Community-based Participatory Qualitative Inquiry Processes to Enhance Understanding of Acculturative Stress in Community Health Assessment

To understand complex health issues which influence immigrant communities, there is a great need to place health in context1. Community-driven, qualitative inquiry is well suited to provide insight on context in community health assessment2. Traditional, quantitative approaches to community health assessment alone, are often ill equipped to examine root causes and community-understood perspectives on health. Achieving an emic understanding, not typically available to traditional researchers, could lead to more effective and relevant public health activities in communities. Though qualitative research methods have a history in healthcare settings, they remain underutilized for community health assessment3. Using the author’s lens as a research assistant, research partner, data collector, community disseminator and student of public health, the purpose of this effort is to use one component of our findings to demonstrate the role that participatory qualitative inquiry can play to improve understanding of complex, contextual factors in a local community health assessment effort, Little Village Community Health Assessment (LV CHA).    

Participatory Qualitative Inquiry is a valuable tool for community health assessment because it:

•  encourages and enables stakeholder involvement11 •  is a structured opportunity for community voice on health •  promotes mutuality between academics and community •  facilitates new partnerships10 between non-profit organizations and the

community, independent of the university involvement •  Respects and acknowledges diverse perspectives •  Allows for academic and community stakeholders to discover new

ways to do their jobs

Community voice as data in Community Health Assessment may enhance understanding of health in critical ways.

Conclusion

This framework provides a unique socio-political framework contextualized in the community. The overarching community health assessment has been framed using a community-based participatory research (CBPR) approach, relying on both Quantitative and qualitative data for theory and methodological triangulation for the analysis of findings5. The iterative qualitative data analysis process used a phenomenological lens and grounded theory approach, and employed the DEPICT Model4 for participatory data analysis (Figure 1). Figure 4: Evolution of Methods & Health Priority Topic Areas

.

Collaborative Methods & Research Processes

Background

Introduction

Acknowledgements

LV CHA uses mixed methods, heavily reliant on participatory qualitative inquiry to explore community health as it is experienced within a Chicago neighborhood, Little Village (South Lawndale). This assessment uses the author’s field notes, meeting notes, evaluation report, local dissemination opportunities, academic literature on participatory research etc. to describe how this process is an essential tool for CHA. Participatory Qualitative Inquiry4 is an umbrella term which includes: •  Participatory data analysis •  Community feedback •  Inter-rater reliability   This assessment is “community-driven” at every stage of the process5. •  Community members have been viewed as experts •  Designed with feedback from community partners •  Interview participants, incentives and locations were identified by community partners •  Preliminary data presented at locations identified by both community and academic partners •  Open invitation for community members at all meetings and events

Implications

Community driven, participatory qualitative inquiry contributes to culture shift towards better health by:

•  Involving non-traditional entities to participate in a core function of public health •  Promoting authentic and meaningful relationships between academic and community partners •  Placing stakeholders at the center of assessment activities •  Challenging traditional data collection methods and activities to respect and

honor local needs •  Achieving greater ecological validity

Nuanced Findings: Acculturative Stress & Unique Outputs

Across all Individual Interviews, Focus Groups, and Oral Histories stress and acculturation were identified as paramount health concerns in Little Village. Primary sources of stress included parenting, migration, occupation and cumulative daily fear. Cultural stigma against talking about mental health as well as a lack of behavioral health services were identified as barriers to care seeking, as well as differing intergenerational opinions of health priorities. Stress and acculturation issues in the community are compounded by daily exposure to daily cumulative economic and social stressors. Barriers to healthy coping strategies8 (physical activity, healthy eating) emerged throughout the data, most often because of daily hassles8 related to lack of time due to caring for others, lack of safe space (or resources) for exercise as well as sociocultural norms that make certain health behaviors more difficult or stressful. These findings are consistent with much of the literature on behavioral wellness in Latino communities, and have been historically demonstrated through the use of quantitative scales including the Hispanic Stress Inventory9. Community strengths, which can moderate or exacerbate stress, were also heard from all participants, including the community’s strong work ethic, sense of “familisimo,” and deep commitment to community.

Parenting

●  Raising and providing for children ●  Parental involvement and childcare (too

much or not enough) ●  Concern for involvement in gangs ●  Differing generational and acculturative

social norms (“man up”, “chin up”) ●  Familisimo

Migration/Occupation

●  Documentation status ●  Separation from Family/Social network ●  Engagement in low-wage and high-risk work ●  Oppressive work environments ●  Documentation Privilege ●  Strong work ethic

Cumulative Daily Fear ●  The unknown (especially for those who

recently immigrated) ●  Interpersonal violence ●  The ‘system” ●  Being out at night ●  Presence of abandoned buildings, litter

Participatory Data Analysis and Codebook Development

This community-based health assessment evolved from being equitably mixed methods assessment to primarily focusing on qualitative processes, namely through oral histories. The transformative framework of the data collection and analysis process allowed for health priority topics naturally emerge and build from each “level” of the reserach7 .(Figure 4).

Consistent contact with community stakeholders through community partner meetings, “Think Tanks”, health fairs and community ‘Platicas’ and other community events provided opportunities for authentic relationship building and member checking to inform what we were learning from the data.

Jessie Schwiesow Community Health Sciences Division

Dynamic Reading

-Primary documents collated and assigned to members of “Think Tank” team, which included both community and academic partners -Microsoft Word used for initial cleaning and memoing of primary documents -Primary Question: “What ideas seem to important in these texts?”

Engaged Codebook Development

-Bi-monthly “Think Tank” meetings facilitated at UIC and in LV -Important emerging concepts discussed and debated among team -Codes definitions and criteria result from continued discussion -Primary questions: “What is our agreed upon list of categories and sub-categories that we will use for codebook? “Do we have the right categories?” “Do we understand what they mean and how to apply them?”

Participatory Coding

-Transcripts are assigned and distributed amongst “Think Tank” team members -Each transcript was reviewed and coded using ATLAS.ti software -Primary Question: “Which sections of the transcript fit into which categories for our emerging codebook?”

Inclusive Reviewing and

Summarizing of Categories

-Codebook evolves to include example quotes, inclusion and exclusion criteria (Figure 2) -Team members discuss and debate code definitions and criteria -Criteria used to subsequently re-organize emerging codebook -Primary Questions: “What are the main ideas?” “Where is there disagreement?” “What are some key quotes?”

Collaborative Analyzing

-Evolutionary “Final” codebook distributed to team members prior to “Think Tank” meetings -Code families of primary emergent themes organized in network views using ATLAS.ti software (Figure 3) -Findings discussed amongst team members to ensure shared understanding and agreement Primary Questions: “What does it all mean? “Where are our most important findings?” “What questions do we still have?”

Translating

-’Major emerging themes’ document distributed to Think Tank members -Codebook and Major Themes document shared at bi-monthly community partner meetings, in addition to Think Tank -Findings presented at community partner-identified spaces Primary Questions: “Who are the best messengers?” “How do we get the word out?”

The participatory qualitative data analysis process (Figure 1) was characterized by ample opportunity for community feedback and dialogue. This structure falls in line with CDC recommendations for increased community engagement in public health activities6.

Figure 2: Excerpt from Codebook Figure 3: Mental Health Network View from ATLAS.ti

8. Carr, D. & Umberson, D. (2013). The social psychology of stress, health, and coping. In J. DeLatamer, J & A. Ward (Eds.), Handbook of Social Psychology (12, (2)p. 465-487). Springer. 9. Cervantes, R.C., Padilla, A.M., Salgado de Snyder, N. (1990). Reliability and validity of the Hispanic stress inventory. Hispanic journal of behavioral science. 12. p. 76-84. 1. Chang, C., Salvatore, A.L., Tau Lee, P., San Liu, S., Tom, A.T., Morales, A., Baker, R., Minkler, M. (2013). Adapting to context in community-based participatory research: “participatory starting points” in a Chinese immigrant worker community. American Journal of Community Psychology (51, p. 480-491). 7. Creswell, J.W. (2013). Qualitative inquiry & research design: choosing among five approaches. 1 (3). Sage. 4. Flicker, S. & Nixon, S.A. (2013). The depict model for participatory qualitative data analysis. Health Promotion International. 6. Guion, L.A., Diehl, D.C., & McDonald, D. (2011). Triangulation: establishing the validity of qualitative studies. University of Florida, IFAS Extension Series (p. 1-3). 10. Israel, B.A., Schulz, A.J., Parker, E.A., Becker, A.B. (1998). A review of community-based research: assessing partnership approaches to improve public health. Annual review of public health. 19, 173-202. 2. Lincoln, Y.S. (1995). Emerging criteria for quality in qualitative interpretive research. Qualitative Inquiry, 1 (3), p. 275-289. 5. Minkler, M. (2005). Community Based Research Partnerships: Challenges and Opportunities. Journal of Urban Health. (82, (2), p. ii3-ii12) 3. Morse, J.M. (2011). What is qualitative health research?. In N.K Denzin & Y.S. Lincoln (Eds.), The Sage Handbook of Qualitative Research (4, (1), p. 401-414). Los Angeles, CA: Sage. 11. Wallerstein, N., Duran, B. (2010). Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. American Journal of Public Health. 100 (S1), p. S40-S46.

Level 3: Community Assets (Spring 2014-present)

Oral Histories: 19, ~20-60 minutes Who: Community Residents- 5 couples, 10 in Spanish

Focused on: Community Assets

Level 2: Community Assets, Occupation, Immigration & Mental Health (Fall 2013)

Focus Groups: 4, ~60 minutes Who: Community residents, 2 in Spanish

Focused on: Occupation (2), Immigration (2)

Oral Histories: 8, ~60 minutes Who: Community residents

Focused on: Assets in the Community

Level 1: Chicago Department of Public Health Priorities (Spring 2013)

Individual Interviews: 12, ~60 minutes Who: Community residents, Nonprofit

program admins., community organizers

Focus Groups: 6, ~90 minutes Who: 3 youth, 2 older adult women, 1 adult

men, 3 in Spanish

Evolution of Methods & Health Priority Area

Figure 1: LV CHA Data Analysis Process adapted from the DEPICT model for qualitative data analysis4

Focus Groups, Individual Interviews and story-sharing can be a transformative process for interviewees, stimulating conversation and promoting community dialogue on health.

Citations

Community Partners: Dolores & Yvette Castaneda; Enlace Chicago, Simone Alexander; Erie Neighborhood House, Evelyn Rodriguez and Sandy De Leon; Esperanza Health Center, David Moreno, Gregory Hampton; Hope Response Coalition, Erica Rangel; Latinos Progressando, Luis Guiterrez, Marshall Square Resource Network, Telpochcalli, Maria Velasquez; Roots to Wellness, Kevin Rak; Taller de Jose, Sr. Kathy Brazda, Kerry McGuire, Anna Mayer Faculty Partners: University of Illinois Chicago, School of Public Health: Epidemiology and Biostatistics: Vicky Persky, MD; Community Health Sciences: Noel Chavez, PhD, RD, LDN; Jennifer Felner, MPH; Jennifer Hebert-Beirne, PHD, MPH; Joan Kennelly, PhD, MPH; EOHS: Linda Forst, MD, MPH; School of Nursing: Kamal Eldeirawi, PhD University of Miami School of Education, Dina Birman, PhD Lead Graduate Students: Brian Bamberger, Emily Bray, Laura Campbell, Ana Genkova, Sylvia Gonzales, Sarah Hernandez, Marissa Hoover, Melissa Martin, Regina Meza Jimenez, Rebecca Rapport, Rachel Reichlin