Integration of Creative Expression into Community Based Participatory Research and Health Promotion with Native Americans

Abstract

Involvement in creative expression has the potential of engaging individuals in personal and community level change through reflection, empowerment, and the facilitation of connectedness. It is a process that can be a powerful component of community based participatory research as it can facilitate and support the principles of co-learning, egalitarian relationships, and respect for non-academic knowledge. It is also a valuable means of appreciating culture and strengthening identity, which enhances health. This article reviews and discusses methods and benefits of incorporating creative expression into health promotion programs and community based participatory research with Native Americans.

Community based participatory methods have demonstrated potential to benefit communities faced with health disparities.¹ By being fully involved in developing and implementing health promotion programs, communities create culturally relevant and potentially sustainable methods of enhancing community health. Native American nations, and ethnic and racial groups that have been exploited as subjects of academic research, are rightfully insisting on a different approach to research in their communities.^2-4 The guiding principles of community based participatory research (CBPR) include the importance of developing a co-learning process that brings community members and researchers together to empower community participants to increase control and ownership over their lives and their health.^5-7 Thus, this approach can be responsive to community needs and highlight resilience and positive growth, rather than focusing on negative characteristics and problems.

CBPR sets the stage for academic acceptance of non-traditional means of engaging communities that may not be receptive to highly verbal scientific and/or academic techniques of data gathering and program implementation and evaluation. Frequently these procedures are alienating and distance participants from their personal experience and potential sources of self-understanding and change. This detachment may facilitate disinterest in the process and lead to difficulties with collaboration, recruitment and retention in programs and research projects. Through the use of creative expression activities, it is possible to enhance the interpersonal quality of the collaboration and provide respect for methods of self-expression that are traditionally used in the community. Community, by traditional Native standards, is not necessarily synonymous with location, but rather a relationship with place. Thus, culture is about honoring relationships that thread connectedness to all aspects of the lived experience. By engaging in traditional/cultural creative and artistic activities together, the academics/researchers and community members learn to share their knowledge and perceptions in a mutually respectful manner through relationship building. The atmosphere of delight in learning and understanding each other that can occur in this process opens the door to meaningful knowledge that is useful and culturally relevant to the community.

All cultural and ethnic groups have histories of creative and artistic expression. Traditions have been passed down through the generations that include methods of communicating belongingness, creating group cohesion, and maintaining community identity. Oral traditions, such as storytelling, and traditional crafts, such as mask making, painting and other visual arts, are examples of methods of connecting with the past and maintaining cultural congruity and positive group identity. Engaging in these activities also promotes resilience in the face of adversity. Bien⁸ discusses how creative expression is a means of dealing with the ongoing trauma in Native American communities that has resulted in a “loss of soul or spirit” for some. It can awaken the innate desire for balance and provides the means for restoring personal equilibrium.⁸ The writer Leslie Marmon Silko highlights the relationship of creative expression with personal change, “The way you change human beings and human behavior is through a change in consciousness and that can be effected only through literature, music, poetry—the arts.” ^9(p14)

Incorporating Native traditions of storytelling and artistic expression into research methods and community interventions is a means of focusing on the importance of traditional modes of connectedness or culture. Doing so may boost the impact of health promotion programs because identification with one's culture and enculturation have been associated with resilience and health.^10-12

Traditional storytelling among Native Americans is an enduring practice that has health promoting qualities. Stories communicate societal values and practices of a people's collective wisdom in an engaging and entertaining manner.^13,14 Stories and other types of artistic expression may create a metaphoric transformation that can lead to behavior change by providing a means to reflect on individual experience within a larger, relational context.⁸ They may create receptiveness to change because they are presented in an indirect manner that reinforces established values and beliefs. Listeners are able to interpret meaning through their own experiences and make decisions about their behavior.^14,15 Creative expression and storytelling establish a non-threatening environment where people can develop a sense of belonging, reflect on personal experience, and reconnect with tribal traditions. This personal empowerment may lead to changes in community norms that reaffirm the traditional values and beliefs that have maintained survival and resilience.

The method of “photovoice” is a means of telling personal and community stories through photographs. In health promotion program development, it is especially useful as a method of needs assessment that easily incorporates the CBPR process. Photovoice is a method that was introduced by Caroline Wang^16-18 and has been used to empower communities and work toward positive change. Use of photovoice with CBPR principles provides a gateway to engaging communities through the opportunity to reflect on cultural norms and social influences.¹⁹ Castleden et al.² note that there was only one report²⁰ of the use of photovoice with an indigenous community prior to their study in which they modified the technique for a CBPR project they were conducting with a First Nation in Canada. The process was modified to include a continuous participant-community feedback loop that allowed for on-going change related to the learning that occurred. They found that the modified photovoice process they used was culturally relevant, fostered trust between researchers and community members, and created a sense of ownership regarding the information they gathered.² All of these factors are essential to decrease the power differential between communities and researchers.

Community arts events have also been used as a CBPR method. Chung et al.²¹ collected survey data at art events in an African American community in South Los Angeles to assess collective efficacy in relation to depression care. They used photography exhibits, group discussions, poetry and story reading, and comedy performances as catalysts for responses that were obtained through a survey. Gray, Wolf and Ore de Boehm²² used a similar process when conducting a CBPR project with a southwest Native American tribe. As part of a community needs assessment, five hours of community activities were conducted in a revolving workshop format in one afternoon. Options of participating in traditional and contemporary artistic activities were provided to youth and adults. The project's community advisory board members determined what workshops would be offered to give inspiration and voice to thoughts about community health concerns. Traditional arts such as painting, drawing, craftwork, and storytelling about traditional healing methods were the topics of the workshops. A poetry-writing workshop included mixing poems with music and recording and/or videotaping the final production. The creative work was collected, reviewed, and interpreted by the community advisory board and became a source of determining community needs and potential solutions to common concerns.

An additional source for creating a picture of health and wellbeing in the community was through digital storytelling and video interviews.²² The community advisory board members were trained to use video cameras, and they interviewed people they thought could best share their experiences and contribute to the project. Some board members participated in digital storytelling training and created short digital stories about their lives, their experiences with health problems, and their road to wellness. This sharing of personal and community narrative had a healing effect for the board members and also provided important information for the community needs assessment.

Another method of using creative expression in the needs assessment process took place at a community Native American wellness event.²³ Participants were invited to create a “wellness tree” that illustrated the factors related to being healthy and unhealthy. Individuals or family groups were provided with a poster size paper with a drawing of a tree trunk and they were asked to write on the provided “leaves” different ways we are healthy and unhealthy. They then pasted the leaves on the tree with one side representing the positive aspects of health and the opposite side representing the negative aspects of health. After the event, the project's community advisory board summarized and categorized the health issues from the wellness tree activity and the information was incorporated into the final community needs assessment.

Bringing community members together to engage in art activities is an element of the cultural development movement that is more common in Europe than in the United States. Great Britain has numerous community arts projects and their Arts Council reported on the positive impact that involvement in art has on health, academic achievement and preventing involvement in the justice system.²⁴ Johnson and Stanley²⁵ also discussed the beneficial results of an evaluation of a community arts project in Australia. The Rockefeller Foundation has funded several community cultural development projects in the United States.²⁶ These projects are based on key principles that include a focus on diversity as a social asset and culture as a source of social connection and transformation. The process of cultural expression is more important than an end product it produces and artists are viewed as having an important and legitimate social role in transforming communities.²⁷ Social justice and inclusion are highlighted in community dance, theatre, music and art projects that facilitate cultural creativity and social action. Other cultural development projects have focused on recording oral histories of individuals and communities and emphasize the importance of intergenerational transmission of cultural history and traditional stories.²⁸ Hamilton, Hinks, and Petticrew²⁹ discussed how these types of projects can potentially change human lives, and they emphasized the need to adequately evaluate these programs and substantiate the connections between art involvement and health. In a review of HIV/AIDS performing arts prevention programs, Glik et al.³⁰ highlight the significant elements for success of performing arts programs and discuss how they can be evaluated through the use of formative, process, and summative methods.

Digital storytelling is a process of creative self-expression with a number of potential benefits.³¹ By telling personal stories, writing a script, and collecting photos to illustrate the story, individuals are able to explore how their identities have developed and are shaped by social forces. Through this potentially emotional process, they may feel empowered to change their lives and to challenge social conditions that have led to marginalization and oppression. By reflecting on one's social and cultural history, a sense of belonging is created that may build community and connection with others.³² The mental health benefits of telling one's personal story are described in Wyatt and Hauenstein's review³³ of digital storytelling. They emphasize the importance of its use in promoting health and self-efficacy.³³

Indigenous groups are now seeing the benefits of digital storytelling as a means of using digital technology to promote personal and communal health and increase advocacy and awareness of significant social, political, and health issues. The Center for Native Digital Storytelling was recently founded by Brenda Manuelito in Seattle, Washington (Oral Communication, March 2009). The center provides three-day intensive workshops for participants to learn how to create digital stories. This approach is viewed not only as a way to document important historical and personal events, but a means of enhancing cultural identity and healing. It promotes individual and community health through personal involvement in the development of health messages that are culturally relevant to Native Americans. With a focus on digital video and internet access, Hopkins³⁴ explained how engaging in digital storytelling may have an impact on Native people because it has the potential to change indigenous representations and establish new and democratic methods of expressing lived experience and creating community.

There are few publications regarding projects that have used video creation as a method to promote health or assess community needs. Although health promotion videos and health related video games have been used to educate individuals, especially youth, about healthy behavior and self-care, studies related to the use of video production as a prevention methodology are rare. The benefits of being an active learner in this creative process have been discussed³⁵ and the potential for empowerment, self-efficacy and gaining a sense of control over one's life is similar to other creative expression methods.^30,36-39

Some indigenous groups have engaged youth and/or adults in the process of video production in an effort to give voice to community concerns and provide a source of empowerment and advocacy. The Chiapas Media Project⁴⁰ provides video and computer equipment and training to indigenous communities in Chiapas and Guerrero, Mexico. They have produced films regarding identity and indigenous rights and offer them for sell on their website. Another excellent example of democratizing media production and using it as a means of community and individual empowerment is the collaborative work of Samia Goodie⁴¹ with indigenous Australian groups. They have used video creation as a means of empowerment and expression of identity and they are assessing the impact of engaging in this process on the health and well being of indigenous Australians.

There is an inherent connection between media making and CBPR principles⁴² that make video production a particularly beneficial method to use in community research and prevention interventions. It facilitates a group process that can incorporate personal and social change with behavioral skill development and community connectedness. Some studies provide evidence that this method may be effective in prevention interventions. In their description of a six-week summer program for urban children that included video production, Knight Lynn et al.⁴³ found that participants increased in learning and development of friendships across cultures. Ager, Parquet, and Kreutzinger⁴⁴ conducted a video production substance abuse prevention intervention with a group of ten urban African American youth and concluded that video production was an innovative method of facilitating a prevention program. They emphasize the benefits of including community involvement in the intervention process in order to extend the impact beyond the group creating the videos. Gray et al.^45,46 have conducted CBPR health promotion projects that have incorporated components of creative expression and youth video production into the intervention methodologies. Native American community members, youth peer educators, and staff members who have collaborated in the development and implementation of these projects have observed educational and health benefits for the Native American youth who have participated. Including video production and health message creation as part of a youth intervention enhances recruitment and retention in prevention programs and preliminary data suggest benefits to self-esteem and symptoms of depression.⁴⁵ In addition, these projects^45,46 have always included presentations of the youth created videos to the communities where the youth live. Sharing their work with family members, friends and other community members has disseminated their views of crucial issues facing Native American youth today. By showing their videos that contain health messages, they have contributed to a health promotion process that may have an impact in their communities.

Conclusion

Creative expression is a powerful component of health promotion that may enhance the process of CBPR by actively involving participants in considering community concerns and potential solutions. It facilitates the incorporation of traditions and culture into prevention methods and enhances positive self and community identity by providing a voice of strength and possibility. It also offers the opportunity to raise community awareness regarding the social determinants of health and practice behavioral skills that may increase resilience and coping. The use of creative expression has tremendous potential as a means of reducing health disparities among Native Americans and further research is needed to substantiate these benefits.