitical awareness, (3) promoting alliances between Roma and community resources/institutions, and (4) building a common agenda for promoting Roma health justice. We highlighted best practices for developing processes to influence Roma health equity in local health policy agendas.

Reflecting on Leadership Development through Community Based Participatory Action Research

The need for leadership in nursing is well-documented and Domain Six of the doctoral section of the National Nursing Education Framework of the Canadian Association of Schools of Nursing (CASN) is Leadership. While there are likely many paths to achievement of these leadership components, the intent of this paper is to share my journey through iteration of and reflection on my PhD dissertation research focused on a four-cycle community-based participatory action research study (CBPR) related to clinical teaching in Ghana. The focus of CBPR is to engage the researcher and the participant group (community) in collaborative, and egalitarian processes to assess and problem solve an issue in the community. Similarly, leadership promotes collaborative interpersonal relationships among leaders and followers to address issues and institutes change strategies in policies. This paper presents my experiences in building leadership capacity through this scholarly endeavor (PhD thesis) in relation to the CASN guideline.

Healing the Past by Nurturing the Future-co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study

INTRODUCTION

Child maltreatment and other traumatic events can have serious long-term physical, social and emotional effects, including a cluster of distress symptoms recognised as 'complex trauma'. Aboriginal and Torres Strait Islander (Aboriginal) people are also affected by legacies of historical trauma and loss. Trauma responses may be triggered during the transition to parenting in the perinatal period. Conversely, becoming a parent offers a unique life-course opportunity for healing and prevention of intergenerational transmission of trauma. This paper outlines a conceptual framework and protocol for an Aboriginal-led, community-based participatory action research (action research) project which aims to co-design safe, acceptable and feasible perinatal awareness, recognition, assessment and support strategies for Aboriginal parents experiencing complex trauma.

METHODS AND ANALYSIS

This formative research project is being conducted in three Australian jurisdictions (Northern Territory, South Australia and Victoria) with key stakeholders from all national jurisdictions. Four action research cycles incorporate mixed methods research activities including evidence reviews, parent and service provider discussion groups, development and psychometric evaluation of a recognition and assessment process and drafting proposals for pilot, implementation and evaluation. Reflection and planning stages of four action research cycles will be undertaken in four key stakeholder workshops aligned with the first four Intervention Mapping steps to prepare programme plans.

ETHICS AND DISSEMINATION

Ethics and dissemination protocols are consistent with the National Health and Medical Research Council Indigenous Research Excellence criteria of engagement, benefit, transferability and capacity-building. A conceptual framework has been developed to promote the application of core values of safety, trustworthiness, empowerment, collaboration, culture, holism, compassion and reciprocity. These include related principles and accompanying reflective questions to guide research decisions.

Implementing evidence-based patient and family education on oral anticoagulation therapy: a community-based participatory project

AIMS AND OBJECTIVES

This study aimed at developing and implementing evidence-based patient and family education on oral anticoagulation therapy.

BACKGROUND

The number of persons with chronic diseases who live at home is increasing. They have to manage multiple diseases and complex treatments. One such treatment is oral anticoagulation therapy, a high risk variable dose medication. Adherence to oral anticoagulation therapy is jeopardised by limited information about the medications, their risk and complications, the impact of individual daily routine and the limited inclusion of family members in education. Hence, improved and tailored education is essential for patients and families to manage oral anticoagulation therapy at home.

DESIGN AND METHODS

A community-based participatory research design combined with the Precede-Proceed model was used including a systematic literature review, posteducation analysis, an online nurse survey, a documentation analysis and patient/family interviews. The study was conducted between April 2010-December 2012 at a department of general internal medicine in a teaching hospital in Switzerland. Participants were the department's nursing and medical professionals including the patients and their families.

RESULTS

The evidence-based patient and family education on oral anticoagulation therapy emerged comprising a learning assessment, teaching units, clarification of responsibilities of nurse professionals and documentation guidelines.

CONCLUSION AND CLINICAL RELEVANCE

The inclusion of the whole department has contributed to the development and implementation of this evidence-based patient family education on oral anticoagulation therapy, which encompasses local characteristics and patient preferences. This education is now being used throughout the department.

"Another day in paradise": a photovoice journey of rural older adults living with diabetes

This article provides the results of a photovoice project conducted with older adults affected by diabetes living in three rural counties in the southern region of the United States. Photovoice is a community-based participatory action methodology that puts the tools of research in the hands of participants. This project was an initial community engagement activity that promoted trust-building and formed part of a larger comprehensive community needs assessment. The process revealed themes of personal and community resilience focused on the daily living with diabetes, formal and informal supports, barriers to taking care of their diabetes, accessibility to fruits and vegetables, changes to food preparation and consumption, and exercise supports and barriers. The impact of the photovoice project on the participants and the implications for practice are discussed.