Decolonizing Impact Through the Culture-Centered Approach to Health Communication: Mobilizing Communities to Transform the Structural Determinants of Health.

In this issue, we outline the central tenets of the culture-centered approach to health communication. What does the culture-centered approach address when suggesting the co-creation of voice infrastructures? What is the theory's methodological emphasis for mobilizing and transforming structures that shape health inequalities for communities at the margins? Drawing on examples of culture-centered interventions in over fifty communities spread across 17 countries and three continents, a large number of them housed under the umbrella of the Center for Culture-centered Approach to Research and Evaluation (CARE) at Massey University in Aotearoa, New Zealand, we articulate the communicative processes (referring to actionable sources and targets of communicative action) that shape the building of voice infrastructures mobilizing toward structural transformation. For instance, African American communities organizing under the framework of the culture-centered approach, documented in Dutta, Collins, and colleagues study in 2019, discuss the building of voice infrastructures where community members participate in co-creating heart health information based on comparative effectiveness research, building an African American media ecosystem disseminating the information alongside community-led initiatives growing healthy food, community-led youth activities, and activism addressing the racist structural drivers that adversely impact African American heart health. In this essay, we describe the impact of culture-centered interventions reflected in the voice infrastructures within communities that witness and articulate the oppressions that threaten human health at the margins and in the transformations of these structures that organize various facets of life and livelihood at the global margins linked to health.

Situating Health Experiences: A Culture-Centered Interrogation.

Culture-centered studies of health communication de-center the theorization of health as an individual behavior and reveal the structural conditions that shape inequalities in health outcomes. The present study examines the ways in which space and housing shape experiences of health in a low-income site in Auckland undergoing radical redevelopment. We draw from a culture-centered project undertaken in 2018-2021 predominantly among Maori and Pasifika peoples involving 60 initial in-depth interviews, seven focus groups, a series of filmed interviews, and 32 additional in-depth interviews conducted during the COVID-19 pandemic. The residents' narratives foregrounded the detrimental health impact of inadequate housing, financial constraints, transience, and displacement that severs ties to place and community. These findings reveal the relationship between housing challenges, economic marginalization, and neoliberal capitalism, highlighting the need for policy interventions to address housing as a fundamental determinant of health disparities among marginalized communities.

The United Nations (UN) Card, Identity, and Negotiations of Health among Rohingya Refugees.

Being persecuted and expelled from Myanmar, Rohingya refugees are now distributed throughout the world. The Southeast Asian nation of Malaysia has been a preferred destination for Rohingyas fleeing Myanmar's state-sponsored genocide and more recently in a bid to change their fates from the refugee camps in Bangladesh. Refugees are one of the most vulnerable groups in Malaysia and often face dire circumstances, in which their health and wellbeing are compromised. Amidst a plethora of structural challenges, Rohingya refugees try to claim some of their rights with the aid of the UN card (UNHCR ID cards) in Malaysia. Guided by the culture-centered approach (CCA), this study examined the perspectives and experiences of healthcare among Rohingya refugees while living in Malaysia, now resettled in Aotearoa, New Zealand. The participants' narratives showed that the UN card not only materialized their refugee status in Malaysia but also offered them a way of living in a world where documents anchor the materiality of health.

Health Orientation as a Psychographic Framework for Understanding Physical Exercise Behavior.

The consistent association between regular physical exercise and positive health outcomes presents a compelling case for investigating the differences between individuals who exercise regularly and those who do not. Based on a randomized cross-sectional survey of 1,201 households, this study adopts a psychographic framework to investigate the role of health orientation in physical exercise behavior. This study extends the concept of health orientation, operationalized as five psychographic subscales (health information orientation, preventative orientation, exercise orientation, healthy eating orientation, and health information efficacy) as well as three behavioral constructs (sedentary behavior, BMI and cigarette smoking) to understand physical exercise behavior. The results show significant differences between regular exercisers and non-exercisers, and suggest that a psychographic framework based on health orientation could offer a more holistic approach for understanding physical exercise behavior by highlighting the treatment of the whole individual. Physical exercise, as a specific health behavior, is in fact interlinked with other health behaviors through an underlying health orientation toward health issues in general.

Receiving Healthcare Amidst Poverty During the COVID-19 Lockdowns: A Culture-Centered Interrogation.

COVID-19 has exacerbated existing health inequalities globally. Guided by the culture-centered approach, this study examined perspectives and experiences of healthcare during two lockdowns in four marginalized contexts in Aotearoa New Zealand. The participants' narratives depicted dissatisfaction with the new modes of healthcare delivery, reporting longer waiting times, a preference for face-to-face delivery, language barriers, and issues with the limitations in support people attending appointments. This resulted in healthcare being delivered in a way that was not in keeping with the localized cultural norms of communication and collective support, further exacerbating existing health inequalities. Our findings suggest that public health interventions in response to COVID-19 within the context of healthcare delivery have the potential to further reify and reproduce exclusions and experiences of marginalization, with cultural marginalization reifying structural marginalization.

Negotiating Health Amidst COVID-19 Lockdown in Low-income Communities in Aotearoa New Zealand.

Aotearoa New Zealand's public health crisis communication approach amidst the COVID-19 pandemic effectively mobilized the nation into swift lockdown, significantly reducing community transmission. This communication approach has been applauded around the world. How did communities situated amongst the "margins of the margins" in Aotearoa New Zealand navigate through the existing structural barriers to health during the pandemic? In this study, we use a culture-centered analysis to foreground the structural context of disenfranchisement amidst the COVID-19 lockdown. Drawing on in-depth interviews with participants in a larger ethnographic project on poverty and health across three communities in Aotearoa New Zealand, we attend to the ways in which health is negotiated amidst the COVID-19 outbreak and lockdown response at the "margins of the margins." The narratives point out that health communication interventions to prevent COVID-19 in the context of Aotearoa New Zealand furthered the marginalization of communities at the margins, and community voices were largely erased from the enactment of interventions. With the extant structures failing to recognize these aspects of everyday struggles of health at the margins, the health and access challenges were further magnified during COVID-19. Our attention to communication situated in relationship to structures builds a register for health communication scholarship in the context of COVID-19 that is committed to disrupting the behaviorally based hegemonic health communication literature and transforming the unequal terrains of health experiences.

Singapore's Extreme Neoliberalism and the COVID Outbreak: Culturally Centering Voices of Low-Wage Migrant Workers.

I draw on the key tenets of the culture-centered approach to co-construct the everyday negotiations of COVID-19 (coronavirus disease 2019) among low-wage male Bangladeshi migrant workers in Singapore. The culture-centered approach foregrounds voices infrastructures at the margins as the basis for theorizing health. Based on 87 hours of participant observations of digital spaces and 47 in-depth interviews, I attend to the exploitative conditions of migrant work that constitute the COVID-19 outbreak in the dormitories housing low-wage migrant workers. These exploitative conditions are intertwined with authoritarian techniques of repression deployed by the state that criminalize worker collectivization and erase worker voices. The principle of academic-worker-activist solidarity offers a register for alternative imaginaries of health that intervene directly in Singapore's extreme neoliberalism.

Ten considerations for effectively managing the COVID-19 transition.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

Space within the Scientific Discourse for the Voice of the Other? Expressions of Community Voice in the Scientific Discourse of Community-Based Participatory Research.

Community-based participatory research (CBPR) has captured public health attention and support because it is positioned as an approach that involves researchers and communities as equitable partners in addressing health disparities. However, it is unknown the extent to which CBPR creates a participatory space in the scientific discourse to signal "community voice," which we define as textual expression of community-centered perspectives on collective roles, interests, and worldviews. In this study, we utilized the culture-centered approach to examine the expression of community voice in the abstracts and public health relevance statements of 253 extramural CBPR projects in the U.S. that received funding from the National Institute of Health and Centers for Disease Control and Prevention in 2009. We found that project abstracts and public health relevance statements contain four textual domains, or potential sites of contest to signal the articulation of community agency and voice within the CBPR projects. These domains include: 1) the rationale for the community health issue, 2) the roles of community partners, 3) community-centered outcomes of the partnership, and 4) elements of participatory research process. The degree of culture-centeredness of the texts is suggested in the extent to which articulations of community agency and voice are signaled across the four domains. We conclude that the dynamics of CBPR may shape culture-centered expressions of problem identification, solution configuration, structural transformations, reflexivity, values, and agency in the project abstracts and public health relevance statements.

Culture-centeredness in community-based participatory research: contributions to health education intervention research.

Health education research emphasizes the importance of cultural understanding and fit to achieve meaningful psycho-social research outcomes, community responsiveness and external validity to enhance health equity. However, many interventions address cultural fit through cultural competence and sensitivity approaches that are often superficial. The purpose of this study was to better situate culture within health education by operationalizing and testing new measures of the deeply grounded culture-centered approach (CCA) within the context of community-based participatory research (CBPR). A nation-wide mixed method sample of 200 CBPR partnerships included a survey questionnaire and in-depth case studies. The questionnaire enabled the development of a CCA scale using concepts of community voice/agency, reflexivity and structural transformation. Higher-order confirmatory factor analysis demonstrated factorial validity of the scale. Correlations supported convergent validity with positive associations between the CCA and partnership processes and capacity and health outcomes. Qualitative data from two CBPR case studies provided complementary socio-cultural historic background and cultural knowledge, grounding health education interventions and research design in specific contexts and communities. The CCA scale and case study analysis demonstrate key tools that community-academic research partnerships can use to assess deeper levels of culture centeredness for health education research.

A Culture-Centered Community-Grounded Approach to Disseminating Health Information among African Americans.

This study highlights the role of local communities in creating culturally rooted health information resources based on comparative effectiveness research (CER), depicting the role of culture in creating entry points for building community-grounded communication structures for evidence-based health knowledge. We report the results from running a year-long culture-centered campaign that was carried out among African American communities in two counties, Lake and Marion County, in Indiana addressing basic evidence-based knowledge on four areas of cardiovascular disease (CVD). Campaign effectiveness was tested through an experimental design with post-test knowledge of CER among African Americans in these counties compared to CER knowledge among African Americans in a comparable control county (Allen). Our campaign, based on the principles of the culture-centered approach (CCA), increased community CER knowledge in the experimental communities relative to a community that did not receive the culturally centered health information campaign. The CCA-based campaign developed by community members and distributed through the mass media, community wide channels such as health fairs and church meetings, postcards, and face-to-face interventions explaining the postcards improved CER knowledge in specific areas (ACE-I/ARBs, atrial fibrillation, and renal artery stenosis) in the CCA communities as compared to the control community.

The Interplay between Stigma, Collective Efficacy, and Advocacy Communication among Men Who Have Sex with Men and Transgender Females.

Stigma and discrimination are primary drivers of health disparities among marginalized communities. Drawing on stigma management, minority stress model, and social cognitive theories, this article tests the interplay between dimensions of stigma, collective efficacy, and advocacy communication among men who have sex with men (MSM) and transgender females. Using data from a cross-sectional survey conducted in south India (N = 225), five distinct dimensions of stigma were identified using factor analysis: experienced stigma, self-stigma, felt normative stigma, and two new dimensions-HIV-related vicarious stigma and media stigma. Respondents reported highest levels of media stigma. While most of the dimensions of stigma were negatively associated with both collective efficacy and advocacy communication, collective efficacy mediated the relationship between stigma and advocacy. Implications for public health campaigns among MSM groups are discussed.

The women's heart health programme: a pilot trial of sex-specific cardiovascular management.

BACKGROUND: There is increasing knowledge of sex-specific differences in cardiovascular disease and recognition of sex disparities in management. In our study, we investigated whether a cardiovascular programme tailored to the specific needs of women could lead to improved outcomes. METHODS: We randomised 100 female patients to receive cardiology follow-up with the conventional sex-neutral cardiac programme (control), or the sex-tailored Women's Heart Health Programme (intervention). The intervention group was managed by an all-women multidisciplinary team and received culture-centred health intervention workshops, designed through in-depth interviews with the participants. The primary outcome was cardiovascular risk factor improvement at 1 year. Secondary outcomes include cardiovascular event rates, quality of life scores, and self-reported improvement in knowledge, attitudes, intentions and practices. Generalised structural equation model analysis was used to determine if the intervention group had better outcomes at alpha level 0.1. RESULTS: The mean age was 67.3 ± 12.7 years, with an ethnic distribution of 70% Chinese, 18% Malays, and 12% Indians. The majority of these patients had no formal or primary level of education (63%), and were mostly unemployed (78%). Patients in intervention group had better control of diabetes mellitus (lower HbA1c of 0.63% [CI 0.21-1.04], p = 0.015) and lower body-mass-index (0.74 kg/m2 [CI 0.02-1.46], p = 0.092) at 1 year, but there was no significant difference in blood pressure or lipid control. Overall, there was a trend towards better risk factor control, 31.6% of intervention group versus 26.5% of control group achieved improvement in at least 1 CV risk factor control to target range. There was no significant difference in incidence of cardiovascular events, quality of life, or domains in knowledge, attitudes, intention and practices. CONCLUSION: This pilot study is the first of its kind evaluating a new model of care for women with heart disease. The potential to improve outcomes needs to be studied in a larger trial with longer follow up. TRIAL REGISTRATION: This trial was prospectively registered clinicaltrials.gov on 6 May 2013. Trial Number: 2013/00088. Identifier: NCT02017470.

Trust Ecologies and Channel Complementarity for Information Seeking in Cancer Prevention.

Our paper extends channel complementarity theory, which has focused on evidence of complementarity and patterns of channel use, by elucidating the notion of trust complementarity. We examined trust, an information-carrier characteristic and a core construct in health-focused decision-making to understand cancer information seeking, based on data from two nationally representative surveys in Singapore. Trust is found to be differential, relational, and ecological, with implications for individuals' access to and reliance on doctors, family/friends, newspapers/magazines, radio, TV, and the Internet for cancer prevention information. In an ideal trust complementarity environment, an individual should be able to traverse a range of communication channels seamlessly. Our findings however suggest that although individuals trust different channels complementarily, their trust patterns are limited and fettered. We identified two types of trust ecologies shaped by dual-channel and polymorphic complementarity patterns that suggest that health information seekers are trapped within specific trust ecologies that prevent them from navigating a broader range of communication channels for cancer prevention.

Health Information Seeking Among Singaporeans: Roles and Collective Contexts.

This article seeks to contribute to the literature on health information seeking (HIS) by culturally locating the search for health information within the local contexts of everyday life in Singapore, and within the meaning-making processes that individuals participate in. Based on in-depth interviews with 100 participants selected through stratified sampling, it asks: How do Singaporeans make sense of HIS in the realm of their everyday lived experiences? The study contributes to the literature on the roles familial ties play in information gathering and sharing in a collective context. More importantly, these familial ties provide perspective on the ways in which culture spatio-temporally constitutes HIS. HIS is informed by familial role expectations in a collectivist context where filial piety and "respect for the elderly" are guiding anchors for behavior. Moreover, harmony and community well-being define societal roles and responsibilities of caregiving, directed broadly at communal care. These collective-oriented contexts therefore inform HIS.

Health Meanings among Foreign Domestic Workers in Singapore: A Culture-Centered Approach.

Economic migration is integral to processes of globalization, with large numbers of the global poor moving across borders in search of employment in the face of structural adjustment programs and large-scale displacement of the poor from traditional forms of livelihood. One such group are foreign domestic workers (FDWs). In this culture-centered study, we listen to the voices of FDWs in Singapore to understand the key meanings of health held by this group of migrant workers as they negotiate living and working in Singapore. Through the representation of FDW voices at sites where they have previously been excluded, we hope to co-create participatory spaces in national discourse so that policies and interventions can be developed to address the health needs of FDWs. The results represented in this essay are part of a larger project engaging the CCA to foster communicative platforms for structural transformation.

Health Communication in the Time of Ebola: A Culture-Centered Interrogation.

This brief essay is a commentary on how critical health communication theory can contribute to an understanding of the cultural dynamics of infectious disease pandemics. In particular, we focus on a specific trajectory of health communication theorizing-the culture-centered approach-and its heuristic and pragmatic utility in enhancing knowledge about public health crises like infectious disease outbreaks. In the backdrop of the mobilizations against the 2014 Ebola virus disease epidemic in the 3 West African nations of Guinea, Sierra Leone, and Liberia, indigenous cultural practices were construed as pathogenic and local agency of affected communities disregarded, even as the global risks of the epidemic were highlighted. In contrast to this interventionist notion of culture, the culture-centered approach offers a heuristic rubric through which to scrutinize the dialectical interrelationship between indigenous cultural practices, structural determinants of health, and the everyday agency of individuals of affected communities. We argue that such a listening-based paradigm of communication theorizing is instrumental in developing authentic, ethical, and effective health communication practice in public health crises.

Migration and Health in the Construction Industry: Culturally Centering Voices of Bangladeshi Workers in Singapore.

Construction workers globally face disproportionate threats to health and wellbeing, constituted by the nature of the work they perform. The workplace fatalities and lost-time injuries experienced by construction workers are significantly greater than in other forms of work. This paper draws on the culture-centered approach (CCA) to dialogically articulate meanings of workplace risks and injuries, voiced by Bangladeshi migrant construction workers in Singapore. The narratives voiced by the participants suggest an ecological approach to workplace injuries in the construction industries, attending to food insecurity, lack of sleep, transportation, etc. as contextual features of work that shape the risks experienced at work. Moreover, participant voices point to the barriers in communication, lack of understanding, and experiences of incivility as features of work that constitute the ways in which they experience injury risks. The overarching discourses of productivity and efficiency constitute a broader climate of threats to worker safety and health.

A Replication of Channel Complementarity Theory among Internet Users in India.

This article examined channel complementarity in health information seeking among Internet users in India. It posited that online users complementarily use different channels to search for health information. Based on the existing literature, it suggested that age is an important moderator of different channels as health information sources. Data regarding the consumption of 11 different channels were collected from nearly 1,000 Internet users. The results demonstrated complementary use of different channels as health information sources in relationship to the Internet as a health information source, except for newspapers and family members. Moreover, not supporting our hypothesis regarding the sources of health information among online users, the Internet was surprisingly not the primary source of health information, being shadowed by the predominant and significantly greater use of newspapers as sources of health information among online users in India. Extending the theory of channel complementarity, we found that age is an important moderator of complementary relationships among various channels as health information sources, demonstrating that younger users were more likely to use greater numbers of channels complementarily as compared to older users. Contributions to channel complementarity and implications of research are discussed on the basis of the findings.