Since the mid-1970s, millions of immigrants and refugees have come to the United States from Southeast Asia (U.S. Census Bureau 2007). Unlike some of the more established segments of the American population, these new Americans suffer from higher poverty, lower education and numerous health-related disparities. The challenges faced by these communities can be amplified further by low health literacy, limited English proficiency, real and perceived discrimination, and a lack of community infrastructure to support their diverse needs.
Over the last decade, the Asian American population grew by 43 percent nationally, while the White population shrank (U.S. Census Bureau,2011a). Between 2000 and 2010, the population of Philadelphia grew by 0.9 percent, the first decennial gain for the city since the 1940-1950 period (U.S. Census Bureau 2011b). This was driven in large part by the influx of immigrants and other minorities.
The Southeast Asian Mutual Assistance Associations Coalition, Inc. (SEAMAAC), a Philadelphia-based nonprofit organization, has been serving refugees, asylees and other immigrants in the region for nearly three decades. Among SEAMAAC’s community activities are programs related to citizenship, English language education, youth and elderly outreach, social services and health promotion. Frustrated by the lack of reliable data that accurately reflected the true health status of Southeast Asians in the Philadelphia region, the staff of SEAMAAC partnered in 2007 with public health experts at the University of Pennsylvania and Drexel University to embark on the process of collecting community-based health data for the communities they served (the research team was later joined by a researcher from Thomas Jefferson University, as well). These data pointed to a number of important health disparities that to date had not been systematically reported for this underserved community (Nguyen et al. 2011). However, it was clear that data alone would not lead to sustainable improvements in the health of their communities.
The use of personal narratives was proposed as a potential avenue for bringing about community-wide behavior change to support healthy lifestyles. This idea is supported by the fact that, unlike many European American traditions that may emphasize the use of stories for entertainment purposes, Asian families may be more likely to use storytelling for the purpose of education and to reinforce social norms (Miller, Wiley, Fung, & Liang 1997). Hence, the creation of an infrastructure that supports health-related storytelling and involves residents, community organizations, and local media carries great potential (Ball-Rokeach, Kim & Matei 2001).
In autumn 2007, a team including the University of Pennsylvania Asian Health Initiatives, SEAMAAC, WHYY (the local public broadcasting station), Thomas Jefferson University and Temple University’s Project SHINE successfully obtained funding for a video storytelling project using the newly collected data as a springboard for community action and engagement of Southeast Asian immigrant elders. This partnership used a community-based participatory research (CBPR) approach (Viswanathan et al. 2004) and included community stakeholders, experts in video production (WHYY), experts in immigrant community outreach (SEAMAAC), and experts in CBPR, primary care medicine, program evaluation, and adult learning (academic partners). The project’s logic model is shown in Figure 1.
At the core of the new project was an Elders Council comprised of members of the Laotian and Vietnamese immigrant communities. The leadership at SEAMAAC envisioned this Council as a means by which members of the community could reclaim their traditional status of leader and advisor as they grew older. In Asia, younger adults would often turn to their elders for guidance, yet in the United States, the opinions and wisdom of elders were often neglected and forgotten.
The Elders Council grew out of a weekly elders breakfast gathering hosted by SEAMAAC, where older immigrants had been gathering every week to meet new friends, enjoy rice porridge and noodles, and play traditional board games. When a small group of attendees approached the leadership of SEAMAAC to see if something could be done about safety and other conditions in their neighborhood, it became apparent that some of the elders had an interest in civic engagement, yet few avenues to act upon that interest.
The Elders Council included members of both the Laotian and Vietnamese immigrant communities of Philadelphia, largely because these were the communities represented at the weekly breakfast gatherings. The size of the Council started at eight members (both men and women), but the total membership fluctuated over time as some members moved away or became busy with family responsibilities, and other members joined to take their place.
A Multiethnic and Multilingual Council
Some of the Elders Council members were able to speak English, and a few were bilingual in Lao and Vietnamese. However, the majority of members were monolingual in the languages of their countries of origin. Despite these linguistic differences, the Council members had a shared experience as immigrants and refugees, and they had become comfortable with each other through the weekly breakfast gatherings. As a result, the elders were quite clear that they did not wish to have a separate Laotian Council and Vietnamese Council. They saw themselves as a single unit, with shared goals.
The realities of working with a multiethnic and multilingual community advisory council meant that planning meetings and training sessions usually required much more time than standard meetings. Although SEAMAAC had outreach workers who could speak Lao and Vietnamese, they had no single outreach worker who was fluent in both languages. English, therefore, was used as a common language with which to facilitate the language interpretation. Moreover, some of the academic collaborators could speak neither Lao nor Vietnamese, and they also relied on English. Consequently, those who attended Elders Council meetings quickly learned that they needed to speak in brief phrases to allow each sentence to be translated into two other languages before a conversation could proceed. This was time-consuming, but the Elders Council members and other collaborators showed tremendous patience with the process, because everyone believed in the value of this endeavor.
Linguistic concerns were not the only challenge, however. The Vietnamese elders had the benefit of a more functional educational system in their homeland when they were growing up than did the Laotian elders, and the Vietnamese American community was more established in Philadelphia than was the Laotian American community. As a result, the Vietnamese members of the Elders Council were more vocal and larger in number. Overall, there were no major disagreements, but it was nonetheless important to ensure that the experiences, needs, and concerns of the Laotian elders were not overlooked during the Council discussions.
Setting the Course
The Elders Council was charged with the task of reviewing reports from the community health data described earlier, and combining that information with their own personal experiences in the community, in order to choose health topics that would become the focus of the collaborative project. The data reports were presented in a concise fashion, with the understanding that the community members were not scientists and had varied levels of educational attainment.
After reviewing the data and having a group discussion, the Elders Council decided that the project should focus on high blood pressure and on doctor-patient communication.
The elders received basic training from the Learning Lab at WHYY (now known as the Hamilton Public Media Commons), a digital media lab set up to teach community members how to create their own digital media. The Learning Lab had worked with some older community members in the past, but their experience was primarily with youth, and this was the first time they had worked with non-English speaking Asian elders. It was a growing process for everyone involved, but the elders were enthusiastic and eager to gain experience with the camera equipment. Although the elders were highly motivated, it became clear that there would be limits to how much they would be able to perform with regard to the more complicated technology, given the rate at which training could proceed and the timeline of the grant-funded project. Tasks such as lighting setup, sound checks, digital editing, and subtitling were simply beyond the scope of what could be done by the elders given the timeline of the project.
The challenges mentioned above provided the team with an unexpected opportunity to bring an intergenerational component to the project that had not been planned at the beginning. Undergraduate students and graduate interns from the Southeast Asian communities were able join the project, serving as on-set assistants, ad hoc interpreters, and video editors. This type of intergenerational collaboration was enriching for both the young people and the elders alike.
The key component of the project was, of course, the stories that were being told. For example, one gentleman told of his experiences with high blood pressure, a condition that at first he took lightly; he did not take his medicine consistently, until one day he felt ill while driving and had a car accident. The paramedics found his blood pressure to be very high when they arrived at the scene of the accident; this was a wake-up call for him. Another man spoke about the trouble he had trying to receive linguistically appropriate healthcare services, while one woman spoke about strategies she used to make sure that she kept her hypertension under control. These stories came directly from the elders, or from other community members recruited by the elders or by SEAMAAC staff. The stories were edited and woven into an interactive workshop curriculum designed for adult learners of all ages (not just the elderly).
“But Don’t Call Me A Leader”
Humility is a key component of Asian values (Kim, Li, & Ng, 2005). As such, the Elders Council members were rather reluctant to be called “leaders”. Although several of them had a long history of volunteering at religious and social organizations in their communities, they were somewhat hesitant to be recognized as leaders of their communities when they became involved in the Elders Council. Nonetheless, they demonstrated a great deal of leadership skill that blossomed even more as their involvement in the project continued.
The volunteers on the Elders Council did more than just set the original direction of the project. They reviewed and edited the interview guides used to prompt community members to share their experiences during filming sessions. They watched the raw video footage and offered recommendations about whether sufficient material had been recorded, or whether additional questions should be added to broaden the scope of responses being collected. They pilot tested the educational workshop materials, and some of them served as workshop helpers when educational sessions were presented by the SEAMAAC outreach workers.
To some degree, the elders themselves were rather surprised at how well the process worked. Toward the end of the workshop development process, one of the elders admitted that he was rather skeptical about the idea of doing a media project such as this; however, when the videos were completed and fully integrated with the new workshop curriculum, he could see how valuable and effective this could be.
The partnership process described in this paper led to the realization of a number of points that could be useful to others who might wish to implement a similar model of community engagement. Following are a few lessons learned:
- When doing a participatory project involving multiple languages, do not underestimate the amount of time that will be required.
- When engaging non-English speaking immigrant elders in a video project, not all steps in the production process can be feasibly done by the elders, even with formal training (for example, video editing, subtitling, etc.).
- Video editing for non-English language footage is a challenge when production experts do not understand the language. However, it can be accomplished with adequate multilingual volunteer support (and training of the volunteers).
- When working with multiple ethnicities, be aware of any imbalance due to differences in representation from different subgroups, as well as differences in baseline experience or education that might result in one subgroup having a stronger voice than another.
- Immigrant elders (even those with limited English proficiency) welcome the chance to be engaged in non-profit work with their communities, particularly if appropriate opportunities and linguistic resources are provided.
Acknowledgements and Disclosures
This project was funded by grant from New Routes to Community Health, a national program of the Robert Wood Johnson Foundation and administered by the Benton Foundation (PI: G.T. Nguyen). After this project was initiated, authors Giang Nguyen and Elaine Yuen were asked to serve on the Board of Directors of SEAMAAC; at the time of this writing, both authors continue to serve in this capacity as volunteer board members. Some of the material in this paper was presented in 2010 as part of “Creative Action: The Arts in Public Health,” a seminar series hosted by the Center for Public Health Initiatives of the University of Pennsylvania, Philadelphia, PA.
Giang T. Nguyen, MD, MPH, MSCE is an Assistant Professor of Family Medicine and Community Health at the University of Pennsylvania, where he leads the Penn Asian Health Initiatives. His research focuses on Asian immigrant health, community based participatory research, and cancer prevention and screening. In addition to seeing patients, he also teaches medical students, family medicine residents, and public health students.
Ethan T. Nguyen, MPH is a health researcher at the University of Pennsylvania. His work focuses on social media and disease prevention, translational cancer care, and health care access in immigrant communities.
Elaine J. Yuen, PhD, MBA is an Adjunct Associate Professor in the Jefferson School of Population Health at the Thomas Jefferson University. Her research interests include healthy aging, diversity, cultural competency and access to care, and community-based participatory research. As a result of her research activities, Dr. Yuen has a long record of successful collaboration with community groups, physicians and other health care providers in articulating research aims, as well as developing and executing research methodologies that will meet these goals. Dr. Yuen also teaches the Cultural Humility and Competency, Research Methods, and Geographic Information Systems courses at Jefferson.
Craig Santoro is Director of Media Instruction at WHYY Public Media. Craig joined WHYY in 2002 and shortly thereafter started the station’s first youth media program. Since then, he has created and managed ongoing after-school documentary workshops for Philadelphia teenagers and partnered with community centers to hold video production classes for teens who have dropped out of school. He’s developed award-winning video summer camps, partnered with numerous schools to train teachers to use video in their classrooms and created video learning experiences for nonprofit organizations, higher education institutions and learners of all ages.
Tina Kluetmeier, MSEd is an education consultant with over 20 years of experience teaching ESL, developing programs and providing training and technical assistance to community-based organizations and universities in the U.S. and abroad. Previously, Tina directed Project SHINE, a national civic engagement initiative coordinated out of Temple University’s Intergenerational Center. SHINE builds partnerships that bring college students and older immigrants together to serve their communities
Thoai Nguyen is a first generation Vietnamese refugee whose family immigrated to the United States. He is a long time community organizer and advocate who has worked for peace and social justice in many communities throughout Africa, Asia, Eastern Europe, and North America. Thoai is the current CEO of SEAMAAC, Inc. whose mission is to serve and advocate for refugees and immigrants in the Greater Philadelphia area.
Ball-Rokeach, S. J., Kim, Y.-C., & Matei, S. (2001). Storytelling Neighborhood: Paths to Belonging in Diverse Urban Environments. Communication Research, 28(4), 392-428.
Kim, B. S. K., Li, L. C., & Ng, G. F. (2005). The Asian American Values Scale — Multidimensional: Development, Reliability, and Validity. Cultural Diversity and Ethnic Minority Psychology, 11(3), 187–201.
Miller, P. J., Wiley, A. R., Fung, H., & Liang, C. H. (1997). Personal storytelling as a medium of socialization in Chinese and American families. Child Development, 68(3), 557-568.
Nguyen, G. T., Yuen, E. J., Hsu, L., Kue, K. N., & Nguyen, T. (2011). Community-partnered health surveys of Asian Americans: Public health and policy implications. Journal of Health Care for the Poor and Underserved, 22, 1101-1114.
U.S. Census Bureau. (2011a). Overview of Race and Hispanic Origin: 2010. 2010 Census Briefs(C2010BR-02).
U.S. Census Bureau. (2011b). Population Distribution and Change: 2000 to 2010. 2010 Census Briefs(C2010BR-01).
US Census Bureau. (2007). The American Community - Asians: 2004 (No. US Census ACS-05)o. Document Number)
Viswanathan, M., Ammerman, A., Eng, E., Gartlehner, G., Lohr, K. N., Griffith, D., et al. (2004). Community-based participatory research: Assessing the evidence (No. AHRQ Publication No. 04–E022-2). Rockville MD: AHRQo. Document Number)