Refereed Essay:

Nimmon_Manifestation_Volume1_Number1_November_2008.pdf

Laura Nimmon

Contact Information

Laura Nimmon, University of British Columbia, Vancouver, British Columbia, Canada

http://www.photonovel.ca, laura@photonovel.ca

A project of participation: creating a sustainable community partnership that builds ESL-speaking immigrant women’s health literacy status

Introduction

Community-based research is defined as a research process that involves collaborative relationships between researchers and community members (Harris, 2006).  Although there has reportedly been an increased interest in the concept of community-based research, there has not been a lot of research conducted and disseminated on how this type of research occurs in practice in peer-reviewed journals (Buysse, Sparkman, Wesley, 2003).  This project review will describe a successful community based research project conducted at an immigrant society in Victoria, BC that ultimately facilitated in ESL-speaking immigrant women to learn about health, while simultaneously raising their consciousness.  Guided by the principles of respect, flexibility and empowerment this community-based participatory research project received national recognition through wining a Population and Public Health Masters Research Award (2006).

Conceptual Framework: Health Literacy

The conceptual framework for my study lies under the rubric of health literacy, which has recently emerged as a specific form of situated literacy.  Health literacy is the capacity to obtain, interpret and understand basic health information and health services needed for informed health decision-making (Ratzan & Parker, 2000).  Many ESL-speaking immigrants, especially women, face obstacles obtaining health information because it is incomprehensible to them (Wilson, 2003, CIHI, 2004).  In particular, immigrant women struggle to understand health information because they have lower literacy rates on average than immigrant men (Boyd, 1991) and they also have significantly lower literacy levels than the Canadian born population (Statistics Canada, 2005).  Of the many approaches targeted at educating ESL speakers about health, I proposed that user created photonovels could be an effective way to have immigrant ESL-speaking women think and learn about health (Rudd & Comings, 1996; Wang & Burris 1994; James, et al., 2005).  Photonovels are formulated like comic books, but contain photographic stills and balloon captioned text.

Access

This study took place at the Inter-Cultural Association (ICA) of Greater Victoria.  The ICA is a non-profit organization that assists newcomers to settle in the area and facilitate in their inclusion and full participation in society.  The ICA’s mandate is to encourage sensitivity, appreciation, and respect for individuals of all cultures.

I approached the ICA in the spring of 2005 and explained my concept for the project.  The initial meeting was with the two directors, Mark and Pedro, and the women’s group facilitator, Alexis (all names are pseudonyms*).  The directors and women’s group facilitator told me that they had tried several ways to teach immigrant women about health, but nothing seemed to resonate with the women and there was, in general, a lack of understanding about health information.  Thus, they were very open to the photonovel idea and predicted that the concept “would spread like wild fire” in immigrant organizations in BC.  In this context, there was a parallel between the academic research and the needs of the community based partners and participants.  Had there been a discrepancy, however, I would have respected the expertise of people working daily with immigrant women and worked in tandem with them to come up with creative solutions towards improving the health literacy of immigrant women.

I had a few meetings before the project started in September with the directors and the women’s group leader to fine-tune the details of the project.  During this time, Mark and Pedro wrote a support letter for the funding I was applying for (which I later received) through BC TEAL’s (Teachers of English as an Additional Language) AIDS and Health Education Grant.  When writing the grant, we dialogued about the budget and where the money was to be allocated.  I was asked if I could top up the salary of Alexis because she would be attending all of my sessions and helping me recruit the women.  I agreed, as I was aware that grass-roots organizations often lack resources and funding and, also, because I was grateful that the ICA was sharing their space and resources with me.  Through respectful and open dialogue, my relationship with the ICA staff was enriched.

Alexis helped me recruit the participants for this study by going into classrooms at the ICA with me and inviting women to participate in the project.  Alexis then suggested to me that I hold the meetings for my study independently of the women’s group because she felt that there was not enough time available for me to come in and do my study.  Thus, I respected her concern, and as a result this study involved the women who attended the ICA’s women’s group, but was held independently of it.  I was also notified the women should be able to bring their small children to the meetings because I was told that childcare responsibilities could be a barrier to their attendance.  Initially, I did not anticipate that children would be attending the meetings, so I had to be flexible and align my project to the needs of the community.  I, thus, provided activities for children to do in the same room, like colouring, while their mothers were creating the photonovel.  Actually, having the children present brought a sense of joy and liveliness to the project that helped fuel creativity and build community amongst the participants.

The Participants

The core group was composed of five women ranging from the ages of 35-80 years old.  Their time in Canada ranged from 10 months to 35 years.  All of the women spoke English as a second language, and their degree of fluency in English ranged from about a low-intermediate to high-intermediate level of English.  Three women were landed immigrants; the other two didn’t have immigrant status yet.  Two women were divorced from abusive relationships, two were married, and one was single.  Three women had a university education, and the other two had gone to high school.  Finally, two women were currently working in insecure jobs, one woman was at home with her child, and the other two women were at retirement age and, thus, not working.

Project Design

In the preliminary session, the women collaboratively defined nutrition as the most pressing health concern upon migrating to Canada.  In this session, I also conducted a focus group and individual interviews to learn more about the women’s health experiences, where there was a lot of talk about how the nutrition in Canada had affected the women’s health negatively. I then invited a Registered Public Health Nurse to inform and educate the women about nutrition from a Canadian health practitioner’s perspective.

In the next two sessions, the women wrote the story line, developed characters, then acted and photographed each other to create a photonovel using their own cultural health perspectives and the strategies given by the nurse.  My role in this whole process was to act as a facilitator in the creation of the photonovel, but ultimately it was the participants who created the health related photonovels.  In the final session, I hired a graduate student to help the women compile the photonovel onto a computer program by putting bubble captions on the photos.  Our final session involved a final focus group and final individual interviews.  We then had a potluck where we shared food and exchanged emails and Christmas cards.  The women also had a chance in this final meeting to review the photonovel From Junk Food to Health Eating: Tanya’s Journey to a Better Life  (www.photonovel.ca) and make any changes that they wanted to before it was printed in multiple copies to be disseminated.

Acknowledging My Role

Countless researchers have discussed the power dynamic between researcher and participant about appropriate distance taken by the researcher from the participant.  Essentially, I believe, that my data was richer because I had built a relationship with the women and came to understand them in a more meaningful way than if I were merely at a distance.  I would like to acknowledge, however, that although my aim was to avoid power imbalances within the research process, it was not always so.

At one point in our final interview, one participant noted that I [italics added] had done a very, very good job, which was an interesting comment that exposes the inevitable power imbalance that exists in researcher-participant dynamics because she acknowledges me, the researcher, as having created the photonovel and even though she and the other women were the creators.  Also, at the end of our final interview, the same participant made a point of saying to me “I hope that you [italics added] can take the pictures, so that every country people can use it”.  The power imbalance researchers face when working with immigrant women is also noted by Mojab (1999) whose research focused on immigrant women and who pointed out that “the unequal distribution of power between researcher and researched is always present” (p. 124). Ultimately “the researcher is free to leave the field at any time and is generally the final author of any account” (Fonow & Cook, 1991, p. 9).  Undoubtedly, the researcher is given a lot of power in the research process along with inequities, such as my social status and education level.

Dissemination at the Community Level

Even though researchers are recognizing the importance of tapping into the rich perspectives of community members as we conduct research, we do not promote sustainable relationships with community members (Buysse et al., 2003).  The challenge for researchers is to shift the focus from knowledge as residing within the experts to knowledge as residing within the practice community (Lave & Wenger, 1991).  One way I was able to spread the results of my research was through disseminating my research findings through mediums, other than academic publications, that would reach the community level.  Thus, I published my research findings in various immigrant newsletters and also actively conducted photonovel workshops for staff to use with immigrant women at various provincial immigrant societies.  Another way I disseminated within the community setting was through disseminating copies of the photonovel the immigrant women created to numerous provincial immigrant societies for other immigrant women to read and learn about health.  It is important to note that, when immigrant women create health-related materials and distribute them to other ESL speakers to read, they are able to have a powerful voice and are play a vital role in their new country, which is empowering for them (Nimmon, 2007).

Sustaining Immigrant Society Partnerships

This project was awarded the National Population and Public Health Award for its very creative approach to health promotion; showing evidence of a likely impact both in terms of health literacy innovation and new tools, as well as impacting users.  Much of the project’s success is due to the collaboration with an outstanding immigrant society, the ICA of Greater Victoria, and the wonderful support I received as a new researcher from the staff and participants at this organization.

I sustained contact with the participants of my study and invited them to my defense party a year later, in which all of my participants attended except one.  The following year, I was saddened to learn of passing of one of my participants, Maki Yamamoto, a woman of whose gentleness and generosity continues to speak to me and to whom I dedicated my publication in the Canadian Journal of Public Health.

In the future, I am interested in offering back to the immigrant community through sustaining the community partnerships I built with immigrant societies in the province and focusing on health literacy from a broader more conceptual framework in my doctoral research.  As literacy is constructed and enacted within social, cultural and political contexts (Purcell-Gates, 2007), I would like to investigate the extent that social networks can be useful for coping with individual health problems.  In collaboration with a provincial immigrant society, I hope to develop a mentorship health literacy program that will build on the social support resources of Arab-Muslim immigrant women.  Ultimately, through community-based collaboration based on the principles of respect, equality and empowerment, I intend to introduce another intervention that will contribute to improving the health literacy levels of a specific immigrant population living within Canada.

References

(1)Boyd, M. (1991). Gender, nativity and literacy: Proficiency and training issues. In Adult literacy in Canada: Results of a national study (pp. 76-84). Ottawa: Statistics Canada.

(2)Buysse, V., Sparkman, K., & Wesley, P. (2003). Communities of practice: Connecting what we know with what we do.  Council for Exceptional Children, 69(3), 263-277.

(3)Canadian Institute for Health Information. (2004). Recent immigrant women report being healthier than Canadian born women. Retrieved December 1, 2004, from http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_27oct2004_e.html

(4)Fonow, M., & Cook, J. (1991). Feminist scholarship as lived research. In M. Fonow & J. Cook (Eds.), Back to the future: A look at the second wave of feminist epistemology and methodology (pp. 1-15). Indianapolis, IN: Indianapolis University Press.

(5)Harris, G. (2006).  Practicing HIV/AIDS community-based research.  AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV, 18(7), 731-738.

(6)James, S., Reddy, P., Ruiter, R., Taylor, M., Jinabhai, C., Van Empelen, P., et al. (2005). The effects of a systematically developed photonovella on knowledge, attitudes, communication and behavioural intentions with respect to sexually transmitted infections among secondary school learners in South Africa. Health Promotion International, 20(2), 157-165.

(7)Lave, J. & Wenger (1991). Situated learning: Legitimate peripheral participation.  New York: Cambridge University Press.

(8)Mojab, S. (1999). De-skilling immigrant women. Canadian Women Studies, 19, 123-128.

(9)Nimmon, L. (2007). Within the eyes of the people: Using a photonovel as a consciousness-raising health literacy tool with ESL-speaking immigrant women. Canadian Journal of Public Health, 98(4), 337-340.

(10)Purcell-Gates, V. (Ed.). (2007). Cultural Practices of Literacy: Case studies of language, literacy, social practice, and power. Mahwah, NJ: Lawrence Erlbaum

(11)Ratzan, S.C., & Parker, R.M. (2000). Introduction. In C.R. Seldon, M. Zorn. S.C. Ratzan, & R.M Parker (Eds.), National library of medicine current bibliographies in medicine: Health literacy (NLM Pub. No. CBM 2000-1). National Institute of Health, U. S. Department of Health and Human Services.

(12)Rudd, R., & Comings, J. (1996). Learner developed materials: An empowering product. Health Education Quarterly, 21(3), 313-327.

(13)Statistics Canada. (2005, November 9). The daily: International adult literacy and skills survey. Retrieved December 10, 2006, from http://www.statcan.ca/Daily/English/051109/d051109a.htm.

(14)Wang, C., & Burris, A. (1994). Empowerment through photonovella: Portraits of participation. Health Education Quarterly, 21(2), 171-186

(15)Wilson, J. (2003). The crucial link between literacy and health. American College of Physicians, 139(10), 875-879.

* Near the end of the project, the directors of the ICA requested that I acknowledge the ICA in the project’s dissemination, as they were proud of the project.  I respected their request and received human ethical approval to do this.  To date, however, I, unfortunately, do not have approval to name the people at the ICA or my participants who contributed to this project; leading me to question how human ethical policies might, in some cases, silence members of a community and create an unintentional division between researcher and community collaborators.