Meaning of good health
Most study participants believed that good health on an individual level meant being “physically active” and/or engaging in “exercise” and “eating well”. According to participants, eating well included a diet that was rich in fruits and vegetables and limited in fatty or fried foods. Some participants believed that good health meant “having good emotional health”, “mental wellbeing”, or being a “well-rounded person emotionally, spiritually and physically”. Participants also believed that good health meant having a “balanced life”, “not being overly stressed”, “feeling good about oneself”, and having “strong” family and personal relationships.
Study participants believed that good health on a community level meant having resources to offer its residents. They viewed goods and services as a marker of good community health, such as the availability and accessibility of health and social services, recreational activities, and affordable healthy foods. Participants also believed that a community had good health if it was safe for residents to live, walk, or play. They discussed safety in terms of crimes against persons and the existence of gang and drug activity, but also in terms of the physical environment, such as the lack of sidewalks and adequate lighting.
Enabling and inhibiting factors of good health
The majority of study participants reported that they did not consider their respective communities to be healthy. The most common reasons cited were high rates of poverty in the community, lack of community resources that supported health-promoting activities, discrimination, and high rates of chronic conditions, such as type 2 diabetes and obesity. Study participants listed these and other factors related to socio-economic status, such as lack of education, financial difficulties, and unemployment, as unique characteristics of their communities that inhibited residents from being healthy. They also identified safety concerns, such as gangs, domestic violence, and drug and alcohol abuse as community problems that prevented or limited residents’ ability to lead healthy lifestyles. One study participant, Laura, shared her views on inhibiting factors that echoed the sentiments of other participants. At the time of the interview, Laura was 57 years old and had been working for seven years on educational programming for the Latino adults in her community. She stated:
I am realizing that this area is a very dangerous zone. Gangs, right? That can also influence… in some ways well the families don’t leave their homes. The families that want to take care of their health and it’s night and around here they can [be] assault[ed]…It’s a factor in this area that really harms the mental health, above all, of our children.
Additionally, participants of the Latino communities perceived that residents faced language and cultural barriers as well as lack of legal status which kept residents from being healthy.
Despite the sentiments of Laura and others, all study participants identified at least one specific resource available in their communities that they believed enabled a healthy lifestyle. These resources included health clinics, food pantries, family resource centers, and health, nutrition or exercise classes. The majority of participants viewed the factors which promoted community health within the context of family and community cohesion. Participants perceived that the community’s health-related values were centered on providing for the family and on living a long life with family. These views were illustrated in the interview with Richard, the director of a non-profit organization in the community. He stated:
I think from what I have seen also, it’s around family. The idea of being healthy is connected to the value of having a strong family, having a happy family, being able to provide for the basic necessities [if] they can provide what their children need, then…their children are being healthy and their family is being healthy.
Many participants also viewed traditional and cultural activities as positive, health-promoting practices, although the specific activities differed by community. Several participants of the Latino communities indicated that preparing traditional meals was healthy because the meals reinforced residents’ culture and unity, which were thought to be important components of health for both the individual and the community as a whole. Several participants of the American Indian community shared similar beliefs in that cooking and socializing with others promoted good health and strengthened social ties. However, many participants of the American Indian community believed that other cultural activities, such as fishing, and gathering roots and berries, promoted physical activity and community unity. No participant of the Latino communities mentioned these same activities as health-promoting cultural practices. As one participant from the American Indian community commented, “that’s what I see as healthy… exercising some of the traditions which we do. We go to the celebrations. We do the healthy things [together] that enrich our soul”. Nonetheless, most study participants, regardless of the community they represented, saw cultural practices as vehicles for bringing families and friends together, strengthening those social ties, and creating a more unified community as a result.
Most important health-related concerns
Study participants identified preventable chronic conditions as the most important or pressing health concerns in their communities. Type 2 diabetes was most commonly mentioned by participants, followed by obesity, hypertension, and high cholesterol. Other pressing health-related issues identified included depression, suicide, hunger, and food insecurity. Participants reported an unbalanced or poor diet and lack of exercise as the major factors attributing to these health problems in the community. Participants also cited stress and trauma as contributors to poor health in the community.
Three themes emerged from the grounded analysis of healthy living discussions: Social connectedness is integral to health, trauma has an ongoing negative impact on health, and invisibility of residents in the community underlies poor health.
The first theme that emerged from our thematic analysis was the participants’ views that being socially integrated with family, friends, and the community at-large supported an individual’s attempts to lead a healthy life. We found that almost all study participants believed that having dense social networks were key motivators for pursuing a healthy lifestyle and were foundational for good health. One key informant from the rural Latino community remarked, “That you’re able to have [people] surround you that love you and you are able to love, you know, people who support you when you’re really sick or sad. For me, that is health”. The importance of being socially connected and its connection to health was a notion that was shared by many study participants from all communities.
We found that social connectedness was an important feature of the family but also of the larger community. Some participants believed that social connections helped pass the “healthy word” along to others and encouraged participation in health-promoting activities. However, being socially connected also meant “keeping an eye out” for each other, “checking in” with others, and helping people in need in the community at-large. The following excerpt represented the sentiments shared by many study participants about being socially connected beyond the immediate family:
I think it’s important for them [residents] to stay healthy, not just in their family but in their community….Everybody’s concerned about sharing the healthy information to people so it is something that….that they understand needs to be thought about in order to have a healthy community, a healthy family, healthy children.
This excerpt demonstrated participants’ views that social connections are fundamentally important to good health at the family and community level. Conversely, lack of social connections or “bad blood” with others can be harmful to health, according to study participants. As one participant stated, “sometimes there are people who close themselves off when they have a problem or they don’t have a solution or don’t know where to get solutions or who to talk to and that also may affect [them] emotionally or mentally”.
The second theme that emerged from our grounded analysis of healthy living discussions was that personal and community-wide traumatic experiences negatively impacted residents’ health and sense of wellbeing. While the type of trauma described differed slightly across communities, study participants from all three communities shared the view that both present-day and past traumatic experiences affected the current health of their residents.
In the American Indian community, several study participants indicated that they lowered their health ratings of their community because of the trauma experienced within the community. Study participants discussed trauma in terms of community-level historical events and in terms of one’s own family where the behavior of one member affected another or the family as a whole. Examples of community-wide trauma that were considered as major contributing factors to the American Indian community’s health problems included having had tribal lands taken away, forced residential schooling, and the betrayal of the U.S. government. Examples of family-level trauma included alcoholism, drug abuse, and personal violence.
Study participants’ discussions indicated that trauma at the community and family levels was actually intertwined and viewed as intergenerational. Veronica, an American Indian study participant worked at a community health center and was asked what she meant by “[inter]generational trauma”. She responded,
Well, the loss of their language, the loss of their way of life, the violence perpetrated on them, you know. And I mean we’re talking hundreds of years, but the violence perpetrated to get them into reservations, taking away their self-respect. Violence was committed on them by others, perpetuated on each other by themselves, alcoholism, you know, all those kinds of things that break families and has never been addressed or talked about.
Other American Indian community study participants echoed these sentiments, suggesting that trauma was a form of violence that destroyed traditional customs and foods, the environment, and the structure of the family. The cumulative impact of these losses was seen as having a detrimental effect on the health of community residents, leading to “depression”, “poor eating habits”, “violence”, and “poverty”, among other problems.
Study participants of the Latino communities also identified traumatic experiences as factors that influenced health. In contrast to the study participants of the American Indian community, who emphasized family- and community-level sources of trauma, the study participants of the Latino communities emphasized personal-, family-, and community-level sources of trauma. At the personal level, trauma was experienced during the immigration experience. Carolina, a woman with over ten years’ experience working for a health center in the Latino community shared,
But many of them [immigrants], you know, come from Mexico. Many of them, they get arrested. Some people experience bad [things] when they are crossing the [border] or they experience being sexual[ly] assault[ed]. Other experiences, who knows. There are so many things they’ve been collecting on their way here, to this dream, you know, is going to affect their lifestyle and is going to affect their health.
At the family level, examples of trauma were similar to those identified in the American Indian community, such as personal violence. One participant discussed the manner in which present-day trauma affected the health of her community. She stated,
Oftentimes, as the kids see and witness domestic violence in the home, they later in life kinda turn things against mom…so there’s a lot of factors that come into play when it comes to literally living a healthy lifestyle.
Examples of trauma at the community level included gang violence and drug dealing. While study participants of the American Indian community also identified these problems in the community, community-level trauma was most often discussed in terms of historical events and the effect of those historical events on the community over time. Thus, the Latino and American Indian communities differed in the ways that trauma was experienced by residents; nonetheless, trauma as a source of poor health or a barrier to good health emerged as a cross-cutting theme among all study participants.
Some study participants in all communities believed that discrimination in the community was a form of trauma that persisted in their communities, which some or all community residents endured. While participants’ discussions of discrimination were set in different contexts for each community, the discussions consistently pointed to the negative health effects of discrimination.
The third theme that emerged from our analyses of the interview transcripts was that some residents were invisible in the community, making them especially vulnerable to poor health. Study participants believed that some residents were not valued or respected in the work place, did not have representation in government or policy agenda-setting activities, or were not treated with respect and/or dignity in their communities in general, or in specific settings such as medical offices. The following interview excerpts illustrated this notion of invisibility:
…Often workers talk about feeling as though [in the] places that they work, the livestock or the crops are more valued than they are. I mean not everyone speaks in this sense, but it’s a common sense in many workers. – Participant from the rural Latino community
…A lot of it is the elders in our community don’t have transportation or because of their health situation…they need to be seen by a doctor…and not be overlooked…That’s the kind of concern that I’m getting calls [about]. – Participant from the American Indian community
Although these excerpts referred to unique situations of each community, they both reflected a similar notion of invisibility. These discussions by study participants also suggested that being invisible in the community created a sense of powerlessness among residents and damaged a person’s health. When asked if the migrant seasonal farmworkers in the rural Latino community were healthy, one participant answered:
No, because of access, cost, the economics of health care and the fact that they [farmworkers] are really not recognized or appreciated for what they do. They’re looked upon more as just a labor force instead of people…. I see a lot of the men out here, the day laborers that we have, who can’t afford to have good health care. Many of them are undocumented so there’s a lot of places that receive federal funds that can’t assist them because of their documented status.
This excerpt illustrated farmworkers’ invisibility in the workplace and migrant camps and the connection of invisibility to health. In this statement, the participant tied lack of access to unhealthy living conditions and being undocumented, suggesting that these factors, which reflected not having a place in the community, kept the residents from having good health. Similar views were shared by study participants of the other communities.